A system for monitoring and dispensing epoetin

This article describes one hospital's system of providing epoetin therapy for patients with renal failure undergoing dialysis. Nurses complete a drug dosing worksheet which alerts pharmacists to the need for both epoetin and iron dextran doses. The patient's weight and hematocrit are included on the form as are initial dose calculations made by the nurse. Pharmacists use this information for patient monitoring and double checking dose calculations. Then individually packaged unit dose injectables are prepared by pharmacy for use by nurses. A drug use evaluation for epoetin assures that appropriate use criteria are fulfilled when epoetin is used.

Cultured skin fibroblasts in schizophrenia: quantitative two-dimensional electrophoresis

Recent developments in the standardization and commercial availability of quantitative high resolution two-dimensional electrophoresis make feasible the systematic search for protein alterations characteristic of psychiatric disorders. To avoid the effects of such variables as drug intake or diet on quantitative protein makeup that might obscure its relationship to diagnosis, the investigators studied cultured fibroblasts derived from the skin biopsies of psychiatric patients. Although the method was able to resolve human fibroblast protein mixtures into 1,125 spots, no significant deviation in the quantitation of any individual spot was found to characterize the fibroblasts of patients with schizophrenia.

TRH attenuates scopolamine-induced memory impairment in humans

The brain tripeptide thyrotropin-releasing hormone (TRH) has been demonstrated to facilitate cholinergic neurotransmission. To test its interaction with the cholinergic system in humans, high-dose TRH (0.5 mg/kg) or placebo was administered intravenously (IV) to normal controls pretreated with scopolamine (0.5-0.75 mg IV), a centrally active muscarinic antagonist, which has been used to model aspects of the memory impairment of normal aging and of dementia. Compared to placebo, TRH markedly attenuated scopolamine-induced impairment of some measures of memory, most notably on a selective reminding task. This cognitive study is the first in humans to suggest a neuromodulatory effect of a peptide on the cholinergic system, and suggests a facilitatory role for TRH in human memory processes.

Absence of nimodipine premedication effect on memory after electroconvulsive therapy

While highly efficacious for affective disorders, electroconvulsive therapy (ECT) is sometimes accompanied by troublesome although temporary cognitive dysfunction. We speculated that the efficacy of ECT can be separated from its cognitive dysfunction by administration of nimodipine, a calcium channel blocker that crosses the blood-brain barrier and has prevented electroshock-induced amnesia in animal studies. However, in our single-blind repeated-measures trial on 8 patients, nimodipine 30-60 mg orally 2 h prior to ECT was indistinguishable from placebo in effects on verbal learning and retrograde and anterograde memory during the 2 h after ECT.

Clinical heterogeneity and treatment response in inclusion body myositis

Inclusion body myositis has been described as an inflammatory myopathy with distinctive clinical and pathologic features that is refractory to treatment. Ten cases of inclusion body myositis, as defined by histopathologic findings, were reviewed to determine whether the clinical characteristics are different in patients whose disease has been defined by light and electron microscopic studies compared with those whose disease has been defined by light microscopic studies alone. The clinical characteristics of both groups of patients were similar, and 2 patients have had excellent responses to treatment. Although inclusion body myositis represents a histologic subset of polymyositis, from a clinical perspective, it must be considered a nonspecific designation. Despite a generally poor prognosis, therapeutic intervention is still warranted.

Acute effects of high-dose thyrotropin releasing hormone infusions in Alzheimer's disease

Thyrotropin releasing hormone (TRH) was administered intravenously to ten patients with Alzheimer's Disease (AD) in a high-dose paradigm, thought to maximize central nervous system effects and potentially produce facilitation of cholinergic function, a known property of the neuropeptide. Acute effects of TRH on behavioral, cognitive and physiologic measures were assessed after patients received 0.1 mg/kg TRH, 0.3 mg/kg TRH and placebo, the higher TRH dose and placebo being given in a randomized, double-blind fashion. Patients showed statistically significant increases in arousal and improvement in affect, as well as a modest improvement in semantic memory, all after receiving the higher TRH dose. Both TRH doses produced transient rises in systolic blood pressure, with no effect on diastolic blood pressure, heart rate or temperature. This study suggests that high-dose TRH can be safely administered to AD patients and is neurobehaviorally active; further studies are needed to determine the extent and mechanism of the cognitive and psychobiological properties of this peptide in AD and other neuropsychiatric disorders.

