From natural disaster to pandemic: A health-system pharmacy rises to the challenge

Purpose

This report describes a health-system pharmacy’s response to a natural disaster while staff members simultaneously prepared for the coronavirus disease 2019 (COVID-19) pandemic. By detailing our experience, we hope to help other institutions that are current facing or could encounter similar crises.

Summary

In early March 2020, a tornado destroyed the health system’s warehouse for storage of most clinical supplies, including personal protective equipment and fluids. The pharmacy purchasing team collaborated with suppliers and manufacturers to recover losses and establish alternative storage areas. Days later, the pharmacy department was forced to address the impending COVID-19 pandemic. Key elements of the COVID-19 response included reducing the potential for virus exposure for patients and staff; overcoming challenges in sourcing of staff, personal protective equipment, and medications; and changing care delivery practices to maintain high-quality patient care while maximizing social distancing. The pharmacy department also created distance learning opportunities for 70 pharmacy students on rotations. After an initial plan, ongoing needs include adjustment in patient care activities if significant staff losses occur, when and how to resume clinical activities, and how to best utilize the resources accumulated. Elements of practice changes implemented to reduce COVID-19 threats to patients and pharmacy personnel have proven beneficial and will be further evaluated for potential continuation.

Conclusion

The pharmacy department’s efforts to respond to a natural disaster and unprecedented pandemic have proven successful to this point and have illuminated several lessons, including the necessity of cohesive department communication, staff flexibility, prioritization of teamwork, and external collaboration.

Evaluating the Impact of Auto-Calculation Settings on Opioid Prescribing at an Academic Medical Center

BACKGROUND

Overprescribing of opioids is a key contributor to the opioid epidemic, which has led to a substantial increase in overdose deaths. The purpose of this study was to evaluate the discontinuation of a dispense quantity automatic calculation function on prescribing of as needed (PRN) opioids.

METHODS

During the implementation of a new electronic health record (EHR), Vanderbilt University Medical Center discontinued functionality that autocalculated the maximum needed dispense quantity for PRN outpatient prescription opioids. This study analyzed prescribing trends for immediate-release hydrocodone- and oxycodone-containing prescriptions 90 days before and after implementation of the new EHR.

RESULTS

A total of 21,323 prescriptions were analyzed in the preintervention group and 22,730 prescriptions in the postintervention group. Discontinuing the autocalculation functionality resulted in a mean decrease of 1.4 dispense units per prescription (58.5 vs. 57.1; p = 0.006) across all patient care areas. The most significant finding was a 10.5% relative decrease in dispense units from inpatient discharge prescriptions (37.2 vs. 33.3; p < 0.001). In the new EHR, PRN oxycodone products defaulted to a dispense quantity of 30, which resulted in a 142.0% (10.0% vs. 24.2%; p < 0.001) increase in oxycodone prescriptions ordered for 30 dispense units but was a net reduction in the doses dispensed per oxycodone prescription.

CONCLUSION

This study suggests that removing the autocalculation functionality reduced the number of opioid units ordered. In addition, using a default dispense quantity for PRN opioid prescriptions may decrease the number of opioid dispense units per prescription.

Randomised clinical trial: the analgesic properties of dietary supplementation with palmitoylethanolamide and polydatin in irritable bowel syndrome

BACKGROUND

Intestinal immune activation is involved in irritable bowel syndrome (IBS) pathophysiology. While most dietary approaches in IBS involve food avoidance, there are fewer indications on food supplementation. Palmithoylethanolamide, structurally related to the endocannabinoid anandamide, and polydatin are dietary compounds which act synergistically to reduce mast cell activation.

AIM

To assess the effect on mast cell count and the efficacy of palmithoylethanolamide/polydatin in patients with IBS.

METHODS

We conducted a pilot, 12-week, randomised, double-blind, placebo-controlled, multicentre study assessing the effect of palmithoylethanolamide/polydatin 200 mg/20 mg or placebo b.d. on low-grade immune activation, endocannabinoid system and symptoms in IBS patients. Biopsy samples, obtained at screening visit and at the end of the study, were analysed by immunohistochemistry, enzyme-linked immunoassay, liquid chromatography and Western blot.

