Best management practices for minimizing nitrate leaching from container-grown nurseries.

Containerized plant production represents an extremely intensive agricultural practice; 40,000 to 300,000 containers may occupy one acre of surface area to which a large amount of chemical fertilizer is applied. Currently, recommended fertilizer application rates for the production of containerized nursery ornamental plants are in excess of plant requirements, and up to 50% of the applied fertilizers may run off or be leached from containers. Among the nutrients leached or allowed to runoff, nitrogen (N) is the most abundant and is of major concern as the source of ground and surface water pollution. In this report, current N fertilizer application rates for different container-grown nursery ornamental plants, the amount of nitrate leaching or runoff from containers, and the potential for nitrate contamination of ground and surface water are discussed. In contrast, our best N management practices include: (1) applying fertilizers based on plant species need; (2) improving potting medium's nutrient holding capacity using obscure mineral additives; (3) using controlled-release fertilizers; and (4) implementing zero runoff irrigation or fertigation delivery systems that significantly reduce nitrate leaching or runoff in containerized plant production and encourage dramatic changes in N management.

Cost comparison of oral, nasogastric, and intramuscular cimetidine drug delivery systems.

Under diagnosis-related group prospective payment, the role of the hospital pharmacy department is to develop and promote cost effective and rational drug therapy. This study, conducted in a simulated fashion, evaluated the cost effectiveness of various cimetidine drug delivery systems: oral, nasogastric, and intramuscular. The evaluation was also extended to compare time efficacy between different dosage forms for each route of administration with the exception of the intramuscular route. Each of four nurses and four pharmacy technicians conducted 10 trials for each system to detect a statistical significance difference in pharmacy preparation and nursing administration time with at least 80% statistical power. The results showed no statistically significant difference (P > 0.1) between the total oral administration time of a unit-dose tablet or liquid. A significant difference was detected among the pharmacy-prepared liquids, and unit-dose liquid administered nasogastrically (P < 0.01). The most cost-effective system is the orally administered unit-dose tablet and the most expensive system is the unit-dose liquid administered nasogastrically.

Impact of a pharmacist/physician cooperative target drug monitoring program on prophylactic antibiotic prescribing in obstetrics and gynecology.

The pharmacist's role in promoting rational, cost-effective use of drugs has been described in the literature. In a target drug monitoring program (TDMP), a single agent or group of agents becomes targeted for review. Antibiotics have been the primary focus of TDMP because of their therapeutic impact and cost considerations. The objectives of this project were to assess the prophylactic antibiotic prescribing habits of OB/GYN physicians and to evaluate the impact of a pharmacist/physician cooperative TDMP on prophylactic antibiotic prescribing and cost. The study was conducted in three phases: 1) a retrospective chart review of 150 patients, 2) an in-service education session, and 3) a concurrent chart review of 107 patients. Patient selection, timing of preoperative dose, and use of single dose prophylaxis were according to criteria in greater than 90% of patients both before and after the in-service training. Compliance with recommended regimens increased from 45 to 73% after the in-service training. A cost savings was not realized because the physicians wished to use a regimen with anti-anaerobic coverage (i.e., cefotetan) rather than a less expensive agent. However, the cost of selection of resistant organisms must be considered when discouraging the use of multiple broad spectrum agents. Active involvement of the medical staff in a pharmacy-based TDMP produces a cooperative atmosphere in which to educate clinicians and promote rational prescribing habits.

A cost comparison of intravenous cimetidine delivery systems.

Five systems for preparing and three systems for administering intravenous medications, using forty doses for each system were evaluated on the basis of product acquisition, ancillary supply and personnel costs. Time and motion studies were conducted on solutions (System 1: minibag prepared with a vial of cimetidine; System 2: minibag prepared with a premixed syringe; System 3: ready-to-use minibag; System 4: large volume cimetidine infusion; System 5: premixed syringe) prepared by pharmacy technicians and administered by nurses. The total cost for the large volume infusion system was 50% less than the other systems. Labor costs accounted for only a small portion of total cost and did not appear to influence the rank established by drug and supply costs. Based on the study results, using a large volume cimetidine infusion could result in a cost savings for both pharmacy and nursing departments and should be considered when pharmacy and nursing time is at a premium.

Improvement of long-term survival in extensive small-cell lung cancer.

The effect of adding the epipodophyllotoxin etoposide (VP-16-213) to a standard chemotherapy regimen for patients with extensive stage small-cell lung cancer was evaluated during a randomized trial. Chemotherapy consisted of vincristine, doxorubicin, and cyclophosphamide (VAC) alone or with etoposide (EVAC). Of 139 patients enrolled, 136 patients were eligible for study and all but five were evaluable for response. The overall objective response was 46% in the VAC group v 70% in the etoposide-treated group (P = .008) with complete response (CR) rates of 12% v 29%, respectively (P = .030). Although the time to the observation of disease progression was significantly longer in the group of patients receiving etoposide (9.6 v 6.5 months, P = .010), overall survival was similar; this was probably due to administration of other agents including etoposide at the time of VAC failure. However, there were noteworthy differences in long-term (greater than or equal to 2 year) survival. Whereas only four (6%) patients treated with VAC lived 2 years, 11 (16%) of the etoposide-treated group did so (P = .100). Two-year failure-free survival was attained in one (2%) of the VAC patients and eight (11%) of the patients treated with etoposide (P = .034). Long-term survivorship, heretofore usually reported in patients with limited stage disease after a variety of treatments, may be possible with this drug combination in the setting of extensive disease.

