Impulse control disorders in Parkinson's disease: don't set your mind at rest by self-assessments.

BACKGROUND AND PURPOSE: Impulse control disorders (ICDs) and related conditions in Parkinson's disease (PD) patients are frequent, disabling and sometimes devastating neuropsychiatric behaviors. Current knowledge on the prevalence of ICDs in PD is mainly based on assessments with questionnaires or patient interviews. This study was designed to evaluate the reliability of self-assessed ICDs and related conditions in PD by exploring the agreement between self-assessment of ICDs and related conditions in PD patients on the one hand and the estimation of their caregivers on the other hand. METHODS: After a short validation study of a novel ICD screening questionnaire, a cross-sectional study in 150 PD patients was performed. All patients filled out the self-assessment version of a screening questionnaire for ICDs, and caregivers completed an adapted version (n = 64). RESULTS: When comparing self-assessments of PD patients and ratings by their caregivers, significant differences with regard to the estimated prevalence of hypersexuality (55% vs. 17%), dopamine dysregulation syndrome (31% vs. 3%) and punding (22% vs. 9%) were found. CONCLUSIONS: Patients underestimate the presence and severity of some ICDs and related conditions, which shows how important assessments with caregivers are. After all, ICDs are probably much more frequent in PD than previously reported.

Significance of self-reported sleep quality (SQ) in chronic kidney disease (CKD): the Renal Research Institute (RRI)-CKD study.

BACKGROUND: There has been limited research on sleep quality (SQ) in CKD. METHODS: This prospective cohort study of adults with CKD Stages 3 - 5 at four US centers collected self-reported SQ information from the Kidney Disease Quality of Life (KDQOL) instrument, including an estimated SQ score (0 - 100), and 3 SQ-related questions. "Poor" SQ was defined as SQ score < or = 60. Logistic and multiple linear regression assessed associations between SQ and its potential predictors. Times to death and end stage renal disease (ESRD) were examined using Cox regression. A comparison with SQ in ESRD patients from the Dialysis Outcomes and Practice Patterns Study (DOPPS), was additionally performed. RESULTS: Mean SQ score was 59.4 +/- 23.6 (n = 689), and "poor" SQ was reported by 57%. Mean estimated glomerular filtration rate (eGFR) was 24.9 +/- 10.6 ml/min/1.73 m2. Higher SQ significantly correlated with KDQOL mental and physical component summary scales. Significant predictors of lower SQ score included--younger age, presence of dyspnea, self-reported depression, pain, and itchness. There were no significant pairwise differences in SQ from CKD Stage 3 through ESRD. Self-reported daytime sleepiness was significantly associated with higher risk of mortality prior to ESRD (HR = 1.85, p = 0.02). CONCLUSION: Self-reported "poor" SQ was common in a CKD cohort (Stages 3 - 5) and was not only associated with lower quality of life scores and several modifiable symptoms, but also with higher risk of pre-ESRD mortality. Greater attention to this clinical problem is highly recommended in this high-risk population.

Prediction of serum vancomycin concentrations following intraperitoneal loading doses in continuous ambulatory peritoneal dialysis patients with peritonitis.

The pharmacokinetics of vancomycin were studied in continuous ambulatory peritoneal dialysis patients with peritonitis. Six patients received an intraperitoneal loading dose of 15 mg/kg and 4 received an intraperitoneal dose of 25 mg/L. The ability of 2 methods to predict serum concentrations during the loading dose exchange was determined. The mean serum concentration after the exchange was 17.8 +/- 2.2 mg/L in patients receiving the loading dose. The mean dialysis clearance in all patients was 0.94 +/- 0.34 L/h. 66.6 +/- 13.4% of a dose was absorbed into the circulation in 4 h. The volume of distribution was 0.61 +/- 0.46 L/kg, and the half-life for equilibration of vancomycin into the circulation from dialysate was 2.76 +/- 0.94 h. Two methods of predicting serum vancomycin concentrations were tested, with 1 method predicting values significantly different from measured concentrations while the other did not. Serum vancomycin concentrations can be accurately predicted during a loading dose exchange.

Pharmacokinetics of intermittent intraperitoneal ceftazidime.

