bluuebunny/crossref_metadata_2025 huggingface dataset:
Delusions and Self-Esteem
Authors: Bowins B , Shugar G
Published: January 2017

Objective:

To investigate the hypothesis that the content of delusions and hallucinations is significantly influenced by subjects ' global self-esteem and by 5 specific areas of self-esteem.

Method:

The delusions and hallucinations of 40 psychotic patients were assessed by 2 independent raters for content indicative of positive or negative self-esteem and for the extent to which the delusional content would be self-enhancing (or diminishing) and comforting (or discomforting) to the subject. These ratings were correlated with the results of self-esteem inventories completed by the subjects.

Results:

The content of delusions reflects both global self-esteem and self-regard.

Conclusions:

This study demonstrates that 2 specific personality factors, global self-esteem and self-regard, are reflected in the content of delusions and influence whether those delusions are experienced as comfortable (or uncomfortable) and enhancing (or diminishing). Delusional content is therefore consistent with patients ' views of themselves, and this may partially account for the persistence of delusions.
Autonomie Correlates of Antidepressant Treatment Using Heart-Rate Variability Analysis
Authors: Khaykin Yaariv , Dorian Paul , Baker Brian , Shapiro Colin , Sandor Paul , Mironov Dmitry , Irvine Jane , Newman David
Published: January 2017

Objective:

To assess the 24-hour temporal-domain heart-rate variability correlates of treatment with fluoxetine or doxepinfor depression.

Method:

A randomized evaluation of fluoxetine and doxepin measured a 50% change in the Hamilton Depression Rating Scale (HDRS) score as a response to therapy and was correlated with measures of standard deviation of the mean of all 5-minute segments of normal electrocardiographic R-R intervals (SDANN), standard deviation of all normal R-R intervals (SDNN), root mean square of successive differences in R-R intervals (r-MSSD), and percentage difference between adjacent normal R-R intervals that are greater than 50 msec (pNN50)from 24-hour electrocardiogram (ECG) tapes.

Results:

Ten out of 14 patients responded. Response was associated with an increase in SDANN of 17% (P < 0.05). Nonresponse was associated with a 17% decrease in SDANN and a 22% decrease in SDNN (both P < 0.05). No other measures correlated with therapeutic response. No heart-rate variability (HRV) differences between the 2 drug therapies were observed.

Conclusion:

Twenty-four-hour HRV measures may be useful in assessing response to antidepressant therapy.
Anxious Attachment and Self-Reported Depressive Symptomatology in Women
Authors: West Malcolm , Rose M Sarah , Verhoef Marja J , Spreng Sheila , Bobey Mary
Published: January 2017

Objective:

Lack of intimacy has been identified as an important provoking agent that increases the risk of depressive symptoms in women. This study precisely characterized lack of intimacy by assessing a woman's attachment style and investigated the specificity of association between depressive symptoms and an anxious attachment pattern.

Method:

Four hundred and twenty women participated in this cross-sectional study of depressive symptomatology and anxious attachment. All participants completed the following measures: a sociodemographic questionnaire, the Centre for Epidemiological Studies Depression Scale (CES-D), the Reciprocal Attachment Questionnaire, the Social Support Questionnaire, the Rosenberg Self-Esteem Scale, and the Global Assessment of Recent Stress Scale.

Results:

A score of 16 or above on the CES-D, which indicates the presence of depressive symptoms, was used to divide the sample into 2 groups: a depressed group (N = 129) and a nondepressed group (N = 291). We found that women in the depressive symptomatology group were more likely than women in the nondepressive symptomatology group to exhibit anxious attachment and adverse social and cognitive characteristics. Lower levels of self-esteem and higher levels of recent stress were also predictive of depressive symptomatology. Feared loss of the attachment figure and a lack of use of the attachment figure were independent predictors of depressive symptomatology in the same model.

Conclusion:

The feared loss of security associated with an attachment figure seems to be related to an increased likelihood of depressive symptoms.
The Use of Clozapine in the Treatment of Aggressive Schizophrenia
Authors: Hector R Ian
Published: January 2017

The atypical antipsychotic drug clozapine was introduced to clinical practice in 1972. It is a dibenzodiazepine derivative with, among other known receptor site activities, a relatively high D1/D2 receptor affinity ratio. The serious side effects of bone marrow suppression and agranulocytosis delayed the acceptance of clozapine into common clinical practice but scrupulous application of a monitoring protocol led to adequate protection from these side effects. There is now a broad consensus about the benefits of clozapine which supports the use of clozapine as a first-line treatment of schizophrenia. There is good evidence that relapse and rehospitalization drop to 22% of the incidence in preclozapine treatment patients. The majority of responders are identified within 4 months of treatment. Clozapine has been demonstrated to be an effective treatment for neuroleptic refractory patients. Forty percent of clozapine-treated patients show significant improvement, with 11% of treated patients showing no residual psychosis. This review also describes the results of clozapine on aggressive and violent assault in a patient population characterized by severe functional deficits, typically chronic schizophrenia with severe impairment, chronic brain syndromes, and developmental handicap. Prior to the introduction of clozapine therapy, in a chronically disrupted milieu that precluded adequate psychosocial programming, seriously assaultive behaviour resulting in peer and staff injury was a common occurrence. Evidence suggests that clozapine is an effective medical treatment for the target symptoms of hostile agitation, threatening, and assaultive violence.
Stalking Part I: An Overview of the Problem
Authors: Abrams Karen M , Robinson Gail Erlick
Published: January 2017

Objective:

This paper is the first of a 2-part review on the topic of stalking. It outlines the behaviours involved, epidemiology, motivation of offenders, and mental health consequences for the victim.

