Developing and implementing a contract for electronic infusion devices.
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Competitive Bidding↗
Biomedical subjects
M R Alexander
Publications and source records attributed to M R Alexander.
Therapy of chronic obstructive airways disease.
The most frequently employed measure in attempts to alleviate symptoms and improve the quality of life of patients with chronic obstructive airways disease (COAD) is to prescribe medications. However, COAD is largely an irreversible condition and no therapeutic intervention has been shown to be universally useful. Theophylline or corticosteroid are occasionally helpful but most patients will not benefit. Of the remaining options, only oxygen has been shown to be effective in selected patients and should be administered on a continuous basis. It is becoming increasingly evident that clinicians should be more discriminating when making therapeutic decisions for persons with COAD. Maintenance therapy with pharmacological agents should be entertained only after individually conducted therapeutic trials. Moreover, enormous costs can result from treating even a small fraction of the population estimated to have COAD.
Adrenal Cortex Hormones↗
Dipyridamole: a critical evaluation.
Dipyridamol is a vasodilator that is used primarily in clinical practice as an antiplatelet agent. It increases coronary blood flow and was originally introduced as an antianginal agent. An ability to prolong a shortened platelet survival has been used to justify its value in preventing thromboembolic complications. Conditions characterized by a reduction in platelet survival and where dipyridamole has been used include heart valve replacement, arterial grafting, cerebrovascular disorders, and disorders of peripheral circulation. The in vivo effect of dipyridamole on platelet aggregation has not been well defined and may depend on additional factors. Prostaglandins appear to have important roles in platelet homeostasis; their relationships to the action of dipyridamole are discussed. Dipyridamole usually is combined with aspirin for synergistic anti-aggregatory purposes. However, the nature of the interaction has not been elucidated and benefit from the addition of dipyridamole has not been demonstrated in clinical studies. A review of clinical studies using dipyridamole indicates that it currently has limited value.
Angina Pectoris↗
Theophylline in stable chronic airflow obstruction. A reappraisal.
Theophylline is commonly recommended for patients who have stable chronic airflow obstruction (CAO). Recent evidence confirms that serum theophylline concentrations between 10 and 20 mg/L may increase forced expiratory volume in 1 s (FEV1) and forced vital capacity in these patients. Exercise tolerance, however, and the classic respiratory symptoms of wheezing, breathlessness, cough, and sense of well-being do not improve. A reappraisal of the role of this medication in patients with stable CAO is therefore necessary; we recommend not prescribing this medication for all patients. Instead, the response of FEV1 after isoproterenol inhalation (0.15 mg) should be monitored. This simple test has good efficacy for predicting the response to oral theophylline therapy and could diminish the cost and unnecessary side effects of theophylline while benefiting those who will respond.
Administration, Oral↗
Therapeutic use of albumin: 2.
It has previously been shown that albumin costs in a Veterans Administration Hospital constituted a large portion of the pharmacy drug budget and that much albumin was prescribed inappropriately. Therefore, a program of education and use monitoring was instituted to improve understanding and prescribing of this product. Inappropriate use declined from 41% to 26% of total albumin units and, more dramatically, total cost of albumin used had decreased by 90% one year after this program was initiated. Projected yearly savings from decreased use was more than $85,000. These results demonstrate that such a program can promote more appropriate use of albumin and effect a cost savings for hospitals.
Albumins↗
Bronchial secretion concentrations of tobramycin.
The mean concentrations of tobramycin in bronchial secretions from patients with pneumonia were almost two times greater than secretions from patients free of lung infection. Mean tobramycin bronchial secretion to serum concentration ratios also were higher when obtained from infected lungs (0.66 versus 0.17) These data suggest that lung infection enhances the concentrations of tobramycin in bronchial secretions.
Aged↗
The efficacy of isoproterenol inhalation for predicting the response to orally administered theophylline in chronic obstructive pulmonary disease.
Orally administered theophylline is commonly prescribed for patients with chronic obstructive pulmonary disease (COPD). It would be advantageous to predict those patients who will or will not respond to this methylxanthine. Forty men with COPD received placebo and theophylline orally, each for 1 month in a double-blind, single cross-over fashion. The acute response of the forced expiratory volume in one second (FEV1) to isoproterenol inhalation (015 mg) during placebo therapy was determined. The subjective and objective responses after 1 month of therapeutic theophylline concentrations (15.1 +/- 4.2 microgram/ml), mean +/- SD) in these clinically stable subjects also were measured. The sensitivity and specificity of isoproterenol aerosolization for predicting an objective response to theophylline was 75 and 96%, respectively. We conclude that isoproterenol inhalation can predict the response to orally administered theophylline in patients with COPD.
