Evaluating dispensing error detection rates in a hospital pharmacy

OBJECTIVES

The filling of unit dose orders and checking for filling errors are two essential distributive responsibilities of a hospital pharmacy. Previous studies have shown that nonpharmacists, usually technicians, are capable of assuming these distributive tasks traditionally performed by hospital pharmacists. The study tested whether nonpharmacists, in this case licensed practical nurses/medication nurses, were as competent as pharmacists in checking for errors in unit dose cassettes prepared for hospital patients.

METHODS

A university teaching hospital was used for the study. Artificial errors (n = 812) were introduced into the drug distribution system during a 4-month period in 1995. Included in the study were seven staff pharmacists and nine medication nurses (licensed practical nurses) involved in the decentralized drug distribution system. The primary measure was the ratio of errors detected to the number of artificial errors introduced into the system. This primary measure is different from those used in prior studies that do not separate dispensing errors and checking errors.

RESULTS

Overall, pharmacists were significantly more accurate in detecting errors (87.7% vs. 82.1%). In one category of serious errors, that of wrong strength, the difference between pharmacists and licensed practical nurses was even greater (93.3% vs. 83.3%).

CONCLUSIONS

This study's results do not support conclusions of prior studies that nonpharmacists can match the error detection accuracy of pharmacists. It demonstrates the importance of considering the types of errors under examination and of using appropriate measures of error checkers when drawing conclusions on relative competence.

Comparable renal graft survival in African-American and Caucasian recipients

In past years, many pediatric transplant centers found African-American renal transplant recipients to have poor graft survival. Since 1991 anti-lymphocyte induction therapy has been routinely used for pediatric cadaveric (CAD) and living-related donor (LRD) renal allograft recipients at the University of Tennessee, Memphis. Sixteen African-American first renal allograft recipients received induction therapy: 11 CAD allografts (10 OKT3, 1 ATGAM) and five LRD (all ATGAM). Sixteen Caucasian recipients received induction therapy; 3 CAD (all OKT3), 1 living-unrelated donor (OKT3), and 12 LRD (9 ATGAM, 3 OKT3). Mean age at renal transplantation was 11.8 and 10.5 years for African-American and Caucasian recipients, respectively. Predicted graft survival (PGS) estimated by the Kaplan-Meier method for the African-American patients was 94% at both 1 and 3 years, and for Caucasian patients was 94% and 85% at 1 and 3 years, respectively. Eleven African-American CAD recipients had a PGS of 91% at 1 and 3 years. Renal allograft survival for African-American and Caucasian pediatric recipients at our center appears to be comparable. This could be due, in part, to the use of anti-lymphocyte induction therapy. However, other factors, such as improved compliance or better immunological and pharmacological monitoring, may also have contributed.

Mitochondrial control of apoptosis: the role of cytochrome c

Mitochondrial cytochrome c (cyt c) has been found to have dual functions in controlling both cellular energetic metabolism and apoptosis. Through interaction with apoptotic protease activating factors (Apaf), cyt c can initiate the activation cascade of caspases once it is released into the cytosol. The loss of a component of the mitochondrial electron transport chain also triggers the generation of superoxide. Although cyt c can be released independent of the mitochondrial permeability transition (MPT), the accompanying cellular redox change can trigger the MPT. Since another apoptotic protease, AIF, is released by MPT, the two separate pathways provide redundancy that ensures effective execution of the cell death program. Anti-apoptotic Bcl-2 family proteins function as gatekeepers to prevent the release of both cyt c and AIF. In spite of their stabilization effect on the mitochondrial outer membrane, Bcl-2 proteins may also be involved in the direct binding of Apaf molecules as regulatory elements further downstream from the mitochondrial apoptotic signals.

Glutathione measurement in human plasma. Evaluation of sample collection, storage and derivatization conditions for analysis of dansyl derivatives by HPLC

Literature values for human plasma GSH vary over 10-fold despite the use of apparently valid analytical procedures for GSH measurement. The purpose of this study was to develop a procedure to minimize error in sample collection, processing and storage that could contribute to such differences. HPLC with fluorescence detection of dansyl derivatives was used for quantification. The results show that collection of blood with a butterfly needle and syringe reduces overestimation due to limited hemolysis and that use of a preservation solution designed to inhibit autooxidation and enzymatic degradation allows quantitative recovery of both GSH and GSSG. Stability tests showed that non-derivatized samples were stable for at least 2 months at - 80 degrees while dansyl derivatives were stable in the dark at 0-4 degrees for 12 months. Results from 59 healthy individuals (20-43 years) provided a mean (+/-1 SD) GSH value of 2.09+/-1.14 micromolar.

