Two for One: Merging Continuing Professional Development and Faculty Development in the CATE Curriculum for Pharmacy Preceptors

Background

Continuing professional development (CPD) and faculty development (FD) are not traditionally combined, although there is evidence that integrating them enhances knowledge acquisition.

Objective

To explore preceptors' perceptions and the effectiveness of CATE (Clinical And Teaching Education), an education model that blends clinical content with the application of that clinical knowledge through a specified teaching technique.

Methods

Thirty-five hospital and community pharmacy preceptors from the Leslie Dan Faculty of Pharmacy, University of Toronto, participated in CATE, which consisted of a 2-hour synchronous, online workshop integrating clinical content about depression with the "One-Minute Preceptor" (OMP) teaching skill. Qualitative and quantitative data were collected longitudinally using surveys and semistructured interviews. Participant and process outcomes were explored through descriptive and thematic analysis using a modified Kirkpatrick framework.

Results

Participants valued the incorporation of educational theory and opportunities to practise the OMP using scripted role plays based on the depression-related content. The combination of FD and CPD was appealing, although participants wanted more clarity about their integration. The CATE model positively influenced their approaches to serving as preceptors, and using the OMP helped to reveal learners' knowledge gaps. There was a desire to share the teaching technique with colleagues to provide a more cohesive approach to teaching.

Conclusions

Integrating CPD and FD in a synchronous, online environment was feasible and well received, and it helped to solidify preceptors' roles as educators. Combining CPD and FD represents an effective strategy to build the clinical and educational expertise of preceptors, which in turn has the potential to improve the quality of experiential learning for pharmacy students. This novel method of fostering the pedagogical growth of preceptors could be a model for other health professions.

Physician and nurse practitioner perspectives of a modified Routine Opioid Outcome Monitoring (ROOM) Tool

Introduction The Routine Opioid Outcome Monitoring (ROOM) Tool was developed for use in community pharmacies in Australia. It facilitates pharmacists' screening and brief interventions regarding an individual's opioid use for chronic pain. At our academic teaching hospital, the ROOM Tool was adapted to incorporate a communication tool that includes a pharmacist's assessment and recommendations for primary care providers. This modified ROOM Tool was implemented as part of usual care in our outpatient pharmacies; however, the value to primary care providers is unknown. Aim The aim of this study was to determine primary care provider perspectives on the modified ROOM Tool. Methods Focus groups were conducted with primary care providers from an Academic Family Health Team. The focus group encompassed topics related to the positive and negative aspects of the modified ROOM Tool in supporting the care of patients using opioids for chronic pain. Qualitative content analysis of transcripts was performed to identify themes. Results Three focus groups were conducted with a total of six participants. Four themes emerged: (i) Facilitators to using the tool, (ii) Barriers to using the tool, (iii) Recommendations for improvement, (iv) Impact of the tool on patient care and safety. Discussion The ROOM Tool paired with the communication tool supports collaboration between pharmacists and primary care providers. The communication tool standardises the approach for communicating the pharmacist's assessment and recommendations. Recommendations to refine this modified ROOM Tool may increase its utility to primary care providers and enhance the impact on patient care and safety.

Superficial temporal artery injury and delayed post-cranioplasty infection

OBJECTIVE

Complications after cranioplasty after decompressive craniectomy (DC) have been reported to be as high as 40%. The superficial temporal artery (STA) is at substantial risk for injury in standard reverse question-mark incisions that are typically used for unilateral DC. The authors hypothesize that STA injury during craniectomy predisposes patients to post-cranioplasty surgical site infection (SSI) and/or wound complication.

METHODS

A retrospective study of all patients at a single institution who underwent cranioplasty after decompressive craniectomy and who underwent imaging of the head (computed tomography angiogram, magnetic resonance imaging with intravenous contrast, or diagnostic cerebral angiography) for any indication between the two procedures was undertaken. The degree of STA injury was classified and univariate statistics were used to compare groups.

RESULTS

Fifty-four patients met inclusion criteria. Thirty-three patients (61%) had evidence of complete or partial STA injury on pre-cranioplasty imaging. Nine patients (16.7%) developed either an SSI or wound complication after cranioplasty and, among these, four (7.4%) experienced delayed (>2 weeks from cranioplasty) complications. Seven of 9 patients required surgical debridement and cranioplasty explant. There was a stepwise but non-significant increase in post-cranioplasty SSI (STA present: 10%, STA partial injury: 17%, STA complete injury: 24%, P=0.53) and delayed post-cranioplasty SSI (STA present: 0%, STA partial injury: 8%, STA complete injury: 14%, P=0.26).

CONCLUSIONS

There is a notable but statistically non-significant trend toward increased rates of SSI in patients with complete or partial STA injury during craniectomy.