Ceftazidime is currently recommended as an alternative first-line agent in the treatment of peritonitis and for Pseudomonas peritonitis. The pharmacokinetics of intermittent intraperitoneal (i.p.) ceftazidime have been poorly characterized. This study was designed to characterize the pharmacokinetic disposition of a single dose of ceftazidime in anuric and non-anuric CAPD patients, over 48 hours. This was a prospective, open label, pharmacokinetic study. The study was conducted in an independent, outpatient dialysis center. Ten volunteer continuous ambulatory peritoneal dialysis (CAPD) patients with and without residual renal function, no peritonitis or antibiotics in the previous 4 weeks, and on CAPD for at least 2 months were recruited. Patients received a single dose of i.p. ceftazidime (15 mg/kg) in the first daytime exchange over a 6-hour dwell, after an overnight dwell. Serum, urine, and dialysate were collected over a 48-hour period. A high-pressure liquid chromatography (HPLC) assay was used to analyze ceftazidime in these samples. Pharmacokinetic parameters were calculated. Six of the 10 patients were non-anuric with a mean residual renal creatinine clearance of 2.9 +/- 1.6 mL/min. The mean +/- SD bioavailability was 72% +/- 14%, and the volume of distribution was 0.34 +/- 0.08 L/kg. The mean serum elimination half-life of 22 +/- 5 hours. The peritoneal clearance was 5.74 +/- 1.6 mL/min. No difference was detected between anuric and nonanuric patients. Mean plasma and dialysate concentrations at 24 hours were 24 +/- 6 microg/mL and 18 +/- 7 microg/mL, respectively, and were 12.0 +/- 3.6 microg/mL and 7.4 +/- 3.1 microg/mL at 48 hours, respectively. Once-daily i.p. dosing of ceftazidime achieves serum and dialysate levels greater than the MIC of sensitive organisms over 48 hours.

End-stage renal disease: factors affecting referral decisions by family physicians in Canada, the United States, and Britain.

The objective of this study is to determine how patient age, sex, creatinine level, and comorbidity affect referral decisions for the treatment of end-stage renal disease (ESRD) and whether these decisions are affected by physician characteristics in three countries: Canada, the United States, and Britain. A vignette-based questionnaire was mailed to a random sample of family physicians in Ontario, Canada (1,818 physicians); all family physicians in the state of New York (1,814 physicians); and a sample of general practitioners from the south of England (2,228 physicians) in 1996. Physicians were presented with clinical scenarios involving a patient with varying degrees of renal insufficiency and a complicating comorbidity, including angina, diabetes, cancer, mental illness, or socioeconomic circumstances. They were asked to indicate the likelihood of referral. Half the physicians received a questionnaire describing a male patient, and half, a female patient. Mean creatinine levels at which physicians would refer were 260 micromol/L for British physicians, 297 micromol/L for Canadian physicians, and 340 micromol/L for American physicians. No difference in referral rates was found based on the sex of the patient or physician. Sixty-five percent of American and Canadian physicians would refer regardless of patient age, but only 49% of British physicians would do so. Family physicians in the United States, Canada, and Britain function as gatekeepers for patients with ESRD. They are less likely to refer based on increasing severity of comorbid conditions. They also discriminate based on age, but not sex.

Gastrointestinal absorption of americium-241 by orally exposed swine: comparison of experimental results with predictions of metabolic models.

Two groups of 11-week-old swine (40 miniature and 40 domestic swine) received a single oral administration of 1.9 X 10(8) Bq (5.2 mCi) of 241Am citrate, and groups of eight animals, four of each type, were killed and sampled at 1, 2, 4, 8, 16, 24, 48, 72, and 96 h and 30 days later. Uptake and excretion patterns of the radioactivity appeared to occur in three phases: rapid uptake, rapid excretion, and then a slower excretion. All animals were systematically dissected, and the eviscerated carcasses were autoclaved for separation of bone and muscle. The predominant site of deposition was bone, and autoclaving had little effect on releasing 241Am from either bone or muscle. The maximum fractional gastrointestinal absorption of 1.1 X 10(-3) occurred 8 h after radionuclide administration. The tissue distribution data suggest partitions of 50, 20, and 30%, for bone, liver, and other soft tissues, respectively. Two metabolic models were evaluated: a modified Mewhinney-Griffith model and the ICRP 30 model to compare the biological data with model predictions. All models underestimated the actual early time data, but the fits to the experimental results were better at later times.

