Using the Pharmacist Interaction Tracking Tool for Capturing Student-Patient Interactions in Direct and Simulated Patient Care Activities

Objective. To create and implement a standardized data collection tool for capturing student-patient interactions in direct and simulated patient care activities. Design. Faculty members and students determined key elements, design, and an implementation plan for the tool, which was to be used by students across professional years to quantify numbers and types of interactions with patients for tracking student progression toward achievement of curricular outcomes. Assessment. During the 2013-2014 academic year, 27 778 entries were completed, with 17 767 (64%) advanced pharmacy practice experiences, 7272 (26%) introductory pharmacy practice experiences, and 2739 (10%) simulation. Direct patient care interactions occurred with 11 090 patients and 10 983 providers, with 14 252 drug-related problems identified. Data was used by students for their professional portfolios, by administrators for curricular assessment, and to student impact on patient care. Conclusion. The PITT Form enabled the collection of data from actual and simulated patient care activities, allowed for curricular assessment of activities across years, and was used by individual students.

Changes in Student Performance and Confidence with a Standardized Patient and Standardized Colleague Interprofessional Activity

OBJECTIVE

To assess the impact of a standardized patient and standardized colleague interprofessional activity on student performance and perceived confidence in communicating with patients and physicians.

METHODS

Students in the third professional year were presented with a practice and final activity including a standardized patient interaction, SOAP note preparation, and standardized colleague interaction. Student performance was measured by assessment rubrics on practice and final activities. Students' perceived confidence was measured via presurvey and postsurvey.

RESULTS

Students performed significantly better from the practice to the final activity with regard to communicating with patients, SOAP note, and the overall activity with a mean difference (95% CI) of 9.2 (6.9-11.5), 3.6 (1.3-5.8), and 3.9 (2.0-5.7), respectively. There was a positive significant change from presurvey to postsurvey in students' confidence talking to patients and physicians on majority of questions.

CONCLUSION

This study demonstrates that active learning and integrated assessments improve overall student performance. Integration of interprofessional education also has positive effects on students' perceived confidence.

Evaluating Pennsylvania Pharmacists' Provision of Community-based Patient Care Services to Develop a Statewide Practice Network

OBJECTIVE

To identify and describe Pennsylvania pharmacists who currently provide or are interested in providing community-based patient care services and are interested in joining a statewide practice network.

DESIGN

Cross-sectional survey.

SETTING

February to June 2009 in Pennsylvania.

PARTICIPANTS

1700 pharmacists.

INTERVENTION

Mailed and electronic survey.

MAIN OUTCOME MEASURES

Number and geographic location of pharmacists providing or interested in providing community-based patient care in Pennsylvania. Description of patient care documentation methods; physical space; services provided; perceived barriers to providing patient care; training needs; and interest in joining a statewide practice network.

RESULTS

The final analysis included data from 1700 pharmacists. Approximately one-third of pharmacists (n=554) were providing patient care services to community-based patients. Most were routinely documenting (67.5%) and many had a semi-private or private space to provide care. MTM and immunizations were the most common services provided. Respondents reported the most significant barrier to providing MTM, diabetes education, and smoking cessation education was time constraints, whereas training was a barrier for immunization provision. Most pharmacists were not being compensated for patient care services. Of the 869 pharmacists interested in joining a statewide network, those providing care were more interested in joining than those who were not (70.8% vs. 43.8%, p < 0.001). CONCLUSION: Pennsylvania pharmacists are interested in providing community-based patient care services and joining a statewide practice network focused on providing community-based patient care services. This research serves as a foundation for building a pharmacist practice network in Pennsylvania.

An introductory pharmacy practice experience providing pharmaceutical care to elderly patients

OBJECTIVE

To develop, integrate, and assess an introductory pharmacy practice experience (IPPE) in providing pharmaceutical care to patients at senior centers (Silver Scripts).

DESIGN

First-year pharmacy students learned and practiced the pharmaceutical care process in the classroom to prepare for participation in the Silver Scripts program, in which the students, under faculty mentorship, conducted comprehensive medication reviews for senior citizens attending senior centers in Pittsburgh, Pennsylvania.