Temporal Construal Effects Are Independent of Episodic Future Thought

Human thought is prone to biases. Some biases serve as beneficial heuristics to free up limited cognitive resources or improve well-being, but their neurocognitive basis is unclear. One such bias is a tendency to construe events in the distant future in abstract, general terms and events in the near future in concrete, detailed terms. Temporal construal may rely on our capacity to orient toward and/or imagine context-rich future events. We tested 21 individuals with impaired episodic future thinking resulting from lesions to the hippocampus or ventromedial prefrontal cortex (vmPFC) and 57 control participants (aged 45-76 years) from Canada and Italy on measures sensitive to temporal construal. We found that temporal construal persisted in most patients, even those with impaired episodic future thinking, but was abolished in some vmPFC cases, possibly in relation to difficulties forming and maintaining future intentions. The results confirm the fractionation of future thinking and that parts of vmPFC might critically support our ability to flexibly conceive and orient ourselves toward future events.

Initiating communities of practice for teaching and education scholarship in hospital settings: a multi-site case study

This article was migrated. The article was marked as recommended. Background and Rationale: Numerous calls have been made for faculty development programming to better address faculty members' ongoing needs, to situate training strategies within the workplace and to utilize social learning perspectives, communities of practice in particular. Reviews have pointed to a paucity of published qualitative research on faculty development communities of practice and, more generally, on the processes of change and the organizational contexts in which interventions are implemented. Intervention: An initiative was started to instigate education scholarship communities of practice in three highly distinct academic health care settings, to address faculty members' ongoing needs for community and, ultimately, to serve as a source of support for the application of new knowledge to routine education activities. A research project was launched jointly to describe the process and progress of attempting to develop communities of practice at the three sites and to identify common and unique influences on sites' progress. Data Collection: Phone interviews were conducted with group facilitators from each site following group meetings, for the duration of the initiative. Analysis: Multiple case study methodology was employed to describe and compare the processes and progress of attempting to initiate communities of practice at the three sites and to identify obstacles related to organizational context. Findings: All three sites made limited progress in developing a shared domain of interest and a shared history of regular interaction (i.e. regular meetings). Participants identified different professional backgrounds and different education practices as challenges to establishing shared interest. More prominently, they identified busy schedules, geographic barriers, and absence of protected time as obstacles to regular and consistent meetings. Discussion: Difficulty establishing shared interest and shared history are considered in light of the unclear meaning of "education scholarship", cognitive and ethical boundaries between professions, and time constraints within modern, highly complex academic healthcare settings. Conclusions: While CoPs may appeal as self-sustaining, low-cost alternatives to formal programming, limited progress is possible without institutional investment and allowance commensurate with the implied scope and challenges.

Deprescribing in a family health team: a study of chronic proton pump inhibitor use

BACKGROUND Proton pump inhibitors (PPIs) are often used inappropriately, without an indication, or for longer durations than recommended. Few tools exist to guide reassessment of their continued use and deprescribing if required. We aimed to reduce inappropriate drug use by developing and implementing a PPI deprescribing tool and process in a family medicine unit. ASSESSMENT OF PROBLEM Primary care providers of adults taking a PPI for 8 weeks with an upcoming periodic health examination were reminded to reassess therapy via electronic medical record (EMR) messaging. A PPI Deprescribing Tool was uploaded into the EMR as a second reminder and to guide reassessment and deprescribing where indicated. Ten weeks after the examination a chart review assessed changes to PPI use. A follow up survey of providers assessed the utility and barriers to implementing the Deprescribing Tool. RESULTS Forty-three of 46 patients on PPIs (93%) had their PPI reassessed, resulting in 11 patients (26%) having their PPI deprescribed. Strategies for Improvement Routine reassessment of long-term medications is often overlooked because of extensive demands on primary care providers' time. Deprescribing likely improved because potentially eligible patients were identified to the provider and a tool was provided at the time of the encounter to guide the deprescribing process. LESSONS Reassessment and deprescribing of PPIs can be supported by implementing a standardised process and use of guidance tools for clinicians. Providers found the timely and selective reminder message to deprescribe the most useful component of the intervention. KEYWORDS proton pump inhibitor; deprescribing; reassessment; primary care; medication therapy management; gastroesophageal reflux disease.