Effects of 24-hour ambulatory blood pressure monitoring on daily activities.

Compared the self-monitored activities, locations, and postural positions of 28 hypertensives while they wore an alarm watch and then while they wore a 24-hr ambulatory blood pressure monitor (ABPM) to see if wearing the ABPM led to alterations in behavior. Within the limitations of the study (no counterbalancing of order and twice as many ABPM measures as watch measures), we found significant differences in frequency of being at home or in miscellaneous settings, in standing and reclining positions, and in mental, physical and miscellaneous activities between the two occasions.

Bilateral renal cortical necrosis associated with cefuroxime axetil.

Cefuroxime axetil has been associated with few reported adverse effects. We report a case of bilateral renal cortical necrosis in a female after receiving 7 doses over 4 treatment days. The patient presented with worsening symptoms consisting of arthralgias, pruritus, and abdominal pain. Laboratory data obtained was indicative of worsening renal failure and thrombocytopenia. The patient required hemodialysis by the third day. Kidney biopsy revealed cortical necrosis. The possible pathogenesis of cefuroxime axetil causing cortical necrosis in this case and a review of other reported cases of chemical induced renal cortical necrosis is discussed.

Knowledge of hemodialysis and CAPD patients about their prescribed medicines.

A questionnaire was designed to determine and compare the extent of knowledge of 40 continuous ambulatory peritoneal dialysis (CAPD) and 40 hemodialysis (HD) patients about their medicines. It was administered orally to outpatients attending a clinic by an investigator unknown to the patients. Data were collected pertaining to the following target drugs: calcium supplements, phosphate binders, vitamins B and C and folic acid. HD and CAPD groups were closely matched for age and sex. Sixty percent of CAPD and 49% of HD patients were taking four or more medications. The dose of folic acid was accurately recalled by 91% and 71% of CAPD and HD patients. Indications for calcium supplements and phosphate binders were known by only 8% and 30% of CAPD patients compared to 72% and 73% of HD patients. More HD patients knew the indications for all target drugs (p less than 0.01). More CAPD than HD patients knew the expected duration of therapy (p less than 0.01). There was a trend between decreased knowledge of whether the medication was working with increasing age of CAPD patients. Most drug information was supplied by physicians, but many CAPD patients (21%) obtained information from lay sources. When given the opportunity to ask questions about their medicines, only 56% CAPD and 46% HD patients did so. The knowledge of CAPD and HD patients studied was grossly deficient in terms of indications, effectiveness, duration and action to be taken if doses were missed.

Incidence of CAPD peritonitis in patients using UVXD or O-set systems.

Eighty-one patients were placed either on the O-set (39) or the UVXD germicidal system (42). Total experience was 13.7 +/- 8.0 and 17.8 +/- 14.8 months, respectively. There were 48 and 85 new episodes of peritonitis in 24 and 28 patients, respectively, and an additional 11 and 28 episodes of relapse or probable relapse. The peritonitis rate was 1 episode each 11.14 and 8.83 patient months, which was not significantly different. There was no significant difference between the 2 groups in terms of the mean numbers of peritonitis-free days (393.7 versus 503.8) or in the mean time to the first episode of peritonitis (6.60 versus 6.54 months). The odds ratio of relative risk of peritonitis with the two systems was 1:1.17 (O-set:UVXD). There appears to be no difference in ability of the two systems to prevent peritonitis.

Evaluation of drug-related problems in an outpatient hemodialysis unit and the impact of a clinical pharmacist.

