Lavoisier Cardozo

Telemedicine for recently discharged older patients.

Congestive heart failure, chronic obstructive pulmonary disease, diabetes, and hypertension are common causes of hospitalization in the elderly. Short-term postdischarge clinical outcomes regarding compliance, symptom control, readmission, functional status, and mortality rates are in need of improvement. This observational study documents the results of a home-based case-managed telemedicine (CMTM) program delivered over a 2-month period postdischarge. A population of 851, predominantly elderly (over age 60), recently discharged patients were enrolled in the program. They received a nurse visit up to 3 times/week and home telemedicine monitoring (weight, blood pressure, pulse rate, blood glucose, and oximeter recordings) on a daily basis. Patient education was provided by the nurse and reinforced through telemedicine. Compliance rates, quality of life parameters, patient satisfaction with telemedicine, and data regarding nine quality of care measures (QCM), hospital readmission, and mortality rates were documented. Patient demographics and outcomes of care were analyzed. There were 68% females and 56% African Americans. The readmission rate was 13% and mortality 2%. Treatment goals were met in 67%, patient compliance rate was 77%, and the average improvement in the nine QCM indicators was 66%. A majority of patients showed improved quality of health perception, better disease understanding, and high satisfaction rates with telemedicine. This is one of the larger observational studies in a predominantly elderly patient population enrolled in a CMTM program, to date. This model of care was well accepted by the elderly and produced excellent short-term clinical outcomes.

Evaluation of the Pharmacokinetic and Pharmacodynamic Interaction Between Quinidine and Nifedipine

Quinidine and nifedipine appear to be subject to metabolism by the same isozyme of cytochrome P‐450. In addition, both drugs have been reported to alter the pharmacokinetics of other compounds. To investigate a potential interaction, 10 healthy subjects (five male, five female) received quinidine sulfate (200 mg orally), nifedipine (20 mg orally), or the combination of both drugs every 8 hours for 4 doses using a randomized, cross‐over study design with a 2‐week washout period between treatments. Drug concentration, heart rate, and mean arterial pressure were measured at frequent intervals after the final dose. Quinidine concentrations were unchanged by the co‐administration of nifedipine. Nifedipine area under the curve (AUC0–8) increased 36.6% from 333 to 455 μg · hr/L (P <.05) after quinidine administration. Heart rate was significantly higher in the nifedipine‐quinidine treatment at 0.5, 1.0, 1.5, and 2.0 hours when compared with either drug alone. The maximum increase in heart rate (17.9 beats/minute) occurred at 0.5 hours after nifedipine administration and was significantly correlated with serum concentrations at that time (r = .78). These results suggest that quinidine inhibits nifedipine metabolism, and this pharmacokinetic interaction results in enhanced pharmacologic response.

Racial differences in drug response: Isoproterenol effects on heart rate following intravenous metoprolol

Healthy young black men and white men received single intravenous doses of metoprolol (0.07 mg/kg) or participated in an isoproterenol sensitivity study before and after metoprolol (0.07 mg/kg followed by 50 µg/min) in a randomized, crossed‐over fashion. Noncompartmental pharmacokinetic parameters were calculated. The dose of isoproterenol versus change in heart rate response curves were constructed, and comparisons of dose ratio, ED50, Emax, and Ka, with the apparent association constant for metoprolol binding to β1receptors, were made. There were no pharmacokinetic differences observed between the groups. The predicted Emax for the black group was 52.7 ± 8.7 beats/mm at a metoprolol concentration of 29.8 ± 6.1 ng/ml, which was higher (p < 0.05) than that in the white group, i.e., 43.7 ± 7.3 beats/min at a concentration of 27.6 ± 9.1 ng/ml. There were no differences in dose ratio, ED50, or Ka. The racial differences in β1‐receptor responses to exogenous isoproterenol following metoprolol can simply be explained by an increase in β1‐receptor activity in the black subjects, assuming homogeneity in cardiac β2‐receptor responses.

Racial Differences in Drug Response: Isoproterenol Effects on Heart Rate in Healthy Males

It was the purpose of this study to investigate racial alterations in β-adrenoceptor response. Two groups of healthy, male volunteers gave their consent. There were eight black Americans (mean age, 26.1 ± 2.5 years) and eight white/Caucasian Americans (mean age, 24.4 ± 1.8 years). Each subject underwent an isoproterenol sensitivity test. There was a significant (P < 0.05) decrease in the ratio of Emax to ED50 in the white group (25.3 ± 6.4) compared with the black group (37.1 ± 12.4). Over the dose range of 0.1 to 1.0 µg there was a significant increase in response at both the 0.25- and the 0.5-µg dose (P < 0.05), with the black American group appearing to respond with a greater rate of rise in heart rate following the initial doses.

Implementing a clinical pathway for congestive heart failure: experiences at a teaching hospital.