No evidence of risk-taking or impulsive behaviour in a person with episodic amnesia: Implications for the role of the hippocampus in future-regarding decision-making

Does advantageous decision-making require one to explicitly remember the outcome of a series of past decisions or to imagine future personal consequences of one's choices? Findings that amnesic people with hippocampal damage cannot form a clear preference for advantageous decks over many learning trials on the Iowa Gambling Task (IGT) have been taken to suggest that complex decision-making on the IGT depends on declarative (episodic) memory and hippocampal integrity. Alternatively, impaired IGT performance in amnesic individuals could be secondary to risk-taking and/or impulsive behaviour resulting from impaired episodic future thinking (i.e. prospection) known to accompany amnesia. We tested this possibility in the amnesic individual K.C. using the IGT and the Toronto Gambling Task (TGT), a novel task that dissociates impulsivity from risk-taking without placing demands on declarative memory. K.C. did not develop a preference for advantageous over disadvantageous decks on the IGT and, instead, showed a slight preference for short-term gains and an inability to acquire a more adaptive appreciation of longer-term losses. He also did not display impulsive or risk-taking behaviour on the TGT, despite a profound inability to imagine personal future experiences. These findings suggest that impaired decision-making on the IGT in amnesia is unlikely to reflect a predilection to act in the moment or failure to take future consequences into account. Instead, some forms of future-regarding decision-making may be dissociable, with performance on tasks relying on declarative learning or on episodic-constructive processes more likely to be impaired.

Evaluation of a Community Pharmacy-Based Screening Questionnaire to Identify Patients at Risk for Drug Therapy Problems

STUDY OBJECTIVE

To determine if a short screening questionnaire can identify patients at risk for drug therapy problems (DTPs) in a community pharmacy setting.

DESIGN

Self-administered questionnaire.

SETTING

Three community pharmacies in Saskatoon, Canada.

PATIENTS

Forty-nine adults who were picking up a refill prescription for a medication that had remained stable over the past 6 months (i.e., no changes to drug, dose, or regimen) during 4 consecutive weeks at each of the three pharmacies between November 2013 and February 2014.

MEASUREMENTS AND MAIN RESULTS

All patients completed a self-administered screening questionnaire and underwent a blinded comprehensive medication assessment with a clinical pharmacist. Agreement between the screening questionnaire responses and responses based on information from the medication assessment were assessed with Cohen's κ coefficient. The DTPs identified during the medication assessments were categorized in one of the eight standard DTP categories: unnecessary drug therapy, inappropriate drug, subtherapeutic dose, supratherapeutic dose, drug therapy required, adverse drug reaction, noncompliance, and other or unsure. The DTPs were also assigned a severity-mild, moderate, or severe-using adapted Schneider criteria. The number and severity of DTPs identified were compared among patients categorized as high versus low risk for DTPs as determined by the questionnaire responses. Of the 49 patients who completed the study, 18 (37%) were high risk and 31 (63%) low risk. The agreement between risk categorization based on the screening questionnaire and medication assessment was very good (κ = 0.91, p<0.01). Also, patients identified as high risk on the screening questionnaire had a mean of 3.7 (p<0.01) more DTPs than low-risk patients. Seventeen (94%) of the 18 high-risk patients had at least one moderate or severe DTP compared with 15 (48%) of the 31 low-risk patients.

CONCLUSION

The screening questionnaire was a reliable method for identifying patients in community pharmacies who have a large number of DTPs.

Identification of inappropriate medication use in elderly patients with frequent emergency department visits

OBJECTIVE

To determine the demographic and health care characteristics of elderly family health team patients who are frequent emergency department (ED) users, focusing on potentially inappropriate medications (PIMs) and access to primary care services.

DESIGN

Cross-sectional retrospective chart review.

SETTING

Academic family medicine clinic in Toronto, Ontario.

PARTICIPANTS

A total of 46 elderly patients (age >65 years) with 4 or more visits to a University Health Network-affiliated ED between April 1, 2010, and March 31, 2011.

MAIN OUTCOME MEASURES

Using the validated STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, PIMs were identified. The primary objective was to determine whether PIMs were associated with more frequent ED use. The secondary objective was to determine whether patients who had previously undergone a clinic pharmacist-led medication review had fewer PIMs. We also determined the health characteristics of these patients at the time of their last ED visit of the study period. Utilization of primary care resources, both prior to and after ED visits, was determined.

RESULTS

Sixty-five percent of patients were taking at least 1 PIM. The total number of PIMs in the study population was 71. Having more PIMs was significantly correlated with a higher number of ED visits (r = 0.32, p < 0.05). Patients with a previous medication review had a similar number of PIMs compared with those without a review. The mean number of concurrent medications was 12.1 and the mean Charlson Comorbidity Index score was 3.7. Significant delay between hospital discharge and primary care follow-up (median 13 days) was observed.

CONCLUSION

Elderly patients who are more frequent ED users have a greater number of PIMs. Primary care resources appear to be underused in this population.