Administration, Intranasal↗
[Volumetric correction of the maximal expiratory flow 25-75% in chronic obstructive bronchopneumopathies].
After inhalation of a bronchodilator aerosol, indices of airway obstruction usually improve whereas the forced expiratory flow between 25 and 75% (FEF25-75%) of the forced vital capacity (FVC) commonly remains the same or may decrease. This is due to the fact that the FEF25-75% after bronchodilatation is measured at lower absolute lung volumes with subsequently less elastic recoil pressure. A goal of this study was to analyze this test after volume adjusting so that the flows before and after a bronchodilator are compared at equal volumes (isovolume). Thirty-seven men with chronic obstructive pulmonary disease (COPD) performed maximal forced expiratory maneuvers before and 15 minutes after isoproterenol (0.15 mg) inhalation. The mean value of isovolume (0.56 +/- .30 1. sec-1) was significantly greater (p less than 0.001) than the FEF25-75% recorded before (0.45 +/- .26 1. sec-1) and after (0.50 +/- .27 1. sec-1, p less than 0.01) bronchodilator inhalation. The FVC was improved in 18 patients but only 6 (33%) had an improved conventional FEF25-75%. On the other hand, isovolume FEF improved in 12 (66%) patients. Isovolume FEF also improved twice as frequently as conventional FEF25-75% in those demonstrating an improvement in forced expiratory volume in the first second (FEV1). Furthermore, when the conventional FEF25-75% demonstrated no improvement after isoproterenol inhalation, isovolume improved in 8/26 (31%) of these patients. Our results suggest that volume adjusting the FEF25-75% after isoproterenol inhalation increases its sensitivity for detecting acute bronchodilation in patients with COPD, and that this methods appears practical in routine pulmonary function testing.
Forced Expiratory Flow Rates↗
Isoproterenol challenge during placebo and oral theophylline therapy in chronic obstructive pulmonary disease.
Because it is common to perform a bronchodilator challenge while a patient continues oral methylxanthines, we wanted to determine if this procedure might be misleading for subsequent therapy. Thirty-eight men with a long smoking history and a clinical diagnosis of chronic obstructive pulmonary disease (COPD) were given placebo and oral theophylline (each for one month) in a double-blind, single-crossover manner. Pulmonary functional tests were performed before and after isoproterenol nebulization on the final day of each 4-wk period. There were significantly larger increases in FVC (p less than 0.001) and FEV1 (p less than 0.01) after isoproterenol challenge when receiving placebo than when receiving theophylline. According to the intermountain Area rating criteria, only the results after isoproterenol challenge during placebo therapy would indicate improvement. These results suggested that isoproterenol inhalation challenge be performed after methylxanthines have been discontinued if used to predict which patients with COPD may respond to oral theophylline therapy.
Bronchial Provocation Tests↗
Therapeutic use of thrombolytic agents.
The use of thrombolytic agents for clotting disorders as compared with standard anticoagulant therapy is reviewed. The resolution rates of pulmonary emboli (PE) were examined in a comparison of streptokinase, urokinase, and heparin therapy in several studies. The effectiveness of streptokinase therapy was compared to heparin treatment of deep vein thrombosis (DVT) as well. In addition, studies on the use of thrombolytic agents for acute myocardial infarction (AMI) are reviewed. Clinical studies show that although streptokinase and urokinase promote more rapid resolution of PE and DVT (as determined by perfusion lung scans, angiography, and venography), superiority over conventional treatment has not been established. The disadvantages include greater cost and more frequent bleeding episodes than anticoagulant therapy. The studies of thrombolytic agents for AMI did not find significant beneficial effects on the mortality rates. It is recommended that thrombolytic agents not be used routinely for the treatment of PE, DVT, or AMI.
Angiography↗
Treatment of chronic obstructive pulmonary disease with orally administered theophylline. A double-blind, controlled study.
Theophylline is commonly prescribed for chronic obstructive pulmonary disease (COPD), although controlled studies do not exist to support this use. We administered theophylline and placebo orally to 40 ambulatory COPD patients in a double-blind, crossover manner. Pulmonary function tests were conducted before and after isoproterenol nebulization on the final day of each four-week study period. Theophylline therapy produced small, but significant, increases over placebo in mean values. However, only the forced expiratory volume in 1 s was "improved," according to published criteria. There were no significant differences in subjective effects between treatment periods. Six patients were identified as "responders"; responder status could be predicted on the basis of improvement in flow rates after isoproterenol nebulization. Theophylline therapy is not beneficial to most COPD patients, and potential responders should be given carefully monitored therapeutic trials rather than arbitrarily being given maintenance therapy.