RESULTS

A total of 54 patients with IBS and 12 healthy controls were enrolled from five European centres. Compared with controls, IBS patients showed higher mucosal mast cell counts (3.2 ± 1.3 vs. 5.3 ± 2.7%, P = 0.013), reduced fatty acid amide oleoylethanolamide (12.7 ± 9.8 vs. 45.8 ± 55.6 pmol/mg, P = 0.002) and increased expression of cannabinoid receptor 2 (0.7 ± 0.1 vs. 1.0 ± 0.8, P = 0.012). The treatment did not significantly modify IBS biological profile, including mast cell count. Compared with placebo, palmithoylethanolamide/polydatin markedly improved abdominal pain severity (P < 0.05).

CONCLUSIONS

The marked effect of the dietary supplement palmithoylethanolamide/polydatin on abdominal pain in patients with IBS suggests that this is a promising natural approach for pain management in this condition. Further studies are now required to elucidate the mechanism of action of palmithoylethanolamide/polydatin in IBS. ClinicalTrials.gov number, NCT01370720.

The joint power of sex and stress to modulate brain-gut-microbiota axis and intestinal barrier homeostasis: implications for irritable bowel syndrome

BACKGROUND

Intestinal homeostasis is a dynamic process that takes place at the interface between the lumen and the mucosa of the gastrointestinal tract, where a constant scrutiny for antigens and toxins derived from food and microorganisms is carried out by the vast gut-associated immune system. Intestinal homeostasis is preserved by the ability of the mucus layer and the mucosal barrier to keep the passage of small-sized and antigenic molecules across the epithelium highly selective. When combined and preserved, immune surveillance and barrier's selective permeability, the host capacity of preventing the development of intestinal inflammation is optimized, and viceversa. In addition, the brain-gut-microbiome axis, a multidirectional communication system that integrates distant and local regulatory networks through neural, immunological, metabolic, and hormonal signaling pathways, also regulates intestinal function. Dysfunction of the brain-gut-microbiome axis may induce the loss of gut mucosal homeostasis, leading to uncontrolled permeation of toxins and immunogenic particles, increasing the risk of appearance of intestinal inflammation, mucosal damage, and gut disorders. Irritable bowel syndrome is prevalent stress-sensitive gastrointestinal disorder that shows a female predominance. Interestingly, the role of stress, sex and gonadal hormones in the regulation of intestinal mucosal and the brain-gut-microbiome axis functioning is being increasingly recognized.

PURPOSE

We aim to critically review the evidence linking sex, and stress to intestinal barrier and brain-gut-microbiome axis dysfunction and the implications for irritable bowel syndrome.

[Haemostasis control during laparoscopic partial nephrectomy without parenchymal renorrhaphy: the VIVOSTAT(®) experience]

OBJECTIVE

To present our experience using an autologous fibrin sealant prepared with the Vivostat system(®) to control haemostasis without any renal parenchymal reconstruction.

MATERIAL AND METHODS

We performed 45 laparoscopic partial nephrectomies using this haemostatic agent. The surgical steps were: colon mobilization, identification of ureter, renal vessels and renal tumor, renal artery control with Rummel tourniquet, tumor excision with harmonic scalpel, application of fibrin glue to the resection bed twice (before and after kidney reperfusion). Patients were evaluated for acute or delayed bleeding.

RESULTS

Mean age was 63.9 years (33-80); mean tumor size was 2.5cm (1.5-4); mean operative time was 136.1min (90-180). Mean warm ischemia time was 19.2min (10-30). Mean blood loss was 97ml (50-300). Individual haemostatic stitches were performed before application of the sealant if acute bleeding was observed (14 cases). We did not achieve any case of postoperative bleeding from resection bed or renal failure. 1 patient required transfusion due to an abdominal wall haematoma. 65% were clear cell carcinoma, 10% were papillary carcinoma, 20% were oncocitoma. Free margin rate was 100%. Mean hospital stay was 4 days (2-6). Mean follow-up was 14 months (5-45).

CONCLUSIONS

Excluding renorrhaphy during laparoscopic partial nephrectomy is feasible and safe. Our initial experience with the vivostat system in laparoscopic partial nephrectomy has been encouraging, but longer follow-up is needed to determine the real benefit of this surgical technique in laparoscopic partial nephrectomy.