Impaired event memory and recollection in a case of developmental amnesia

A current debate in the literature is whether all declarative memories and associated memory processes rely on the same neural substrate. Here, we show that H.C., a developmental amnesic person with selective bilateral hippocampal volume loss, has a mild deficit in personal episodic memory, and a more pronounced deficit in public event memory; semantic memory for personal and general knowledge was unimpaired. This was accompanied by a subtle difference in impairment between recollection and familiarity on lab-based tests of recognition memory. Strikingly, H.C.'s recognition did not benefit from a levels-of-processing manipulation. Thus, not all types of declarative memory and related processes can exist independently of the hippocampus even if it is damaged early in life.

Deficits in past remembering extend to future imagining in a case of developmental amnesia

Patient and neuroimaging studies report that the ability to remember past personal experiences and the ability to envision future personal experiences are interconnected. Loss of episodic memory is typically accompanied by loss of future imagining, and engaging in either activity recruits common brain areas. The relationship between episodic memory and future imagining is also suggested by their co-emergence in ontogenetic development. However, it is unknown whether a failure of one ability to emerge in early development precludes the development of the other ability. To investigate this possibility, we tested H.C., a young woman with amnesia of developmental origin associated with bilateral hippocampal loss, and demographically matched controls on an adapted version of the Autobiographical Interview using Galton-Crovitz cueing. In response to cue words, participants described both past personal events and imagined future personal events that occurred, or could occur, in near and distant time periods. Results indicated a parallel pattern of impairment for both past and future event generation in H.C., such that her narratives of both types of events were similarly deficient. These results indicate that mental time travel can be compromised in hippocampal amnesia, whether acquired in early or later life, possibly as a result of a deficit in reassembling and binding together details of stored information from earlier episodes.

Development, implementation, and evaluation of an Interprofessional Falls Prevention Program for older adults

This article describes the development and implementation of an Interprofessional Falls Prevention Program (IFPP) designed for community-dwelling seniors. The program was a collaborative pilot research study conducted in a retirement home and an outpatient hospital setting. The pilot was successful and was positioned into a permanent falls prevention program. The IFPP aimed at improving physical function and balance and reducing the fear of falling in seniors with a history of falls. The pilot study included an interprofessional falls assessment followed by a 12-week program of once-weekly group education and exercise sessions, 3- and 6-month follow-up visits, and individual counseling. To measure program effectiveness, the Berg Balance Scale, the Timed Up and Go Test, the Falls Efficacy Scale, and the Morse Fall Risk Scale were used at baseline, upon program completion, and at 3- and 6-month follow-up. Process measures were also collected, including patient satisfaction. Persistent improvements were found in participants' balance, strength, functional mobility, and fear of falling. Patient satisfaction with the program was high. Challenges faced in program implementation are also highlighted.

Smoke from traditional commercial, harm reduction and research brand cigarettes impairs oviductal functioning in hamsters (Mesocricetus auratus) in vitro

BACKGROUND

Cigarette smoke from 2R1 research brand cigarettes and specific toxicants in smoke inhibit oviductal functioning. Our purpose was to test the hypothesis that smoke from commercial cigarettes, including harm reduction cigarettes, inhibits oviductal functioning and to measure the concentration of previously identified toxicants in smoke from research and commercial cigarettes.

METHODS

Mainstream (MS) and sidestream (SS) smoke solutions from two research, six traditional commercial and three harm reduction brands were tested in vitro using an oviductal assay that measures ciliary beat frequency, oocyte retrieval rate and smooth muscle contraction.

RESULTS

Generally, smoke from each brand of cigarette was inhibitory in the three oviductal bioassays. SS, the major component of environmental tobacco smoke, was usually more inhibitory than MS, the smoke inhaled by active smokers. Nine cigarette toxicants, previously shown to be highly inhibitory in the oviductal bioassays, were quantified in MS and SS. 4-Methylpyridine, which was inhibitory by itself in picomolar doses, was present in the highest concentration in MS and SS solutions from all brands tested. In general, toxicant concentrations were higher in SS than in MS solutions.

CONCLUSIONS

These data show that commercial brands of cigarettes, including harm reduction cigarettes, contain toxicants that inhibit biological processes in the oviduct and could affect reproductive outcomes.

Antibiotic use in Ontario facilities that provide chronic care

OBJECTIVE

To determine the incidence and variability of antibiotic use in facilities which provide chronic care and to determine how often clinical criteria for infection are met when antibiotics are prescribed in these facilities.

DESIGN

A prospective, 12-month, observational cohort study.

SETTING

Twenty-two facilities which provide chronic care in southwestern Ontario.

PARTICIPANTS

Patients who were treated with systemic antibiotics over the study period.