Administration, Oral↗
Therapeutic use of albumin.
Increasing use of normal human serum albumin may be contributing to the rising cost of medical care. To investigate whether albumin is extensively overused or abused, a study of the quality of albumin use was conducted in a Veterans Administration Hospital. Specific criteria for appropriate use were developed using guidelines defined at a national symposium. A review of use during a three-month period showed that surgery patients received 91% of the albumin administered during that period; of the total amount administered, 41% was used inappropriately; the decision to administer albumin to patients undergoing surgery appeared to be correct only 29% of the time; and an estimated $40,000 was spent on inappropriately used albumin at this hospital in 1977.
Costs and Cost Analysis↗
Bronchial secretion levels of amikacin.
Amikacin was given to 14 noninfected men as three consecutive intramuscular injections (7.5 mg/kg) at 12-h intervals. Serum and bronchial secretion specimens were obtained at various times during flexible fiberoptic bronchoscopy after the final dose. Serum and bronchial secretion concentrations obtained between 1.5 and 2.0 h after the final dose ranged from 17 to 40 mug/ml and 2.3 to 8.4 mug/ml with a mean of 23.7 +/- 2.9 and 5.23 +/- 1.5 mug/ml, +/-1 standard error of the mean, respectively. The highest bronchial secretion concentration in each subject correlated with the highest serum concentration (r = 0.83, P < 0.001), and all concurrent serum and bronchial secretion concentrations demonstrated a significant correlation (r = 0.82, P < 0.001). Clearance occurred at the same rate (half-life serum = 2.84 h; half-life of bronchial secretion = 2.60 h, P > 0.5). The mean bronchial secretion concentration of the 15 specimens obtained more than 7 h after the final dose was less than 1.0 mug/ml, with a range from 0.3 to 1.6 mug/ml. It is concluded that amikacin may achieve minimal inhibitory concentrations for many gram-negative bacteria in the bronchial secretions of noninfected patients 1 to 2 h after the final dose. However, levels fall below the reported minimal inhibitory concentrations against negative bacteria 6 to 7 h after the final dose. Furthermore, bronchial secretion levels may never reach the minimal inhibitory concentration against Pseudomonas aeruginosa.
Aged↗
The concentration of tobramycin in bronchial secretions.
Fifteen noninfected patients received three consecutive doses of tobramycin (1.7 mg/kg intramuscularly). Serum and bronchial secretions were obtained during bronchoscopy. Microbiologic assay demonstrated that bronchial secretions containing tobramycin produced inappropriately small zone sizes when compared with serum. Also, it was shown that bronchial secretions frequently do achieve therapeutic concentrations of tobramycin at this dosage level and route of administration.
Adult↗
Phenothiazine analgesia--fact or fantasy?
Double-blind clinical trials involving the use of phenothiazines as analgesics or potentiators of analgesics (aspirin, meperidine, morphine sulfate) and adverse effects of phenothiazines are reviewed and evaluated. Promethazine, promazine and propiomazine were not found to possess analgesic or potentiating properties. One chlorpromazine study contained important design and reporting deficiencies which precluded a recommendation for use of chlorpromazine in the treatment of pain. Methotrimeprazine was determined by numerous authors to have analgesic properties; however, most of the studies also were deficient in design or data presented, or both. Adverse reactions to phenothiazines, including hypotension, sedation, drowsiness, extrapyramidal symptoms, tardive dyskinesia, cardiac toxicity and agranulocytosis, are often more common and severe than those attributed to narcotic analgesics. Because of the lack of data supportive of analgesic activity and the adverse reactions associated with phenothiazines, use of these agents in the management of pain should be discouraged. The prophylactic use of phenothiazine for narcotic analgesic-induced emesis also is, in most cases, a questionable practice.
Analgesics↗
Savings achieved through selection of amino acid solutions.
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Amino Acids↗
Tuberculosis: review of treatment failure, relapse and drug resistance.
Factors affecting the success and failure of tuberculosis (TB) treatment programs are reviewed. Topics covered include incidences of primary and secondary resistance; methods and probability of bacteriologic transfer of resistance; factors affecting delivery of successful treatment of TB; and retreatment concepts, history and regimens for TB relapse and treatment failures. Isoniazid, rifampin and ethambutol hydrochloride produce a high percentage of cure in initial and retreatment TB therapy. Attention to patient compliance should be emphasized to assure effective treatment.
Aminosalicylic Acid↗