Method:

Computerized literature searches were used to identify relevant papers from psychiatric and legal journals. Publications by victims' and women's organizations provided additional information.

Results:

Up to 1 in 20 women will be stalked during her lifetime. The majority of victims are female, while the offenders are usually male. Stalking behaviours range from surveillance to threatening aggressive or violent acts. The majority of stalking relates to failed intimate relationships. Stalkers may also suffer from erotomania or obsessional love with a primary psychiatric diagnosis. Victims may experience anxiety, depression, guilt, helplessness, and symptoms of posttraumatic stress disorder (PTSD).

Conclusion:

Stalking is a serious offence perpetrated by disturbed offenders. It can cause major mental health consequences, which are often poorly understood by society.
Factors in Delays in Discharge from Acute-Care Psychiatry
Authors: Kelly Ann , Watson Diane , Raboud Janet , Bilsker Dan
Published: January 2017

Objective:

To determine if there are any potential opportunities for patients to be discharged earlier and to determine what factors are responsible for delays in discharge.

Method:

A survey was completed by clinical staff of all patients on the wards of 12 adult psychiatry units in the Greater Vancouver Regional Hospital District (GVRD) for a 1-day period. The survey included a modified Brief Psychiatric Rating Scale (BPRS) and the Discharge Readiness Inventory (DRI). A 1-month follow-up measured discharge and nondischarge outcomes.

Results:

Of the 327 patients surveyed, 42% were ready for discharge at the time of the assessment, and 37% of those who were ready were not discharged within 2 weeks. Delayed patients had significantly higher scores for disorientation, hallucinations, conceptual disorganization, and manifest psychopathology and significantly lower scores for Community Adjustment Potential (CAP) (P < 0.05). The most frequent reasons given for delays were ongoing medication adjustment, behaviour stabilization, and discharge planning. Patients who were delayed were more likely to need services, to need or be waitlisted for a residential placement, to be a client of the community-based mental health team that provides ongoing support to clients living in the community, to have a diagnosis of schizophrenia, and to have had no previous psychiatric hospital admission.

Conclusion:

The removal of all barriers to delays would reduce lengths of stay by 11% for this sample of patients. This would require a shift of about 42 out of 327 beds to an alternate level of care. These “earlier discharge patients” will need ongoing medication and behaviour monitoring through a variety of community services.
Binge/Purge Symptoms and Comorbidity in Adolescents with Eating Disorders
Authors: Geist Rose , Davis Ron , Heinmaa Margus
Published: January 2017

Objective:

To identify the diagnostic subtypes of eating disorders (EDs), the psychiatric comorbid diagnoses, and associated specific and nonspecific psychopathology in a series of 120 adolescents undergoing standardized assessment for an ED.

Method:

Consecutive patients referred to our large pediatric hospital for ED assessment completed a semistructured diagnostic interview for children and adolescents. The following self-report scales were administered to assess specific and nonspecific psychopathology: the Children's Depression Inventory (CDI), the Brief Symptom Inventory (BSI), the Eating Disorder Inventory 2 (EDI-2), and the Family Assessment Measure (FAM-III) of family functioning.

Results:

Female subjects with a mean age of 14.5 years and a mean body mass index (BMI) of 18.1 comprised 93% of the sample. The restrictive subtypes of anorexia nervosa (AN) (43%) and eating disorder not otherwise specified (EDNOS) (16%) were the most common diagnoses. Patients with restricting symptoms (R) could be grouped together because they were more similar to each other with respect to self-report symptoms of psychopathology than they were to patients with binge/purge (B/P) symptoms and vice versa. Patients with R endorsed significantly fewer subjective symptoms, both ED-specific and nonspecific, and rated their families' functioning better than did B/P patients. Comorbid, current major depressive disorders and dysthymic disorders occurred in 66% of subjects, but depressive, dysthymic, and oppositional disorders occurred in 96% of those with B/P symptoms. Severity of the CDI was the best single discriminator between R and B/P subjects.