Double-balloon jejunal perfusion to compare absorption of vitamin E and vitamin E acetate in healthy volunteers under maldigestion conditions

BACKGROUND/OBJECTIVES

The vitamin E derivative, α-tocopheryl acetate, is often included in formulations used in enteral nutrition. In this respect, we compared α-tocopherol and α-tocopheryl acetate absorption under 'maldigestion' conditions, such as occurring during enteral tube feeding, using differentially labeled RRR-[5,7-methyl-((2)H(6))]-α-tocopherol and RRR-[5-methyl-(2)H(3)]-α-tocopheryl acetate allowing direct comparison between free and esterified forms.

SUBJECTS/METHODS

The two derivatives were given together in a single dose to six volunteers directly into the jejunum using a double-balloon perfusion system. Perfusion lasted for 1 h, and the collected blood and effluent samples were analyzed by liquid chromatography-mass spectrometry.

RESULTS

In the isolated 20-cm length of exposed jejunum, on average ~ 6% of the two vitamin E forms were absorbed >1 h based on subtraction of effluent from influent. There was substantial difference in the absolute absorbed quantity between individuals, but no significant differences were observed in the absorption between the two labeled forms as assessed in the plasma. (2)H(3)-α-tocopherol was not present in the influent, but appeared in the effluent, indicating that the acetylated form of vitamin E is cleaved by brush border enzymes in the small intestine.

CONCLUSIONS

This study shows that even in the absence of digestive enzymes and bile salts, the appropriately solubilized acetylated form of α-tocopherol exhibits the same bioavailability as free α-tocopherol. This suggests that both forms can be absorbed equally under maldigestion conditions such as present clinically during enteral tube feeding.

Acute experimental stress evokes a differential gender-determined increase in human intestinal macromolecular permeability

BACKGROUND

Intestinal epithelial dysfunction is a common pathophysiologic feature in irritable bowel syndrome (IBS) patients and might be the link to its clinical manifestations. We previously showed that chronic psychosocial stress induces jejunal epithelial barrier dysfunction; however, whether this epithelial response is gender-specific and might thus explain the enhanced female susceptibility to IBS remains unknown.

METHODS

Intestinal responses to acute stress were compared in age-matched groups of healthy women and men (n = 10 each) experiencing low background stress. A 20-cm jejunal segment, was perfused with an isosmotic solution, and intestinal effluents were collected under basal conditions, for 15 min during cold pain stress and for a 45-min recovery period. Epithelial function (net water flux and albumin output), changes in stress hormones, and cardiovascular and psychologic responses to cold stress were measured.

KEY RESULTS

Heart rate and blood pressure significantly increased during cold pain stress with no differences between men and women. Adrenocorticotropic hormone and cortisol levels during cold pain stress were significantly higher in men. Basal net water flux and epithelial permeability were similar in men and women. Cold pain stress increased water flux in both groups (72 ± 23 and 107 ± 18 μL min(-1) cm(-1) , respectively; F(5, 90) = 5.5; P = 0.003 for Time) and, interestingly, this was associated with a marked increase of albumin permeability in women but not in men (0.8 ± 0.2 vs.-0.7 ± 0.2 mg/15 min; P < 0.0001).

CONCLUSIONS & INFERENCES

Intestinal macromolecular permeability in response to acute experimental stress is increased in healthy women, a mechanism that may contribute to female oversusceptibility to IBS.

Treatment of warfarin-related intracranial hemorrhage: a comparison of prothrombin complex concentrate and recombinant activated factor VII

OBJECTIVE

Warfarin-related intracranial hemorrhage (ICH) is a devastating complication of warfarin therapy. Several studies have demonstrated successful correction of the international normalized ratio (INR) using prothrombin complex concentrate (PCC) or recombinant activated factor VII (rFVIIa). To our knowledge, no study has directly compared these agents for treatment of warfarin-related ICH.

METHODS

We retrospectively reviewed the charts of 15 patients who received rFVIIa and 9 who received PCC for treatment of warfarin-related ICH over a 2-year period. The primary objective was to compare the efficacy of rFVIIa and PCC in correcting the INR to 1.3 or less. Baseline INR was compared to INR obtained within 1, 3, 6, 12, and 24 hours after rFVIIa or PCC administration.

RESULTS

Six patients in the rFVIIa group and five in the PCC group had a follow-up INR within 1 hour of agent administration. In the rFVIIa group, the mean INR decreased from 6.1 to 1.1 and from 2.3 to 1.48 in the PCC group. At 6 hours, all rFVIIa patients and six (67%) PCC patients had at least one subsequent INR, with 93% and 50% correcting to an INR of 1.3 or less. Mean dose for all patients included was 53.4 ± 17.5 μg/kg and 27.8 ± 15.4 units/kg for rFVIIa and PCC, respectively.