ASSESSMENT

Students, preceptors, and senior center staff members indicated the experience was positive. Specifically, first-year students felt they gained benefit both from an educational standpoint and in their own personal growth and development, while staff contacts indicated the patients appreciated the interaction with the students.

CONCLUSION

The Silver Scripts experience is a model for linking classroom experiences and experiential learning. The cycle of experiencing, reflecting, and learning has provided not only a meaningful experience for our P1 students but also a worthwhile focused review of seniors' medication use. This experience could be used as a model for other colleges and schools of pharmacy and their communities.

Implementation of a Medication Therapy Management Program in a Hospital-Based Outpatient Pharmacy

Purpose

To describe the integration of a medication therapy management (MTM) service in a hospital-based outpatient pharmacy, including adapting Medicare-based screening criteria to target a primarily non-Medicare population, integrating data into the medical center's electronic medical record, and designing a method to track identified drug-related problems (DRPs).

Methods

The hospital-based outpatient pharmacy at the University of Pittsburgh Medical Center (UPMC) established an MTM service to enhance patient medication safety. Identification criteria were developed in accordance with the Medicare Modernization Act of 2003 and institutional practices: older than 65 years, more than 5 chronic medications, more than 3 chronic disease states, presence of diabetes, tobacco use, or possible adverse drug event (ADE). As this was a proof of concept pilot, both Medicare and non-Medicare patients were included. Additionally, an intervention tracking form was developed to use in conjunction with the medical center's electronic medical record.

Results

During an 18-month period, 319 patients met the criteria upon random screening. Sixty-eight patients enrolled in the MTM program, resulting in 234 patient visits. One hundred and seventy DRPs were identified, with 2.5 DRP per patient. The most common problems found were the need for additional drug therapy and nonadherence. The overall physician acceptance rate for recommendations was 69%.

Conclusion

MTM programs are adaptable to a hospital-based outpatient pharmacy utilizing Medicare-based screening criteria in a primarily non-Medicare population resulting in identification of DRPs.

A small sample randomized clinical trial methodology using N-of-1 designs and mixed model analysis

BACKGROUND/OBJECTIVES

To date, research on substance abuse prevention relied extensively on large sample randomized clinical trials to evaluate intervention programs. These designs are appropriate for certain types of randomized prevention trials (e.g., efficacy or effectiveness for broad populations) but are unfeasible for other prevention science scenarios (e.g., rare pathologies, pilot studies, or replication tests at specific locales).

METHODS

An alternative randomized clinical trial is described that relies on much smaller samples, less resources than the large sample designs, randomization, N-of-1 designs for the intervention group, and mixed model analysis.

RESULTS

This methodology is illustrated using a small sample prevention study, which demonstrates its statistical power, flexibility, and sophistication for experimental testing of prevention-oriented research questions.

SCIENTIFIC SIGNIFICANCE

This methodology can be applied to many existing prevention datasets to facilitate secondary analyses of existing datasets as well as novel studies. It is hoped that such efforts will include further development of the small sample design in substance abuse prevention contexts.

Instructor satisfaction with a technology-based resource for diabetes education

OBJECTIVES

To evaluate instructor use patterns and satisfaction with DM Educate, a comprehensive, Web-based diabetes course.

METHODS

Instructors completed a post-course survey instrument to assess their use of course materials and components, as well as satisfaction with the course content, design, and technology utilized, and to solicit their suggestions for additional content areas.

RESULTS

Thirty-eight percent of respondents utilized DM Educate as a standalone elective and 62% had integrated materials into existing courses. The pharmacotherapy module was the most utilized at 91% and slide sets were the most utilized course components at 63%. All instructors stated that they would use the course again the following year. Suggestions for improvement included incorporation of more active-learning activities and patient cases.

CONCLUSION

Instructors' were highly satisfied with the course materials and technology used by DM Educate, a Web-based diabetes education course, and indicated they were able to customize the course materials both to establish new courses and supplement existing courses. All instructors planned to use the course again.