Conclusions:

Adolescents with EDs in the early stage of their illness are similar to adults with EDs in the following ways: they meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for subtypes of EDs (excluding amenorrhea) and commonly have comorbid psychiatric disorders, especially depressive disorders. Patients with B/P symptoms can be distinguished from restricting subjects because they endorse significantly more ED-specific and nonspecific psychopathology and have a higher frequency of comorbid Axis I diagnoses (especially depressive disorders) than restricting patients. Oppositional defiant disorder (ODD) occurs more commonly in adolescents with EDs associated with B/P symptoms.
A Community-Based Clinic Survey of Antidepressant Use in Persons with Schizophrenia
Authors: Lam Raymond W , Peters Ron , Sladen-Dew Nicholas , Altman Siemion
Published: January 2017

Objective:

To determine the rates of antidepressant and antipsychotic use in the treatment of schizophrenia.

Method:

The primary therapists at 8 community mental health centres in a metropolitan Canadian city completed a survey questionnaire for all of their active clients. Information was collected about diagnoses, medication treatments, and clinical variables.

Results:

There were 3555 clients, 1552 (43.7%) of which had a diagnosis of schizophrenia. Of clients with schizophrenia, 94% were prescribed antipsychotic medications, and 11.6% of these were also prescribed antidepressant medications. There were differences between the combination-treatment group and the antipsychotic-alone group in gender ratio, rates of concurrent diagnoses of mood disorder, level of current functioning, and total number of hospitalizations.

Conclusion:

In this community-based sample of clients with schizophrenia, antidepressants and antipsychotics are commonly prescribed in combination, even though the rate of concurrent mood disorders diagnoses is low. Further studies should clarify the efficacy and indications for antidepressant use in this population.
Mental Illness and Violence: An Epidemiological Appraisal of the Evidence
Authors: Arboleda-Flórez J
Published: January 2017

Objective:

To conduct a critical review of the literature on the matter of mental illness and violence, to examine whether there is enough evidence to establish a causal link, and to provide epidemiological background to measure the risk to the population.

Method:

Based on a computerized search of the literature on mental illness and violence previously conducted for Health Canada, studies in the area were critically reviewed and divided into 3 main categories: 1) studies of criminal and violent behaviour among psychiatric patients, 2) studies of psychiatric illness among offenders (prevalence studies in institutions, analytical studies, and community follow-up of offenders), and 3) epidemiological community-based studies on the issue of mental illness and violence (police-citizen encounters, representative samples, and other epidemiological studies). Causality rules andmeasures of risk were then applied to the evidence elicited.

Results:

The review of the literature suggests that only a small minority of hospitalized patients, typically those suffering from acute psychotic symptoms, are involved in violent incidents. Formerly hospitalized patients are at a higher risk of committing violence if they are not properly treated and are experiencing threat/control-override psychotic symptoms. Substance abuse disorders significantly raise the risk for violence. Family members are the most at risk of being victimized.

Conclusion:

An association exists between mental illness and violence, but the many covariations that naturally affect the equation between them introduce uncertainties in establishing causality.
Adoptee Overrepresentation among Clinic-Referred Boys with Gender Identity Disorder
Authors: Zucker Kenneth J , Bradley Susan J
Published: January 2017

Objectives:

To test the hypothesis that adoptees are overrepresented among a sample of clinic-referred boys with gender identity problems (N = 238). To compare the adoptees and nonadoptees on demographic, behaviour problem, and gender-typed measures.

Method:

The percentage of clinic-referred boys with gender identity problems adopted in the first 2 years of life (“early adoptees”) was compared to the base rate of boys adopted in Ontario. Parent-report and behavioural measures were used to compare the early adoptees with “late adoptees” (adopted after the second year of life) and nonadoptees.

Results:

The percentage of boys with gender identity problems who were early adoptees (7.6%) was significantly higher than the base rate of males adopted in Ontario in the first 2 years of life (1.5%). Both the early and late adoptees were significantly less intelligent than the nonadoptees. The early adoptees also had significantly higher externalizing T scores on the Child Behavior Checklist than did the late adoptees and the nonadoptees. The 3 groups did not differ in the percentage who met the complete Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for gender identity disorder and on 4 other measures of gender-typed behaviour.

Conclusion:

Adoptees are overrepresented among clinic-referred boys with gender identity problems. The reasons for this finding are not clear but may be accounted for by general risk factors that increase the likelihood of clinical referral or by psychosocial and biological factors associated with adoption.
Pentobarbital for Sedation during Mechanical Ventilation in the Pediatric ICU Patient
Authors: Tobias Joseph D.
Published: January 2017