High-dose naloxone in older normal subjects: implications for Alzheimer's disease

The behavioral and cognitive effects of naloxone HCl, in doses of 5 micrograms/kg, 0.1 mg/kg, and 2.0 mg/kg administered as an IV bolus, were assessed in a double-blind, placebo-controlled, randomized study of eight normal subjects ranging in age from 44 to 74 years (mean 63). Naloxone produced mild behavioral effects with slight cognitive impairment after the 2.0 mg/kg dose only. The threshold, dose dependency, characteristics, and magnitude of these behavioral effects were similar to what has previously been reported in young normal subjects, but markedly different from those observed in patients with dementia of the Alzheimer type (DAT) matched in age to the current study sample. These data suggest that the metabolic fate of naloxone is not substantially affected by age within the range studied. The findings of this study provide further support for a role for endogenous opiate systems in the modulation of behavior and cognition, and suggest that the unusual behavioral sensitivity of patients with DAT to naloxone cannot be accounted for by the effect of age.

Psychiatric rehabilitation programs: putting concepts into practice?

Mental health settings serving the severely psychiatrically disabled or the long-term chronic client have begun developing a rehabilitation orientation in an attempt to increase their effectiveness with this group. The authors have, in an earlier work, described basic elements of a rehabilitation program. These elements have been refined. Forty rehabilitation-oriented community and hospital agencies were assessed in terms of the presence or absence of these elements of a rehabilitation approach. Results indicate that the programs in the agencies clearly value client involvement and a program focus on improving skill and resource utilization. These concepts, however, are only beginning to be systematically implemented in practice.

Professional pre-service training for working with the long-term mentally ill

The knowledge base with respect to helping persons with long-term mental illness is expanding dramatically. Specific skills can be identified as critical for those who work with the long-term mentally ill. In contrast to in-service training, preservice (university-based) programs have been slow in offering relevant skills-based curricula. A model is proposed for describing current and future pre-service curricula. Curricula can be categorized as to whether it provides exposure, experience, or expertise in working with the long-term mentally ill. More than ever before the pre-service training programs seem ripe for the introduction of skill-based curricula relevant to helping persons who are psychiatrically disabled.

Kainic acid induced damage to the striatum increases DT diaphorase activity

A significant increase in the striatal specific activity of DT diaphorase is demonstrable from one to six weeks after intrastriatal injection of kainic acid (KA). At six weeks, there is a significant dose-response relation (ANOVA, F(2,18) = 25.8, p less than 0.001); 1, 3 and 5 nmoles produce 12.3, 39.6 and 118% increases, respectively. Loss of acetylcholinesterase activity (AChE), used as an indicator of neuronal damage, is positively correlated with the enhanced DT diaphorase activity (r = 0.823, p less than 0.01).

Cultured skin fibroblasts in schizophrenia: acute growth and susceptibility to damage

The study of cultured fibroblasts derived from skin biopsies of patients with inherited neurodegenerative disorders has aided in the elucidation of their pathological basis. This usefulness might be expected to extend to the study of fibroblast characteristics in schizophrenia in view of recent evidence of neurodegenerative changes in the disorder. In this study, the acute growth characteristics and response to toxic oxygen metabolites of fibroblast cell lines derived from skin biopsies of patients with schizophrenia (n = 9) are compared with those derived from psychiatric patients with various diagnoses not associated with a deteriorating course (controls = 11). No significant differences between the cell lines of the two patient groups are found.

Detoxification enzymes following intrastriatal kainic acid

A complete explanation of the neurotoxicity that follows kainic acid (KA) injection into the rat striatum is lacking. An assessment of the chronological course after intrastriatal KA injection of the activities of enzymes preferentially concentrated in glia or involved in the detoxification of oxygen metabolites is accomplished. An enhancement of the specific activities of glutathione peroxidase (GP) and catalase is found without an alteration in the specific activity of superoxide dismutase (SOD). There is no increase in the in vivo striatal levels of malondialdehyde, a putative indicator of lipid peroxidation, the expected result of cell membrane damage from oxygen metabolites. Understanding the mechanism and importance of the preferential induction of the activities of the detoxification enzymes will require further study.

