Perioperative latex allergy.

The prevalence of latex allergy varies greatly depending on the population studied and the methods used to detect sensitization. Subjects considered to be at high risk for latex allergy are rubber industry workers, children with spina bifida and urological abnormalities, children undergoing multiple surgical procedures and with urinary catheterization, health care workers and people with food allergy (latex fruit syndrome). In this paper we report a review of latex proteins, the symptoms of latex allergy, diagnosis and management in subjects with latex allergy.

Successful engraftment of allogeneic PBSC after conditioning with busulfan alone.

A 44-year-old woman with AML, while receiving a conditioning treatment with BU-CY for an allogeneic sibling transplant, developed septic shock with pulmonary embolism and heart failure. Conditioning was stopped at the end of the busulfan course and cyclophosphamide omitted. After antibiotics, dopamine and steroids the patient was allografted, using the donor's G-CSF-primed PBSC. She recovered her peripheral blood counts promptly and developed an acute GVHD grade II that responded to steroids. The DNA microsatellite analysis showed full donor engraftment up to a year from transplantation. This case suggests that the use of PBSC may facilitate engraftment in the absence of an effective immunosuppression during conditioning.

High incidence of chronic GVHD after primary allogeneic peripheral blood stem cell transplantation in patients with hematologic malignancies.

To assess feasibility and potential advantages of PBSC allograft, we transplanted nine patients (age 20-47 years) with advanced or poor-risk hematologic malignancies. These included eight HLA-identical sibling transplants and one partially matched. Cells were collected from donors by apheresis after rh-G-CSF 10-16 micrograms/kg/day for 4-5 days, and stored at 4 degrees C until infusion. Patients were conditioned with busulfan 16 mg/kg and cyclophosphamide 200 mg/kg, and received GVHD prophylaxis with CSA-MTX. The graft consisted of PBSC alone, with a median of 101.2 (range 28-254.2) x 10(4)/kg CFU-GM, 6.84 (range 4.57-15.9) x 10(6)/kg CD34+ cells and 2.5 (range 1.2-6) x 10(8)/kg CD3+ cells. An ANC > 0.5 x 10(9)/1 occurred on (median) day 13 range 11-17), and a platelet count > 50 x 10(9)/l on (median) day 15 (range 12-29) post graft. One patient died of ARDS on day 13, the others are alive 96-485 (median 245) days from the graft. Two patients have relapsed, one of them with isolated CNS involvement. Acute GVHD (grade I-II) occurred in three patients and severe chronic GVHD in six patients, with no relationship to CSA withdrawal. This unexpected incidence of chronic GVHD might be linked to the high number of CD3+ cells in the graft, contributing to a favourable GVL effect.

PBSC mobilization, collection and positive selection in patients with chronic lymphocytic leukemia.

We report the results of PBSC mobilization and immune selection in 17 patients with advanced chronic lymphocytic leukemia (CLL) enrolled in a multicenter Italian study of autologous transplantation with peripheral CD34+ selected cells. Mobilization was achieved by cyclophosphamide (CY) 4 g/m2 + G-CSF 5 microg/kg. CD34+ cells were positively selected by means of avidin-biotin immunoaffinity columns (Ceprate SC) or immunomagnetic beads (Isolex 300i) systems. Evaluation of minimal residual disease was performed by PCR analysis of the IgH gene rearrangment on the apheresis product before and after selection. Our results showed that after CY a median of 3.6 x 10(6)/kg (0.5-12.8) CD34+ cells were collected with a median of two aphereses in 14 out of 17 patients; three failed to mobilize a number of CD34+ cells adequate for subsequent manipulation. We found that in CR patients CD34+ cell yield per apheresis was significantly higher than in PR patients (P < 0.05). Sixteen selection procedures were performed in 13 patients. CD34+ cell recovery was 33.5% (10-85) with a median final yield of 1 x 10(6)/kg CD34+. Two patients underwent marrow collection due to the low number of CD34+ cells recovered. Final purity was 59% (range 22-94) and CD5/20+ cell depletion was 2.7 log (1.6-4.4). Our data showed a statistically higher CD34+ cell recovery and purity with the Isolex device compared to Ceprate (P < 0.01 and 0.01, respectively). All the evaluable samples remained PCR positive after selection. The main issues to be addressed in the future are the identification of patients who fail mobilization and the improvement of purging methods.

Transplantation of unmanipulated allogeneic PBSC: preliminary report on 24 patients.