In most pediatric intensive care units (PICUs), sedation is provided using opioids and benzodiazepines, either alone or in combination. While these agents are effective in most patients, certain situations may arise in which this usual combination is ineffective. There are no large series outlining the use of pentobarbital for sedation in the PICU population. The current report is a retrospective review of the use of pentobarbital for sedation of 50 patients in the PICU and provides information concerning the use of phenobarbital to prevent withdrawal symptoms following the prolonged administration of pentobarbital. The 50 patients ranged in age from 1 month to 14 years and in weight from 3.1 to 56 kg. All required sedation during mechanical ventilation. Prior to changing to pentobarbital, sedation was inadequate despite midazolam doses of ≥0.4 mg/kg/hr, fentanyl doses of ≥10 μg/kg/hr, and morphine doses of ≥100 μg/kg/hr. The duration of pentobarbital infusion ranged from 2 to 37 days (median 4 days) in doses ranging from 1 to 6 mg/kg/hr (median 2 mg/kg/hr). Twelve patients also received an ongoing opioid infusion for more than 48 hours after starting the pentobarbital infusion to control pain related to a surgical procedure or an acute medical illness. There was an increase in pentobarbital infusion requirements over time. In the 14 patients that received pentobarbital for 5 days or more, the requirements increased from 1.2 ± 0.4 mg/kg/hr on day 1 to 3.4 ± 0.7 mg/kg/hr on day 5 ( p < 0.01). Pentobarbital was effective in all 50 patients without significant adverse effects.
The Compartment Syndrome of the Abdominal Cavity: A State of the Art Review
Authors: Wittmann Dietmar H. , Iskander Gaby A.
Published: January 2017

Abdominal compartment syndrome gains increasing recognition. It impairs physiology and requires treatment. It occurs more commonly with acute rather than chronic abdominal hypertension. Functional impairments involve the cardiovascular system, respiratory system, hepatic, renal, and gastrointestinal function, and intracranial pressure. Abdominal hypertension decreases venous return, increases systemic vascular resistance and intrathoracic pressure, and therefore reduces cardiac output. It also adversely affects cardiovascular monitoring. In the presence of increased abdominal pressure, atelectasis and pneumonia are likely to develop and impaired ventilation may lead to respiratory failure. Also, blood flow to the liver and kidney may be reduced, resulting in functional impairment of both organs. The adverse effects on gastrointestinal function result from impairing lymphatic, venous, and arterial flow. Anastomotic healing may become a problem under these circumstances. Decreased venous return through the inferior vena cava in obese patients may lead to venous stasis ulcers and hemorrhage. The correlation of increased intracranial pressure and intra-abdominal pressure may be a problem for trauma patients with simultaneous injuries to the head and the abdomen. There are three severity grades of increased intra-abdominal pressure: Acute sustained elevation of intra-abdominal pressure above 10–20 mmHg is called mild abdominal hypertension. Physiologic effects are generally well compensated and usually clinically nonsignificant. Nonoperative therapy may be required. Moderate hypertension is defined as sustained elevation of 21–35 mmHg. Therapy is generally necessary. Surgical abdominal-decompression may be critical. Severe hypertension or abdominal compartment syndrome is defined as sustained elevation above 35 mmHg. Operative decompression is always indicated. The gap between the abdominal wound edges must be temporarily covered to prevent fascia retraction and formation of a huge hernia. All detrimental effects of elevated intra-abdominal pressure and the methods and benefits of its decompression have been well studied, both in the laboratory and in clinical practice. Diagnostic suspicion may be confirmed with objective measurements of intra-abdominal pressure to select patients who may benefit from decompression. Operative decompression is achieved by abdominal fasciotomy and covering the fascial gap with mesh made of Marlex®, Gore-Tex®, silastic, or by a Velcro-like closure mesh (artificial bur). All meshes help to effectively decompress the abdomen. The artificial bur offers further advantages by permitting successive reapproximation of the fascia until final fascial closure, and avoiding the fistula and hernia formation seen with the other meshes.
Candida Infections: Outcome and Attributable ICU Costs in Critically Ill Patients
Authors: Pelz Robert K. , Lipsett Pamela A. , Swoboda Sandra M. , Diener-West Marie , Powe Neil R. , Brower Roy G. , Perl Trish M. , Hammond Janet M. , Hendrix Craig W.
Published: January 2017

Candida species are an increasingly common cause of nosocomial infections. Candida infections have been associated with significant attributable morbidity and mortality, especially among critically ill patients. However, little is known about the cost implications of these increasingly common infections. In order to evaluate the costs associated with Candida infections in the critically ill, we report the findings of a 3–month prospective cohort study of Candida infections in the medical intensive care unit (MICU) and the surgical intensive care unit (SICU) at Johns Hopkins Hospital. Infections were diagnosed according to prospectively established definitions. Cost data were extracted from the computerized billing database and used to estimate the ICU costs associated with nosocomial Candida infection. Using multiple linear regression, the effect of Candida infections on cost was adjusted for clinical variables in order to estimate the cost of ICU care attributable to Candida infection. Of 117 ICU patients enrolled in the study, 14 developed Candida infections. In a stepwise linear regression model adjusting for multiple clinical variables including APACHE II score, infection with Candida species was associated with an attributable ICU cost of $21,590. Over the cohort, the increased cost associated with Candida infections translates into a cost of $230/ICU patient-day. In addition, Candida infections were associated with an increased length of hospital stay of 17 days and an increased length of ICU stay of 8 days. In this small, prospective, cohort study, nosocomial Candida infections are independently associated with an increase in the cost of ICU care and an increased length of stay. No increase in mortality was noted, though it is possible a difference in mortality was missed due to the study's small sample size.
Asystole Associated with Lidocaine Use in a Hyperkalemic Patient during Advanced Cardiac Life Support
Authors: Lehmann David F. , Shively Bruce K. , Tzamaloukas Antonios H.
Published: January 2017