MEASUREMENTS

Characteristics of antibiotic prescriptions (name, dose, duration, and indication) and clinical features of randomly selected patients who were treated with antibiotics.

RESULTS

A total of 9,373 courses of antibiotics were prescribed for 2,408 patients (66% of all patients in study facilities). The incidence of antibiotic prescriptions in the facilities ranged from 2.9 to 13.9 antibiotic courses per 1,000 patient-days. Thirty-six percent of antibiotics were prescribed for respiratory tract infections, 33% for urinary infections, and 13% for skin and soft tissue infections. Standardized surveillance definitions of infection were met in 49% of the 1,602 randomly selected patients who were prescribed antibiotics. Diagnostic criteria for respiratory, urinary, and skin infection were met in 58%, 28%, and 65% of prescriptions, respectively. One third of antibiotic prescriptions for a urinary indication were for asymptomatic bacteriuria. Adverse reactions were noted in 6% of prescriptions for respiratory and urinary infections and 4% of prescriptions for skin infection.

CONCLUSIONS

Antibiotic use is frequent and highly variable amongst patients who receive chronic care. Reducing antibiotic prescriptions for asymptomatic bacteriuria represents an important way to optimize antibiotic use in this population.

Synthetic peptide YY analog binds to a cell membrane receptor and delivers fluorescent dye to pancreatic cancer cells

Pancreatic cancer continues to have a dismal prognosis despite multimodality treatment plans. Peptide YY (PYY) is a gut hormone that suppresses pancreatic exocrine and endocrine function. Previous experiments have shown that shortened synthetic PYY(22-36) analog decreases pancreatic cancer cell growth while also decreasing intracellular cyclic adenosine monophosphate. Our purpose was to construct an optimal synthetic PYY analog that binds to pancreatic cancer cells that may be used for imaging and therapy. Biotinylated PYY analogs with lengths ranging from PYY(1-36), PYY(9-36), PYY(14-36), PYY(22-36), and PYY(27-36) were tested with flow cytometry and receptor cross-linking studies to measure cell membrane binding. Growth inhibition studies were also performed using monotetrazolium tests to determine potency of various PYY analogs. Quantitative flow cytometry reveals the highest specific binding of PYY(14-36) to pancreatic cancer cells. Cross-linking studies reveal a receptor on the cell membrane of human pancreatic ductal adenocarcinoma cells. Growth inhibition studies reveal that PYY (14-36) has the highest potency against PANC-1 and MiaPaCa-2 cells. A novel synthetic PYY analog binds to the cell surface of pancreatic cancer cells and has the ability to deliver fluorescent dyes. The strategy of using biotinylated peptides to deliver avidin-dye complexes to cancer cells will allow imaging of pancreatic tumors and delivery of therapeutic agents.

Hypericin and photodynamic therapy decreases human pancreatic cancer in vitro and in vivo

BACKGROUND

The treatment of pancreatic cancer has remained dismal despite advances in medical and surgical care. Recent preclinical data have revealed that hypericin, a photochemical dye, is activated by green light and generates toxic radical species in tumors. We hypothesized that interstitial hypericin and laser phototherapy would decrease pancreatic cancer growth.

METHODS

MiaPaCa-2 and PANC-1 cells were grown in tissue culture. In vitro experiments were performed with addition of 10 microg of hypericin/500,000 cancer cells. Cells were incubated with hypericin for 2 h. Cells were then exposed to KTP532 green laser light for 1 min at 0.6 W using a cylindrical diffuser tip. Cell growth was measured by MTT assay 24 h after laser treatment, N = 12. MiaPaCa-2 cells were implanted subcutaneously and orthotopically in pancreas of nude mice. After 5 weeks, both tumors were injected with 100 microg of hypericin followed by insertion of a cylindrical diffuser tip into the tumor center. Mice received 200J KTP laser light at 1.0 W in two sites. Tumors were measured before and 4 weeks after laser treatment.

RESULTS

Both in vitro and in vivo mice data showed a significant decrease in growth of pancreatic cancer. Pancreatic cancer cell growth was suppressed by 66.1 +/- 0.2%, n = 12, P < 0.01, ANOVA. Subcutaneous shoulder tumors were suppressed by 91.2 +/- 2.3%, n = 12, P < 0.001, and orthotopically grown pancreatic tumors were suppressed by 42.2 +/- 8.1%, n = 12, P < 0.05, compared to pretreatment sizes. Data expressed as percentage reduction vs paired controls in the MTT assay and vs pre-photodynamic therapy in mice experiments. Paired Student's t tests were performed vs pretreatment sizes.

CONCLUSION

Both in vitro and in vivo results revealed a significant decrease in pancreatic cancer cell growth. Laser or dye alone had no effect, indicating that intratumor hypericin and laser therapy may prove useful in unresectable pancreatic cancer.

