Attitudes of Ohio hospital pharmacy directors toward national voluntary pharmacy technician certification.

Ohio pharmacy directors' attitudes about national voluntary pharmacy technician certification were surveyed. In May 1996 a questionnaire was mailed to all 224 hospitals in Ohio. The questionnaire contained 29 attitudinal statements constructed as forecasts of the effects of certification; pharmacy directors were asked to rate their level of agreement or disagreement with each statement using a 7-point Likert scale. The response rate was 61.4% (137 questionnaires returned). Respondents indicated modest agreement with 21 of 27 attitudinal statements and therefore had a generally positive view of certification. For example, they agreed that certification will improve technicians' knowledge, image, confidence, skills, and job satisfaction. They disagreed that certification will allow technicians to function independently, result in the replacement of pharmacist positions with technicians, or eliminate the need for on-the-job training of technicians. There were significant differences in scores between directors working at hospitals employing certified technicians and directors working at hospitals not employing certified technicians for only three statements. Overall, Ohio hospital pharmacy directors had positive attitudes about pharmacy technician certification.

Health-related quality-of-life claims in prescription drug advertisements.

Health-related quality-of-life (HRQOL) claims in drug advertisements and HRQOL advertisements' compliance with FDA regulations were studied. HRQOL advertisements from three medical journals from the years 1984, 1988, and 1992 were analyzed. Information was collected on the drug products and classes for which HRQOL claims were made and (1) whether the claims were explicit or implied, (2) how the products were claimed to affect HRQOL, and (3) whether claims related to overall well-being, a specific physiological aspect, or functional ability. For 1992 only, the compliance of HRQOL advertisements with FDA regulations was assessed. Ninety-four HRQOL advertisements were identified: 27 for 1984, 41 for 1988, and 26 for 1992. The drug classes for which HRQOL advertisements were most commonly used were diuretics (1984), nonsteroidal anti-inflammatory drugs (all three years), antianginals (1984 and 1988), antihypertensives (1988 and 1992), and anti-depressants (1992). Almost all the advertisements contained a claim (usually implicit) related to a specific physiological aspect of HRQOL, and claims concerning physical functioning outnumbered other function-related claims. In 1992, 42% of the HRQOL advertisements appeared out of compliance with at least one FDA regulation. In 1984, 1988, and 1992, HRQOL claims in prescription drug advertisements in three medical journals were mainly implicit and related mainly to specific physiological aspects of HRQOL. Over 40% of the HRQOL advertisements reviewed for compliance with FDA regulations for prescription drug advertising appeared not to comply.

Perceptions and use of performance measures by hospital pharmacy directors.

The extent to which hospital pharmacy directors use and value specific pharmacy department performance measures was studied. Questionnaires were mailed to pharmacy directors at 834 randomly selected hospitals. The questionnaires contained a list of seven data collection methods and 32 financial, 25 productivity, and 9 quality assurance measures obtained from a review of the literature. Respondents were asked to indicate familiarity, perception of usefulness, and current use of each method or measure. Perception of usefulness was measured on a five-point scale (1 = not useful, 5 = very useful). Respondents were also asked if the measures were requested by hospital administration or an external consultant. The overall response rate was 24.1%. Less than 30% of the respondents indicated that they used any of the data collection methods; however, the mean value for perceived usefulness was higher than 3 for almost all of the methods. Only five of the financial measures, two of the productivity measures, and two of the quality assurance measures were being used by more than 50% of the respondents. The value for mean perceived usefulness was higher than 3 for all but two of the measures. Most of the measures showed significantly higher frequency of use when they were requested by hospital administrators than when they were not. Requests by external consultants showed less effect on the use of the measures. The use of performance measures was low, but hospital pharmacy directors were familiar with many of these measures and perceived them to be useful.

Perspectives on pharmacy-coordinated drug administration programs.

This article has described the history, operation, and impact of a pharmacy-coordinated drug administration program that existed for 20 years. It enabled pharmacy to reduce medication errors and expand its clinical role. It is not clear whether medication error rates have increased or will increase as a result of transferring this responsibility back to nursing. The clinical programs have been well established, so that their existence no longer depends on the program. Recent audit results suggest that pharmacy-nursing relations are not as good. PCUDDA programs still have a logical place in organized health care settings, particularly in view of the nursing shortage and nursing salaries. The program has clearly proven to be safe and effective and to reduce the incidence of medication errors. It is also likely to reduce cost. It is unfortunate that decisions about programs such as PCUDDA are often made on the basis of professional turf and politics rather than on patient care and economic factors, which should be the basis for such decisions.

Multivariate analysis of survival in differentiated thyroid cancer: the prognostic significance of the age factor.