A case report of fatal asystole associated with use of lidocaine in a hyperkalemic patient is presented. The patient was a 61–year-old man with a rapidly increasing serum potassium level related to acute renal failure. Ventricular tachycardia with a pulse developed twice, for which lidocaine was administered according to the American Heart Association's ACLS protocol. Both episodes were immediately followed by asystole, the second of which was terminal. Available information suggests that this phenomenon can be explained by a synergistic effect on membrane responsiveness and conduction velocity. Thus, extreme caution should be exercised in the use of lidocaine when ventricular tachycardia complicates severe hyperkalemia.
Clinical Pharmacy Practice in the Operating Room
Authors: Shafer Amy L.
Published: January 2017

An operating room pharmacy has traditionally been focused on the provision of controlled substance accounting and drug distribution services. Clinical pharmacy can be practiced in this setting as well, to the benefit of patients and operating room staff. The operating room pharmacist can provide such services as drug information, drug use evaluation, participation in patient care rounds, adverse drug reaction reporting, assistance in emergency drug therapy, formulary management, research collaboration, pharmacokinetic and pain management consultation, and education regarding drug therapy. The clinical expertise of the operating room pharmacist can be gained through literature review, surgical case observation, attendance and participation in anesthesia conferences, and direct patient care. By providing clinical services appropriate to a given institution's needs in the operating room setting, and delegating direct distributive functions to pharmacy technicians whenever possible, the pharmacist can move into a rewarding role as a clinician member of the operating room health care team.
The Role of the Pharmacist in Ambulatory Surgery
Authors: Kollar Kathleen M.
Published: January 2017

The American Hospital Association predicts that by 1995 more than 60% of patients requiring surgery will be treated in an outpatient (ambulatory) setting.1 Compared with 10 years ago, the types of surgical procedures performed on an outpatient basis have greatly expanded. This can be attributed to a change in the guidelines used for determining patients suitable for outpatient surgery, which has mainly occurred secondary to changes in technology and the introduction of new shorter-acting anesthetic agents onto the market. This article will describe the role of the pharmacist in ambulatory surgery as well as discuss the types of surgery performed on an outpatient basis; how the medications administered preoperatively, intraoperatively, and postoperatively differ from the inpatient setting, and the criteria used to assess the preoperative patient.
Malignant Hyperthermia
Authors: Dever Laura Ann
Published: January 2017

Malignant hyperthermia (MH) is a rare, genetically inherited hypermetabolic syndrome that remains dormant until triggered by exposure to certain conditions (emotional and physical stresses) or pharmacological agents (anesthetic gases and succinylcholine) in susceptible individuals. It is believed that MH is caused by a derangement in the control of intracellular calcium ions, which results in a hypermetabolic state from sustained muscle contractures. Without supportive measures and immediate treatment with the antidote, dantrolene, the mortality rate from MH can be as high as 70%. A complete personal and family medical history before surgery can show important clues that might alter the anesthetic regimen preoperatively and postoperatively (eg, the use of nontriggering agents) in MH-susceptible patients. Anesthesia personnel need to recognize the early signs of a MH crisis (eg, tachycardia, muscle stiffness, hypercapnia, and tachypnea), then monitor for other signs (eg, arrhythmias, blood pressure changes, fever, metabolic and respiratory acidosis, and mottling cyanosis), and initiate prompt treatment. Because immediate recognition and treatment of this potentially fatal hyperpyrexic episode increase a patient's chance of survival, other health care personnel (eg, nurses, pharmacists) play key roles in the emergency treatment of a MH crisis. A suspected episode of MH should be followed up with contracture testing to determine MH susceptibility (MHS). Reports of MH should be reported to the North American MH Registry.
Estrogen Replacement Therapy: The Benefit Outweighs the Risk
Authors: Moore Andrea O. , Briggs Geneva C.
Published: January 2017

Menopause and the related decline in estrogen result in multiple symptoms including genitourinary atrophy, vasomotor instability, and osteoporosis. The most significant long-term effect of estrogen deficiency is increased risk of cardiovascular disease. Estrogen replacement therapy (ERT) decreases osteoporosis and associated fractures, decreases symptoms associated with menopause, and offers cardioprotection. However, ERT is not without risk because it may lead to increased risk of endometrial cancer if used without progestin, and has been questionably linked to breast cancer. Educating the post-menopausal woman concerning the risks and benefits of ERT is essential to assure compliance. ERT decreases mortality incidence and improves quality of life, and its use for any post-menopausal woman without contraindications is recommended.
Cancer in Women: Trends in Care
Authors: Keller James H.
Published: January 2017