Evaluation of INR Monitoring Frequency and Time in Therapeutic Range

Background:

Although anticoagulant therapy has been used for more than 50 years, the optimal interval between international normalized ratio (INR) measurements in patients who demonstrate a stable dose response remains unsettled. Based on the results of observational studies, the American College of Chest Physicians currently recommends that patients receiving a stable dose of warfarin undergo INR testing at least once every 4 weeks.1

Objective:

To determine whether an increased frequency of INR monitoring impacts time in therapeutic range (TTR) among patients receiving maintenance warfarin therapy managed by an anticoagulation clinic.

Methods:

A total of 2,222 INR results belonging to more than 700 adults who were followed by the anticoagulation service at the University of Pittsburgh Medical Center and who were receiving maintenance warfarin therapy between April 1, 2006, and September 30, 2006, were retrospectively reviewed. INR measurements were categorized as having been determined fewer than 21 days or 21 or more days after the previous measurement, and the percentage of INRs within the therapeutic range was calculated for each interval.

Results:

During the evaluation period, INRs measured within 21 days of the preceding test were within the therapeutic range 75.1% of the time, whereas INRs obtained at least 21 days after the antecedent INR test were within the therapeutic range 79.9% of the time (p < 0.001). Additionally, the proportion of INRs below 1.5 or above 5.0 was not significantly different between the 2 groups, representing only 0.04% of all results at either interval (p > 0.05).

Conclusions:

Our evaluation suggests that more frequent INR monitoring among patients receiving maintenance warfarin does not impact TTR to a clinically meaningful extent. Moreover, these findings support the reevaluation of the anticoagulation service management algorithm to reduce the frequency of INR measurements among patients within the maintenance phase of therapy.

Advanced Practice Programs in Hospital Pharmacy: Pharmacy-Based Immunization

The Director's Forum series is written and edited by Michael Sanborn and Robert Weber and is designed to guide pharmacy leaders in establishing patient-centered services in hospitals and health systems. Another specific goal of this column is to address many of the key challenges that pharmacy directors currently face, while providing information to foster growth in pharmacy leadership and patient safety. This month's article describes providing immunizations in a hospital-based retail pharmacy. As the pharmacists' role in immunization evolves to one of procurement, advocacy, and immunizer, hospitals can provide a valuable public health service to patients using hospital-based retail pharmacies. Developing this program may also further develop more advanced-practice programs in patient medication education and medication therapy management.

A Web-based interprofessional diabetes education course

OBJECTIVE

To develop a comprehensive diabetes management course for pharmacy students that is available to all colleges and schools of pharmacy via the Internet.

DESIGN

DM Educate, a Web-based course consisting of 12 topic modules with video lectures, active-learning exercises, and test questions prepared by nationally recognized experts was developed. The modular design allows use as a standalone, 3-credit course or use of individual module content as a supplement to an existing course.

ASSESSMENT

Two pilot studies found the comprehensive, interprofessional nature of the material beneficial for learners. Students showed a significant increase in knowledge of the subject material by correctly answering 26 of 34 questions on the posttest compared to answering only 14 of 34 questions correctly on the pretest (p < 0.001). Student feedback was positive for the flexibility of the Web-based format.

CONCLUSION

Pilot studies demonstrated the effectiveness of the course, which became available in the 2006-2007 academic year.

Medication therapy management: Its relationship to patient counseling, disease management, and pharmaceutical care

OBJECTIVE

To delineate the relationship, including similarities and differences, between medication therapy management (MTM) and contemporary pharmacist-provided services, including patient counseling, disease management, and pharmaceutical care, to facilitate the continued evolution of commonly used language and a standard of practice across geographic areas and practice environments.

SUMMARY

Incorporation of MTM services into the array of Medicare-funded services affords an opportunity for pharmacists to develop direct patient care services in the community. Defining the role of MTM within the scope of pharmacist-provided patient care activities, including patient counseling, disease management, and all currently provided pharmacy services is essential to the delineation of a viable and sustainable practice model for pharmacists. The definitions of each of these services are offered, as well as comparisons and contrasts of the individual services. In addition to Medicare-eligible patients, MTM services are appropriate for anyone with medication-related needs. MTM is offered as an all-encompassing model that incorporates the philosophy of pharmaceutical care, techniques of patient counseling, and disease management in an environment that facilitates the direct collaboration of patients, pharmacists, and other health professionals.