Paracellular glucose transport plays a minor role in the unanesthetized dog

Traditionally, intestinal glucose absorption was thought to occur through active, carrier-mediated transport. However, proponents of paracellular transport have argued that previous experiments neglected effects of solvent drag coming from high local concentrations of glucose at the brush-border membrane. The purpose of this study was to evaluate glucose absorption in the awake dog under conditions that would maximize any contribution of paracellular transport. Jejunal Thiry-Vella loops were constructed in six female mongrel dogs. After surgical recovery, isotonic buffers containing L-glucose as the probe for paracellular permeability were given over 2-h periods by constant infusion pump. At physiological concentrations of D-glucose (1-50 mM), the fractional absorption of L-glucose was only 4-7% of total glucose absorption. Infusion of supraphysiological concentrations (150 mM) of D-glucose, D-maltose, or D-mannitol yielded low-fractional absorptions of L-glucose (2-5%), so too did complex or nonabsorbable carbohydrates. In all experiments, there was significant fractional water absorption (5-19%), a prerequisite for solvent drag. Therefore, with even up to high concentrations of luminal carbohydrates in the presence of significant water absorption, the relative contribution of paracellular glucose absorption remained low.

The effects of acetaminophen on pharmacokinetics and pharmacodynamics of warfarin

The oral anticoagulant warfarin is clinically administered as a racemic mixture of two enantiomers, (R) and (S). Many relevant drug interactions with warfarin have been attributed to the specific metabolic inhibition of the elimination of the more pharmacologically active (S)-enantiomer. To investigate reports that acetaminophen can potentiate the anticoagulant effect of warfarin, 20 healthy male volunteers were each given single oral 20 mg doses of racemic warfarin on three separate occasions: (1) alone, (2) after 1 day of acetaminophen (4 g/d), and (3) after 2 weeks of acetaminophen (4 g/d). The urinary excretion pattern of acetaminophen and its metabolites was not significantly altered over its course of administration. The (R)- and (S)-enantiomers of warfarin exhibited significantly different pharmacokinetic properties. However, acetaminophen did not alter the disposition of either (R)- or (S)-warfarin. All subjects exhibited a pharmacodynamic response to racemic warfarin. The response was not significantly altered in the presence of acute or chronic acetaminophen dosing, as assessed by prothrombin time and factor VII concentrations.

Diverting loop versus end ileostomy during ileoanal pullthrough procedure for ulcerative colitis

A two-stage ileoanal pullthrough procedure (IAPP) is often used for patients with ulcerative colitis (UC) requiring proctocolectomy. We analyzed the recent University of California at Los Angeles experience with diverting end and loop ileostomies in patients undergoing a two-stage IAPP. A retrospective analysis of 21 patients with UC undergoing loop ileostomy between March 1992 and March 1995 was performed. Comparison was made with 21 age- and gender-matched patients undergoing end ileostomy between January 1991 and December 1995. There was no mortality or major septic complications. A second laparotomy was required in all patients with end ileostomies, whereas loop ileostomies were closed without abdominal exploration. During ileostomy closure, operative time and mean hospital stay were significantly reduced with the use of loop ileostomy. The time to oral feeding was not significantly different between end and loop ileostomy groups after ileostomy closure. The complication rate after IAPP was similar between groups. However, after ileostomy closure, the complication rate was significantly reduced with the use of loop ileostomy. We conclude that loop ileostomy is a desirable option for UC patients undergoing intestinal diversion during IAPP. Loop ileostomies can be created easily and without an increase in operative time. Subsequent ileostomy closure can be performed as a local procedure, which may shorten operative time and length of hospital stay.

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement: infection rates and voiding mechanisms

PURPOSE

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement have recently been reported to be associated with a high incidence of infection. We reviewed our results to define the infection rate and outline the mechanisms of voiding in our patient population.

MATERIALS AND METHODS

A total of 29 patients underwent a simultaneous procedure. The etiology of lower urinary tract disease was exstrophy in 14 patients, myelomeningocele in 10, lipomeningocele in 3, spinal cord injury in 1 and radical retropubic prostatectomy in 1. We used 19 gastric, 5 ileal and 5 colonic intestinal segments. Average followup was 33 months. All patients were followed for a minimum of 2 years. Preoperatively all cases had mechanical bowel preparation and documented sterile urine cultures or treated bacteriuria.

RESULTS

Infection developed in 2 patients (6.9%) necessitating artificial urinary sphincter removal at 1 week and 9 months. There were no infections associated with gastrocystoplasty. Clean intermittent catheterization was required in 21 patients, while the remaining 8 voided spontaneously. Of the 8 patients 4 were catheterized at least once daily to monitor residual urine volumes. Of all patients 5 were catheterized with a gastric tube, 5 with an appendicovesicostomy and 14 per urethra.

