An interview project with native American people: a community-based study to identify actionable steps to reduce health disparities.

OBJECTIVES: The primary objective of this study was to work with tribal communities to define and develop their own healthcare services and strategies for positive change regarding injection drug use, human immunodeficiency virus (HIV), and hepatitis C virus (HCV) infection. The secondary objective of this study was to incorporate community capacity building strategies to develop and sustain programming and resources to optimize tribal communities' responsiveness to reduce health disparities. STUDY DESIGN: Semi-structured qualitative interviews. METHODS: Interviews were guided by community-based participatory research (CBPR) principles to create programs, projects, and policy recommendations meaningful to American Indian and Alaska Native (AI/AN) people. RESULTS: The study generated a formative understanding of the context of AI/AN people who inject drugs (PWID) in three distinct AI/AN communities as well as developed local capacity for future programming, projects, and policy. CONCLUSIONS: This study confirms CBPR methods should be part of an iterative cycle to inform policy and programs. CBPR has helped strengthen local research capacity and has formed ongoing relationships between study investigators, local liaisons, and the community that will be essential for next phases of program design and policy implementation. This cycle of CBPR could be replicated in other tribal communities to bring awareness of the opioid epidemic and its effects and to prioritize local indigenous and community-led responses.

Acupuncture in Premenopausal Women With Hypoactive Sexual Desire Disorder: A Prospective Cohort Pilot Study.

INTRODUCTION: Female sexual dysfunction affects up to 43% of women in the United States and hypoactive sexual desire disorder (HSDD) is the most common type; however, we lack treatment options showing improvement for this condition. AIMS: To investigate whether acupuncture therapy could improve HSDD. METHODS: Premenopausal women with a primary diagnosis of HSDD were included in a single-arm prospective pilot study that was approved by the institutional review board. After providing informed consent, subjects completed validated questionnaires. Participants underwent 25-minute twice-weekly acupuncture sessions for 5 weeks with one certified acupuncturist. Questionnaires were completed again 6 weeks after onset of treatment. MAIN OUTCOME MEASURES: Based on a statistically significant change in the desire domain of the Female Sexual Function Index from 2.0 (at baseline) to 2.4 (after intervention with a specialist) in our population of patients diagnosed with HSDD, a sample of 13 was determined, with 90% power and α 0.05. RESULTS: Fifteen women were enrolled and 13 completed the study. Mean age was 36.9 ± 11.4 years. Most were white (n = 9, 60%), heterosexual (n = 15, 100%), and non-smokers (n = 14, 93%). Most were sexually active more than four times per month (n = 8, 53%) and none had a history of sexual abuse (n = 15, 100%). Participants received a mean acupuncture needle application of 17 ± 2 at each session. Sexual function improved after intervention, particularly desire (2.1 ± 0.6 to 3.3 ± 1.2, P < .0001), arousal (P < .0001), lubrication (P = .03), and orgasm (P = .005). CONCLUSION: In this cohort of premenopausal women with HSDD, 5 weeks of acupuncture therapy was associated with significant improvements in sexual function, particularly desire. This supports a role for acupuncture as a therapeutic option for women with low desire.

Identification of endogenous gibberellins in strawberry, including the novel gibberellins GA123, GA124 and GA125.

Extracts of carboxylic acids from immature fruits of strawberry (Fragaria x ananassa Duch. cv. Elsanta) were analysed for gibberellins by combined gas chromatography-mass spectrometry. The following previously characterised gibberellins were identified by comparison of their mass spectra and Kovats retention indices (KRIs) with those of standards or published data: GA1, GA3, GA5, GA8, GA12, GA17, GA19, GA20, GA29, GA44, GA48, GA49, GA53, GA77, GA97, GA111 and GA112. Evidence for endogenous 1-epi GA61 (GA119) and 11alpha-OH-GA12 was also obtained. In addition, a number of putative GAs were detected. Of these, three were shown to be 12alpha-hydroxy-GA53, 12alpha-hydroxy-GA44, and 12alpha-hydroxy-GA19 by comparison with authentic compounds prepared by rational synthesis, and have been allocated the descriptors GA123, GA124 and GA125, respectively.

Clinical and molecular epidemiology of vancomycin-resistant Enterococcus faecium during its emergence in a city in southern Texas.

