Counseling patients about allergic rhinitis.

Allergic rhinitis affects 10% to 30% of Americans. Intranasal corticosteroids are safe and effective in managing allergic rhinitis without systemic effects. Pharmacists should educate patients about the proper use of intranasal corticosteroids and advise them to avoid exposure to allergens.

Primary care in Cuba: a public health approach.

Cuba's primary health care model is presented. Unlike ambulatory care services, which are but one component of primary care, Cuba's model is a comprehensive public health approach that meets the World Health Organization's definition of primary care. The history of the development of Cuba's model is presented, including an update on the innovative neighborhood/home clinics. Achievements in health outcomes as a result of Cuba's model and the consequences for women's health care are discussed. Examples are presented of the effects on health care delivery of the economic hardship that Cuba has experienced since 1991 as a result of the loss of 85% of its trade with the former Soviet Union and the intensified U.S. embargo. A critique of Cuba's model concludes the article.

PIP: Cuba has been able to achieve some things that few Western countries have been able to achieve: equal access to health services for the entire population and equity in health status. After the 1959 revolution, community organizations conducted a census to obtain baseline demographic and epidemiologic data about the population, a literacy campaign, and sanitary and immunization campaigns. Polyclinics provided various social, environmental, and community health services free of charge. They were geographically distributed. Cuba instituted its neighborhood/home clinic model in 1984, a holistic, family, and neighborhood approach to comprehensive health care of the community. The family physician and nurse live in the neighborhood. Health education and health promotion are central to this model. The physicians and nurses are expected to conduct research and to present their findings at congresses or in journals. Cuba's infant mortality rate is not much higher than that of the US (1993, 9.4 vs. 8.3). Major causes of death in Cuba match those in developed countries, mainly heart disease and cancer. More than 95% of pregnant women attend their first prenatal visit during the first trimester. They receive prenatal care monthly unless they have a high-risk pregnancy when they receive prenatal care once a week. Infants receive well-baby care once a month. Sex education is available to everyone. All primary care facilities provide contraception. Nevertheless, the induced abortion rate is high, which concerns the government and health providers. Key effects of the economic hardship Cuba faces caused by the fall of the Soviet Union include food rationing, emigration, increased use of traditional herbs, lack of exchange of professional literature between the US and Cuba, and lack of enough paper to continue publications of medical and nursing journals. Cuba has prioritized health and education over economic development.

Comprehensive care and the sanatoria: Cuba's response to HIV/AIDS.

The authors present an overview of Cuba's response to HIV/AIDS including: (a) the development of comprehensive health care in Cuba; (b) the epidemiology of AIDS in Cuba; (c) the sanatoria approach to treatment and recent changes; (d) the idea of comprehensive HIV/AIDS care as a basic human right; (e) the effects of the special period on the HIV/AIDS program and containment of the epidemic; and (f) a critique of Cuba's HIV/AIDS program.

DUEs for the '90s: multicentered, outcome-oriented.

The likely development of healthcare alliances and affiliations will create a logical role for multicentered DUEs that study treatment regimens or indications in a healthcare system made up of several institutions. Such a study is under way in New Jersey, involving 15 hospitals. The DUE is evaluating usage patterns of ticarcillin/clavulanate and two other broad-spectrum antibiotics. A multicenter DUE presents challenges, such as the need for additional resources and for consensus among disparate elements; but this methodology also opens up expanded roles for pharmacists, including participation in quality assurance activities.

Food interaction and steady-state pharmacokinetics of itraconazole capsules in healthy male volunteers.