CONCLUSION

Defining the role of MTM within the current patient care models, including patient counseling, disease management, and all who provide pharmacy services, is essential in delineating a viable and sustainable practice model for pharmacists.

Oral clonidine pre-treatment and diazepam/meperidine sedation

Clonidine has recently been used as a pre-operative medication and sedative/anxiolytic drug. Its extended duration of action makes it suitable for longer procedures. In this randomized, crossover, placebo-controlled clinical trial, we characterized the effects of oral clonidine pre-treatment on intravenous diazepam/meperidine sedation using the bi-spectral index (BIS) in 13 participants. Clonidine significantly increased the numbers of BIS-depressed readings and percent memory loss during sedation, while reducing total diazepam and post-operative analgesic dosages by 44% and 55%, respectively. Systolic, diastolic, and mean arterial blood pressures, as well as pulse rates, were reduced. Respiratory rate, oxygen saturation, end-tidal CO(2), and recovery from sedation were unchanged. Participants, surgeons, and sedationists preferred clonidine over the placebo. Clonidine pre-treatment increased and prolonged sedation and amnesia and stabilized vital signs while significantly decreasing diazepam and post-operative analgesic usage. These results suggest that pre-operative clonidine administration could be a useful supplement to intravenous sedation for dental procedures of long duration.

Using the Internet for training

An indisputable fact of life is that the Internet is changing the way business is done. The number of businesses that have web sites is growing at an incredible rate. Many of these supply training; online training offers numerous advantages over traditional training methods.

A comparison of sonically derived and traditional cephalometric values

The roentgenocephalometric technique is the standard used by orthodontists to assess skeletal, dental, and soft-tissue relationships. However, this technique exposes patients to radiation, preventing orthodontists from taking frequent cephalograms to assess growth and to monitor treatment. Recently, the Dolphin Imaging Company developed the DigiGraph, a nonradiographic cephalometric method that uses sound waves and mathematical algorithms, and consequently does not expose patients to radiation. But the DigiGraph's accuracy as a cephalometric alternative has not been adequately investigated. The purpose of this study was to compare the values obtained by traditional cephalometrics with those obtained by the DigiGraph technique for 30 well-known measurements, and then to assess the repeatability (intraobserver comparison) and reproducibility (interobserver comparison) for both techniques. Eighteen of the 30 measurements had mean differences that were statistically significant (p > .0067). Regression plots generally illustrate low correlations for the measurements, although Ricketts' esthetic line (upper and lower lip) and Steiner's soft-tissue convexity reveal strong linear relationships between the two methods. Additionally, the radiographically generated measurements showed greater repeatability and reproducibility.

A logistic dose-ranging method for phase I clinical investigations trials

This paper describes an alternative to the continual reassessment method (CRM) for phase I trials. The logistic dose ranging strategy (LDRS) uses logistic regression and a dose allocation scheme similar to the CRM. It can easily be implemented from any logistic regression program. The LDRS can be a stand alone dose allocation scheme or it can be incorporated into standard three on a dose strategies to indicate when escalation can proceed more rapidly. Finally, the effect of covariates such as age or comorbid conditions on the toxicity expected for the dose selected for a phase II trial can be examined.

Effect of methoxychlor on implantation and embryo development in the mouse

Methoxychlor (MXC) has been shown to have adverse effects on reproductive functions. However, it has not been fully determined whether the effects of MXC on reproduction are due to its estrogenic or antiestrogenic effects. Therefore, to further elucidate the estrogenic action of this pesticide in the mouse, we studied the effect of MXC on implantation and embryo development. MXC was found to initiate implantation in most delayed implanting mice at 400 microg/g body weight. However, at the higher dose of 800 microg/g body weight, MXC initiated implantation in only 50% of animals and the number of embryos implanting was significantly decreased (P < 0.05). It was determined that MXC inhibited implantation in intact pregnant mice only when given on Day 1 or Day 2 at 800 microg/g but not at lower doses or later in the preimplantation period. Embryonic development and transport were delayed on Days 3 and 4 in these animals. Finally, reciprocal embryo transfers with donor embryos recovered from MXC-treated animals (800 microg/g body weight on Day 1) transferred to untreated recipients resulted in no implantation compared to 79% implantation when donor embryos were treated with vehicle. These data indicate that MXC acts as an estrogen agonist at the level of the uterus and oviduct but as an antiestrogen in the ovary. In addition, MXC appears to alter normal preimplantation embryonic development. These results suggest the need for further studies to assess the mechanism of action of MXC in preimplantation embryos.

