Biomedical subjects

Kelly M Smith

Publications and source records attributed to Kelly M Smith.

62 records · Page 4Linked to original sources

PubMed2002

Club drugs: methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride, and gamma-hydroxybutyrate.

The abuse of methylenedioxymethamphetamine (MDMA), flunitrazepam, ketamine hydrochloride, and gamma-hydroxybutyrate (GHB) is discussed. Club drugs are chemical substances used recreationally in social settings. Use is increasingly frequent among young people, especially during all-night dance parties. All four agents have been classified as controlled substances. MDMA ("ecstasy") is available as a tablet, a capsule, and a powder; formulations may contain many adulterants. MDMA increases the release of neurotransmitters. The desired effects are euphoria, a feeling of intimacy, altered visual perception, enhanced libido, and increased energy. The most common adverse effects are agitation, anxiety, tachycardia, and hypertension. More serious adverse effects include arrhythmias, hyperthermia, and rhabdomyolysis. Flunitrazepam is a potent benzodiazepine. At higher doses, the drug can cause lack of muscle control and loss of consciousness. Other adverse effects are hypotension, dizziness, confusion, and occasional aggression. Ketamine is a dissociative anesthetic used primarily in veterinary practice. It may be injected, swallowed, snorted, or smoked. Like phencyclidine, ketamine interacts with the N-methyl-D-aspartate channel. Analgesic effects occur at lower doses and amnestic effects at higher doses. Cardiovascular and respiratory toxicity may occur, as well as confusion, hostility, and delirium. GHB, a naturally occurring fatty acid derivative of gamma-aminobutyric acid, was introduced as a dietary supplement. Increasing doses progressively produce amnesia, drowsiness, dizziness, euphoria, seizures, coma, and death. Flunitrazepam, ketamine, and GHB have been used to facilitate sexual assault. Supportive care is indicated for most cases of club drug intoxication. The increasing abuse of MDMA, flunitrazepam, ketamine hydrochloride, and GHB, particularly by young people in social settings such as clubs, should put health care professionals on guard to recognize and manage serious reactions.

Flunitrazepam↗

PubMed2002

A controlled trial of hospital versus home-based exercise in cardiac patients.

BACKGROUND: Large numbers of patients who stand to benefit from the exercise training component of cardiac rehabilitation are not being served due to access issues. Home-based exercise training may be a potentially useful alternative to training in institutional environments. PURPOSE: The purpose of this study was to examine the benefit of 6 months of hospital-based exercise training versus 6 months of monitored, home-based exercise training with respect to physical, quality of life, and social support outcomes in patients after coronary artery bypass graft (CABG) surgery. METHODS: Randomized controlled trial of "direct-to-home" (Home; = 120) versus "direct-to-hospital" (Hosp; = 122) exercise training, 35-49 d post CABG surgery. The primary outcome was peak exercise capacity, measured by peak oxygen consumption (VO(2)) on a symptom-limited cycle ergometer exercise test. Secondary outcomes were health-related quality of life (measured by the SF-36) and social support (measured by the ISEL). Measurements were taken at baseline and after 3 and 6 months of exercise training. RESULTS: The study groups had similar demographic and health profiles at baseline. Peak VO(2) improved significantly in both groups after 6 months of exercise training; 36% in the Hosp group (1,222.1 +/- 269.0 mL x min(-1) to 1,497.2 +/- 594.3 mL x min(-1); < 0.0001) and 31% in the Home group (1,260.3 +/- 306.5 mL x min(-1) to 1,433.4 +/- 589.7 mL x min(-1); < 0.05). The Home group reported greater total social support than the Hosp group at 3 (36.2 +/- 4.5 vs 34.0 +/- 6.7; < 0.0001) and 6 months (36.0 +/- 4.9 vs 34.6 +/- 6.4; = 0.05). The Home group demonstrated a greater improvement in health-related quality of life (physical) by 6 months in comparison to the Hosp patients (51.2 +/- 6.4 vs 48.6 +/- 7.1; = 0.004). CONCLUSION: This study suggests that low-risk CABG surgery patients may be served as well or better with a monitored, home-based exercise program than with an institution-based program.

Coronary Disease↗

PubMed2002

Treatment of azole-resistant oropharyngeal candidiasis with topical amphotericin B.