PURPOSE: Drug-related morbidity and mortality are significant problems in the U.S. Recognition and resolution of drug-related problems (DRP) will decrease drug-related morbidity and mortality and promote optimal therapeutic outcomes. It was the objective of this study to identify DRP in hemodialysis outpatients by performing medication reviews; make appropriate recommendations and determine the significance of any interventions; and estimate outcome in terms of any changes in number of medications/patient or doses/day. METHODS: A thorough medication review was conducted with each patient after review of the computerized medication profiles and medical records. Each updated profile was assessed by a clinical pharmacist for the presence of any of the 8 classical DRP plus 2 additional categories (therapeutic duplication and other [specific for dialysis e.g., dry weight]). Appropriate recommendations were made to the physician. Accepted recommendations were deemed as interventions and assigned a significance rank on a published scale of 1 (adverse significance) to 6 (extremely significant) by each of the investigators. A final rank was assigned upon agreement between investigators. Changes in numbers of doses/day or medications/patient were determined. RESULTS: 49 patients were reviewed and 45 patients (21 women, 24 men) were included in the final analysis. Over one month 126 DRP were identified and 102 interventions were made. Drug interactions constituted the most common DRP (27.5%). The second most common DRP (26.5%) was in the dialysis-specific group. The number of interventions per significance rank were as follows: rank 1:0 (0%); rank 2: 7 (6.9%); rank 4: 80 (78%); rank 5: 5 (4.9%); rank 6: 1 (1%). Patients were taking a mean of 10.9 +/- 3.9 medications and a mean of 14.5 +/- 6 doses/day (range, 2-33) prior to the study and 10.7 +/- r and 14.4 +/- 5.8 by the end of the study period. CONCLUSIONS: With the addition of a clinical pharmacist in an hemodialysis unit numerous DRP were detected and interventions made. The majority of interventions were significant and possibly led to better therapeutic outcomes.

Effect of a sliding scale protocol for heparin on the ability to maintain whole blood activated partial thromboplastin times within a desired range in hemodialysis patients.

A prospective, randomized and open study was conducted to evaluate the ability of an individualized heparin dosing protocol to achieve and maintain whole blood activated partial thromboplastin times (WBAPPT) within a predetermined range in hemodialysis patients. Thirty-one hemodialysis outpatients who received a total of 99 dialyses were studied. Systemic heparinization was achieved with a loading dose and a continuous infusion. WBAPPT, used as a monitoring parameter for heparin therapy, was measured at 5 minutes and 1, 2, 3 and 3 1/2 hours after the start of heparinization. An initial heparin loading dose of 50 u/kg dry weight was used, with a continuous infusion of 15 u/kg/h and a sliding scale to adjust infusion rates to target WBAPPT in the goal range of 150-190 seconds. Individual heparin loading doses for subsequent treatment sessions were titrated to achieve the lowest dose which would still result in clear dialyzers at the end of hemodialysis. There was a high degree of interindividual variability in heparin requirements. A loading dose of 20-25 u/kg placed the majority (72.4%) of the patients within the 150-190 seconds range at the 5 min WBAPPT measurement. The sliding scale method was effective in keeping about 60% of the WBAPPT within the desired range throughout the rest of the hemodialysis session. As the loading or total doses were increased, the incidence of clear dialyzers increased. In conclusion, this heparin protocol is effective for individualizing heparin doses to achieve therapeutic WBAPPT in hemodialysis patients.

Indinavir-induced nephropathy.

We report the case of a 38-year-old male who developed renal insufficiency while on the protease inhibitor, indinavir. This patient had an increase in serum creatinine over a period of approximately one year, along with persistently abnormal urinalysis. A renal biopsy was performed and showed marked tubular crystal deposition. The indinavir was discontinued, and after two months the patient's serum creatinine and urinalysis returned to normal. To our knowledge this is the second case of indinavir associated nephropathy.

The emergency department care of hemodialysis patients.

AIMS: To describe the emergency department (ED) presentation, evaluation and disposition of maintenance hemodialysis (HD) patients. MATERIALS AND METHODS: A retrospective review of adult HD patients seen 1/1-12/31/97. The following was collected: demographics, mode of arrival, chief complaint, etiology of renal failure, evaluation, treatment, disposition, length of stay and facility charges. During the study period, this tertiary care ED had an annual adult census of 45,000. No clinical pathways were in place. RESULTS: 143 patients made 355 visits: 351 charts were available. Mean patient age was 51 (range 20-86), 62% were male, 51% were white. 70% presented from home, 26% from dialysis. EMS transported 32%. Medicare insured 78%. Etiologies of renal failure included hypertension (33%), diabetes (27%), HIV (7%) and glomerulonephritis (8%). Complaints were related to infection (18%), dyspnea (17%), vascular access (16%). chest pain or dysrhythmia (15%) and gastrointestinal complaints (12%). ED evaluation included CBC (79%), electrolytes (75%), CXR (57%) and EKG (48%). Antibiotics were administered to 21%. HD was performed earlier than scheduled in 14%. Two hundred and eighteen patients (62%) were admitted (ICU 11%, telemetry 22%), 19 (5%) refused admission and 2 expired in the ED. The average hospital length of stay was 7.8 days (range 1-59), with 29% hospitalized more than 1 week, compared to 6.54 days for non-HD patients. The mean facility charge for admitted subjects was $14,758, while the average cost for non-HD admissions was $7,152. Of the 133 patients (38%) who were discharged directly from the ED, the mean length stay was 223 minutes (range 30 to 750) and the mean charge was $658. The mean length of stay for non-HD patients was 124 minutes. CONCLUSION: The ED evaluation of adult HD patients involves multiple diagnostic modalities, and patients are usually admitted. The admit rate, ED length of stay for discharged patients and hospital charges for care were substantially higher in the HD patients than in the general population. Further research in the ED care of these complex patients should be undertaken.