Cataract surgery and anticoagulants

Sixty-nine new cases are reported to reinforce the author's contention that anticoagulants should not be terminated for cataract surgery. All surgeries were performed through clear corneal wounds and 44 utilized topical anesthesia. As no blood vessels are encountered by this technique, bleeding is not possible; the remainder of the procedures were done under regional anesthesia, producing one retrobulbar hemorrhage.

Active human cytomegalovirus protease is a dimer

The quaternary state of the human cytomegalovirus (hCMV) protease has been analyzed in relation to its catalysis of peptide hydrolysis. Based on results obtained from steady state kinetics, size exclusion chromatography, and velocity sedimentation, the hCMV protease exists in a monomer-dimer equilibrium. Dimerization of the protease is enhanced by the presence of glycerol and high concentrations of enzyme. Isolation of monomeric and dimeric species eluted from a size exclusion column, followed by immediate assay, identifies the dimer as the active species. Activity measurements conducted with a range of enzyme concentrations are also consistent with a kinetic model in which only the dimeric hCMV protease is active. Using this model, the dissociation constant of the protease is 6.6 microM in 10% glycerol and 0.55 microM in 20% glycerol at 30 degrees C and pH 7.5.

Activation of the herpes simplex virus type 1 protease

The catalytic efficiency of the mature HSV-1 protease has been examined as a function of solvent composition. With the peptide substrate HTYLQASEKFKMWG-amide, the specificity constant (kcat/Km) at pH 7.5 for cleavage is 5.2 M-1 s-1. This value increases to 38 M-1 s-1 when 25% glycerol is present in the reaction mixture. It was found that glycerol activation is but one case of the general phenomenon of HSV-1 protease activation by kosmotropes, or water structure-forming cosolvents. For example, an 860-fold increase in the protease activity (kcat/Km = 4500 M-1 s-1) occurs in the presence of 0.8 M sodium citrate. Similarly, the presence of 0.8 M sodium phosphate activates the catalytic efficiency by 420-fold (kcat/Km = 2200 M-1 s-1). The extent of HSV-1 protease activation by various anions correlates with the Hofmeister series. Both the susceptibility to proteolysis by trypsin and the protein fluorescence spectra of the HSV-1 protease change in the presence of activating solvents, suggesting a conformational change accompanying activation.

Crystal structure at 1.9-A resolution of human immunodeficiency virus (HIV) II protease complexed with L-735,524, an orally bioavailable inhibitor of the HIV proteases

L-735,524 is a potent, orally bioavailable inhibitor of human immunodeficiency virus (HIV) protease currently in a Phase II clinical trial. We report here the three-dimensional structure of L-735,524 complexed to HIV-2 protease at 1.9-A resolution, as well as the structure of the native HIV-2 protease at 2.5-A resolution. The structure of HIV-2 protease is found to be essentially identical to that of HIV-1 protease. In the crystal lattice of the HIV-2 protease complexed with L-735,524, the inhibitor is chelated to the active site of the homodimeric enzyme in one orientation. This feature allows an unambiguous assignment of protein-ligand interactions from the electron density map. Both Fourier and difference Fourier maps reveal clearly the closure of the flap domains of the protease upon L-735,524 binding. Specific interactions between the enzyme and the inhibitor include the hydroxy group of the hydroxyaminopentane amide moiety of L-735,524 ligating to the carboxyl groups of the essential Asp-25 and Asp-25' enzymic residues and the amide oxygens of the inhibitor hydrogen bonding to the backbone amide nitrogen of Ile-50 and Ile-50' via an intervening water molecule. A second bridging water molecule is found between the amide nitrogen N2 of L-735,524 and the carboxyl oxygen of Asp-29'. Although other hydrogen bonds also add to binding, an equally significant contribution to affinity arises from hydrophobic interactions between the protease and the inhibitor throughout the pseudo-symmetric S1/S1', S2/S2', and S3/S3' regions of the enzyme. Except for its pyridine ring, all lipophilic moieties (t-butyl, indanyl, benzyl, and piperidyl) of L-735,524 are rigidly defined in the active site.