OBJECTIVE: To report a case of successful treatment of azole-refractory oropharyngeal candidiasis with topical amphotericin B. CASE SUMMARY: A 30-year-old white woman presented with recurrent oral thrush. The patient had been exposed to azole antifungals for >20 years, and in vitro susceptibility tests revealed class resistance. The patient started taking amphotericin B 100 mg oral suspension swish-and-spit 4 times daily. After 4 weeks of topical amphotericin B treatment, the patient reported significant symptomatic improvement. The oral candidiasis worsened following a course of oral antibiotics, but improved once the antibiotic was discontinued and after receiving amphotericin B swish-and-swallow for 4 additional weeks. DISCUSSION: Current Infectious Diseases Society of America guidelines include topical amphotericin B as a potentially effective option for the treatment of oropharyngeal candidiasis. There is limited evidence to support this recommendation. Besides lack of data, an appropriate dosing regimen and consistent means of product formulation need to be determined. CONCLUSIONS: This report demonstrates the potential role for topical amphotericin B in the treatment of azole-refractory oral candidiasis. Double-blind, randomized, controlled trials are needed to define dosing, efficacy, administration, and long-term safety of oral amphotericin B.

Administration, Topical↗

PubMedDate not supplied

Effect of a postoperative telephone intervention on attendance at intake for cardiac rehabilitation after coronary artery bypass graft surgery.

BACKGROUND: Enrollment in cardiac rehabilitation (CR) after coronary artery bypass graft (CABG) surgery is suboptimal (25%-30%). OBJECTIVES: The purpose of this study was to examine the effect of a nurse-initiated telephone call (NIC) on attendance at a CR intake appointment. METHODS: By using a retrospective cohort design, data were collected on 3536 patients who underwent CABG between April 1996 and March 2000 and were referred to CR. Of these, 2285 patients received standard care (no NIC) and 1251 received the NIC. RESULTS: Patients who received the NIC were significantly more likely to attend their CR intake appointment compared with standard care (78.1% vs. 50.1%; P < .0001). Hierarchic logistic regression analysis revealed the NIC as the strongest predictor of attendance at a CR intake explaining 56.9% of the total variance (odds ratio =3.429; 95% confidence interval = 2.919-4.028; P < .0001). CONCLUSION: These findings suggest that pre-appointment telephone contact by a cardiovascular nurse is a valuable tool to enhance attendance at a CR intake appointment after CABG.

Aged↗

PubMedDate not supplied

A survey of academic medical centers to distinguish between quality improvement and research activities.

OBJECTIVES: Institutional Review Boards (IRBs) are charged with ensuring the protection of humans enrolled in research. IRB activities are governed by the United States Office for Human Research Protections, which does not clearly differentiate quality improvement from research. More clear standards are needed so that the protection of human subjects (including their right to privacy) can be ensured and health care providers can efficiently meet their objective of improving patient care through quality improvement efforts. While past commentaries on this subject have provided some guidance, no standard definitions exist that distinguish "quality improvement" from "research." METHODS: We conducted a national survey of IRBs serving academic medical centers to determine whether local guidelines exist that make this distinction, and if so, what criteria are used to guide decision making. RESULTS: On the basis of the findings of our survey, we propose a decision algorithm to guide IRBs and quality improvement oversight committees as they define local policies that distinguish research projects from quality improvement efforts. CONCLUSIONS: The decision algorithm should result in greater ability to conduct quality improvement work in an efficient manner without compromising the protection of human subjects. The criteria identified are consistent with, but clearer than, the exemption standards provided in the common rule.

Academic Medical Centers↗

PubMedDate not supplied

Economic evaluation of the MEDENOX trial: a Canadian perspective. Medical Patients with Enoxaparin.