A retrospective analysis of tumour and patient characteristics was performed in 202 patients with papillary (n = 132) or follicular (n = 70) thyroid carcinoma, in order to identify prognostic factors related to survival. The following facts were found to be unfavourably related to survival: follicular histology, extrathyroidal growth of the primary tumour (stage pT4), regional lymph node involvement (stages pN1-3), presence of distant metastases at diagnosis (stage pM1), male sex (in papillary cancer) and old age (only death due to thyroid tumour was evaluated). For 190 patients sufficient material was available to permit extensive histopathological investigation. In patients with papillary cancer the presence of small anaplastic foci and/or greater than 25% solid structures (n = 18) was correlated with a reduced survival rate. Our study underlines the importance of distinguishing, histologically, between papillary and follicular cancer and in addition demonstrates the prognostic value of histological grade in papillary (but not follicular) carcinoma. We applied Cox's proportional hazard model to the survival data of these 190 patients and, after stage grouping, found that tumour stage (locoregional vs. advanced disease) was the most important prognostic factor. The second most important factor was the histological (sub)type (well differentiated papillary carcinoma vs. moderately differentiated papillary carcinoma and follicular carcinoma). Age at diagnosis and sex appeared to be of lesser importance. Therefore our study does not recommend the use of age as a guide for therapeutical decisions in differentiated thyroid cancer.

Resynchronization patterns for urinary rhythms in rats after light-dark shifts.

Diurnal urinary rhythms during a fixed 12:12 light-dark cycle were studied in male and female rats. After a control period of 9 days the light-dark cycle was shifted either +6 or -6 h by delaying or advancing the light period, respectively. Subsequently the resynchronization process was studied for 19-21 days. In both male and female rats an asymmetry effect was present: resynchronization was more rapid after a -6-h shift than after a +6-h shift. However, female rats exhibited a rate of resynchronization slower than male rats. During the process of resynchronization a state of transient internal dissociation was found for all urinary constituents. These results probably point to different control systems rather than to different circadian pacemakers. Further analysis of the role of sex steroid hormones is required in view of the sex variations reported.

Morphologic characteristics of benign and malignant adrenocortical tumors.

Differentiation between benign and malignant tumors of the adrenal cortex was studied by means of seven histologic parameters. Each separate criterion was significantly different in two groups, one consisting of patients without metastases within 10 years after operation and one of patients with metastatic tumors. Discrimination on the basis of single parameters in individual patients, however, was of little value. When a histologic index was calculated using the same parameters but after "weighing," a much better discrimination was obtained. The histologic index and, to a lesser degree, the mitotic activity seems to be related to the survival time of the patients with adrenal cortical carcinoma. The authors conclude that the calculation of a histologic index based on a summation of different parameters makes it possible to differentiate between malignant and benign adrenal cortical tumors. As single parameters, tumor weight and mitotic activity have the highest discriminating value.

The treatment of adrenocortical carcinoma with o,p'-DDD: prognostic implications of serum level monitoring.

Thirty-four patients with adrenocortical carcinoma were treated with o,p'-DDD. Twenty-eight patients presented with metastases at entry, and spillage of tumour cells occurred at surgery in 6 other patients. Eight patients had objective tumour regression, of whom 7 had serum levels over 14 micrograms/ml. The 3 patients with a lasting remission had levels of greater than 15, greater than 25, greater than 25 micrograms/ml respectively during prolonged periods. Increased survival times were found in the group of 14 patients with o,p'-DDD serum levels higher than 14 micrograms/ml when compared with patients not treated after discovery of metastases. In the patients with levels less than or equal to 10 micrograms/ml no therapeutic effect was seen. Levels of over 20 micrograms/ml are associated with symptoms of reversible neuromuscular toxicity. Monitoring of serum levels during treatment is mandatory. It is suggested that serum levels of about 25 micrograms/ml during longer periods may be curative.

The influence of intravenous infusion of electrolytes on the diurnal excretory rhythms.

In freely moving rats the diurnal in electrolyte excretion was studied. Food was available during either the dark or the light period. The lights were on from 0800-2000; the dark phase extended from 2000-0800 hrs. The electrolyte excretory rhythms were studied during a control period, in which the minerals were present in the food, and during experimental periods, when successive minerals were not present in the food but were instead given by constant intravenous infusion. For both groups the excretory rhythms of K, Mg and P persisted during continuous infusion but the times of maximum and minimum excretion differed. Day-fed animals exhibited a remarkable decrease in amplitude during the mineral infusion period. In contrast, the calcium excretory pattern was only influenced by the feeding period.

O,p'-DDD (mitotane) levels in plasma and tissues during chemotherapy and at autopsy.

The distribution of o,p'-DDD in various body compartments of patients being treated for metastatic adrenocortical carcinoma was studied. A highly significant semilogarithmic relationship was found between plasma and adipose tissue concentrations during therapy and between plasma and brain at autopsy. A linear relationship was found at autopsy between concentrations in adipose tissue and those in various other tissues, such as tumour and brain. The semilogarithmic relationship can be explained by the assumption of two plasma pools for o,p'-DDD, one with low affinity and high capacity and one with high affinity and low capacity. Plasma concentrations must be carefully monitored to obtain an impression of the tumour concentration and to detect impending central nervous system intoxication.