Detection of pro-caspase-3 in cytosol and mitochondria of various tissues

Caspases are a family of cysteine proteases of critical importance in the apoptotic cell death process. They are normally present as zymogens (pro-caspases) in the cytoplasm of vertebrate and other organisms. In this study we have shown that pro-caspase-3 is localized to cytosol and mitochondria of various rat tissues (brain, heart, kidney, liver, spleen and thymus). Although the majority of pro-caspase-3 was localized in the cytosol, the amount of mitochondrial pro-caspase-3 was significant. The ratio of cytosolic and mitochondrial pools of pro-caspase-3 appeared to vary between different tissues. The higher amount of mitochondrial pro-caspase-3 was found in thymus and spleen, i.e. tissues in which spontaneous apoptosis plays an important role. Our findings provide further support for mitochondrial localization of pro-caspase-3 and the critical role of this organelle in apoptosis.

Cytochrome c release and caspase activation in hydrogen peroxide- and tributyltin-induced apoptosis

The ability of H2O2 and tributyltin (TBT) to trigger pro-caspase activation via export of cytochrome c from mitochondria to the cytoplasm was investigated. Treatment of Jurkat T lymphocytes with H2O2 resulted in the appearance of cytochrome c in the cytosol within 2 h. This was at least 1 h before caspase activation was observed. TBT caused cytochrome c release already after 5 min, followed by caspase activation within 1 h. Measurement of mitochondrial membrane potential (delta psi(m)) showed that both H2O2 and TBT dissipated delta psi(m), but with different time courses. TBT caused a concomitant loss of delta psi(m) and release of cytochrome c, whereas cytochrome c release and caspase activation preceded any apparent delta psi(m) loss in H2O2-treated cells. Thus, our results suggest that different mechanisms are involved in triggering cytochrome c release with these apoptosis-inducing agents.

Superoxide in apoptosis. Mitochondrial generation triggered by cytochrome c loss

Activation of apoptosis is associated with generation of reactive oxygen species. The present research shows that superoxide is produced by mitochondria isolated from apoptotic cells due to a switch from the normal 4-electron reduction of O2 to a 1-electron reduction when cytochrome c is released from mitochondria. Bcl-2, a protein that protects against apoptosis and blocks cytochrome c release, prevents superoxide production when it is overexpressed. The switch in electron transfer provides a mechanism for redox signaling that is concomitant with cytochrome c-dependent activation of caspases. The block of cytochrome c release provides a mechanism for the apparent antioxidant function of Bcl-2.

Glutathione in human plasma: decline in association with aging, age-related macular degeneration, and diabetes

Blood samples were analyzed for GSH and GSH redox state in 40 age-related macular degeneration (ARMD) patients (> 60 y), 33 non-ARMD diabetic patients (> 60 years), 27 similarly aged non-ARMD and nondiabetic individuals (> 60 years), and 19 younger individuals (< 60 years) without ARMD or diabetes. Results showed a significantly lower plasma GSH in older individuals (ARMD, diabetes, and controls) than in younger individuals (p < .01). Total GSH (GSHt) obtained following treatment with dithiothreitol was significantly lower only in diabetic cases (p < .05) but also approached significance for ARMD cases (p = .089). Estimation of redox potential indicated that the plasma GSH pool is considerably more oxidized in all of the older groups. Analyses of whole blood GSH showed that GSH was significantly lower in diabetic cases compared to the other groups, but did not reveal any difference associated with age or ARMD. In contrast, GSSG in whole blood was significantly higher in the older groups compared to the younger controls. The results suggest that in studies of age-related pathologies, oxidation of GSH may be a more important parameter than a decline in pool size, while in specific pathologies such as diabetes, both oxidation and a decline in pool size may be important.

Glutathione oxidation is associated with altered microtubule function and disrupted fertilization in mature hamster oocytes

We hypothesized that depletion of glutathione (GSH) with diamide, a relatively specific GSH oxidant, may alter the meiotic spindle apparatus in mature hamster oocytes. Immunofluorescent analysis of oocytes exposed to diamide for 1.5 or 3 h revealed time- and concentration-dependent disruption of spindle morphology accompanied by chromosome clumping. In oocytes first cultured in diamide for 1.5 h and then in diamide-free medium for 1.5 or 3 h, microtubules appeared to repolymerize, but normal spindle structure was not regained. HPLC confirmed that diamide oxidized oocyte GSH under conditions identical to those associated with spindle-related abnormalities. Exposure of oocytes to 25 or 50 microM diamide before in vitro fertilization did not affect their ability to undergo fertilization. A significant proportion of the fertilized oocytes that had been exposed to 50 microM diamide before insemination exhibited abnormal multiple female pronuclei with an apparently normal male pronucleus. These observations indicate that mature hamster oocytes are susceptible to oxidative stress during the critical period that precedes fertilization and provide further evidence that GSH plays important roles in oocyte spindle function and pronucleus development.