CONCLUSION

Correction of the INR is more reliably obtained with rFVIIa when compared to PCC. Larger, prospective studies comparing these therapies for warfarin-related ICH are needed.

Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration system

PURPOSE

Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration (BCMA) system were evaluated.

METHODS

All patients receiving warfarin who were admitted to a university medical center between July 1, 2008, and February 6, 2009, in inpatient units with BCMA systems were candidates for inclusion in this study. Medication-error alerts displayed to the nurse administering the warfarin were reviewed to determine whether a true potential error was detected. Each alert was converted to a scenario, and its potential to require treatment or cause patient harm was rated using a validated severity scale of 0-10, where a score of 0 indicated no probable effect on the patient and 10 indicated that the error would likely result in patient death. A severity score was obtained by averaging the scores of four pharmacist reviewers.

RESULTS

Of the 18,393 warfarin doses ordered during the study period for 2,404 patients, error alerts associated with only 99 warfarin doses were found to be clinically meaningful. The mean ± S.D. severity rating of these alerts was low (2.93 ± 1.42), with a standardized Cronbach's coefficient alpha of 0.845. The mean ± S.D. warfarin dose attempted when the nurse received an alert was 4.10 ± 2.48 mg. The majority of doses with alerts (70%) were for patients who had an active order for warfarin.

CONCLUSION

Of the large number of medication-error alerts generated through a BCMA system, only a small proportion were considered clinically significant. This indicated that the rate of false-positive alerts was unexpectedly high, increasing the risk of alert fatigue.

Pharmacist-Managed Direct Thrombin Inhibitor Protocol Improves Care of Patients with Heparin-Induced Thrombocytopenia

Use of direct-thrombin inhibitors (DTIs) for the management of patients with heparin-induced thrombocytopenia (HIT) is challenging. A pharmacist-managed DTI protocol was implemented to standardize and improve the care of patients with HIT. A background study that compared DTI protocol–treated patients to those who did not receive treatment with the DTI protocol found that significantly more of the DTI protocol–treated patients received care that was consistent with level 1 guidelines from the American College of Chest Physicians (41% vs 0%). Because outcomes were poor regardless of whether the DTI protocol was used, the protocol was revised to require pharmacist implementation and oversight. A follow-up study compared DTI protocol patients from the background study (non-pharmacist-managed) to the pharmacist-managed DTI protocol group. There were significantly fewer dosing errors, improved nursing documentation, and less reexposure to heparin when the pharmacist was responsible for managing the DTI protocol. A trend toward reduced bleeding was noted. The management of patients with HIT is complex, and there are a number of pitfalls that may lead to poor outcomes. DTIs are high-risk medications that require careful dosing and monitoring to minimize risk for adverse drug events. A DTI protocol may improve care of patients with HIT, and pharmacist oversight of DTI use can help to reduce risk for errors and adverse medication events.

Impaired intestinal gas propulsion in manometrically proven dysmotility and in irritable bowel syndrome

BACKGROUND

Intestinal manometry is the current gold standard for diagnosing small bowel dysmotility; however, the functional significance of abnormal manometry is unknown. Our aim was to determine whether, and to what extent, intestinal gas propulsion is impaired in patients with manometrically proven dysmotility compared with healthy controls and patients with IBS.

METHODS

Clearance and tolerance of a jejunal gas load (12 mL min(-1) for 2 h) were measured in 15 patients with severe abdominal symptoms and intestinal dysmotility evidenced by manometry, 15 patients with IBS and 15 healthy subjects. Thereafter, the effect of neostigmine (0.5 mg i.v. bolus) vs placebo (i.v. saline) was tested in six dysmotility patients.

KEY RESULTS

After 2-h gas infusion, patients with dysmotility developed significantly more gas retention (717 +/- 91 mL) than IBS patients (372 +/- 82 mL; P = 0.0037) and healthy subjects (17 +/- 67 mL; P < 0.0001 vs dysmotility; P = 0.0060 vs IBS). Despite the greater retention in dysmotility patients, abdominal perception (2.5 +/- 0.6 score) and distension (7 +/- 2 mm girth increment) were similar to IBS (3.9 +/- 0.6 score and 7 +/- 2 mm, respectively). In dysmotility patients, neostigmine produced immediate clearance of gas, and by 30 min had reduced gas retention (by -552 +/- 182 vs 72 +/- 58 mL after saline; P = 0.008), abdominal symptoms (by -0.8 +/- 0.3 score vs 0.3 +/- 0.2 after saline; P = 0.019) and distension (girth change -5 +/- 1 mm; P = 0.003 vs-2 +/- 2 mm after saline).