CONCLUSIONS

A simultaneous procedure was associated with an acceptable prosthetic infection rate and gastric segments were associated with the lowest incidence of infection. The minority of patients voided spontaneously. The combination procedure was effective in achieving continence. However, in the future a nonprosthetic means of providing urethral resistance may provide better treatment.

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement: infection rates and voiding mechanisms

PURPOSE

Simultaneous augmentation cystoplasty and artificial urinary sphincter placement have recently been reported to be associated with a high incidence of infection. We reviewed our results to define the infection rate and outline the mechanisms of voiding in our patient population.

MATERIALS AND METHODS

A total of 29 patients underwent a simultaneous procedure. The etiology of lower urinary tract disease was exstrophy in 14 patients, myelomeningocele in 10, lipomeningocele in 3, spinal cord injury in 1 and radical retropubic prostatectomy in 1. We used 19 gastric, 5 ileal and 5 colonic intestinal segments. Average followup was 33 months. All patients were followed for a minimum of 2 years. Preoperatively all cases had mechanical bowel preparation and documented sterile urine cultures or treated bacteriuria.

RESULTS

Infection developed in 2 patients (6.9%) necessitating artificial urinary sphincter removal at 1 week and 9 months. There were no infections associated with gastrocystoplasty. Clean intermittent catheterization was required in 21 patients, while the remaining 8 voided spontaneously. Of the 8 patients 4 were catheterized at least once daily to monitor residual urine volumes. Of all patients 5 were catheterized with a gastric tube, 5 with an appendicovesicostomy and 14 per urethra.

CONCLUSIONS

A simultaneous procedure was associated with an acceptable prosthetic infection rate and gastric segments were associated with the lowest incidence of infection. The minority of patients voided spontaneously. The combination procedure was effective in achieving continence. However, in the future a nonprosthetic means of providing urethral resistance may provide better treatment.

Off-site determinations of effective renal plasma flow using technetium-99m-MAG3 and single blood sampling

This study evaluated the feasibility of determining effective renal plasma flow (ERPF) at an off-site central laboratory by transferring blood samples from the on-site laboratory.

METHODS

Blood samples were obtained from 66 patients referred for renal imaging with 99mTc-MAG3. ERPF values were determined using the single blood sample method (BSM) at both on- and off-site laboratories. The ERPF values were classified clinically as normal or abnormal. Both the ERPF values and clinical classification were compared between on- and off-site laboratories.

RESULTS

The off-site ERPF overestimated those on-site by 2.8% (paired Student's t-test p < 10(-5)). However, off-site ERPF values highly correlated with the values obtained on-site (r = 0.99; p < 10(-5)). In addition, the clinical classification for each patient determined at each site was identical.

CONCLUSION

ERPF can be determined accurately off-site. This method should allow many nuclear medicine departments access to the ERPF determination by the BSM at a central off-site laboratory.

Abnormal serum transaminases following therapeutic doses of acetaminophen in the absence of known risk factors

J.M., a healthy, 25-year-old male, volunteered for a study involving warfarin and acetaminophen. Acetaminophen 1 g four times a day was started for 21 days. Liver function tests taken at regular intervals for the first 12 days were unremarkable. On day 18, however, aspartate aminotransferase (AST) was 527 IU/liter and alanine aminotransferase (ALT) was 166 IU/liter. Acetaminophen was discontinued and serum transaminase levels returned to baseline levels two weeks later (AST = 26, ALT = 20). Analysis of J.M.'s urine samples over the first 18 days showed excretion patterns of glucuronide, sulfate, and glutathione derived cysteine and mercapturic acid conjugates were similar to the other subjects in the study. Acetaminophen causes hepatotoxicity in overdose or malnourished or alcoholic patients, none of which applied to our subject. Differences in metabolic activation and capacity for glutathione synthesis can predispose individuals given therapeutic doses of acetaminophen to adverse effects. Failure to detoxify a highly reactive metabolite, formed by P-450 metabolism, via glutathione conjugation is responsible for the development of acute hepatic necrosis. Accumulation of the toxic metabolite due to depleted glutathione stores may have occurred with prolonged high dosing in our subject and been responsible for his abnormal rise in liver enzymes.

