Imatinib mesylate inhibits the profibrogenic activity of TGF-beta and prevents bleomycin-mediated lung fibrosis

Idiopathic pulmonary fibrosis is a progressive and fatal fibrotic disease of the lungs with unclear etiology. Prior efforts to treat idiopathic pulmonary fibrosis that focused on anti-inflammatory therapy have not proven to be effective. Recent insight suggests that the pathogenesis is mediated through foci of dysregulated fibroblasts driven by profibrotic cytokine signaling. TGF-beta and PDGF are 2 of the most potent of these cytokines. In the current study, we investigated the role of TGF-beta-induced fibrosis mediated by activation of the Abelson (Abl) tyrosine kinase. Our data indicate that fibroblasts respond to TGF-beta by stimulating c-Abl kinase activity independently of Smad2/3 phosphorylation or PDGFR activation. Moreover, inhibition of c-Abl by imatinib prevented TGF-beta-induced ECM gene expression, morphologic transformation, and cell proliferation independently of any effect on Smad signaling. Further, using a mouse model of bleomycin-induced pulmonary fibrosis, we found a significant inhibition of lung fibrosis by imatinib. Thus, Abl family members represent common targets for the modulation of profibrotic cytokine signaling.

Effect of publication bias on retrieval bias

Publication bias is the main etiologic factor in retrieval bias. The authors measured the influence a positive study outcome had on housestaff's selecting the study for presentation.

A continuous-improvement approach for reducing the number of chemotherapy-related medication errors

A comprehensive, interdisciplinary approach for reducing the number of chemotherapy-related medication errors at the National Institutes of Health Clinical Center, where approximately 8500 doses of chemotherapy agents are dispensed annually, is described. Heightened awareness of the seriousness of chemotherapy-related medication errors prompted formation of an interdisciplinary task force in June 1995 to analyze and improve the hospital's system for ordering, checking, processing, and administering cancer chemotherapy agents. Problems were analyzed and rectified in accordance with the hospital's plan-do-check-act performance-improvement model. Performance monitors for the improvements included a system to record and categorize all chemotherapy-related prescribing errors and a hospital-wide occurrence-reporting system. The task force identified seven major categories in which improvements were needed: protocol development, computer-system enhancements, dose verification, information access, education for health care practitioners, error follow-up, and infusion pumps. Despite the Clinical Center's good safety-net system, 23 modifications were made to the existing system through December 1999. These changes resulted in an overall 23% decrease in prescribing errors and a 53% decrease in serious prescribing errors. The task force membership was recently broadened to include representatives of additional departments where chemotherapy agents are used, and this group recommended more than 20 additional system changes. The changes are being implemented, and their effect on reducing the number of chemotherapy-related errors will be measured. The continuous-improvement process used prospectively by the task force helps ensure that safe chemotherapy practices are instituted uniformly throughout the hospital.

Challenges of thalidomide distribution in a hospital setting

The various physician, patient, and pharmacy requirements for participation in the System for Thalidomide Education and Prescribing Safety (S.T.E.P.S.) program and procedures that institutions may implement in order to comply with these requirements are described. In 1998, FDA approved the marketing of thalidomide (Thalomid, Celgene). Because of the drug's known teratogenic effects, FDA tightly controls the distribution of thalidomide in the United States. To comply with FDA requirements, Celgene developed the S.T.E.P.S. oversight program, which includes registration of thalidomide prescribers and pharmacies that dispense thalidomide, extensive patient education about the risks associated with thalidomide, and a registry of all patients receiving thalidomide. The S.T.E.P.S. program is considered part of the product label. The pharmacy requirements of the program were developed with a focus on a retail pharmacy practice model, which does not adequately reflect current hospital practice. The pharmacy department of the National Institutes of Health Clinical Center developed a model that adapts the S.T.E.P.S. program requirements to inpatient and outpatient institutional pharmacy practice. Procedures for registering patients and prescribers and dispensing thalidomide in the hospital setting were developed; the procedures were designed to meet the needs of both the inpatient and outpatient pharmacies and to comply with the requirements of the S.T.E.P.S. program.