The influence of food on itraconazole pharmacokinetics was evaluated for 27 healthy male volunteers in a single-dose (200 mg) crossover study with capsules containing itraconazole-coated sugar spheres. This study was followed by a study of the steady-state pharmacokinetics for the same subjects with 15 days of administration of itraconazole at 200 mg every 12 h. Concentrations of itraconazole and hydroxyitraconazole, the active main metabolite, were measured in plasma by high-performance liquid chromatography. The results of the food interaction segment showed that a meal significantly enhances the amount of itraconazole absorbed. The mean maximum concentration in plasma of unmetabolized itraconazole after fasting (140 ng/ml) was about 59% that after the standard meal (239 ng/ml). The rate of elimination was not affected (terminal half-life, approximately 21 h). The mean maximum concentration in plasma of hydroxyitraconazole after fasting was about 72% the postmeal concentration (287 and 397 ng/ml, respectively). The terminal half-life of hydroxyitraconazole was approximately 12 h. Steady-state concentrations of itraconazole and hydroxyitraconazole were reached after 14 or 15 days of daily dosing. The average steady-state concentrations were approximately 1,900 ng/ml for itraconazole and 3,200 ng/ml for hydroxyitraconazole. The shape of the elimination curve for itraconazole after the last dose was indicative of saturable elimination. This conclusion was confirmed by the sevenfold increase in the area under the curve from 0 to 12 h at steady state compared with the area under the curve from 0 h to infinity after a single dose. It was furthermore confirmed by the larger-than-expected number of half-lives required to achieve steady-state plasma drug levels.

Mercaptopurine-induced fever in a patient with Crohn's disease.

OBJECTIVE: To report a case of mercaptopurine-induced fever. CASE SUMMARY: A patient with Crohn's disease was treated with mercaptopurine (6-MP) for an exacerbation of his illness. The patient developed fever and chills. After thorough diagnostic examinations and failure to respond to antimicrobial therapy, symptoms were attributed to an allergic-type reaction to 6-MP. The patient defervesced after 6-MP withdrawal. Fever and chills, along with arthralgias, recurred upon rechallenge with a single dose of 6-MP. DISCUSSION: Adverse effects attributable to 6-MP therapy in inflammatory bowel disease were reviewed in the literature. Drug-induced fever has been previously reported; however, it is an uncommon adverse effect and is difficult to diagnose. It is also difficult to predict which patients will have the reaction. It is a diagnosis of exclusion requiring a thorough investigation. CONCLUSIONS: Drug-induced fever should be considered when confronted with fever and chills in patients with inflammatory bowel disease being treated with 6-MP. This case report shows the difficulty in differentiating between an infectious process and an adverse reaction to a medication.

Crossover assessment of serum bactericidal activity and pharmacokinetics of ciprofloxacin alone and in combination in healthy elderly volunteers.

To better define the pharmacokinetics and serum bactericidal activity (SBA) of ciprofloxacin and other antimicrobial agents in the elderly, six healthy (greater than 65 years) volunteers with normal renal function were given ciprofloxacin alone orally, ciprofloxacin plus rifampin orally, ciprofloxacin plus clindamycin orally, rifampin alone orally (three volunteers), and, for comparison of SBA against gram-positive cocci, vancomycin intravenously. Mean peak ciprofloxacin concentrations and other pharmacokinetic parameters were not altered significantly by coadministration of either rifampin or clindamycin. Ciprofloxacin had somewhat greater SBA against the oxacillin-susceptible and oxacillin-resistant Staphylococcus aureus strains tested than did vancomycin, but rifampin was by far the most active single agent tested. The SBA of rifampin against S. aureus was modestly antagonized during combination therapy with ciprofloxacin, but substantial SBA still was present. The ciprofloxacin SBA against S. aureus was completely antagonized by clindamycin if the strains were susceptible to the latter agent. Ciprofloxacin had modest SBA against group A streptococci and no SBA against the three pneumococcal strains tested. All of the regimens had poor to absent SBA against Enterococcus faecalis. By contrast, ciprofloxacin had excellent SBA against Escherchia coli and Klebsiella pneumoniae and moderate SBA against Pseudomonas aeruginosa. Combination therapy with rifampin or clindamycin in general enhanced the SBA against the nonenterococcal streptococci and had no effect on the SBA against the gram-negative bacilli.

Preferential nuclear binding of estrogen in the formalin-fixed rat uterus.

Rat uterus fixed overnight in buffered formalin retains the ability to specifically bind estradiol. However, the estrogen binding property of fixed tissue appears preferentially localized in the nuclear fraction regardless of hormonal status. Furthermore, the quantity of the nuclear estrogen receptor in fresh or fixed uterus is virtually identical in the presence or absence of estrogenic hormone. Yet, while both tissue preparations exhibit equivalent increases in the total nuclear receptor occupancy after hormone exposure, only the fresh uterus contains a major cytosolic estrogen binder which decreases in availability upon the estrogen-induced elevation of the nuclear bound steroid. However, the cytosolic estrogen receptor exhibits a significant loss in its ligand binding property after formalin exposure. Thus, the preferential localization of estrogen binding in the nuclear fraction of fixed whole tissue may just reflect that only the tightly bound nuclear estrogen receptor's functional and/or structural integrity survives long-term formation fixation. Our observation of estrogen binding in preserved tissue may also be a clinically useful tool in therapy analysis.