Fat reserves and reproduction in the green turtle, Chelonia mydas

Measurements were made of the fat and water content of standard cores of fat lining the inner carapace of green turtles caught and butchered by indigenous fishermen in Daru, Papua New Guinea. The amount of depot fat, total lipid and neutral lipid per core varied with the sex, maturity and reproductive status of the turtle. The fat content of cores from prepubescent turtles did not vary with sex. In contrast, cores from adult female turtles had a significantly greater fat content than those from males. Cores from pubescent and vitellogenic females had the highest fat content. Neutral (storage) lipid was significantly higher in cores from vitellogenic females than in those from breeding, which suggests that sub-carapace depot fat is used to fuel the energetically expensive costs of migration and egg production. Cores from breeding females had a significantly higher fat content than those from males, which suggests that the energetic costs of vitellogensis and egg-laying are reflected in sub-carapace fat stores. The greater energetic cost to this fat store for breeding by females is also reflected in the significantly higher water content of the fat of females that had bred in the previous season compared with those in vitellogenesis. In contrast, there was no significant difference between the water content of cores from non-breeding and breeding males.

Renal angiomyolipoma associated with neurofibromatosis and primary carcinoid of mesentery

A patient with von Recklinghausen's disease manifested by dermal neurofibromatosis and cafe-au-lait spots presented with complaints of malaise, weight loss, lower extremity weakness, and a palpable left lower abdominal quadrant mass. Evaluation revealed a lumbar neurofibroma, a localized primary carcinoid tumor of the mesentery, and a left renal angiomyolipoma. Although an association between neurofibromatosis and carcinoid has been previously reported, we believe this is the first report documenting the association of all three entities.

Value of serum alkaline phosphatase and radionuclide bone scans in patients with renal cell carcinoma

Ninety-one patients who underwent radical nephrectomy for renal cell carcinoma (RCC) were reviewed to determine the prognostic value of serum alkaline phosphatase (SAP) levels and radionuclide bone scan. A preoperative SAP greater than 127 IU/L was a strong indicator of eventual disease progression or death, and an elevated SAP was a better predictor of eventual outcome than bone scan.

Short-term administration of SMS 201-995 in the management of an external pancreatic fistula

A patient presented to the hospital with a persistent high-output (greater than 250 ml/day) external pancreatic fistula after an enucleation of an insulinoma 5 months earlier. Daily treatment with SMS 201-995, a long-acting somatostatin analogue, for 8 days decreased fistulous output to less than 5 ml/day. The patient was discharged in stable condition 9 days after admission. All drainage ceased 2 days later, and the fistula has remained closed. SMS 201-995 has been shown to be effective in decreasing fistulous output of external pancreatic fistulas of various origins. With its few side effects and remarkable effectiveness, SMS 201-995 should be considered in the conservative management of any external pancreatic fistula.

Sea-Turtle Rookeries in North-Western Torres Strait

Deliverance Island, Kerr Islet and Turu Cay in north-western Torres Strait support a major nesting population and the most northerly recorded rookery of the flatback turtle, Natator depressa. Nesting occurs there year round, with a peak in the early months of the year. The islands are insignificant nesting sites for the green turtle, Chelonia mydas, and the hawksbill turtle, Eretmochelys imbricata. The N. depressa turtles that nest in western Torres Strait-north-eastern Gulf of Carpentaria are smaller and lay smaller eggs on average than the N. depressa turtles that breed in the southern Great Barrier Reef. On Deliverance Island, the inhabitants of nearby Queensland islands and Papua New Guinea coastal villages infrequently harvest N. depressa eggs as well as the green turtles that feed over the surrounding reef flats.

Studies on human monocytes with a multiparameter cell sorter

Suspensions of human lymphocytes and monocytes separated by the Ficoll-hypaque method from the peripheral blood show a Coulter volume distribution, measured with a multiparameter cell sorter, characterized by a minor peak at 500 mu3, containing 5-15% of the cells, and a major peak at 200 mu3. Using fluorescent latex particles we have found that the monocytes, the cells that ingest the latex particles, all lie in the 500 mu3 peak; conversely, all of the cells in the 500 mu3 peak are monocytes. When the cell suspensions are incubated, the monocytes increase both the average volume and in absolute numbers. The number of monocytes approximately doubles during 3 days of incubation, when it reaches its maximum value. At that time we have found that all of the monocytes lack receptors for sheep red blood cells and all possess receptors for human gamma-globulin. The increase in monocyte number appears, therefore, to arise from the enlargement of "monocyte presursors" that resemble lymphocytes in volume and resemble both the monocytes and the B lyphocytes with respect to surface sheep red blood cell and human gamma-globulin receptors.

Scytalone (3,6,8-Trihydroxytetralone), a Metabolite from a Scytalidium Species

A metabolite from culture filtrates of a Scytalidium strain is shown by spectroscopic and chemical means to have structure 1a. The oxygenation pattern is as anticipated from a polyketide precursor.