Handling of gene-transfer products by the National Institutes of Health Clinical Center pharmacy department

Policies and procedures for handling gene-transfer products at the National Institutes of Health (NIH) Clinical Center pharmacy department are described. The pharmacy at the Clinical Center is responsible for handling in vivo gene-transfer delivery systems, which are gene-transfer products that are prepared for direct administration to patients. The gene-transfer products currently handled by the pharmacy are investigational and are composed of viruses containing the gene encoding either of the melanoma antigens MART-1 and gp100. The pharmacy has prepared guidelines, based on the principles of aseptic technique and FDA guidelines for manufacturing facilities, intended to help pharmacy personnel safely dilute a concentrated gene-transfer product into a dose suitable for administration. Before a product is handled, the biological safety level is determined and a biohazard sign is posted. Worksheets detailing all supplies, calculations for dilutions, and procedures that will be required are prepared in advance; the worksheets are part of a drug fact sheet prepared for all investigational drugs dispensed. Personnel must be properly trained and dressed in protective clothing. Aseptic technique and decontamination procedures are used as specified in the guidelines, and all materials used are disposed of as biohazardous waste. All work is documented. If a worker is accidentally exposed, standard procedures are followed. The handling of gene-transfer products at the NIH Clinical Center pharmacy is based on the principles of aseptic technique, FDA guidelines, and experience.

Evolving to provide pharmaceutical care without additional resources in a university hospital

Our department is committed to a process of continuous quality improvement focusing on delivering the best possible pharmaceutical care services. Three committees, each with representation from pharmacists and pharmacy technicians from all areas of the department, were convened in 1991 to 1992 to further identify areas for service enhancement and to plan for the future. Based on the recommendations of these committees, further expansion in ambulatory services is a priority. Other changes will include further automation of the drug-distribution system, examination of the role of the pharmacy technician, development of an automated patient-care system with direct physician order entry, computerized documentation of clinical interventions, and reaffirmation of the role of the pharmacist as the professional responsible for proper use of medications at UMHC.

Impact of a drug-use review program intervention on prescribing after publication of a randomized clinical trial

The effect of a drug-use review (DUR) program intervention on physician prescribing after the results of a randomized clinical trial were published was studied. A Veterans Administration (VA) cooperative study published in June 1986 showed that congestive heart failure (CHF) patients who had hydralazine and isosorbide added to their drug therapy had less mortality than patients given digoxin and diuretics with or without prazosin. Physicians with at least one CHF patient who was receiving the less effective therapy were randomly assigned to intervention and control groups. In September 1986, intervention-group physicians (n = 288) were mailed a letter and questionnaire from the DUR program coordinator, the journal article, and a drug history profile of a CHF patient who might benefit from the information. Control physicians received no mailing. The questionnaire asked whether the physicians already knew about the VA study, intended to alter their prescribing, and could identify factors that would affect their decision. Two thirds of intervention-group physicians were already aware of the VA study. One third indicated that they intended to alter drug therapy based on the study results; factors significantly associated with the intent to adopt a change were physician training and experience, comments by peers, new drug availability, and the size of the reduction in mortality. During four months after the intervention, only 5 physicians in the two groups switched their patients to both hydralazine and isosorbide (full change); 23 switched them to at least one of the drugs or discontinued prazosin (partial change). There was no significant difference in the number of full or partial changes between groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Indicators for the selection of ambulatory patients who warrant pharmacist monitoring

The development of indicators to identify ambulatory patients who might benefit from pharmacist monitoring is described. With the assistance of an eight-member panel of ambulatory-care pharmacists, six prognostic indicators were identified: (1) five or more medications in present drug regimen, (2) 12 or more medication doses per day, (3) medication regimen changed four or more times during the past 12 months, (4) more than three concurrent disease states present, (5) history of noncompliance, and (6) presence of drugs that require therapeutic drug monitoring. The charts of patients who had visited the internal medicine, general surgery, pediatric, and obstetric/gynecology clinics during five randomly selected weeks in 1985 and 1986 were reviewed to determine the presence or absence of the six prognostic indicators and their adverse outcomes. Evidence of drug-therapy-related adverse outcomes was present in 79 (33.1%) of 239 charts. Charts of patients with a documented history of noncompliance were most likely to show evidence of an adverse outcome. The likelihood that a patient chart would show evidence of an adverse outcome increased as the number of prognostic indicators present increased. The presence of individual or multiple prognostic indicators in the charts of ambulatory-care patients should enable pharmacists to identify patients at greatest risk of experiencing drug-therapy-related adverse outcomes.