Shape discriminations of three-dimensional objects depend on the number and location of bends

In three experiments, subjects made shape discriminations of three-dimensional objects differing in orientation, number of bends, and location of bends (e.g., the central arm vs. a minor subarm). In general of bends, but only after a certain threshold of bends in the objects had been reached (Experiment 1). This effect was not due to the subjects' having to search for matching ends of the objects (Experiment 2). In contrast, rotation rates were influenced by the location of the bends, but not by the number of bends per se (Experiment 3). The results support a representational scheme that is hierarchical, but not necessarily one in which the principal axis of an object is paramount.

Purification of active herpes simplex virus-1 protease expressed in Escherichia coli

Assembly of viral capsids for replication of herpes simplex virus requires the proteolytic processing of the assembly protein ICP35. The protease responsible for this process is encoded within the 635-amino acid open reading frame of the UL26 gene of the virus. A simple purification scheme is given in this report for the native, mature form of the protease expressed in Escherichia coli. The scheme allows the preparation of milligram quantities of purified enzyme for elucidation of kinetic mechanism as well as for structural studies. Utilizing a 13-residue peptide substrate representing the natural cleavage site that releases the protease, kcat and Km values of the purified native enzyme are 2.0 min-1 and 0.88 mM, respectively. Thus, peptide cleavage is less efficient than reported for other viral proteases. The possibility exists that viral or cellular factors are involved in vivo for activation of the protease for herpes capsid maturation.

Dissociation and association of the HIV-1 protease dimer subunits: equilibria and rates

The kinetics and equilibrium properties were investigated for the interconversion between the active dimer of human immunodeficiency virus 1 (HIV-1) protease and its inactive monomeric subunits. The equilibrium dissociation constant (Kd) of the dimeric protease as well as the monomer association rate were obtained by monitoring the fluorescence change of an active-site-directed fluorescent probe (L-737244) upon its binding to the protease. The Kd of the HIV-1 protease is strongly pH dependent. At pH 5.5 where the enzyme is most active catalytically, the extrapolated values of Kd are 0.75 and 3.4 nM at 30 and 37 degrees C, respectively. The rate constant for HIV-1 monomer association, approximately 4 x 10(5) M-1 s-1, is within the range commonly observed for protein-protein interactions. Dimer dissociation was further scrutinized in the presence of an inactive, point mutant form of the enzyme. As a result of subunit exchange between the native and mutant enzymes and the formation of an inactive heterodimer, there was a time-dependent decrease in the activity of the native protease. Enzyme activity could be reinstated with the addition of an active-site-directed inhibitor (L-365862) which selectively binds active dimers. The rate of dimer dissociation was found to also decrease with pH. At pH 5.5 and 30 degrees C, the half-life for subunit dissociation is about 0.5 h. The slow dissociation, coupled with the high stability for dimer association, attests to the importance of allowing sufficient time for dimer-monomer equilibration in kinetic assays in order to avoid reaching erroneous conclusions in studies of dimer dissociation.

Fluoxetine-induced SIADH: a geriatric occurrence?

After major depression was diagnosed in a 83-year-old woman, fluoxetine was prescribed. Six days later she became delirious and weak, necessitating hospitalization. She was found to have hyponatremia secondary to fluoxetine-induced syndrome of inappropriate antidiuretic hormone secretion (SIADH). Recovery was complete after discontinuation of the medication.

