Prescribing practice and policy for hypnotics: a model of pharmacy audit.

A problem of overprescribing of hypnotic medication ('sleeping tablets') was identified and quantified within a department of health care for older people in a district general hospital. Data on the volume of prescribing were obtained from computerized pharmacy records, and this information was supplemented by a retrospective survey of case notes of 100 patients. Sixty per cent of patients were prescribed a hypnotic at some stage during their hospital stay. Twelve per cent were prescribed a sleeping tablet on admission on an 'as required' basis but never took this medication, suggesting that such prescribing was becoming routine. As part of an ongoing pharmacy audit within the department, a policy was implemented to try to improve prescribing habits. Following this, hypnotic prescribing fell, with the average monthly number of sleeping tablets prescribed falling from 2392 to 734. A further survey of 100 case notes showed overall prescribing had fallen to 25%, although 2% were still prescribed a hypnotic on admission but never took it.

Brittle diabetes in the elderly.

The term 'brittle diabetes' is now commonly used to describe patients whose lives are disrupted by major variations in metabolic control, whatever their cause. Most reports have focused on the occurrence of such problems in young people, but little attention has been paid to brittle diabetes occurring in elderly patients. We describe six such cases and comment on differences in aetiology and management when compared with younger patients. Although less rigorous objectives for tight blood glucose control as compared with younger people, and more ready acceptance of insulin administration being supervised by another person, such as a district nurse, may reduce swings in blood glucose control in the elderly, accidental mismanagement by the patient as a result of incipient or established senile dementia may be an important factor in generating instability, as was evident in three cases. In one instance, the onset of unstable diabetic control was the earliest clinical feature of mental deterioration.

Fatal rhabdomyolysis associated with hyperosmolar diabetic decompensation.

A patient is described who developed fatal acute rhabdomyolysis in association with hyperosmolar diabetic decompensation. The delay in making the diagnosis of acute rhabdomyolysis may have contributed to the outcome as the use of dantrolene may be of benefit in such patients.

Hospital visiting hours: time for improvement.

In a survey of hospital visiting hours in general medical and surgical wards throughout the United Kingdom a pattern of visiting emerged showing that many hospitals still have very restricted visiting. A quarter of the 404 hospitals that responded permitted visiting for an average of two hours a day or less. In contrast, just over a third of hospitals allowed visiting for more than five hours a day. There was no relation between visiting times and type of hospital, but a striking regional variation in visiting hours was found, with more liberal visiting in south east England and restricted visiting in northern England, Scotland, Wales, and Northern Ireland.

Abnormal cerebrovascular carbon dioxide reactivity in people with diabetes.

Cerebral blood flow was measured both under conditions of normocapnia and hypercapnia in 22 diabetic patients and 20 normal control subjects, using either the intravenous 133Xe method or the closely comparable 133Xe inhalation method. While 19 out of 20 control subjects responded appropriately to hypercapnia with an increase in flow, eight of the diabetic patients failed to respond normally, this difference being significant (p = 0.03). Those manifesting an abnormal response included young, insulin-dependent patients with a short duration of diabetes and no clinical evidence of complications.

Diabetic ketoacidosis.

Diabetic ketoacidosis remains a threat to the survival of an insulin-dependent diabetic. Despite improvements in the management of the condition, mortality is still substantial. In this review, we will discuss approaches to the management of the condition and ways in which incidence, as well as case fatality, might be reduced.

Levodopa withdrawal syndrome identical to neuroleptic malignant syndrome.

A 60 year old woman with idiopathic Parkinson's disease had been prescribed thioridazine for schizophrenia. Five months after this was stopped, Sinemet also considered of dubious therapeutic value, was withdrawn. One week later she developed features of the neuroleptic malignant syndrome (NMS) accompanied by myoglobinuric renal failure. Post-mortem examination confirmed Lewy body degeneration in the substantia nigra. It is proposed that NMS may be caused by levodopa withdrawal in Parkinson's disease, and that it is withdrawal of dopaminergic drive that causes the syndrome.

The effect of beta-adrenergic receptor blocking drugs on cerebral blood flow.

1 Cerebral blood flow (CBF) was measured by the 133xenon inhalation method in 33 newly-diagnosed hypertensive patients prior to commencing therapy. 2 Blood pressure was treated by using a varying sequence of four different drugs, namely labetalol, metoprolol, oxprenolol and sotalol, each of which is a beta-adrenergic receptor blocking agent, but with differing additional properties. 3 CBF measurements were repeated when blood pressure was controlled. No significant change in CBF was found with any of the four drugs, in contrast to the fall which has been reported when drugs of this type are administered acutely.

Comparison of effects on cerebral blood flow of rapid reduction in systemic arterial pressure by diazoxide and labetalol in hypertensive patients: preliminary findings.

1 Diazoxide 300 mg and labetalol 150 mg were each injected intravenously on separate occasions into five patients with essentail hypertension. The reduction in BP caused by labetalol was slightly greater than that produced by diazoxide. 2 In contrast the reduction in cerebral blood flow (CBF) by labetalol was not statistically significant, whereas diazoxide gave a greater and statistically significant reduction in CBF. 3 These observations suggest that labetalol may have an advantage over diazoxide for the rapid reduction in BP.

Comparison of effects on cerebral blood flow of rapid reduction in systemic arterial pressure by diazoxide and labetalol in hypertensive patients: preliminary findings.

1 Diazoxide 300 mg and labetalol 150 mg were each injected intravenously on separate occasions into five patients with essentail hypertension. The reduction in BP caused by labetalol was slightly greater than that produced by diazoxide. 2 In contrast the reduction in cerebral blood flow (CBF) by labetalol was not statistically significant, whereas diazoxide gave a greater and statistically significant reduction in CBF. 3 These observations suggest that labetalol may have an advantage over diazoxide for the rapid reduction in BP.

Obstruction of right ventricular outflow tract by solitary ovarian metastasis.

We report a case in whom there was right ventricular outflow tract obstruction by a solitary metastatic deposit from an ovarian primary. The patient presented with signs of right ventricular overload and the outflow tract obstruction was recognised at cardiac catheterisation, but the final diagnosis was only revealed at necropsy.

Effect of oxprenolol on stage-fright in musicians.

The effect of 40 mg oxprenolol on stage-fright was assessed in 24 musicians in a double-blind crossover trial. Musical performance judged by two professional assessors was found to improve. Greatest improvement was seen on the first performance and in those most affected by nervousness.