Free radical scavenging systems and the effect of peroxide damage in aged human skin fibroblasts

One prominent theory of aging postulates an accumulation of cell damage resulting from nonenzymatic chemical reactions between important cellular components and free radicals. Fibroblast lines derived from skin biopsies of psychiatric patients ranging in age from 22 to 70 were evaluated soon after adaptation to culture. No significant correlation was found between donor age and the detoxification enzyme activities of superoxide dismutase (SOD) or aryl hydrocarbon hydroxylase (AHH) or susceptibility to damage by oxygen metabolites as measured by cell viability or lactate dehydrogenase (LDH) leakage.

Freeing pharmacist time and providing basic clinical services in an 89-bed community hospital

The institution of clinical services in a small community hospital can be accomplished with a mix of the right personnel and a proper environment and approach. Valuable, cost-effective clinical services can be performed with present staff levels in many hospitals. We describe how we went about examining our pharmacy service and making improvements in efficiency in order to free pharmacist time for provision of clinical services. We believe that gathering personnel time to use for clinical functions is a matter of timing, organization, and making every day tasks more efficient.

Naloxone and Alzheimer's disease. Cognitive and behavioral effects of a range of doses

There have been conflicting reports on the effects of naloxone hydrochloride in patients with dementia of the Alzheimer type (DAT). In addition, none of the naloxone studies in DAT used doses of 2.0 mg/kg or more, the amount necessary to produce reliable cognitive and behavioral changes in young normal subjects. In a randomized, double-blind, placebo-controlled study, 12 patients with DAT were administered naloxone hydrochloride in doses of 5 micrograms/kg, 0.1 mg/kg, and 2.0 mg/kg, with detailed evaluation of its behavioral and cognitive effects using measures selected for their potential relevance to DAT and the known effects of blockade of endogenous opiate systems. None of the measures of motor performance, attention, memory, learning, or recognition showed improvement with naloxone. Increased inappropriate verbal productions were noted after 0.1 mg/kg of naloxone hydrochloride. Patients became irritably activated after this dose, which may account for the altered verbal behavior in this study and also for some of the changes suggesting cognitive improvement in prior studies. Differences in the sensitivity and dose dependency of the behavioral effects in patients with DAT compared with prior studies in young normal subjects merit further investigation.

Foot shock induces time and region specific adrenergic receptor changes in rat brain

Rats were subjected to 1 hr or 2 hr of electric foot shock for 1 day or 7 days and adrenergic receptor binding was evaluated in the hypothalamus, brainstem and cortex. beta-Adrenergic receptor density in the hypothalamus was dramatically reduced following 1 hr of shock. Following repeated shock, alpha 2-adrenergic receptors in the cortex and brainstem were observed to increase. Cortical alpha 2-adrenergic receptors were more sensitive to stress than the alpha 2-adrenergic receptors of the brainstem, alterations in the latter only reaching statistical significance following 7 days of shock and 24 hr of recovery. alpha 1- and beta-adrenergic receptors in the brainstem and cortex were relatively resistant to stress induced changes. The significance of type of stress, duration of stress, and strain of rat for understanding the current data are discussed in the context of prior reports of stress induced receptor changes.

Endogenous opioid regulation of hypothalamo-pituitary-adrenal axis activity in schizophrenia

We utilized a naloxone challenge strategy to investigate the functioning of the endogenous opioid system (EOS) in schizophrenia. Patients with schizophrenia, who were on neuroleptic medication or drug-free, demonstrated a significantly larger serum cortisol response to opioid blockade by naloxone than did age- and sex-matched normal controls. Patients, but not normal controls, also demonstrated an inverse relationship between baseline cortisol and the magnitude of the response. This enhanced cortisol response is consistent with tonic hyperactivity of the EOS in schizophrenia.

Design and interpretation of opiate antagonist trials in dementia

In view of the reports of possible beneficial effects of naloxone in dementia, rationales and strategies for studying endogenous opiate systems are reviewed. Important considerations in the design and interpretation of clinical investigations using naloxone are also reviewed. The nature and distribution of endogenous opiate systems are summarized from an historical perspective. Endogenous opiate systems are distributed throughout the central nervous system and play important roles in a variety of brain functions, including memory and learning. In view of this, several rationales are evident for studying endogenous opiate systems in dementia, since it is a syndrome in which structures known to contain opiate systems are disturbed, functions modulated by opiate systems are disturbed, and other neurotransmitter systems (functionally linked to endogenous opiate systems) are disturbed. Different strategies for studying endogenous opiate systems are reviewed, including examination of body fluids and pharmacologic challenge studies. Naloxone hydrochloride, a competitive opiate receptor antagonist, is a commonly used pharmacologic agent. The design of a multidose naloxone study of 12 dementia patients is discussed, with reference to the pharmacokinetics, pharmacodynamics, and specificity of naloxone as well as to the nature of the dependent measures selected for this study. No cognitive benefit was observed in this study. Behavioral arousal was observed at naloxone doses, with more evident psychomotor retardation at higher doses. These findings are contrasted with the results of naloxone challenges in other studies. The varying effects of naloxone within and across populations can be conceptualized in terms of the basic and clinical considerations previously discussed. The importance of dose-finding studies is stressed for this and other drug trials.