A prospective, randomized, double-masked comparison of a zonal-progressive multifocal intraocular lens and a monofocal intraocular lens

INTRODUCTION

Multifocal intraocular lenses (IOLs) have been designed to provide improved near visual acuity without spectacles compared with monofocal IOLs. Early studies have reported variables amounts of decreased visual acuity and contrast sensitivity with multifocal IOLs, and some patients have experienced halos and glare.

METHODS

The authors performed a prospective, double-masked, multicenter evaluation of 62 patients randomized between a new zonal-progressive optic multifocal IOL and a monofocal IOL.

RESULTS

Mean postoperative spherical equivalent, astigmatism, and uncorrected and best-corrected distance visual acuity were similar between the two groups. Patients with a multifocal IOL achieved significantly better uncorrected near visual acuity than patients with monofocal IOLs (J3+ versus J7; P less than 0.0001). With distance correction only, mean near visual acuity was J2 versus J5- (P = 0.0001). Best-corrected near visual acuity was J1 for both groups, with 1.36 diopters (D) for the multifocal group versus 2.37 D for the monofocal group (P less than 0.0001). Regan contrast sensitivity was lower for the multifocal patients at all contrast levels, and achieved statistical significance at very low contrast (11% contrast; P = 0.0024). Fifty-two percent of patients with a multifocal IOL reported that they did not need spectacles at all or used them only for their fellow eye, compared with 25% of the patients with monofocal IOLs.

CONCLUSION

Both monofocal and multifocal implant patients were very satisfied with the results of their cataract extraction and IOL implant surgery. A small loss of contrast sensitivity with the multifocal IOL was demonstrated, consistent with theoretical predictions. The functional significance of the loss of contrast sensitivity appears to be small and counterbalanced by the advantage of improved uncorrected near visual acuity.

Silicone intraocular lens implants and circular anterior capsulotomy (capsulorhexis)

Anterior circular capsulorhexis is used to guarantee accurate placement and stability for the flexible silicone intraocular lens. The smaller wound needed for this procedure allows for immediate postoperative bending by the patient. The visual results achieved with this implant are excellent.

Dentists who practice with spouses or relatives: a pilot study of practitioners in Iowa

Of 130 practicing dentists in Iowa surveyed, 73, or 6% of the practicing dentists in that state, responded that they worked with a total of 108 relatives. Half of the relatives were the dentists' spouses. One to ten relatives worked in each office. Overall, the dentists were satisfied with the associations and expected them to continue. Most dentists had informally defined associations, and 10% had written contracts. Dentists named "office policy and organization" most often and "finances" least often as motives behind the associations and "personal growth" most often and "recognition" least often as a satisfaction with the association. The respondents suggested 567 ideas for other dentists considering such associations.

Effect of proteolytic enzymes on caries lesion formation in vitro

This study investigates enzyme degradation of collagen at various pH levels and is designed to obtain information pertaining to the effect of proteolytic enzymes on caries-like lesion formation and progression. One hundred and eight sections of human teeth with exposed areas on enamel and root face, were placed into an enzyme/buffer system maintained at pH levels of 4.0, 5.5 and 7.0. Periodically, throughout the experimental period, sections were removed and examined histologically for caries-like lesion formation. Results showed consistent surface erosion occurring on the root face only at a pH level of 5.5 in buffer containing enzymes. Sections placed in pH 5.5 buffer only, which served as controls, showed obvious lesion formation on the root face, but with histologically intact surfaces. This interaction occurring between enzymatic activity and acid demineralization suggests that enzymes may have a contributory effect on caries lesion formation in root surfaces.

Altered colchicine-binding capacity in chick brain regions: relationship to intensity or information content of visual input

The binding of [3H]colchicine to postmitochondrial supernatant fractions of chick brain has been studied, absorbing colchicine-bearing proteins on DEAE-cellulose filter discs. This was assayed at several times after unilateral enucleation of day-old chicks. Binding was unaltered in optic lobes or anterior dorsal forebrain regions contralateral to the removed eye, relative to the corresponding regions contralateral to and thus directly or secondarily innervated by the intact eye. Colchicine binding was also assayed after training chicks to suppress pecking at a metallic bead coated with aversive-tasting methylanthranilate. At 4 but not 24 h after the one-trial training, binding was selectively elevated in the anterior dorsal forebrain roof. Results are taken to imply that alterations in tubulin content of chick brain may reflect stress-related changes, possibly mediated by systemic endocrine flux, rather than a more localized learning experience.