Clinical pathways are processes of care that use a multidisciplinary team effort to move patients toward a designed outcome. This article details the challenges of a Quality Enhancement and Clinical Resource Management Team in designing and implementing a successful congestive heart failure pathway at a teaching hospital. Academic institutions have the resources as part of their research mission, to enhance the development of clinical pathways and assess their outcomes.

Racial Differences in Drug Response: Isoproterenol Effects Before and After Propranolol

The aim of this study was to determine in young, healthy men the relative contribution of pharmacodynamic factors inherent between two groups known to respond differently to hypertensive therapy. Black (n = 10) and white (n = 10) men received an isoproterenol sensitivity test before and after propranolol (0.1 mg/kg, then 50 µg/min). There were greater increases (twofold) in systolic BP following the 1.0- and 1.5-µg isoproterenol dose (P < 0.05) in the black group. During propranolol there were no differences in free (1)-propranolol concentrations between the groups; however, propranolol decreased resting heart rate in the white group more than in the black group (P < 0.05). Cardiac index decreased less in the black group compared to the white group (P < 0.05). Following the second isoproterenol challenge, there again were greater increases in systolic BP in the black group at both the 10- and the 20-µg isoproterenol dose (P < 0.05). Our study has highlighted the importance of cross-racial studies in evaluating drug effects.

Quinidine Does Not Alter Antipyrine Metabolism

Quinidine has been reported to be a potent inhibitor of a specific isozyme of cytochrome P‐450 (P‐450db 1) that is responsible for the metabolism of a select group of drugs. In order to investigate the potential for quinidine to inhibit other isozymes of cytochrome P‐450 and to assess whether or not P‐450db 1 plays any role in antipyrine metabolism, we studied the effects of quinidine pretreatment on the pharmacokinetics and metabolism of antipyrine in six healthy, male volunteers. Using a randomized, crossover study design with a 2‐week washout period between treatments, subjects received a single 1 gram antipyrine dose alone or with quinidine sulfate 200 mg orally every 8 hours for 24 hours prior to the dose of antipyrine and over the 48 hours following antipyrine administration. Mean serum concentrations, apparent oral clearance (1.93 ± 0.86 vs 2.06 ± 1.06 L/hr with quinidine) and half‐life (13.5 ± 3.3 vs 12.4 ± 3.6 hr with quinidine) were not significantly different between the two treatments. The fraction of the administered dose recovered as antipyrine and measured metabolites (56.7% vs 59% with quinidine) as well as the recovery of each individual metabolite was not altered with quinidine pretreatment. In addition, the mean formation clearances for norantipyrine, 4‐hydroxyantipyrine and 3‐hydroxymethylantipyrine exhibited no change between treatment phases. These results suggest that the effects of quinidine on the cytochrome P‐450 system are highly specific for particular isozymes, that the isozymes involved in metabolism of antipyrine to its major metabolites are not affected and that P‐450db 1 is not involved in the formation of any of the major metabolites of antipyrine.

The ethics of information disclosure in HIV disease and cancer: a study of medical residents attitudes

The study analyzes medical residents (MRs) attitudes on the ethics of information disclosure in two case scenarios--HIV disease and cancer. A purposeful sample of 120 MRs took part in a self-completion questionnaire administered. Responses were factor analyzed and three factors (17 statements) protecting rights of (1) spouse/family, (2) patient and (3) society, were retained for study. Analysis revealed that: (1) MRs perceived greater justification (P < 0.0001) in protecting family rights in HIV disease and patient rights (P < 0.0001) in cancer; (2) male MRs were significantly more inclined to protect spouse/family rights (P < 0.01) in HIV disease, when compared to female MRs; and (3) international MRs were significantly more inclined to protect spouse/family (P < 0.05) and societal rights (P < 0.01) in HIV disease, compared with United States MRs. Perception differences by MRs on ethics of information disclosure in HIV disease and cancer are based on MRs gender and their cultural background. It is important to document and address these attitudes during residency training.

Preliminary Data from a Pharmacist-Managed Anticoagulation Clinic Embedded in a Multidisciplinary Patient-Centered Medical Home: A Coordinated Quality, Cost-Savings Model

Patient-centered, comprehensive, team-based, coordinated care models are a focal point of healthcare reform. The patient-centered medical home (PCMH) model aims to provide better primary care and health outcomes at a lower cost. To become a PCMH, a set of standards must be met that includes coordination of care transitions.

Thyrotoxicosis in Ugandan Africans

A retrospective 5 year study of thyrotoxicosis at Mulago Hospital, Uganda is presented. 30 cases were analysed and features pertaining to the clinical pattern are described. Comment is made on 5 cases which had associated cardiovascular abnormalities. The increased incidence of the condition in Uganda and other parts of Africa is noted. It is suggested that this may provide the opportunity for workers to follow up larger series, and assess the clinical, epidemiological and immunological aspects of the disease which could provide important clues as regards the genesis of thyrotoxicosis.