How health professionals react to their own commission of serious medication errors

It is our intention to learn about how health professionals react to commission of a serious error and learn more about how these situations are handled, in a supervisory sense, by hospital officials. From the information collected, we hope to be able to profile the people who are most likely to make serious errors, learn more about the environment for such disasters, and finally, establish a list of recommendations for supervisory personnel to use in handling the employee making a serious error.

Hormonal effects of high dose naloxone in humans

Utilizing a double-blind crossover design, the hormonal effects of high dose, 2 mg/kg, were compared to low dose, 0.4 mg (approx. 5 micrograms/kg), naloxone administration in physically healthy humans. A significant naloxone dose effect on plasma cortisol levels was found (p less than 0.001), but no significant effect on plasma or serum levels of prolactin, follicle stimulating hormone, luteinizing hormone, norepinephrine or epinephrine. These results confirm involvement of the endogenous opioid system (EOS) in the tonic regulation of the hypothalamicpituitary-adrenal axis, but fail to find evidence of EOS involvement in the regulation of adrenal medullary function or the gonadotrophic axis in man. The results are however consistent with a continuing action of naloxone as an EOS antagonist even at high doses in man.

ACTH 1-24-induced potentiation of norepinephrine contractile responses in aortic strips from spontaneously hypertensive (SH) and normotensive (WKY) rats

Norepinephrine (NE)-induced contractile responses were less in aortic strips from SH compared to WKY rats. ACTH 1-24 potentiated NE responses in both SH and WKY aortic strips. This effect was more potent in SH aortic strips. NE-induced contractions in SH aortic strips were less sensitive to changes in external Ca2+ levels than were those of WKY aortic strips. ACTH 1-24 did not potentiate NE responses under low external Ca2+ conditions in SH aortic strips or under high external Ca2+ conditions in WKY aortic strips. The greater sensitivity of NE responses following ACTH 1-24 in SH aortic strips may imply that this peptide is modulating a mechanism related to an impaired contractility and that Ca2+ plays a key role in the observed effects.

Endogenous opioid activity in clinical hemorrhagic shock

Plasma beta-endorphin, cortisol and total opioid-like activities were measured upon arrival at the hospital in ten patients with extensive trauma and in a state of shock and 11 patients with minor injury. Patients in a state of shock had significantly (p less than 0.01) higher mean plasma beta-endorphin immunoreactivity than patients with minor trauma (128.8 +/- 24.8 picomolars versus 31.7 +/- 5.6 picomolars). There were no significant intergroup differences in the mean plasma cortisol concentration (27.7 +/- 4.7 micrograms per deciliter versus 20.6 +/- 2.7 micrograms per deciliter) or opioid ligand activity (2.28 +/- 0.62 nanomolars versus 3.17 +/- 0.99 nanomolars). These data are consistent with the hypothesis that certain endogenous opioids may be physiopathologic factors in hemorrhagic shock but provide no proof of a cause and effect relationship.

Naloxone reduces food intake in humans

Hypotheses generated from animal studies that the endogenous opioid system is an important modulator of food intake suggest that blockade of the system in humans should affect eating behavior. To assess this hypothesis, seven normal volunteers were given 2 mg/kg naloxone or placebo on separate days in a double-blind, random but balanced cross-over experimental design. Compared to placebo, naloxone was found to reduce significantly total food intake from preselected prepared trays served 2.75 and 7.75 hours after drug administration (p less than 0.02). The reduction was considerable (28%), and although the magnitude varied greatly among individuals, reduction occurred in each. This reduced food intake was not accompanied by a demonstrable alteration of the volunteers' perceptions of their hunger. Further cautious experimental investigation of naloxone's effects during long-term administration and in patients with eating disorders is warranted in light of its apparent effect of reducing food intake in humans while not decreasing their satiety.