Blood levels of o,p'-DDD following administration in various vehicles after a single dose and during long-term treatment.

Plasma levels of o,p'-DDD were measured after ingestion of a single oral dose. At the onset of therapy o,p'-DDD was administered as commercially available tablets and granules and in milk, chocolate, and an oil emulsion to 9, 12, 14, 10, and 6 patients, respectively. Following administration in chocolate, emulsion, and milk significantly higher mean plasma levels were recorded in the first 5- and 10-h periods than after tablets. Granules gave significantly lower plasma levels than all other forms. Plasma levels were also measured during maintenance therapy, when a total of 200 g o,p'-DDD was administered to 22 patients with adrenocortical carcinoma. The plasma disappearance rate after termination of long-term therapy was found to be between 18 and 159 days. The recovery of o,p'-DDD from faeces was about five times higher after ingestion of tablets than after administration in oil emulsion and milk. As far as the rapid increase in plasma levels and patient compliance are concerned, the best results were obtained with the milk powder mixture.

Investigation of bone and mineral metabolism in hyperthyroidism before and after treatment using calcitonin, 47Ca and balance studies.

Seventeen normocalcaemic patients with severe hyperthyroidism were examined before therapy was initiated; 9 were re-examined about 1 year later. Studies with 47Ca under balance conditions and with calcitonin demonstrated a high rate of bone resorption in untreated patients. As a result of the increased bone turnover, the reaction to 6 MRC units of porcine calcitonin iv was more marked in the untreated than in the treated patients or the control group. In contrast to the normal diurnal pattern for PO4, it was found that during fasting the plasma PO4 level increases in the morning in patients with hyperthyroidism. This increase which was not suppressed by the administered dose of calcitonin developed in spite of an elevated urinary PO4 excretion. After treatment, the serum Ca concentration as well as the urinary and faecal Ca excretion was decreased. The Ca balance improved; the rapidly-exchangeable Ca pool returned to normal. The slowly-exchangeable and the total Ca pools, however, remained enlarged. The rate of bone resorption normalized. The accretion rate on the other hand remained elevated. This is atributed to continued enhancement of bone formation to compensate for the previous loss of bony tissue.

The eosinophilic fibrohistiocytic lesion of the bone marrow. A mastocellular lesion in bone disease.

Seven patients are described, six with severe osteoporosis and the seventh with osteogenesis imperfecta with moderate osteoporosis. The iliac bone marrow trephine biopsy specimens of all seven showed peculiar infiltrates consisting of elongated mast cells, eosinophils, plasma cells, and varying numbers of lymphocytes. Only one patient exhibited signs of allergy with urticaria pigmentosa; the other six patients had no abnormalities that could be related to a known mast cell disease. The lesions described here are the same as those described in five patients by Rywlin as "eosinophilic fibrohistiocytic lesion in the bone marrow". However, in our methacrylate sections the fibrohistiocytes are shown to be mast cells. Although a relationship with drug hypersensitivity is disputed, the presence of the mast cells and eosinophils suggests an allergic condition.

Hypothyroidism in an area of endemic goiter and cretinism in Central Java, Indonesia.

In an area of severe endemic goiter in Central Java, Indonesia, clinical overt or mild hypothyroidism appeared to be present in 7 out of 20 cretins and also in 12 out of 94 non-cretinous subjects, all 5-20 years of age, living in the village of Sengi. Hypothyroidism was not found in a control group of 70 subjects of the same age living in Londjong just outside the edemia. In hypothyroid subjects the plasma PBI-concentration was 0.98+/-0.32 mug/100 ml (mean+/-SD) vs. 2.72+/-1.24 mug/100 ml in euthyroid subjects from Sengi and 4.86+/-0.80 mug/100 ml in controls from Londjong. Values for T3 were 56.3+/-3.17 ng/100 ml in hypothyroids, 140.5+/-38.5 ng/100 ml in euthyroids from Sengi and 121.6+/-27.4 ng/100 ml in controls. The TSH levels (geometric mean and range) in these 3 groups were, respectively, 210.1 (108.0-342), 15.6 (3.0-372) and 4.1 (0.8-7.0) muU/ml. The differences between the mean concentration of PBI, T3 and TSH in the hypothyroid and euthyroid groups were highly significant (P less than 0.001). These data strengthen the clinical diagnosis of hypothyroidism in cretins as well as in non-cretinous subjects. All hypothyroid subjects had a PBI less than 1.8 mug/100 ml and T3 less than 120 ng/100 ml and TSH greater than 100 muU/ml. In 8 hypothyroid subjects, restudied 18 months after iodized oil injection, hypothyroidism was either corrected or markedly improved. It therefore appears that iodine deficiency per se in postnatal life may lead to (juvenile) hypothyroidism, which can be corrected by iodine therapy. Our findings have implications for the definition and diagnosis of endemic cretinism. Not all hypothyroid subjects in an area of endemic iodine deficiency should be classified as cretins.