Breast cancer, ovarian cancer, and cervical cancer are neoplastic diseases of primary concern to women. Breast cancer alone will afflict up to 12% of all women. Early detection and treatment of this disease can account for relatively stable mortality rates in the face of increased incidence. Identification of prognostic factors as well as extensive staging of the disease have been important developments in identifying treatment strategies for breast cancer. Advancements in early detection, breast-conserving surgery, and adjuvant systemic therapy have had a major impact on the treatment of this disease. The principle treatment for both ovarian cancer and cervical cancer is surgery. A large number of patients with ovarian cancer have evidence of metastatic intra-abdominal disease at the time of staging laparotomy. These patients are candidates for chemotherapy, generally with cisplatin- or carboplatin-containing regimens. Intraperitoneal administration of chemotherapy drugs has been used to consolidate therapy or to treat residual therapy in the abdomen. Further development of new and effective drugs such as the new compound Taxol (Bristol-Meyers Squibb) are needed to further enhance the treatment of this disease. Cervical cancer, on the other hand, is largely curative by surgical procedures. Early detection and treatment has had a major impact on the mortality incidence of this disease. However, there are a small number of patients who have metastatic disease at the time of diagnosis or a small subset of patients who fail to respond to curative surgery. These patients are likewise candidates for chemotherapy. The activity of existing regimens has been limited, and there is a need for the identification and development of more active compounds.
Evaluation and Counseling of Teratogenic Risk: The Motherisk Approach
Authors: Koren Gideon , Graham Karen , Feigenbaum Annette , Einarson Tom
Published: January 2017

The authors present a new approach for evaluation and counseling of teralogenic risk. The Motherisk program in Toronto presently deals with 60 inquiries per day from the public and health professionals. Most calls are answered through the telephone, and 16–20 women per week are scheduled for our clinic following exposure to known or suspected teratogens, to new drugs with sparse information, to chronic drug therapy, or drugs of abuse. Also seen in clinic are women who want to be counseled or whose physicians want them to meet us due to high levels of anxiety. Since its inception in 1985 the Program has been very effective in preventing unnecessary terminations of otherwise wanted pregnancies. In addition to the clinical service we follow-up the outcome of these prospectively collected exposures, thus creating a large data base necessary to verify safety/risk of various agents. During the last 2 years Motherisk has completed singly, or in collaboration, large prospective studies on gestational exposure to lithium, antiepileptics, cocaine, and fluexitime. To study the reproductive risks of cocaine we compared first-trimester exposure to cocaine with two control groups. Infants exposed to cocaine did not have higher rates of any adverse perinatal outcome. Their cognitive function at 18 months of age was identical to the control infants. Meta-analysis of all studies assessing gestational risks of cocaine reveals that the results of these studies were dependent on the type of comparison conducted. When babies exposed to cocaine were compared with middle class nonusers, the cocaine groups seemed to be more often different from their controls. Conversely, when cocaine-exposed infants were compared with babies of women exposed to other drugs of abuse but not cocaine, most of these differences cancelled out, suggesting that clustering of other risk factors may cause some of these adverse effects.
Neurologic Concerns in Long-Term Care
Authors: Bowles Susan K.
Published: January 2017

Nursing home residents exhibit a number of different neurological disorders, including behavioral symptoms associated with dementia, sleep disturbances, and drug-induced disorders such as tardive dyskinesia. Behavioral symptoms are frequently treated with antipsychotic agents. However, there is growing evidence that these agents are frequently used inappropriately. While some patients may benefit from pharmacological intervention, it is doubtful that the majority will show dramatic improvement. Some sleep disturbances may be effectively treated with drugs, although they should be used in conjunction with environmental and behavioral interventions. The overuse of psychoactive drugs, particularly the neuroleptics, may result in neurological complications. Pharmacists have a role in ensuring that drugs are used for appropriate indications in elderly nursing home residents and in identifying drug-induced disease.
Inhalational Anesthesia
Authors: Satterlee G. Benjamin
Published: January 2017

Pharmacists have traditionally had little involvement with inhalational anesthetic agents. As the popularity of operating room pharmaceutical care increases, the need for the pharmacist's understanding of the uses and actions of anesthetic agents becomes necessary. This review provides an introduction to inhalational anesthesia, delivery systems, and the agents commonly used in anesthetic practice. Inhalational agents have long been used to provide general anesthesia through combined pharmacological actions. Nitrous oxide and oxygen are delivered as sole gasses or as carrier vehicles for the more potent inhalational anesthetics: halothane, enflurane, isoflurane, sevoflurane, and desflurane. The minimum alveolar concentration (MAC) of anesthetics is a measurement of concentrations that will prevent reflex movement in 50% of patients. A low blood/gas solubility coefficient for inhalational agents is desirable and is equated with low metabolism, rapid onset, and short duration of action. The inhalational agents are depressants to the nervous and respiratory systems and have variable effects on the cardiovascular system. Potent volatile agent induced renal toxicity may be a result of fluorine produced as a byproduct of hepatic metabolism. Newer agents favorably show lower solubility characteristics and increased physical and metabolic stability.
Ongoing Continuous Quality Improvement Strategy Using Pharmacological Stress with Intravenous Dipyridamole and Pharmacist Intervention to Reduce Suboptimal Exercise Myocardial Perfusion Scans
Authors: Greenstein Lisa B. , Hatch John L. , Sherrin Thomas P.
Published: January 2017