Aortic valve debridement by ultrasonic surgical aspirator in degenerative, aortic valve stenosis: follow-up with Doppler echocardiography.

OBJECTIVE: Recently there has been an emphasis on reconstructing diseases native valves as an alternative to prosthetic valve replacement. Whereas; the surgical repair of aortic valve stenosis has been always problematic. This study was performed to estimate the clinical results after aortic valve debridement using ultrasonic energy. METHODS: Between 1990-1994 26 patients underwent ultrasonic aortic valve decalcification. There were 15 females and 11 males, the age was in average 74 years. As a concomitant diagnosis 88% patients (23) had mostly mild, aortic valve insufficiency, 16 (61%) had coronary artery disease and 11 (42%) had mild mitral valve incompetence. All of the patients were operated with cardiopulmonary bypass using moderate hypothermia, cardioplegical arrest and topical cooling for myocardial protection. The calcifications were removed tangentially using Cavitron Ultrasonic Surgical Aspirator. (CUSA), CAVITRON, USA. Leaflet perforation and/or unsatisfactory valve closure have been indications for aortic valve replacement. RESULTS: Two operative death (8%) have occurred and six patients have died in the further course (follow-up mean 17 months ranging from 4 to 61 months). Postoperative Doppler-Echocardiography results taken directly after surgery and then again 17 months later (n = 18) showed a decrease of peak and mean gradients across the aortic valve three and two times respectively (p < 0.001). 17 months after debridement we observed a mild rise in both gradients (by peak gradient p < 0.05). Directly postoperative, the aortic valve area increased doubly and decreased 17 months later slight, but it was still statistically significant in comparison with our preoperative data (p < 0.001). Follow-up echocardiography demonstrated late onset of moderate aortic valve insufficiency in 6 patients. The classification of New York Heart Association was improved in 13 (72%) survivors after 17 months. CONCLUSIONS: Ultrasonic debridement of aortic valve stenosis allows precise and energy-controlled removal of calcium, increased doubly the valve area and decreased of peak and mean gradients statistically significant. The advantages of preserving the native aortic valve in elderly patients are relative good arguments; although a longer follow-up is necessary to establish this procedure.

Occupational medical program alcohol screening. Utility of the CAGE and BMAST.

Alcohol consumption is a primary or secondary factor in many work-related accidents, suicides, homicides, violent crimes, and motor vehicle accidents. The absentee rate in alcoholics is 3.8 to 8. 3 times greater than that for nonalcoholic workers. The purpose of this research was to evaluate the effectiveness of two interview questionnaires-the Brief Michigan Alcoholism Screening Test (BMAST) and the CAGE (cut down, annoyed by criticism, guilty about drinking, and eye-opener drinks). The validity of the BMAST and the CAGE as screening tools for alcohol problems has been verified in a number of nonworkplace settings. If they prove to be as effective for screening workers in an occupational medical setting, follow-up definitive diagnoses could result in earlier detection of alcohol problems and allow prompt intervention. Positive outcomes could include a safer workplace, less absenteeism, improved worker productivity, and a reduction in personal and family problems caused by drinking.

Disposal of CAPD waste in the community.