To explore the feasibility and potential advantages of PBSC in allogeneic transplantation, we grafted 24 patients (age 16-57, median 37) with different hematologic diseases (ALL = 10, AML = 5, MM = 4, NHL = 2, CML = 1, MDS = 1, AA = 1), 23 HLA-identical to their siblings and 1 partially matched. Cells were collected from donors by apheresis after G-CSF 10 to 16 mg/kg/day for 4 to 5 days, and stored at 4 degrees C until infusion. The patients were conditioned with chemotherapy regimens including busulfan and cyclophosphamide in the majority of cases and received GVHD prophylaxis with CSA-MTX in all but two. The graft consisted of PBSC alone, with a median of 143.5 (range 18.1-358.9) x 10(4)/kg CFU-GM, 9.0 (range 3.3-18.0) x 10(6)/kg CD34+ cells and 2.8 (range 1.2 to 8.6) x 10(8)/kg CD3+ and cells. An ANC >0.0.5 x 10(9)/L was recovered on (median) day 13 (range 11-17), and a platelet count >50 x 10(9)/L on (median) day 13 (range 12-55) post graft. There was no correlation between CD34+ cells or CFU-GM number in the inoculum and time to hematologic reconstitution. Acute GVHD (grade II-IV) occurred in 10 out of 22 (45%), chronic GVHD in 10 out of 18 evaluable (55%) patients. We found no relationship between occurrence of acute or chronic GVHD and number of CD3+ cells in the graft. Four patients relapsed and 7 died after transplantation. Fifteen patients are currently alive and disease-free 67 to 710 (median 286) days from the graft. Allogeneic transplantation with unmanipulated PBSC ensures a fast and stable engraftment. Acute GVHD incidence and severity seems comparable to that of bone marrow transplantation, but there may be an increase in chronic GVHD, mainly of the extensive form.

Inhibition of Pseudomonas burn wound infection by mafenide dry foam.

The results of an in vivo evaluation of 8.5% mafenide dry foam are described. Using burned guinea pigs infected with Pseudomonas aeruginosa, mafenide was applied every 12 hr as the dry foam or as the commercially available ointment. After 156 hr of therapy with the medicated dosage forms, the previously infected areas did not demonstrate the presence of Pseudomonas. However, all nonmedicated, infected controls produced positive cultures. Both medicated dosage forms demonstrated equivalent efficacy in the inhibition of Pseudomonas on burn wounds.

Inhibition of supraeschar and subeschar Pseudomonas infection by silver sulfadiazine dry foam.

The results of an in vivo evaluation of silver sulfadiazine dry foam are described. Using burned guinea pigs infected with Pseudomonas aeruginosa, silver sulfadiazine was applied every 12hr as the dry foam or ointment. After 72 hr of therapy with the medicated dry foam, only one of the 15 burns remained infected while seven of the 15 burns remained positive for Pseudomonas after treatment with the corresponding medicated ointment (p less than 0.05 greater than 0.01). It is suggested that the medicated dry foam provided significantly greater activity in treating a supraeschar burn wound infection of recent onset. In addition, a modified crossover study demonstrated that both the medicated dry foam and ointment are less effective in treating subeschar burn wound infections.

Using clinical interventions to cost-justify additional pharmacy staff.

This paper reports on the use of clinical interventions in cost justifying an additional pharmacist in a 316 bed hospital. Data were collected during a 5 month period in 1986 related to clinical interventions by satellite pharmacists. To justify to the hospital administration the permanent hiring of an additional pharmacist, a 10% return on the hospital's investment in salary and fringe benefits was required. The effect of clinical interventions on the cost of drug use was viewed as the only way to demonstrate the administration's mandated return on investment. Actual drug cost savings were $30,657, which resulted in a total estimated annual savings of $73,572 or a 54% return on the hospital's investment in the salary of the additional full time equivalent pharmacist. The 855 interventions resulted in an average savings of $35.88 per intervention. The study successfully demonstrated the use of clinical interventions to cost-justify additional pharmacy staff.

Using DRG data to justify additional clinical pharmacy staff.

The administrative process used to justify additional clinical pharmacy staff is described. A combination of Diagnosis Related Group (DRG) financial data and clinical information was used to justify adding a full-time DRG clinical pharmacist to the 22.6 full-time pharmacy staff in a 316-bed, nonprofit community hospital. A seven-step process was used successfully to gain approval for the new position. A novel strategy was incorporated into the proposal that used a justification based on cost-containment and quality-of-care issues rather than on increased revenues. Also included in the proposal was an evaluation of the DRG clinical pharmacist position at 6 months and after 1 year, based on reducing costs as well as improving patient care. The position was described as an investment by the hospital that would provide a return at least equal to the cost of providing the position.

[Two cases of solitary median maxillary central incisor syndrome]. / Due casi di sindrome da incisivo unico.