OBJECTIVE: To perform an economic evaluation of the Prophylaxis in Medical Patients with Enoxaparin (MEDENOX) trial from a Canadian perspective. METHOD: Using a decision tree model, cost effectiveness analysis was carried out to compare the costs and consequences of thromboprophylaxis using enoxaparin 40 mg with placebo in tertiary and community settings. From a third party payer's perspective, the model calculated the expected rate of symptomatic venous thromboembolism (VTE), and the total expected cost of prophylaxis and VTE management, including inpatient and outpatient treatment, professional fees and long term therapy. Data were derived directly from the MEDENOX trial. Costs are direct medical costs in year 2000 Canadian dollars. RESULTS: In a tertiary setting in which the estimated inpatient to outpatient deep vein thrombosis treatment ratio was 10%:90%, the total expected cost per patient was 64 dollars in the enoxaparin group and 62 dollars in the placebo group. The expected symptomatic VTE rates were 0.8% and 3.1% in the enoxaparin and placebo groups, respectively. The incremental cost effectiveness of enoxaparin 40 mg versus placebo was 87 dollars/VTE avoided. In a community hospital setting (with a 50%:50% inpatient to outpatient deep vein thrombosis treatment ratio), the total expected cost per patient was 68 dollars in the enoxaparin group compared with 72 dollars in the placebo group, indicating that prophylaxis with enoxaparin 40 mg was cost saving. The model was sensitive to the inpatient to outpatient ratio. However, within each setting, the results were not sensitive to changes in key variables. CONCLUSION: For patients hospitalized for acute respiratory failure, congestive heart failure or acute infectious disease and who are at moderate risk of developing VTE, thromboprophylaxis with enoxaparin 40 mg daily is a cost effective strategy in both tertiary and community settings.

Adult↗

PubMedDate not supplied

Use of club drugs by HIV-seropositive and HIV-seronegative gay and bisexual men.

Club drugs such as methylenedioxymethamphetamine (MDMA, ecstasy), gamma hydroxybutyrate (GHB), and ketamine are among the fastest-growing drugs of abuse in the United States. Reports have shown that some gay and bisexual men are likely to engage in club-drug use in a myriad of venues. This is concerning given that the use of club drugs has been linked to high-risk sexual behaviors. Further, the use of club drugs by HIV-seropositive individuals may have detrimental outcomes on disease progression by either influencing adherence, resulting in drug-drug interactions with antiretrovirals, or potentially compounding immune suppression. Clinicians caring for HIV-seropositive and -seronegative individuals should be aware of the clinical effects and management guidelines associated with these chemicals. This article reviews the available literature with regard to the use of club drugs by HIV-seropositive and -seronegative gay and bisexual men. Although club-drug use may be associated with many risk behaviors for HIV infection, this review focuses on risk behavior among gay and bisexual men since this is the group for which the most data have been reported. The clinical effects and management guidelines associated with these agents are described, and the potential detrimental effects of these substances on HIV disease are discussed.

Bisexuality↗

PubMedDate not supplied

Recreational use and misuse of phosphodiesterase 5 inhibitors.

OBJECTIVE: To characterize the rationale for and extent of phosphodiesterase (PDE) 5 inhibitor use in recreational settings, describe risks from such misuse, and discuss postexposure clinical management strategies. DATA SOURCES: Published articles identified by searches through Medline, EMBASE, International Pharmaceutical Abstracts, and Toxline, from 1990 to March 2004, using the search terms sildenafil, tadalafil, vardenafil, phosphodiesterase inhibitor, abuse, overdose, adverse effects, recreational, and street drugs. Additional references identified within articles and information from the Internet were included. STUDY SELECTION: Clinical trials, epidemiologic reviews, case reports, and news releases concerning the misuse of sildenafil. DATA EXTRACTION: By the authors. DATA SYNTHESIS: PDE5 inhibitors, indicated for treatment of erectile dysfunction, can produce several adverse effects, including potentially fatal cardiovascular events. Reports of recreational use and misuse of sildenafil appear in the medical literature and the media. The potential for abuse also exists for the two more recently approved drugs in this class, vardenafil and tadalafil. Increasing access to these drugs via the Internet may facilitate such misuse. Use in social settings has gained popularity, both in young, healthy patients, as well as those with chronic medical conditions, including human immunodeficiency virus infections. In these settings, the PDE5 inhibitors are sometimes used concomitantly with "club drugs" such as ketamine and amyl nitrite, leading to potentially harmful or fatal drug interactions. CONCLUSION: Pharmacists should be cognizant of the potential for PDE5 inhibitors to be misused, particularly in patients who are at greater risk of cardiovascular complications, and should advise patients and other health care professionals accordingly.

Education, Pharmacy, Continuing↗