Exercise electrocardiogram (ECG) testing in conjunction with radionuclide imaging provides prognostic, diagnostic, and important physiological information regarding the presence of ischemia. However, many patients cannot or will not exercise to 85% of maximal heart rate. When this occurs, potential disparities in regional myocardial perfusion may not be apparent. Pharmacological stress testing with intravenous (IV) dipyridamole provides an alternative method of increasing intracoronary blood flow in these patients and decreasing the incidence of suboptimal exercise myocardial perfusion scans. An ongoing program was begun in 1992 to determine the effect of using pharmacological stress testing with IV dipyridamole (in selected patients) on the incidence of suboptimal exercise myocardial perfusion scans. Myocardial perfusion scans from the months of February 1991 and February 1992 were reviewed. Data collected included demographic variables, heart rate, percent of maximum predicted heart rate, anti-anginal drug therapy, and any underlying conditions that could influence the patient's ability to exercise adequately. There was only a slight reduction in inadequate exercise tests between the two study periods, 30% in February 1991 and 23% in February 1992, without pharmacist intervention. There was an increase in the number of dipyridamole perfusion scans, one (<1%) in February 1991 and 10 (6%) in February 1992. These data were presented to physicians as part of an educational program on the availability and appropriate use of pharmacological stress testing with IV dipyridamole. Several suggestions were made to assist in decreasing the incidence of suboptimal exercise myocardial perfusion scans. The review was repeated in February 1993. There was a further increase in the number of dipyridamole perfusion scans (18, or 11% over previous levels); however, the rate of suboptimal exercise tests remained at 24%. This review offered an easy and unique opportunity for the pharmacy to be involved in multidisciplinary continuous quality improvement with nuclear medicine and cardiology. It is anticipated that with continued education and a change in patient screening procedures, along with the development and use of drug use guidelines, a decrease in the number of suboptimal exercise myocardial perfusion scans may be realized.
Providing Cognitive Pharmacy Services to the High-Risk Obstetrical Patient
Authors: Streator Scott E.
Published: January 2017

Obstetrical Pharmacy, a relatively recent specialty area, has allowed the clinical pharmacist to provide consultative services in caring for the high-risk pregnant patient. The obstetrical pharmacist provides cognitive services in the form of direct oral communication with the obstetrician, followed up with a written (signed) pharmacotherapy consult. This consult will generally deal with a multitude of pregnancy-related problems and nonpregnancy-related problems. As part of the health care team, the obstetrical pharmacist helps to ensure a positive therapeutic drug-related outcome by monitoring end points of therapy, providing drug information, and documenting all interventions in the patient records. Third-party payors value the pharmacist's cognitive services in providing this specialized care, as indicated by the successful reimbursement, which is obtained as a result of proper written documentation, for these services.
Drug Therapy of Aggressive Behaviors Accompanying Dementia
Authors: Gardner Marie E.
Published: January 2017

Aggressive behaviors often accompany dementia in the elderly, institutionalized patient. These may include any number of verbal or physical acts, and range from swearing, threatening, to harming self, others, or property. Identifying specific target behaviors for treatment is important in selecting the appropriate therapeutic option. The major neurotransmitters involved in aggression include gamma-aminobutyric acid (GABA) and serotonin, which inhibit aggression, and dopamine, norepinephrine and acetylcholine, which increase it. Drug therapy for control of aggressive behaviors has traditionally included the antipsychotics and benzodiazepines. However, additional, newer therapies are also useful. Among these are the anticonvulsants carbamazepine and valproic acid, various beta-blocking agents, antidepressants, and buspirone. These medications may be needed when nondrug therapy for control of behavioral problems fails or is insufficient. Determining which behaviors are problematic and need treatment, knowing which medications are indicated for those problems, and noting contraindications for particular drug therapies will lead to the best therapeutic option for a given patient.
Hypnotic Use in the Elderly
Authors: Beizer Judith L.
Published: January 2017

Sleep disturbances are a common complaint in the geriatric population. Studies have shown that older people have a different sleep architecture as compared with that of younger people. Older patients with sleep complaints should be evaluated for underlying causes of sleep disturbances such as medication use, medical or psychiatric illnesses. Common sleep disorders in the elderly include sleep apnea, nocturnal myoclonus, restless leg syndrome, and insomnia. To treat insomnia, initial therapy should be nonpharmacological measures such as good sleep hygiene. If pharmacological treatment is necessary, a short course with a low dose of a short or intermediate-acting benzodiazepine or Zolpidem can be attempted. Because of pharmacokinetic and pharmacodynamic alterations, elderly patients are particularly susceptible to the central nervous systemic side effects of hypnotic agents and should be closely monitored.
Lead ‘Poisoning’ and Pharmacotherapy: Is the Cure Necessary, and Worse than the ‘Disease’?
Authors: Bederka John
Published: January 2017