Crown repair with a cast post and core

A technique to make a post and core pattern that can be used to save an existing crown has been presented. The technique should become an additional tool in the treatment armamentarium.

Hyperplastic primary vitreous with microphthalmos and ocular communicating orbital cyst

A 4-month old child with findings of persistent hyperplastic primary vitreous was also noted to have an ocular communicating orbital cyst in the same eye. The ocular component of the cyst was observed to move.

Suppression of postoperative pain by preoperative administration of ibuprofen in comparison to placebo, acetaminophen, and acetaminophen plus codeine

The analgesic effect of preoperatively administered ibuprofen was evaluated in 107 dental outpatients undergoing the removal of impacted third molars. Subjects were given 800 mg ibuprofen prior to the procedure and 400 mg ibuprofen 4 and 8 hours later. Comparison was made to groups receiving either placebo at all three doses, 600 mg acetaminophen administered on the same schedule, or preoperatively administered placebo followed by two doses of postoperatively administered 600 mg acetaminophen plus 60 mg codeine. Ibuprofen pretreatment resulted in significantly less pain than placebo or acetaminophen pretreatment as the local anesthetic wore off. Ibuprofen also resulted in less postoperative pain than acetaminophen plus codeine following the second dose. Side effects were similar across drug treatments and placebo with the exception of greater reports of drowsiness following the opiate-analgesic combination. These findings indicate that pretreatment with a nonsteroidal antiinflammatory drug, such as ibuprofen, results in a suppression of postoperative pain when compared to standard therapy without an increase in side effects.

Removal of partially loosened fixed partial dentures

The technique described offers maximum safety for the abutment tooth and the probability of salvage of the existing restoration. The options of reusing the restoration or recementing it as a temporary restoration are both attractive.

Sensitivity and specificity of early diagnostic tests of lung function in smokers

What are the relative sensitivities and specificities of the "early" tests of lung dysfunction? We describe the findings from a study of virtually the entire population of a rural pollution-free community. Using abnormal spirometry as a marker of obstructive disease, we evaluated the two tests obtained from the single-breath nitrogen curve, closing volume (CV/VC) and the slope of the alveolar plateau (delta N2/L), as well as combinations of the two tests. While CV/VC is highly specific (92.3 percent in male and 94.0 percent in female subjects), it lacks sensitivity (36.8 percent in male and 13.3 percent in female subjects) and is abnormal in only 10.0 and 6.5 percent of male and female smokers, respectively, a percentage not dissimilar from the percentage with abnormal spirometry. However, delta N2/L, abnormal in 24.1 percent of male smokers and 28.8 percent of female smokers, rates reasonably well with regard to both sensitivity (63.2 percent in male and 66.7 percent in female subjects) and specificity (79.3 percent in male and 74.0 percent in female subjects). The group of smokers with abnormal delta N2/L did include fair numbers with abnormal spirometry (20.7 percent in male and 16.1 percent in female subjects). A combination of the two tests (abnormal in either delta N2/L and/or CV/VC) has good sensitivity (68.4 and 80.0 percent for male and female subjects, respectively) and specificity (74.3 and 69.0 percent for male and female subjects, respectively).

Cavernous hemangioma of the optic disc

Cavernous hemangioma of the optic disc and retina is a vascular hamartoma composed of clusters of thin-walled saccular aneurysms partially filled with dark venous blood. It is now considered a neuro-oculo-cutaneous syndrome whose mode of inheritance is probably autosomal dominant. This report describes a cavernous hemangioma of the optic disc in a patient without skin or neurological findings. Its clinical appearance, generally benign ocular nature, and occasional association with central nervous system or cutaneous lesions is emphasized.

Temporomandibular joint marking for radionuclide bone scintigraphy

Anatomical marking of the temporomandibular joint has led to a practical method of delineating and evaluating the temporomandibular joint and glenoid fossa by radionuclide bone scintigraphy.