Failure of amoxicillin to produce false-positive urine screens for cocaine metabolite.

Amoxicillin has been causally linked in the lay and medical literature to false-positive urine drug screens for cocaine metabolites. An exhaustive search of the peer-reviewed medical literature revealed no data to support this link. We hypothesized that amoxicillin does not cause false-positive urine drug screens for cocaine metabolites. To test this hypothesis, we examined the urine of 33 subjects administered a course of amoxicillin, subjecting the specimens to four common urine screening immunoassays. Thirty-one specimens were negative for the cocaine metabolite, benzoylecgonine (BE), by all four screening methods; two were positive for BE by all four screening methods. Both positive specimens were confirmed by gas chromatography-mass spectrometry (GC-MS) for the presence of BE at > 150 ng/mL. Three specimens that screened negative, but produced absorbance values that were intermediate between negative and positive controls, were submitted for GC-MS analysis; BE was detected in all three specimens at concentrations of 54, 94, and 119 ng/mL. Twenty-eight specimens produced screening results indistinguishable from negative controls. Within the limitations of the study design, we conclude that amoxicillin is unlikely to produce false-positive urine screens for cocaine metabolites.

Rational use of sublingual opioids in palliative medicine.

The sublingual administration of opioid analgesics has been a mainstay in the pain management of homebound dying hospice patients who are no longer able to swallow. It is also a potentially useful route of administration in other situations in which the oral route is not available and other routes are impractical or inappropriate. Potential advantages of the sublingual route include rapid analgesic onset and avoidance of hepatic first-pass metabolism. Pharmacokinetic and pharmacodynamic studies have yielded widely disparate data on sublingual morphine. Other opioids have been less studied. Available data suggests limited sublingual availability of hydrophilic opioids (e.g., morphine, oxycodone, and hydromorphone) and superior absorption of the lipophilic opioids (e.g., methadone and the fentanils). Buprenorphine, a potent, lipophilic, partial mu-opioid receptor agonist, appears promising but awaits further study.

Structures, biogenetic relationships, and cytotoxicity of pimarane-derived diterpenes from Petalostigma pubescens.

Extraction of Petalostigma pubescens heartwood followed by chromatographic purifications and crystallizations afforded five tricyclic diterpenes: 5,9-syn-rosanes petalostigmones A and B (1 and 2), the erythroxylane petalostigmone C (3), the norditerpene lactone pubescenone (4), and the known ent-cleistanthane diterpene (-)-sonderianol (5). The structures and relative stereochemistry were elucidated by means of spectroscopic methods, chemical correlations, and, in the cases of 1 and 4, by X-ray crystallographic analyses. The new isolates 1-4 are assumed to belong to the same absolute configurational family (9alphaCH3) of ent-pimarane-derived diterpenes as the known co-occurring (-)-5 (10alphaCH3). Biogenetic schemes originating from a common ent-copalyl diphosphate intermediate are presented to rationalize the structures of these natural products. A novel ring contraction-ring expansion mechanism is suggested to account for the 7-membered B ring of pubescenone. Compounds 1-5 were evaluated for their cytotoxicity; sonderianol (5) showed the highest activity against mouse leukemia cell lines L1210, P388 and mouse liver cancer cells HEPA1c1c7.

Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis.

INTRODUCTION: Cardiopulmonary resuscitation is thought to be a low-yield intervention in cancer patients. In patients with metastatic disease the procedure is thought to be futile. Comprehensive data on survival to discharge in subsets of cancer patients undergoing in-hospital cardiopulmonary resuscitation, however, are lacking. OBJECTIVE: To determine the rate of survival to discharge for adult cancer patients undergoing in-hospital cardiopulmonary resuscitation. METHOD: A systematic search of MEDLINE and our primary sources' references was performed for studies involving in-hospital cardiac arrest, in clearly defined subsets of adult cancer patients, with outcomes that included survival to hospital discharge. RESULTS: Forty-two studies from 1966-2005, comprising 1707 patients met our minimal inclusion criteria. Overall survival to discharge was 6.2%. Survival in patients with localized disease was 9.5%, and in patients with metastatic disease was 5.6%. Analysis of data reported since 1990 reveals a narrowing of the survival gap, with survival rates in patients with localised disease of 9.1%, and in patients with metastatic disease of 7.8%. Survival in patients resuscitated on the general medical/surgical wards was 10.1%, while survival in patients resuscitated on intensive care units (ICUs) was 2.2%. CONCLUSIONS: Overall survival of CPR to hospital discharge in cancer patients compares favorably to survival rates in unselected inpatients. Improved outcomes in recent years in patients with metastatic disease are likely to reflect more selective use of CPR in cancer patients, with the sickest patients deselected.

Radiopharmaceuticals for the palliation of painful bone metastases.

Metastatic bone pain is prevalent in advanced cancer, and, despite a plethora of available therapies, effective palliation remains a clinical challenge. Bone-seeking radiopharmaceuticals are an often-overlooked but valuable analgesic option for select patients. These agents work by binding to hydroxyapatite at the tumor-bone interface of osteoblastic lesions, delivering therapeutic doses of radiation to closely circumscribed tissue regions. They have been shown to reduce pain and improve quality of life. Their safety, simplicity, convenience of administration, and cost-effectiveness make them suitable for hospice and palliative care settings.

Amenorrhea: common causes and evaluation.

Amenorrhea, either primary (before menarche) or secondary (after menarche), is a frequently encountered clinical condition in the primary care office. A patient-oriented approach, utilizing focused diagnostic studies, provides an etiology in the majority of cases.