CONCLUSION & INFERENCES

Patients with manometric dysmotility have markedly impaired intestinal gas propulsion. In IBS patients, impaired gas propulsion is less pronounced but associated with concomitant sensory dysfunction and poor tolerance of gas retention.

Impaired intestinal gas propulsion in manometrically proven dysmotility and in irritable bowel syndrome

BACKGROUND

Intestinal manometry is the current gold standard for diagnosing small bowel dysmotility; however, the functional significance of abnormal manometry is unknown. Our aim was to determine whether, and to what extent, intestinal gas propulsion is impaired in patients with manometrically proven dysmotility compared with healthy controls and patients with IBS.

METHODS

Clearance and tolerance of a jejunal gas load (12 mL min(-1) for 2 h) were measured in 15 patients with severe abdominal symptoms and intestinal dysmotility evidenced by manometry, 15 patients with IBS and 15 healthy subjects. Thereafter, the effect of neostigmine (0.5 mg i.v. bolus) vs placebo (i.v. saline) was tested in six dysmotility patients.

KEY RESULTS

After 2-h gas infusion, patients with dysmotility developed significantly more gas retention (717 +/- 91 mL) than IBS patients (372 +/- 82 mL; P = 0.0037) and healthy subjects (17 +/- 67 mL; P < 0.0001 vs dysmotility; P = 0.0060 vs IBS). Despite the greater retention in dysmotility patients, abdominal perception (2.5 +/- 0.6 score) and distension (7 +/- 2 mm girth increment) were similar to IBS (3.9 +/- 0.6 score and 7 +/- 2 mm, respectively). In dysmotility patients, neostigmine produced immediate clearance of gas, and by 30 min had reduced gas retention (by -552 +/- 182 vs 72 +/- 58 mL after saline; P = 0.008), abdominal symptoms (by -0.8 +/- 0.3 score vs 0.3 +/- 0.2 after saline; P = 0.019) and distension (girth change -5 +/- 1 mm; P = 0.003 vs-2 +/- 2 mm after saline).

CONCLUSION & INFERENCES

Patients with manometric dysmotility have markedly impaired intestinal gas propulsion. In IBS patients, impaired gas propulsion is less pronounced but associated with concomitant sensory dysfunction and poor tolerance of gas retention.

Fondaparinux for the treatment of patients with acute heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is a life-threatening immune response to heparin that is associated with a high risk of thromboembolic complications. We prospectively treated seven subjects with acute HIT with fondaparinux and compared the results to a similar historical control population from the same hospital. Six of the seven fondaparinux-treated subjects were transitioned to warfarin, beginning after platelet count recovery occurred. Ten historical controls were treated with a direct thrombin inhibitor (DTI), eight of which were transitioned to warfarin. The primary study outcome was platelet count recovery which was defined as an increase from baseline by at least 30% of nadir to greater than 100,000/mm(3) by day seven. Seven subjects were prospectively treated with fondaparinux for a median of eight days. Six of the seven had HIT with thrombosis at the time of enrollment. All fondaparinux treated subjects had a complete platelet count recovery, and none experienced a new thromboembolic complication, major bleeding or death by week four. One subject underwent limb amputation. Ten historical controls were treated with a DTI for a median duration of eleven days. Platelet count recovery occurred in eight of the ten historical controls. No new thromboembolic complications or major bleeds occurred but limb gangrene occurred in four controls. The development of limb gangrene in the historical controls may have been a result of delayed recognition of HIT and/or inappropriately early institution of warfarin in the historical controls. This pilot study suggests that fondaparinux may be useful in patients with acute HIT.