During a 19-month period from April 1993 to October 1994, 41 isolates of vancomycin-resistant Enterococcus faecium (VREF) were detected in seven different hospitals in a city in southern Texas. A case-control study to determine the risk factors for acquisition was done in the hospital in which the majority of isolates were detected. Pulsed-field gel electrophoresis (PFGE) of whole-cell DNA was used to determine strain identity. Thirty-five (85%) of the 41 VREF isolates were of the vanB phenotype. Of these, 32 (91%) of 35 were the same strain by PFGE typing. The same vanB strain was documented in five different hospitals in the city. In contrast, 4 (67%) of 6 of the vanA phenotype VREF isolates were distinct strains by PFGE typing. Significant risk factors for colonization or infection with VREF were prior exposure to antibiotics (P = .04), the previous use of third-generation cephalosporins (P = .03), and the previous use of parenteral vancomycin (P = .002). Infection-control and antibiotic-utilization measures were implemented to control cross-transmission and selection of VREF isolates. During the emergence of VREF in our city, clonal dissemination of a single strain of vanB VREF among six hospitals was documented. Limited cross-transmission of vanA phenotype VREF isolates occurred, but most vanA VREF isolates were distinct strains selected in individual hospital environments.

Methicillin-resistant Staphylococcus aureus as a community organism.

An increase in methicillin-resistant Staphylococcus aureus (MRSA) infections prompted a study of MRSA during a 21-month period in a 600-bed university hospital in southern Texas. MRSA cases were classified as community, nosocomial, or transfer cases. A case-control study of risk factors for community MRSA compared with community methicillin-susceptible S. aureus (MSSA) was performed. Pulsed field gel electrophoresis (PFGE) of whole cell DNA typing was used as a marker of strain identity for 31 consecutive isolates collected during the last 8 months of the study. During the 21 months there were 170 patients with MRSA infection or colonization, an incidence of 0.2 per 1,000 patient-days. Ninety-nine (58%) of 170 isolates were from community cases; the community to nosocomial case ratio was 2:1. No significant risk factors differentiated patients with community MRSA compared with community MSSA. Most community MRSA isolates studied (15 [68%] of 22) had distinct PFGE patterns, as did many nosocomial MRSA isolates (4 [44%] of 9). MRSA isolates were commonly present on admission to the hospital, and multiple MRSA strains were demonstrated among both community and hospital isolates.

The clinical and molecular epidemiology of bacteremias at a university hospital caused by pneumococci not susceptible to penicillin.

To determine the epidemiology of bacteremias due to pneumococci not susceptible to penicillin (PNSP) at a university hospital, active microbiologic surveillance of bacteremias due to PNSP was done for 28 months. Controls were bacteremias caused by penicillin-susceptible pneumococci. Antimicrobial susceptibilities for alternative antibiotics were determined. Pulsed-field gel electrophoresis (PFGE) and serotyping were used as markers of strain identity. Of 113 pneumococcal isolates, 14 (13%) were intermediate or resistant to penicillin (MIC > or = 0.1 microgram/mL). Twelve PNSP were resistant to other drugs: chloramphenicol (5), tetracycline (6), trimethoprim-sulfamethoxazole (5), cefotaxime (1), and erythromycin (1). Independently significant risk factors associated with PNSP bacteremia were sepsis and prior treatment with beta-lactam antibiotics. PFGE revealed 10 distinguishable patterns among 12 isolates available for typing. In general, PFGE typing correlated with serotyping. It also distinguished some isolates of the same serotype. PFGE typing and serotyping suggest that the frequency of PNSP in the San Antonio, Texas, area is not due to dissemination of a single clonal strain.

Early, routine paralysis for intracranial pressure control in severe head injury: is it necessary?