The pervalence of caecal threadworms (Trichostrongylus tenuis) in red grouse (Lagopus lagopus scoticus).

Ninety percent of wild red grouse examined carried threadworms in their intenstinal caeca. Old birds had 30 times as many worms as young birds. Some infections were as high as 30,000 worms. The occurrence of worms in old grouse conformed to the negative binomial distribution.

Morphine hyperalgesia: a case report.

We report a case of a patient with metastatic testicular cancer and intractable pain refractory to massive doses of oral, intravenous, and intrathecal (IT) opioids supported by analgesic adjuvants. During our efforts to control his pain, the patient exhibited opioid-induced hyperalgesia, an uncommon but important phenomenon seen with high-dose opioid therapy. With appropriate opioid adjustment--in this case reduction of intrathecal morphine dosage by a factor of 100--the condition rapidly resolved and the patient became pain-free and remained so until his death six weeks later. The keys to identifying this uncommon, but treatable, opioid side effect are recognizing it as a possibility when aggressive efforts to control pain with high doses of opioids, especially when administered neuraxially, are met with increasing pain.

The cost of breathing: an economic analysis of the patient cost of home oxygen therapy.

The oxygen concentrator is a popular means of delivering supplemental oxygen to the home hospice patient. The technology is notable for its reliability, convenience, and ease of use. It is the most cost effective of the various oxygen delivery systems from the institutional standpoint. Cost effectiveness from the patient standpoint has not previously been reported. We present a brief analysis of the cost of operating such a device from the perspective of the patient and suggest possible ways of addressing this cost.

Ideas and innovations: inclusion of pharmacists in chronic pain management services in a primary care practice.

Nonmalignant chronic pain management involves an ongoing process of complex evaluations including proper patient selection, proper prescribing, and careful monitoring. In the Pain Management Refill Clinic, patients are stabilized on an opioid regimen by either a pain specialist or a primary care physician (PCP). The PCP assumes long-term prescription of the regimen and proper follow-up. The inclusion of pharmacists in the management of patients suffering from chronic pain has allowed the physicians to improve opioid prescribing, documentation, and monitoring in accordance with chronic nonmalignant pain guidelines.

Ethyl glucuronide, ethyl sulfate, and ethanol in urine after intensive exposure to high ethanol content mouthwash.

To determine the degree of ethanol absorption and the resultant formation and urinary excretion of its conjugated metabolites following intensive use of high ethanol content mouthwash, 10 subjects gargled with Listerine(®) antiseptic 4 times daily for 3» days. First morning void urine specimens were collected on each of the four study days and post-gargle specimens were collected at 2, 4, and 6 h after the final gargle of the study. Urine ethanol, ethyl glucuronide (EtG), ethyl sulfate (EtS), and creatinine were measured. Ethanol was below the positive threshold of 20 mg/dL in all of the urine specimens. EtG was undetectable in all pre-study urine specimens, but two pre-study specimens had detectable EtS (6 and 82 ng/mL; 16 and 83 µg/g creatinine). Only one specimen contained detectable EtG (173 ng/mL; 117 µg/g creatinine). EtS was detected in the urine of seven study subjects, but was not detected in the single specimen that had detectable EtG. The maximum EtS concentrations were 104 ng/mL and 112 µg/g creatinine (in different subjects). Three subjects produced a total of eight (non-baseline) urinary EtS concentrations above 50 ng/mL or 50 µg/g creatinine and three EtS concentrations exceeding 100 ng/mL or 100 µg/g creatinine. In patients being monitored for ethanol use by urinary EtG and EtS concentrations, currently accepted EtG and EtS cutoffs of 500 ng/mL are adequate to distinguish between ethanol consumption and four times daily use of high ethanol content mouthwash.

Ethyl glucuronide, ethyl sulfate, and ethanol in urine after sustained exposure to an ethanol-based hand sanitizer.

To assess the degree of ethanol absorption and subsequent formation of urinary ethyl glucuronide (EtG) and ethyl sulfate (EtS) following sustained application of hand sanitizer, 11 volunteers cleansed their hands with Purell(™) hand sanitizer (62% ethanol) every 5 min for 10 h on three consecutive days. Urine specimens were obtained at the beginning and end of each day of the study, and on the morning of the fourth day. Urinary creatinine, ethanol, EtG, and EtS concentrations were measured. EtG was undetectable in all pre-study urine specimens, but two pre-study specimens had detectable EtS (73 and 37 ng/mL). None of the pre-study specimens had detectable ethanol. The maximum EtG and EtS concentrations over the course of the study were 2001 and 84 ng/mL, respectively, and nearly all EtG- and EtS-positive urine specimens were collected at the conclusion of the individual study days. Only two specimens had detectable EtG at the beginning of any study day (96 and 139 ng/mL), and only one specimen had detectable EtS at the beginning of a study day (64 ng/mL), in addition to the two with detectable EtS prior to the study. Creatinine-adjusted maximum EtG and EtS concentrations were 1998 and 94 µg/g creatinine, respectively. In patients being monitored for ethanol use by urinary EtG concentrations, currently accepted EtG cutoffs do not distinguish between ethanol consumption and incidental exposures, particularly when urine specimens are obtained shortly after sustained use of ethanolcontaining hand sanitizer. Our data suggest that EtS may be an important complementary biomarker in distinguishing ethanol consumption from dermal exposure.