Ascorbate deficiency and oxidative stress in the alveolar type II cell

The objective of this study was to determine the impact of limited ascorbate (Asc) availability on type II cell sensitivity to oxidant stress. Guinea pigs were fed diets with or without Asc for 18 days, and type II cells were isolated. Although lung Asc was decreased by 90% in deficient animals (scorbutic), type II cell Asc was decreased by 50%. Upon treatment with 250 microM H2O2, the necrotic injury was twofold greater in scorbutic cells compared with control cells. With 100 microM H2O2 treatment, apoptotic injury was twofold greater in scorbutic cells compared with control cells. Although there was less necrotic injury in cells exposed to 95% O2, the scorbutic cells were more sensitive than control cells. Asc pretreatment protected against necrosis and apoptosis. The Asc analog isoascorbate provided partial protection and suggested that part of the protection was not chemical detoxification but was Asc specific. We conclude that limited Asc availability resulted in a functional type II cell but a cell more sensitive to oxidant-induced injury.

Mitochondria-mediated cell injury. Symposium overview

Mitochondria have long been known to participate in the process of cell injury associated with metabolic failure. Only recently, however, have we come to appreciate the role of mitochondria as primary intracellular targets in the initiation of cell dysfunction. In addition to ATP synthesis, mitochondria are also critical to modulation of cell redox status, osmotic regulation, pH control, and cytosolic calcium homeostasis and cell signaling. Mitochondria are susceptible to damage by oxidants, electrophiles, and lipophilic cations and weak acids. Chemical-induced mitochondrial dysfunction may be manifested as diverse bioenergetic disorders and considerable effort is required to distinguish between mechanisms involving critical mitochondrial targets and those in which mitochondrial dysfunction is secondary and plays only a modulatory role in cell injury. The following paragraphs review a few important examples of chemical-induced cytotoxic responses that are manifested as interference with mitochondrial metabolism and bioenergetics, gene regulation, or signal transduction in the form of apoptosis and altered cell cycle control. Greater understanding of the molecular mechanisms of mitochondrial bioenergetics, ion regulation, and genetics will lead to numerous additional examples of mitochondria-mediated cell injury, revealing important new insight regarding the prediction, prevention, diagnosis, and treatment of chemical-induced toxic tissue injury.

Prevention of apoptosis by Bcl-2: release of cytochrome c from mitochondria blocked

Bcl-2 is an integral membrane protein located mainly on the outer membrane of mitochondria. Overexpression of Bcl-2 prevents cells from undergoing apoptosis in response to a variety of stimuli. Cytosolic cytochrome c is necessary for the initiation of the apoptotic program, suggesting a possible connection between Bcl-2 and cytochrome c, which is normally located in the mitochondrial intermembrane space. Cells undergoing apoptosis were found to have an elevation of cytochrome c in the cytosol and a corresponding decrease in the mitochondria. Overexpression of Bcl-2 prevented the efflux of cytochrome c from the mitochondria and the initiation of apoptosis. Thus, one possible role of Bcl-2 in prevention of apoptosis is to block cytochrome c release from mitochondria.

A model for light toxicity of cultured human retinal pigment epithelium

BACKGROUND

The effect of visible light on human retinal pigment epithelial (HRPE) cells has not been characterized under conditions that provide strict thermal control.

METHODS

HRPE cells were isolated and grown to confluence. Cells were exposed to light in an incubator in which the cell temperature was controlled in response to a temperature sensor maintained in the tissue culture medium. Cells were exposed: (A) for 24, 36, and 48 h; and using a 24-h exposure followed by 24 h darkness; (B) at varying intensities of light using neutral density filters; (C) under a yellow filter; and (D) with a 12-h on-off cyclic light.

RESULTS

(A) Light exposure of 36 and 48 h resulted in significant cytotoxicity, while the initial 24-h exposure did not induce subsequent cytotoxicity. (B) Light irradiance levels from 43 to 54 mW/cm2 were required to demonstrate cytotoxicity. (C) Use of a yellow filter did not eliminate the observed cytotoxicity. (D) Cyclic exposure did not result in significant cytotoxicity.

CONCLUSION

This study establishes a model and basic parameters of light toxicity to HRPE cells in vitro using strict temperature control that may be used to evaluate photochemical injury to HRPE cells.

Epitope mapping using histidine-tagged protein fragments: application to Escherichia coli RNA polymerase sigma 70

We present a simple, rapid, and inexpensive method for mapping epitopes of monoclonal antibodies using His-tagged protein fragments. In essence, four steps are involved: (i) purify overproduced His-tagged protein from inclusion body; (ii) fragment the protein by partial chemical or enzymatic hydrolysis and isolate the His-tagged peptides with a Ni(2+)-chelate column to generate a "ladder" containing a distribution of peptide fragment sizes; (iii) fractionate the isolated peptides by SDS-polyacrylamide gel electrophoresis and probe the ladder by immunoblot analysis; (iv) determine the size of the fragments that do and do not bind the monoclonal antibody using size markers specific to the His-tagged protein being studied. We have applied this method successfully to map the epitope positions of known and new monoclonal antibodies to Escherichia coli sigma 70. We believe this method will find broad application.