Use of staff pharmacists to reduce the inappropriate use of parenteral histamine-2 antagonist therapy.

This article describes the development and implementation of a target drug monitoring program using staff pharmacists as primary data collectors. This target drug program increased professional activities of staff pharmacists and showed how pharmacists could make an impact on drug therapy both financially and clinically. Parenteral histamine-2 antagonists were selected based upon amount of use and potential for inappropriate use and dosing. Criteria were developed in conjunction with the Pharmacy and Therapeutics Committee and medical staff. In phase I, pharmacists prospectively monitored all patients receiving parenteral cimetidine and ranitidine. Therapy was reviewed for justification of parenteral therapy (vs. oral), dosage adjustment in renal impairment, and monitoring of specific drug-drug interactions with cimetidine or ranitidine. During this phase, pharmacists collected data without intervening. Results from phase I and a program proposal for phase II were approved by the Pharmacy and Therapeutics Committee. Phase II consisted of the same monitoring procedures; however, when inconsistencies with the criteria were identified in one of the three categories, "chart education sheets" were placed in the chart. Results from phase I indicated a potential for cost savings. During phase II, 45% of the inappropriate parenteral therapy was changed to oral therapy, representing an annualized cost savings of $23,321 in this 540-bed hospital. The pharmacists were also successful in adjusting doses in renal impairment and monitoring potential drug interactions. The target drug program has proved to be an effective method of educating physicians and decreasing costs to the institution without the use of additional personnel.

VP-16-213 in combination chemotherapy with chest irradiation for small-cell lung cancer: a randomized trial of the Piedmont Oncology Association.

The role of etoposide epipodophyllotoxin (VP-16-213) in a combined modality treatment program incorporating local chest irradiation and combination chemotherapy with cyclophosphamide, Adriamycin (Adria Laboratories, Columbus, Ohio), and vincristine has been evaluated in a randomized trial of 165 patients with small-cell lung cancer. The overall response rate (complete response [CR] plus partial response [PR]) was significantly greater in the VP-16-213 arm (85% v 64%, P = .005) primarily as a consequence of improved response in patients with extensive disease (85% v 38%, P = .002 and 30% v 8% for CR only, P = .045). No differences in the response rates were observed in limited disease. The duration of response (months) was greater in the VP-16-213 arm (8.6 v 7.0 overall and 14.4 v 11.5 for CR) but not significantly so. Median survival times (months) were consistently greater in the group receiving VP-16-213 when analyzed according to extent of disease and response (10.6 v 9.5 overall; 15.0 v 13.6 for limited disease; 9.0 v 6.7 for extensive disease; 18.5 v 16.2 for CR overall; and 18.6 v 16.1 for CR in limited disease); the results were not statistically significant. The median survival of extensive disease patients attaining a CR was 15.3 months (range 3.2 to 34.3 + months) in the VP-16-213 arm and 7.4+ and 8.1+ months for the two patients with CR in the other group. Anemia and leukopenia occurred to a greater degree in the four-drug regimen, but no unusual or significant compounding toxicity (ie, neurotoxicity) was observed otherwise. Further investigation of this agent in combination chemotherapy programs for small-cell lung cancer appears to be warranted.

Improved tolerance of vincristine by glutamic acid. A preliminary report.

In a murine model system, glutamic acid has demonstrated host protective properties during administration of vincristine (VCR). Subsequently, glutamic acid has been evaluated in patients receiving VCR during adjuvant chemotherapy for stage II carcinoma of the breast. The cumulative VCR dosage and toxicities incurred in 16 patients receiving glutamic acid have been compared to those observed in 88 patients who previously received VCR without glutamic acid in the same chemotherapy program. All patients received VCR 1.0 mg/m2 weekly for 6 weeks with dose modification for neurotoxicity. Treatment patients received glutamic acid 1.5 grams p.o. daily in three divided doses during the induction course. Of the 16 treatment patients, 9 (56%) received 100% ideal dosage of VCR during induction therapy whereas only 24 of 88 (27%) comparison patients attained this dosage level (p less than .025). Gastrointestinal and hematologic toxicities were similar in both groups. These preliminary results suggest the need for an expanded trial of this agent during administration of VCR.

Justification and operation of a critical-care satellite pharmacy.

Development and implementation of a pharmacy satellite for critical-care areas in a 700-bed community hospital are described. Before the satellite, central-pharmacy personnel filled 70% of critical-care orders; the remainder of medications were floor stock. Large-volume admixtures were prepared by nurses on the critical-care units. In planning for a satellite pharmacy, turn-around time and lost drug charges were studied. Workload and staffing projections and potential expenses and revenues associated with the proposed satellite were presented to the hospital administration. The satellite was approved and serves 82 beds including the critical-care areas. It is open 16.5 hours/day and provides all i.v. admixtures. Drug distribution is computerized, and pharmacists participate on the CPR team and on physician rounds. Data collected four months after the satellite opened showed shorter turnaround time, decreased floor stock inventory, fewer lost charges, and additional revenue from preparation of i.v. admixtures. Ten months after the satellite was opened, a unit dose system was implemented. Through implementation of the satellite, shorter turnaround time for medication orders and i.v. admixtures, improved drug control, and greater control over billing were achieved.