This is a discussion of causes, paint or environmental, and the risks associated with lead exposure, the current treatment, and questions about the propriety of subjecting asymptomatic children to the grueling and painful and questionably efficacious treatment known as chelation. Pharmacists involved in treatment should consider this message and concern when participating in lead poisoning pharmacotherapy. Pharmacists in the health care and general communities should share this message with pediatric and public health officials.
The Evolving Role of Paclitaxel in Breast Cancer and the Ambulatory Care Setting
Authors: Boehnke Laura L.
Published: January 2017

Not since the introduction of doxorubicin has a drug been as exciting and promising as paclitaxel for the treatment of breast cancer. Currently, the only approved use of paclitaxel in breast cancer is the metastatic setting. Paclitaxel is being studied in the adjuvant setting to assess its relative efficacy and to theoretically increase the chances of killing all micrometastases with alternate therapy with a different mechanism of cytotoxic activity. The optimal dose and schedule of administration have not been identified. Toxicities differ depending on dose and schedule, and treatment and prevention strategies for these toxicities are discussed. Continuous infusion administration can be accomplished with the use of ambulatory infusion devices. Issues of central venous access, use of premedications, use of granulocyte colony-stimulating factor (G-CSF), and dosages and schedule of paclitaxel will be discussed in relation to ambulatory paclitaxel administration. Special circumstances that require inpatient administration or special monitoring are also discussed.
Inpatient High-Dose Chemotherapy with Outpatient Autologous Stem Cell Support: A Model of Continuous Pharmaceutical Care
Authors: Gilbert Colleen J. , Morgan Robert T. , May Diana Maravich
Published: January 2017

The adult autologous bone marrow transplant (ABMT) program at Duke University Medical Center has developed an innovative outpatient approach to managing patients with solid tumors with ABMT during their postchemotherapy period of myelosuppression and recovery. The use of colony-stimulating factors in combination with peripheral blood progenitor cells (PBPCs) and bone marrow for hematologic support plus implementation of prophylactic antibiotics with sequential once-daily empiric antibiotic modification regimen were key to the success of this approach. This program reduces the duration of hospitalization, and thus the costs associated with a traditionally complex and difficult therapy. More than 400 patients have been treated in the outpatient setting since May 1992. Patients are initially admitted for 5 days of hospitalization to receive combination high-dose chemotherapy with continuous hydration and antiemetic support. Twenty-four hours after completion of chemotherapy, patients are discharged on oral prophylactic antibiotics, electrolyte supplements, and antiemetic agents. Close to half of the patients are readmitted to the inpatient unit during their period of ambulatory supportive care. Continuous provision of drug therapy and clinical pharmacy services require ongoing communication between pharmacy and both outpatient and inpatient personnel. Months of planning with nurse, physician, and pharmacist input were required to develop a program that meets the changing needs of patients undergoing a complex and potentially toxic therapy. Reliable 7-day pharmaceutical services was one of the essential components required for operation of such an outpatient program. This article reviews the basic principles and procedures used in treating patients in the Duke Outpatient ABMT program, with a focus on the complexity of supportive care issues that occur in the ambulatory setting, and the development of integrated pharmacy services for the program will be discussed.
Development of a Home Chemotherapy Program for Pediatric Oncology Patients
Authors: Holdsworth Mark T. , Chavez Cathy M.
Published: January 2017

Provision of home chemotherapy to pediatric oncology patients offers substantial advantages to children and their families, including improved scheduling and continuity of care and decreased disruption of the family unit. These advantages may positively impact upon both parental anxiety and quality of life for these children and their families. Establishing and maintaining a successful home chemotherapy program is a complex task, requiring a detailed orientation program along with an interdisciplinary team approach, a successful communication network, and close patient follow-up. Home chemotherapy delivery offers a unique practice setting with many professional growth opportunities for clinicians. A home chemotherapy program may also result in substantial monetary savings to patients and third-party payors, especially for protocols that require several days of inpatient admission to deliver.
Perceived Knowledge Level among Home Health Care Nurses: A Descriptive Study
Authors: Astarita Terasa M. , Materna Gayle E. , Savage Christine
Published: January 2017

Education, training, and competency assessment of home health care personnel is receiving increased attention due to the demands of managed care, health care reform, cost containment initiatives, accreditation, and regulatory bodies. Staff development educators carry the burden of competency assessment and therefore are in need of a method to analyze staff's perceived level of knowledge prior to beginning a competency program. This article summarizes the results of a descriptive correlational study that determined how home care registered nurses perceived their level of nursing knowledge. The areas of knowledge covered in the study included nursing process and nursing scientific knowledge. These areas of knowledge have been linked to synthesis of nursing practice and subsequent competency. The results of this research provide staff development with suggested methods to develop or enhance competency programs in home care.