Fifty-nine patients returned a confidential mailed questionnaire, to determine their procedures for disposal of CAPD waste including bags, fluids and needles, and to assess their instruction and opinions on health risks from their wastes. Patients came predominantly from rural communities. Sixty four percent used disposal boxes for used needles, 80% discarded drained bags in the garbage without wrapping them in plastic and 7 to 17% of patients discarded needles straight to the garbage, depending on circumstances. Thirty seven percent did not recall receiving instruction on waste disposal, and of those who did, instructions came predominantly from nurses. Twenty of 32 patients who had suffered peritonitis disposed of their bags during peritonitis in the same manner as when they did not have peritonitis. Most patients (61%) felt issues dealing with CAPD waste disposal were "important" or "very important", but fewer "agreed" or "strongly agreed" that it posed a health risk to others (16%) or to the environment (10%). Inconsistencies in methods of disposal and potential risks of infection dictate that guidelines must be developed to deal with these issues.

Erythropoietin in continuous ambulatory peritoneal dialysis: experience with subcutaneous administration.

Experience in the use of subcutaneous erythropoietin (EPO) in 32 continuous ambulatory peritoneal dialysis (CAPD) patients is presented. All patients were treated with oral iron supplements. The total and mean +/- SD durations of EPO treatment were 466 weeks and 14.6 +/- 10.1 weeks respectively. Twenty-two patients started treatment with normal or elevated iron stores; 10 had an initial iron saturation less than 20%. The initial hematocrit was 23.8 +/- 3.7%. Thirteen patients reached a steady-state hematocrit by the end of the study period, when the mean +/- SD hematocrit for all 32 patients was 34.1 +/- 3.6%. All patients responded to EPO. The initial dose of EPO was 147.1 +/- 53.8 U/kg/week. Maintenance dose was 72 +/- 36 U/kg/week.

Variability in creatinine clearance (CCR) and KT/V due to different methods of calculating volume and CCR.

OBJECTIVE: This study aimed to compare the correlations between KT/V and creatinine clearance (Ccr) calculated by different methods and to determine and compare the correlations between KT/V and Ccr. DESIGN: Nonrandomized, retrospective analysis of data. SETTING: Continuous ambulatory peritoneal dialysis (CAPD) outpatient clinic in a teaching hospital. PATIENTS: All patients were included for analysis if the data collection was complete for the calculations of KT/V and Ccr using five different methods. INTERVENTIONS: Volume of distribution for urea (V) was estimated by four methods: Watson nomogram, ideal body weight (IBW), actual body weight, and total body surface area. Ccr was determined by five methods: Dialysate Ccr was calculated by creatinine (Cr) uncorrected and corrected for the presence of glucose; urinary Ccr was calculated using urinary Cr alone and the average urinary clearance of urea and Cr; and by the Cockcroft and Gault method. MAIN OUTCOME MEASURES: Correlations between KT/V and Ccr. RESULTS: Sixty-three data sets were collected from 52 CAPD patients. The correlations between weekly KT/V and Ccr normalized to 1.73 m2 body surface area were found to be highly variable from one method to another (r2 = 0.012 -0.494). For obese patients (20% above IBW), KT/V values obtained were more variable using the Watson nomogram compared to the IBW and BSA methods. CONCLUSION: KT/V calculated using the Watson nomogram and the Ccr determined using average of urinary urea and creatinine clearance gave the best correlation (r2 = 0.49).

Recovery of S. epidermidis and E. coli from effluent peritoneal dialysate.

The effect of incubation temperature and duration was studied on the growth of organisms in peritoneal dialysate effluent. Penicillin-sensitive, and gentamicin-sensitive clinical isolates of S. epidermidis (SE) and E. Coli (EC), respectively, were inoculated into freshly drained dialysate of 19 CAPD patients who did not have peritonitis. Each dialysate was 1.5% dextrose in strength and had a minimum dwell of 6 hours. Control and test aliquots were incubated at 4 degrees C, 20 degrees C and 37 degrees C for periods of up to 12 hours, and samples collected and plated to determine colony counts. Initial counts at time zero were 9.4 x 10(4) (SE) and 6.6 x 10(3) (EC) CFU/ml. SE showed no change in count at 4 or 20 degrees C up to 12 hours. There was a significant increase (p less than 0.005) at 37 degrees C, at 12 hours to 1.72 x 10(6) CFU/ml. EC showed no change at 4 or 20 degrees C. There was a significant decrease in count for EC at 37 degrees C, 6 hours (5.5 x 10(2) CFU/ml, p less than 0.01) and 37 degrees, 12 hours (2.9 x 10(2) CFU/ml, p less than 0.0001). It is recommended that infected dialysate should be stored in cool conditions until it can be transported for culture to ensure adequate recovery of gram negative organisms.