Crossover assessment of serum bactericidal activity and pharmacokinetics of five broad-spectrum cephalosporins in the elderly.

To better define the pharmacokinetics and serum bactericidal activity (SBA) of the expanded-spectrum cephalosporins in the elderly, we administered single 2-g intravenous infusions of cefoperazone, cefotaxime, ceftriaxone, ceftazidime, and ceftizoxime to six healthy volunteers over the age of 65 years. Serum was collected over 24 h, and concentrations were determined by high-performance liquid chromatography; pharmacokinetic parameters were determined for each drug. SBA was measured against representative strains of Staphylococcus aureus, Escherichia coli, Klebsiella pneumoniae, Enterobacter aerogenes, and Pseudomonas aeruginosa. All agents tested had excellent SBAs against E. coli and K. pneumoniae, often for a longer duration than would be expected on the basis of conventional dosing regimens. Ceftazidime had the greatest SBA against E. aerogenes and was the only agent with a substantial SBA against P. aeruginosa. Although ceftizoxime had the greatest SBA against S. aureus, none of these cephalosporins had substantial antistaphylococcal SBAs. Pharmacokinetic analysis revealed that cefoperazone and ceftriaxone had markedly different concentration-time profiles in the elderly volunteers than would have been expected on the basis of existing data from younger volunteers. For older patients, dosing guidelines for these two agents may need to be altered.

Differential distribution of an estrogen receptor in the submandibular and parotid salivary glands of female rats.

The purpose of this study was to measure the availability of the estrogen receptor in submandibular and parotid salivary glands in female rats. The presence of a specific, competitive, and saturable estrogen binder in rat salivary gland tissue was determined by saturation analysis and steroid competition in cell-free homogenates of salivary gland tissue from adult ovariectomized females. Scatchard analysis of the data indicated an estrogen receptor content of 1971.1 +/- 651.4 femtomoles/gm of tissue in submandibular salivary gland. This was significantly (p less than 0.01) greater than the number of estrogen binding sites in the parotid gland (457.1 +/- 123.4 femtomoles/gm tissue). Thus, there is a differential distribution in estrogen receptor content between parotid and submandibular salivary glands. The presence of an estrogen receptor in salivary gland tissue may serve to promote gender differences in submandibular salivary gland EGF content, to mediate changes in saliva composition during the female reproductive cycle and to regulate EGF release for cyclic uterine growth.

The effect of homogenization temperature upon the apparent cellular compartmentalization of unoccupied estrogen receptor.

Homogenization of rat uterus at elevated temperatures results in an increased nuclear localization of unoccupied estrogen receptor. This is a nonlinear effect which is accounted for by an increased population of KCl-resistant nuclear binding sites at the elevated homogenization temperatures.

Glial fibrillary acidic protein in regenerating teleost spinal cord.

Immunohistological and ultrastructural studies were carried out on normal and regenerating spinal cord of the gymnotid Sternarchus albifrons, and in the brain and spinal cord of the goldfish Carassius auratus, to examine the distribution of glial fibrillary acidic protein (GFAP) in these tissues. Sections of normal goldfish brain and spinal cord exhibited positive staining for GFAP. In normal Sternarchus spinal cord, electron microscopy has revealed filament-filled astrocytic processes; however, such astrocytic profiles were more numerous in regenerated cord. Likewise, while normal Sternarchus spinal cord showed only a small amount of GFAP staining, regenerated cords were strongly positive for GFAP. Positive staining with anti-GFAP was observed along the entire length of the regenerated cord in Sternarchus, and was especially strong in the transition zone between regenerated and unregenerated cord. Both regeneration of neurites and production of new neuronal cell bodies occur readily in such regenerating Sternarchus spinal cords (Anderson MJ, Waxman SG: J Hirnforsch 24: 371, 1983). These results demonstrate that the presence of GFAP and reactive astrocytes in Sternarchus spinal cord does not prevent neuronal regeneration in this species.