The 1st annual meeting of the American Society of Gene Therapy

The inaugural meeting of the American Society of Gene Therapy (ASGT) attracted over 1700 participants to the Pacific gateway city of Seattle, Washington for a multifaceted 4 day meeting organised into a series of symposia, workshops, poster sessions and educational opportunities representative of gene therapy's immense diversity. Presentations from the international assemblage of industrial and academic scientists covered a blend of data from cutting edge research to current clinical investigations across a spectrum of therapeutic targets. Unique educational sessions allowed participants to gain basic information regarding areas of gene therapy research in which they lacked familiarity, whereas several 'Meet the Investigator' sessions allowed participants to interact directly with experts in small group settings in order to obtain a more sophisticated perspective through informal dialogue. A large majority of the symposia and poster presentations showcased the development and current successes of viral-mediated gene therapy although non-viral approaches received their share of attention. Despite the fact that promising results were presented from ongoing clinical trials using viral-mediated gene therapy, much of the symposia addressed the accompanying problems of immunogenicity, low levels of gene expression and lack of control of gene expression that are presently limiting the clinical success of virally mediated gene transfer.

Usefulness of jejunal biopsy in the study of intestinal malabsorption in the elderly

BACKGROUND

small bowel structure and function are not different between elderly people and young people. Thus, in principle it is advisable to perform diagnostic investigation of elderly patients as well as younger patients when they present with symptoms suggestive of intestinal malabsorption. A key test for the etiologic diagnosis of intestinal malabsorption, jejunal biopsy, has not been specifically examined to assess its usefulness and risk of complications in this advanced age patients.

AIM

to establish the usefulness of jejunal biopsy with the Watson's capsule in the elderly patients with suspected intestinal malabsorption.

PATIENTS

patients older than 65 years referred to our Unit for performance of a jejunal biopsy from 1996 to 2001 for suspicion of intestinal malabsorption.

RESULTS

forty-seven patients were included. Appropriate biopsy sample was obtained in 45 cases, although in 3 patients a second try was required. Histologic findings: partial villous atrophy in 10 cases (22.2%), complete villous atrophy in 5 cases (11.1%), intraepithelial lymphocytosis in 5 cases (11.1%), and single cases of intestinal lymphangiectasia, amyloidosis, unspecific jejunitis, and Whipple's disease. Histology was normal in 19 cases (42%). Definitive diagnosis was celiac disease in 14 patients, bacterial overgrowth in 3, jejunitis in 3, Whipple's disease in 1, lymphangiectasia in 1, atrophic gastritis in 3, amyloidosis in 1, and ischemic colitis in 1. Jejunal biopsy achieved an etiologic diagnosis in 20 patients. There were no cases of perforations or bleeding.

CONCLUSION

jejunal biopsy is a useful and safe test for the etiologic diagnosis of intestinal malabsorption in elderly patients.

Central sensitisation and cutaneous allodynia in migraine: implications for treatment

Cutaneous allodynia, pain resulting from application of a non-noxious stimulus to normal skin, is a recently described symptom of migraine, with a potential role in directing optimal treatment for migraine attacks. Manifestations of cutaneous allodynia include discomfort when combing the hair, shaving, and wearing glasses, contact lenses, earrings or tight clothing. The exact mechanism by which a migraine attack is triggered is not known, but it has been theorised that, in some patients, once the attack has begun, central neurons can propagate information about the pain process without the need for further external stimuli. This process is termed central sensitisation. The trigeminal nerves, which innervate intracranial and extracranial tissues, account for head pain and other symptoms in migraine. The first-order neurons in the trigeminal ganglion receive input from the dural blood vessels, which is transmitted to second-order neurons in the trigeminal brain stem nuclear complex and is finally sent to the third-order neurons in the thalamus. Studies in humans and animals have shown that migraine pain progresses along this neural pathway, with throbbing head pain occurring early in the attack (sensitisation of first-order neurons), followed by central sensitisation and cutaneous allodynia within the referred pain area (second-order) and finally extracephalic allodynia (third-order). The data also indicate that once central sensitisation is established in the second- and third-order neurons, migraine treatment designed to prevent the initiation of central sensitisation can lessen the pain to some extent but cannot reverse it. Thus, treatment affecting the initiation of central sensitisation should be administered immediately after the onset of migraine pain to prevent intracranial hypersensitivity and the establishment of allodynia. The serotonin 5-HT(1B/1D) agonist anti-migraine agents (the 'triptans') block meningeal nociceptor transmission at presynaptic sites in the dorsal horn. Studies have shown that triptan therapy can abort pain prior to the development of central sensitisation, but not after allodynia has been established. Therefore, in the subset of patients who report symptoms of cutaneous allodynia with migraine attacks, early initiation of triptan therapy is currently the best intervention to achieve rapid, complete and sustained pain relief.