Solitary median maxillary central incisor syndrome (SMMCI) syndrome is a unique developmental abnormality arising from an unknown event occurring between the 35th and 38th days in utero, and involving mieline structure of the head including the cranial bones, the maxilla and its container dentition (specifically the central incisor tooth germ), together with other midline structures of the body. The SMMCI tooth may be possibly occur as an isolated trait or in association with many other midline developmental anomalies. It is estimated to occur in 1:50000 live births. There is a wide variability in the phenotypic spectrum. SMMCI is considered one of the most minimal expressions of the holoprosencephaly spectrum. Mutation in the Sonic Hedgehog homolog (SHH) gene may be associated with SSMMCI, but recent studies suggests the existence of several other candidate genes. We described two patients with SMMCI. They presented a solitary median maxillary incisor, short stature, hipotelorism and corpus callosus anomalies found on magnetic resonance imaging (MRI). They also present severe hiponatremia. At the best of our knowledge, this is the first report of cases of SMMCI with hiponatremia. We suggest that the sodium disorder may be secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH).

Home chemotherapy: basic concepts.

The diagnosis of cancer imposes a devastating sense of loss of control over a patient's life. Home chemotherapy allows patients to become active participants in administering their own therapy, providing an opportunity to regain some of that control. The purpose of this article is to provide an overview of some basic concepts of chemotherapy that relate to home therapy regardless of the specific therapeutic agent prescribed.

What is the role of the pharmacist in home care?

Pharmacists provide a wide range of medications, along with health and convalescent aids, for patients at home. Traditionally community pharmacists have been viewed as providers of prescription and nonprescription medications administered orally. Today pharmacists in community and hospital pharmacies across the country have expanded their services for the homebound patient and provide a variety of sophisticated products and services in the patient's home.

Risk factors for drug-related problems in elderly ambulatory patients.

Medication use among elderly patients in ambulatory care, home health care, and long-term care settings has become increasingly complicated during the past decade. Home intravenous therapy, multiple drug regimens to treat multiple chronic diseases, increased acuity of nonhospitalized patients, and increased longevity have placed elderly patients at increased risk for drug-related problems.

Viagra for home care patients.

In March 1998 a totally new type of therapeutic agent, sildenafil citrate (Viagra), was approved by the Food and Drug Administration for marketing in the United States as an oral tablet for erectile dysfunction in men. Extensive media coverage may have overshadowed the actual value and potential limitations of this therapeutic agent. Because sildenafil is a prescription-only medication that may be used in ambulatory and home care patients, home caregivers need to understand its intended use, mechanism and dose, and potential problems that may occur in patients who receive it.

Storing parenteral medication at home.

The storage requirements for parenteral products vary with the characteristics of the medication in the product. Temperature, light, moisture, pH, composition of the container, type of infusion fluid, and exposure to other chemical substances are the major determinants of the stability of parenteral medication stored in the patient's home.

Problems with herbal remedies in anticoagulated home care patients.

The increasing popularity of alternative therapies, including herbal remedies, poses new challenges for home health care providers. The cost of herbal remedy use now exceeds $1 billion annually in the United States and is expected to increase. The use of traditional medicine in combination with alternative therapy may lead to complications for patients and their caregivers as evidenced by the adverse effects of certain herbal products in patients who receive traditional anticoagulant or antiplatelet medication.

Using a hand-held spirometer as a monitoring tool in chronic theophylline therapy.

This study evaluates the use of a hand-held spirometer (pocket spirometer, Buhl type) in monitoring pulmonary function as a part of a homebased pharmacokinetic service for patients with respiratory disease. To calibrate the spirometer and determine its accuracy, six healthy volunteers were trained in its use by the pharmacist. Forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were determined for each volunteer once a month for six months. The T test for the presence of outliers showed no statistical difference at p less than 0.05. Seven patients on chronic therapy with theophylline derivatives for respiratory problems were randomly referred by their physicians to the pharmacokinetic service. The pharmacist counseled each patient and measured FVC and FEV1 once a month for six months. The ratio, (FEV1:FVC) X 100, was calculated for each patient before and after steady-state serum level determination and dosage adjustment. The mean value for this ratio was 45.1 before pharmacokinetic intervention and 57.5 after intervention. Using the Student's t-test, these results were significant (p less than 0.05). The correlation coefficient was calculated to determine if a correlation existed between the increase in the ratio and the increase in serum theophylline levels. Serum levels were ordered before and after intervention for five of the seven patients receiving pharmacokinetic intervention. The change in serum levels vs. change in the ratio was associated with a correlation coefficient of 0.718. Monitoring pulmonary function may be a useful adjunct for the pharmacist who provides pharmacokinetic counseling to patients with respiratory disease, but expanded studies are needed to judge the value of routine spirometric measurements on homebased patients.