Substitution of skimmed milk for high-fat milk in the diets of men and women in South Wales

The potential for achieving the NACNE target for percentage of energy derived from fat (34 per cent), resulting from the theoretical substitution of skimmed milk for high-fat milks, was investigated using the dietary records of 738 middle-aged males and females in the South Wales area. The average male in the sample could theoretically achieve the NACNE target by changing to skimmed milk providing that energy intake remained the same. In the small sample of women the average female could not reach the NACNE target. Four groups of individuals were identified: -(1) Those consuming diets providing less than 34 per cent of total energy from fat; (2) those unable to reach the NACNE target by changing to skimmed milk; (3) those who could reach the NACNE target by changing to skimmed milk even if they remained in energy deficit; (4) those who could reach the NACNE target by changing to skimmed milk providing that they made up the lost energy by eating foods free of fat. A graph is presented which would enable a trained person to assess whether substitution of skimmed for high-fat milks would result in an individual achieving the NACNE recommendation.

Evaluation of five systems to determine technician staffing in a unit dose cart-filling area

The development and evaluation of predictive systems to determine staffing needs in a centralized unit dose cart-filling area were studied. Data concerning actual cart-filling time and the hospital's daily census, by total beds and by bed type, were collected over 55 days. Four predictive systems were then developed, as follows: simple average, range average, simple regression, and multiple regression. In addition to these mathematical systems, a pharmacist "best-guess" system was devised, whereby the pharmacist directing the cart-filling area estimated the staffing needs on a daily basis during the trial period. The five systems were then used to predict cart-filling time daily over 14 days. During this time, the actual filling time was recorded and compared with the times predicted by the five systems. The differences among the actual or predicted mean cart-filling times for the five systems were not significant. The pharmacist best-guess system was on average the most accurate in detecting different staffing needs; the advantage of this system is that the pharmacist can evaluate differences in work habits among the scheduled technicians, which the mathematical models would be unable to do. The simple average system correlated well with changes in filling time and most precisely predicted variability in census. Although none of the systems was superior in all respects, a combination of the pharmacist best-guess and simple-average systems appeared to be the best method for predicting daily technician staffing needs in the central cart-filling area.

Patient acuity indicators as predictors of pharmacy workload

The feasibility of using two workload indicators from a nursing patient-classification system as a means of predicting pharmacy workload was studied. Frequency data for 13 pharmacy distribution and clinical activities were recorded daily for 28 consecutive days and compared with daily data for acuity of patient illness and number of standard hours of nursing care required on nine nursing units. The strength of the associations between (1) pharmacy workload and patient acuity and (2) pharmacy workload and standard hours of nursing care was determined by linear regression analysis. Both same-day and one-day-lagged analyses were performed; the one-day-lagged analyses looked at pharmacy workload on a given day in relation to nursing workload on the previous day. A total of 252 observations were available for analysis. Pharmacy workload and same-day standard hours of nursing care were correlated most strongly, although all of the analyses yielded large coefficients of correlation. Analysis of data from individual nursing stations yielded smaller coefficients of correlation, especially for the one-day-lagged analyses. At least 73% of the variance in pharmacy workload could be attributed to variance in nursing workload. The index of patient acuity of illness and the number of standard hours of nursing care are good predictors of pharmacy workload of the same and the following days; the potential exists to use these nursing workload indicators in determining pharmacy staffing requirements.

Personnel costs and preparation time in a centralized intravenous admixture program

The amount of time and the cost of personnel time associated with the preparation of injectable products were determined. A time study consisting of 9041 observations during a seven-day period was conducted to determine the amount of time required of pharmacists and technicians for the preparation of total parenteral nutrient (TPN) solutions, large-volume injectables, antibiotic admixtures, antineoplastic admixtures, and investigational drugs. The established times were used to calculate relative value units for each product line and to determine the cost of pharmacist and technician time associated with the preparation of each product line. Preparation times ranged from 3.7 minutes for an antibiotic admixture to 49 minutes for a pediatric TPN solution. Total personnel costs ranged from $0.71 for an antibiotic admixture to $10.70 for a pediatric TPN solution. The calculated relative value units indicated that existing departmental time standards did not allow sufficient time for the preparation of some products. Establishing relative value units and calculating the cost of personnel time associated with the preparation of injectable products can be helpful for comparing the cost of purchasing ready-to-use products with the cost of preparing the same products.