[Growth of breastfed and bottle-fed infants up to 2 years of age: CLACYD (Lactation, Alimentation, Growth and Development) study 1993-1995]

Studies done in various countries show important differences in the growth of breastfed and bottle-fed children. In addition, it has been found that breast-fed children grow more slowly beginning at the age of 2 or 3 months in comparison with the reference pattern of the U.S. National Center for Health Statistics (NCHS) and the World Health Organization (WHO). These results cast doubt on whether maximum growth is the same as optimal growth. The objective of this study was to compare the growth in weight and length, from birth to 24 months, for a group of children who were breast-fed with that of a group who were bottle-fed. The study was also intended to describe the growth of the breastfed group in relation to the NCHS/WHO norms and a WHO "12-month breast-fed pooled data set." For this research, data were analyzed from the "Cordoba: lactation, feeding, growth, and development" study (or CLACYD study, for its Spanish-language acronym). That study looked at a representative cohort, stratified by social class, of children born in 1993 in the city of Cordoba, Argentina. The researchers analyzed anthropometric data on 74 children who were breast-fed during the first year of life and on 108 bottle-fed children. The data had been recorded, using standardized techniques, at birth and at 6, 12, and 24 months of age. Both groups were homogenous with respect to the age and schooling of the parents, social stratum, birth order, maternal height, and child's weight and length at birth. The living conditions (housing construction and availability of water and sewer services) were better among the group that was bottle-fed (P = 0.04). The breast-fed children had a lower weight and a shorter length at 6, 12, and 24 months than did the bottle-fed children. The breast-fed children also showed a slowing in growth with respect to the NCHS/WHO guidelines beginning in the second semester. This indicates that the NCHS/WHO norms are not totally adequate for evaluating the growth of breast-fed children in Cordoba, Argentina. In the high and middle social strata, the values for the breast-fed group resembled those for the WHO "pooled data set," both in weight and length. In the low and very low social strata, weight values were satisfactory, but the figures for length were less than those of the "pooled data set." The gap in length found among the low and very low social strata does not reduce the validity of the WHO "pooled data set" reference, but rather indicates the influence of living conditions on linear growth.

[Adult body height in women in Cordoba, Argentina, and exploration of the current trend (1978-198)]

The objective of this work was to contribute local data concerning the full adult height of women in Cordoba, Argentina, and to explore the possibility of a secular trend in their heights. For the study, 513 women were examined during May and June 1994. All of the women were between 18 and 40 years of age and were mothers of children who were included in a study on lactation, feeding, growth, and development in Córdoba. The measurements were carried out applying standardized techniques and using as a reference standard the 50th-percentile level data from the U.S. National Center for Health Statistics. The mean full height of the Córdoba population studied was 157.9 cm, 0.97 standard deviation (SD) below the reference norm. For the women from the highest of six socioeconomic strata, the mean height was 159.7 cm (-0.67 SD); the mean for women from the lowest stratum was 156.2 cm (-1.25 SD). The difference in the means of those two socioeconomic groups was statistically significant (P < 0.001). Of the population studied, 2.3% (6.4% of the lowest social stratum) were shorter than 145 cm. In order to explore the possibility of a secular trend, the resulting data were categorized into two groups according to the mother's age at the time of the anthropometric examination, one group with a mean age of 24 and a second group with a mean age of 34. The younger women had a mean adult height 0.4 cm greater than that of the older women (P = 0.47). This secular increase in height is notably smaller than that reported for other Argentine provinces (1.2 and 1.4 cm/decade) and somewhat lower than the average reported in population studies in Australia, Belgium, the United States, Japan, and Norway (0.6 cm/decade). The authors conclude that in the period analyzed, 1978-1988, the living conditions in the city of Córdoba have not improved in a way that is reflected in a significant increase in the height of adult women. The authors recommend that maternal health and nutrition programs concentrate their resources on the mothers from the lowest socioeconomic stratum who are shorter than 145 cm.

Effect of antibiotic treatment on inflammatory markers and lung function in cystic fibrosis patients with Pseudomonas cepacia

BACKGROUND

The acquisition of Pseudomonas cepacia in patients with cystic fibrosis is associated with increasing deterioration in lung function and more frequent hospital admissions. Pseudomonas cepacia is usually resistant to several antibiotics in vitro, but the response of patients colonised with the organism has not been extensively studied in vivo.