OBJECTIVE: To investigate the efficacy of early, routine use of neuromuscular blocking agents for intracranial pressure management in patients with severe head injury. DESIGN: Retrospective review of data from the Traumatic Coma Data Bank. The Traumatic Coma Data Bank was a collaborative project of the National Institute of Neurological Disorders and Stroke that involved four Level I trauma centers. The Traumatic Coma Data Bank prospectively collected data on 1,030 severe head-injured patients (Glasgow Coma Score of < or = 8) between 1984 and 1987. SETTING: Four Level I trauma centers coordinated by the National Institute of Neurological Disorders and Stroke. PATIENTS: A total of 514 Traumatic Coma Data Bank patients who met study inclusion criteria were divided into two groups: group 1 consisted of 239 patients who were pharmacologically paralyzed starting within the first intensive care unit (ICU) shift or < or = 6 hrs into the second shift and lasting for at least 12 hrs. Group 2 contained the remaining 275 patients who did not fulfill these criteria. MEASUREMENTS AND MAIN RESULTS: We analyzed the acute care course of these patients from the time of injury through admission, resuscitation, and ICU stay, as well as their rehabilitation follow-up results for < or = 1 yr. These two groups did not differ significantly regarding admission intracranial computed tomography diagnosis, admission Glasgow motor score, percentage of monitored time that intracranial pressure was > or = 20 mm Hg, or frequency of initial intracranial pressure > or = 20 mm Hg. In group 2, more patients were aged > 40 yrs (24% vs. 15% in group 1) or had admission hypotension (33% in group 2 vs. 25% in group 1). Multivariate regression analysis showed that ICU stay was significantly longer in group 1 (mean 7.76 days) than group 2 (mean 4.84 days; p < .001). The occurrence of pneumonia was significantly higher in group 1 (29% vs. 15%, p < .001). There was a tendency toward a higher occurrence of sepsis in group 1, but this difference did not reach statistical significance (11% vs. 7%, p = .08). The final Glasgow Outcome Scale scores for the two groups were not significantly different in those survivors with good and moderate outcomes. Although there were more deaths in group 2 (39% vs. 24%, p < .001), there were more vegetative or severely disabled survivors in group 1 (8% vs. 4% and 21% vs. 13%, respectively). CONCLUSIONS: Our findings suggest that early, routine, long-term use of neuromuscular blocking agents in patients with severe head injuries to manage intracranial pressure does not improve overall outcome and may actually be detrimental because of the prolongation of their ICU stay and the increased frequency of extracranial complications associated with pharmacologic paralysis. We suggest that routine early management of the head-injured patient in the ICU should be accomplished using sedation alone and that neuromuscular blockade should be generally reserved for patients with intracranial hypertension who require escalation of treatment intensity.

Pharmacoeconomic issues of sedation, analgesia, and neuromuscular blockade in critical care.

Neuromuscular blocking agents (NMBAs) are commonly prescribed as adjunct therapy for many critically ill patients. Controversy exists regarding the appropriate long-term use of these agents, particularly since there are severe potential clinical consequences. The expanded use of NMBAs has had a significant effect on the cost of ICU care. One should determine whether or not NMBAs are being used as adjunct therapy, or as a replacement for optimal sedation and/or analgesia. This article reviews some of the indicative economic issues surrounding the use of sedatives, analgesics, and NMBAs in the critical care arena. Understanding the pharmacokinetic and pharmacodynamic differences of these agents can aid in drug selection and route of administration. Appropriate drug selection can influence the pharmacoeconomics of these agents in the ICU.

Medication adherence patterns in chronic obstructive pulmonary disease.

While medical treatment of COPD has advanced, the failure to adhere to regimens for medication poses a significant barrier to effective management. Furthermore, no data are available regarding adherence for patients within the United States. Data from this investigation indicate that 78 outpatients from a medical center in the southeastern region of the United States were prescribed an average of 6.26 medications with both various dosing schedules and different modes of administration. Adherence was poor, with 42 patients (54 percent) underutilizing medications, 39 patients (50 percent) overutilizing medications during periods of respiratory distress, and 24 patients (31 percent) employing ineffective inhaler dosing techniques. Prescription patterns and adherence were not associated with demographic variables; however, adherence was related to classes of medication and situational variables.

Analysis of workload and staffing requirements for a critical-care satellite pharmacy.

A study to determine the workload and the staffing requirements of a proposed critical-care satellite pharmacy is reported. Data for all patients admitted to the adult surgical intensive-care units (SICUs) of an acute-care teaching hospital were recorded for 30 days. Both clinical and distributive data were collected, such as the number and times of patient admissions to the SICUs, the times medication orders were written and their nature, the number and types of drugs administered per patient per day, the number of medication profile reviews per day, and the number and types of interventions. Productivity standards were determined for specific clinical and distributive tasks and used to project the staffing requirements of the new satellite pharmacy. It was determined that proposed changes in distributive services, including expansion of the i.v. admixture program and implementation of a syringe-pump infusion system, would increase the pharmacist and technician staffing requirements by 1.91 and 6.77 hours per day, respectively. Expansion of clinical services, such as pharmacokinetic monitoring, would increase the pharmacist staffing requirements by 8.68 hours per day. It was estimated that the SICU satellite pharmacy could save the hospital more than $200,000 per year. Hospital administration approved a request to increase staffing by 3 full-time-equivalent (FTE) pharmacists and 1.6 FTE technicians. Workload analyses and projections of staffing requirements must incorporate measurements for clinical as well as distributive services.