Increased dosage requirements of tobramycin and gentamicin for treating Pseudomonas pneumonia in patients with cystic fibrosis

The pharmacokinetic behavior of tobramycin and gentamicin was evaluated in 27 patients who had cystic fibrosis (CF). A previously studied, age-matched group of 334 patients who had been treated with gentamicin and who did not have CF served as controls. The CF patients, who ranged in age from 2 to 32 years and who had normal renal function, received 36 treatment courses with either tobramycin (19) or gentamicin (17) to treat Pseudomonas pneumonia. Serum concentrations were determined after a 1.5-mg/kg dose to compute half-life (t 1/2), elimination rate constant (k), and apparent volume of distribution (V). From these values, doses were calculated to produce steady-state peak concentrations of 8.0 micrograms/ml with a dosing interval of every six hours. For tobramycin the mean (+/- SD) t1/2 was 1.0 (0.4) hours, V was 0.18 (0.06) l/kg, total body clearance (TBC) was 2.19 (0.71) ml/min/kg, and the calculated dose was 8.2 (2.1) mg/kg/day. For gentamicin t1/2 was 1.1 (0.5) hours, V was 0.20 (0.06) l/kg, TBC was 2.28 (0.89) ml/min/kg, and the calculated dose was 8.8 (2.4) mg/kg/day. The pharmacokinetic parameters were not statistically different between the two drugs, but the mean values of t1/2 and TBC of CF patients differed significantly from those of the control group. The calculated doses were larger than the manufacturer's maximum recommended dose of 7.5 mg/kg/day for 63% of tobramycin and 71% of gentamicin treatment courses. A dosing interval change to every four hours would have been appropriate in 28 of the 36 treatment courses (78%).(ABSTRACT TRUNCATED AT 250 WORDS)

Aspiration of blood from the jugular vein during intracarotid drug infusion in monkeys. Implications for extracorporeal drug removal

Circulation of blood in the ipsilateral jugular vein through an extracorporeal circuit for drug removal during intracarotid chemotherapy has recently been reported to decrease the systemic drug exposure. The reduced systemic exposure achieved by the use of this technique should permit a several-fold increase of the intracarotid dose of chemotherapy without increasing systemic toxicity. To determine the influence of the rate of blood removal from the jugular vein on the fraction of the blood flowing through the ipsilateral internal carotid artery (ICA) collected for extracorporeal drug removal, the authors aspirated blood from the jugular bulb into an extracorporeal circuit at varying rates during a constant infusion of the indicator dye, indocyanine green (ICG), into the ICA of rhesus monkeys. The fraction of the ipsilateral carotid blood channeled into the extracorporeal circuit increased linearly with the rate of aspiration of jugular blood. This suggests that the absence of valves in the intracranial venous system should permit increasing fractions of drug removal during intracarotid infusion by increasing the rate of collection of venous blood from the ipsilateral jugular bulb. The measurement of ICG concentrations in a similar manner in patients undergoing isolated perfusion may prove to be a clinically useful method for estimating the maximum safe dose in high-dose intra-arterial chemotherapy.

Managing the inventory control system

The four functions of management--planning, organizing, directing, and controlling--are described in relation to the hospital pharmacy inventory control system. Planning includes the development of inventory system objectives and identification of the resources needed to complete them. Organizing requires the manager to decide on the best method of grouping system activities and resources to complete the objectives in order of priority. Directing is a continual activity that involves obtaining optimal performance from the inventory system resources available. Controlling consists of regulation and verification of inventory system activities. The effective inventory system manager integrates planning, organizing, directing, and controlling in a continuous cycle.

Antibiotic preparation time in a horizontal laminar-airflow hood and in a biological-safety cabinet

Times for preparation of injectable antibiotics in syringes and minibags were compared using a horizontal laminar-airflow hood (HLAH) and a Class II biological-safety cabinet (BSC). Six i.v. admixture technicians who had previous experience with both types of hoods were observed during batch preparation of tobramycin, clindamycin, and cefamandole in syringes and tobramycin, clindamycin, and acyclovir in minibags. Before timing began, the drug products were reconstituted and labels were prepared. Mean times for syringes were 60.4 seconds (n = 267) for the HLAH and 65.9 seconds (n = 186) for the BSC (p greater than 0.05). For minibag doses, mean times were 64.9 seconds (n = 129) for the HLAH and 78.3 seconds (n = 126) for the BSC (p greater than 0.05). Technicians' times for aseptic preparation of injectable antibiotics in syringes and minibags were not significantly greater when the procedures were performed in a biological-safety cabinet than when a horizontal laminar-airflow hood was used.