METHODS

A three month prospective study was performed to investigate the response of 14 Ps cepacia positive patients and 10 Ps cepacia negative patients to a two week course of intravenous antibiotics. All those who were Ps cepacia negative and six of the 14 Ps cepacia positive patients had Ps aeruginosa in their sputum which was sensitive to the prescribed therapy. The inflammatory markers C-reactive protein, white blood cell count, serum lactoferrin, neutrophil elastase/alpha 1-antitrypsin complex, and tumour necrosis factor alpha were measured at the start and end of each antibiotic course.

RESULTS

The median (range) % improvement in baseline FEV1 and FVC following treatment in the group as a whole was 15.2% (-23.5% to 156.3%) and 23.9% (-36.8% to 232.7%) respectively. There was no statistical difference in improvement in lung function, body weight, or inflammatory markers between individuals who were Ps cepacia positive and those who were Ps cepacia negative.

CONCLUSIONS

Patients who are Ps cepacia positive appear to respond as well to intravenous antibiotics as those who are Ps cepacia negative, despite having lower lung function and a bacterium in their sputum which is resistant in vitro to the antibiotics used.

Continuing care for cancer pain relief with oral morphine solution. One-year experience in a regional cancer center

This report is a prospective study of 223 patients with intractable cancer pain who were offered continuing care during the year 1988 at the Pain Relief Unit, Kidwai Memorial Institute of Oncology, Bangalore, India, with a minimum follow-up of 4 months and a maximum follow-up of 16 months. A high percentage of pain relief was attained within a mean duration of 4 days, which on follow-up was maintained at a steady level in most patients (91.1%). Oral morphine could not be continued in three patients because of vomiting. The main side effects noticed were nausea and vomiting, itching, and constipation. At any time during the first 140 days, only 30% of patients had side effects and appropriate medication successfully managed these side effects. During the rest of the study period, the side effects were minimal. Oral morphine used with proper adjuncts offers the best pain palliation in most patients, with minimal side effects.

Experience with oral morphine for cancer pain relief

The authors report a prospective survey of 88 patients with cancer pain who were treated with oral morphine solution during a period of 140 days at the Pain Relief Unit, Kidwai Memorial Institute of Oncology, Bangalore. A high percentage of pain relief was achieved at the end of the first week of titrated therapy; relief was maintained at satisfactory levels throughout the study period in a majority of patients (86%). Interruption of oral morphine administration was necessitated by intractable vomiting in two patients. The majority of patients (65%) did not manifest any side effects, and appropriate medication successfully managed those who did. Oral morphine therapy for cancer pain offers effective pain relief with minimal side effects in the majority of patients.

[Prevalence of thinness and excessive fatness in a group of school children of the city of Cordoba, Argentina]

Findings of a nutritional evaluation study, using triceps skinfold, are reported. The study was carried out in 1,615 school-children from 5 to 12 years, pertaining to the low socioeconomic status of the city of Córdoba, Argentina. Measurements were done during the years 1983 and 1984 by Center's examiners with a Lange caliper, according to international anthropometric methodology. Interintra observer technical error was found to be within tolerance limits reported by other authors. Local standards were used to determine the prevalence of thinness and excessive fatness, by comparing them to tricep skinfold of each child, and selecting those children where this parameter presented values less than or equal to 10th percentile and fatness greater than or equal to 90th percentile. Furthermore, comparison between median triceps skinfold of the examined group, the local standards and Frisancho's norms for US population was also made. Results revealed that: a) the prevalence of thinness (19.9%) was almost twice the percentage expected for a normal population; in contrast, occurrence of excessive fatness (6.4%) was found to be below the expected value; b) prevalence of thinness was not statistically associated to age nor sex; c) frequency of excessive fatness was significantly higher in the 8-11 year-old male group (8, 9%, p much less than 0.0005) and in the girls group (10.8%), P much less than 0.005) the prevalence of fatness in girls increased with age, and figures revealed that from eight years onwards this exceeded the expected percentage, and d) median triceps skinfold of the group under study was generally below local and foreign norms. It is concluded that potential or real nutrition problems as those mentioned above, may be grossly identified using the triceps skinfold as the single anthropometric indicator.