Audit of serum drug concentration analysis for patients in the surgical intensive care unit.

Serum drug concentration measurements can help the practitioner attain maximal therapeutic efficacy and minimal undesirable effects of certain medications. It is necessary, however, to obtain serum samples appropriately to assure that the result will provide useful information. In preparation for expansion of clinical pharmacy services to the surgical ICU, a study was performed to a) identify the drugs for which serum samples were requested and b) assess whether the results of the serum samples were being used appropriately to adjust doses. Currently, the pharmacy pharmacokinetics service routinely analyzes serum concentrations for antimicrobial agents, theophylline, and other drugs as requested. By the end of this year, we expect further expansion to include phenytoin, pentobarbital, phenobarbital, procainamide/NAPA, lidocaine, and digoxin.

Drug utilization review: dipyridamole plus aspirin antiplatelet therapy.

To assess whether dipyridamole was being used appropriately in providing antiplatelet therapy at the San Diego VAMC, a drug utilization review was conducted. Concomitant aspirin therapy was required for dipyridamole to be considered effective in the disease states reviewed. Seventy-three patients on antiplatelet therapy were evaluated, using dosing criteria established through a literature review. Our data indicated tht based on the criteria, only 11% of patients received dipyridamole in appropriate doses; it was underdosed in 89% of patients, and in 19% of patients, it was used when not indicated. In addition, 19% of patients did not receive concomitant aspirin therapy. Results suggest hat dipyridamole is not used optimally in providing antiplatelet therapy to patients in this institution.

Effect of esterification and side-chain alkylation on alteration of translocation characteristics of methamidophos.

1. The phloem mobility and systemic activity of methamidophos (I); propanedioic acid 1-phosphoramidothionic acid O,S-dimethyl ester, 2-methyl, 3-0monoethyl ester (II); propanedioic acid, 1-phosphoramidothionic acid O,S-dimethyl ester, 2,2-dimethyl, 3-monoethyl ester (III); and butenoic acid, 1-monoethyl ester, 2,3,-E & Z, 3-phosphoramidothionic acid O,S-dimethyl ester (IV) were investigated in soybeans (Glycine max L.) with a bioassay using cabbage looper (Tricoplusia ni Hüber) larvae to determine the impact of side-chain alkylation on the translocation of propanedioic acid 1-phosphoramidothionic acid O,S-dimethyl ester 3-monoethyl ester (V). 2. The ethyl ester of ethanedioic acid, 1-phosphoramidothionic acid OS,-dimethyl ester 2-monoethyl ester (VI) was compared with a bukly ester analogue, the 2-(methyl)butyl ester (VII). 3. Monoethylation of the alpha-carbon of II resulted in enhanced insecticidal and systemic activity, which was interpreted as a steric hindrance to fatty acid oxidation of the propanedioic moiety of III, but not of II and V. 4. Compound IV was an effective insecticide by topical and feeding response, but was not a systemic. 5. A large bulky ester (VII) blocked deesterification and the systemic insecticidal response was lost when compared with VI. 6. This study suggests that the utilization of the malonate semialdehyde-pathway enzymes found in plants but not in insects may be fruitful in the molecular design of new insecticides.

Long-term d-amphetamine in rats: lack of change in post-synaptic dopamine receptor sensitivity.

Treatment of rats with d-amphetamine (5 mg/kg) once daily for 25 days did not change locomotor responses, on day 7 of withdrawal, to dopamine (DA) or d-amphetamine into the nucleus accumbens. Nor was there a change in 3H-spiperone binding of caudate nucleus membranes. There was no effect of treatment on the locomotor response of rats to 1.0, 1.5 or 2.0 mg/kg d-amphetamine IP. However, d-amphetamine-treated rats were significantly less sensitive to 0.5 mg d-amphetamine. Although 1, 2 or 3 mg/kg apomorphine produced in same degree of stereotypy in both treatment groups, there was a significant difference in the response of the two groups to 0.5 mg apomorphine, d-amphetamine-treated animals being less sensitive than vehicle-treated animals. No change was found in brain DA levels with or without synthesis inhibition. The present data do not support the hypothesis that chronic treatment of rats with d-amphetamine can produce supersensitive post-synaptic DA receptors.