Work-sampling evaluation of an upgraded outpatient pharmacy computer system

The effect of an upgraded outpatient pharmacy computer system on routine dispensing activities was studied. A computer system that previously generated patient bills, prescription labels, and management reports was upgraded to provide patient profiles, allergy and drug-drug interaction monitoring, auxiliary-label notification, and prescription prices. Four months after the upgraded system was implemented, dispensing activities were analyzed using a work-sampling technique. The percent of time spent in prescription processing, inventory maintenance, problem solving, or miscellaneous activities was determined. These data were compared with data obtained in a study of the old system. A total of 5897 observations of the upgraded system was compared with 5632 observations in the previous study. There were significantly different changes among the four activity groups for the total staff and for pharmacists, technicians, and the data-entry operator. Under the modified system, pharmacists spent more time in prescription coding and less time on patient counseling. The data-entry operator had less computer-entry time. It could not be stated conclusively that overall efficiency was improved by the new system.

Economies of purchasing group size

The relationship of drug price and purchasing group size was evaluated. Thirty drug line items were studied in 26 private hospital purchasing groups of various sizes. Prices were analyzed relative to purchasing group size, age, and location. Drug prices were negatively correlated to group size in a linear relationship. Prices were significantly lower in groups representing greater than 10,000 beds. No significant relationship was found between group age or location and drug prices. The theory that increasing purchasing group size will result in better contract prices was supported.

Pharmacist activities under alternative staffing arrangements

The proportions of time pharmacists spent in professional and nonprofessional activities is compared under alternative staffing arrangements. Daily activities were observed in three pharmacy satellites each serving approximately 100 beds of a 730-bed hospital. Ten pharmacy administrators and residents recorded more than 8000 observations over a 14-day period, 24 hours per day. In each observation, basic functions were noted; these were chosen from a list compiled to include all pharmacy activities. A specific staffing pattern was identified in each observation. The observations were then categorized as professional or nonprofessional activities as predefined by the majority of the pharmacy staff. As staffing patterns varied, significant differences occurred in the ratio of professional to nonprofessional activities. The greatest percentage of professional activity was observed when one pharmacist worked with more than one technician; where the staffing pattern contained more pharmacists than technicians, a smaller percentage of the pharmacists' time was used in professional activity. Overall, pharmacists were engaged in activities considered professional in 52% of the observations. Assuming that the most efficient use of pharmacy personnel involves a high ratio of professional to nonprofessional activity in the pharmacists' workload, the optimum staffing arrangement would include at least the same number of technicians as pharmacists. Factors other than staff mix affect efficient management of pharmacists' professional time.

Patient satisfaction with outpatient pharmaceutical services

Patient characteristics and satisfaction with outpatient pharmaceutical services at a large university hospital were assessed. A mail questionnaire was sent to 700 outpatients selected at random. Most questions had fixed-format answers. Of the 388 (58%) returned surveys, 335 (50%) were usable. A large segment of the respondents (40%) were between the ages of 18 and 34. Fifty-nine percent of the respondents paid for their own prescriptions, and this group was less likely to fill their prescriptions at the university pharmacy. Of the patients who received prescriptions but did not have them filled at the university, 29% were unaware of the existence of the pharmacy, 36% found the pharmacy inconvenient for refills, and 21% thought that the waiting time to get their prescriptions filled was too long. Of the respondents who received prescriptions, 46% ahd them filled at the university pharmacy. Convenience (55%), availability of medications (19%), and low prices (12%) were the major reasons given for going to the university pharmacy. No association was found between the distance from the university and the internal retention rate for prescriptions. Of those who went to the university pharmacy, 94% were satisfied with the services they received.

Therapeutic significance of the drug lag

This study evaluates the therapeutic significance of those drugs commercially available in foreign countries but not in the United States at the end of 1976. Of 198 drugs reviewed, 14% offered a potential therapeutic advance while 75% appeared to offer little or no advance. Another 10.5% could not be properly evaluated. Division by therapeutic class showed some groups to be disproportionate to the overall percentages. The cardiovascular group had a higher-than-average ratio of drugs that offered major advances, 23%. On the other extreme was the CNS group, for which a review of 37 drugs showed no drugs to represent a major advance. It is concluded that few "breakthrough" drugs in general use in other countries are being kept out of the United States drug market.