An Interprofessional Psychiatric Advanced Pharmacy Practice Experience

Objective. To create an interprofessional psychiatry advanced pharmacy practice experience (APPE) and assess the initial outcomes.Design. An elective psychiatry APPE was developed in a setting of interdisciplinary practice. Preceptor responsibilities were shared between a psychiatric pharmacist and an attending psychiatrist or psychiatric nurse practitioner. Students were also given the opportunity to shadow and work with other health care professionals such as nurses, social workers, therapists, family nurse practitioners, and utilization review staff members.Assessment. Midpoint and final evaluations demonstrated student advancement throughout the experience as well as the development of communication skills with patients and an increased ability to work collaboratively with other health care providers. Students rated this practice experience highly and their comments reflected achievement of the established learning objectives.Conclusion. An interdisciplinary elective practice experience in psychiatry at a local teaching hospital was effective in teaching psychiatric care and interprofessional interaction. This teaching model can be adapted for use in other practice settings or specialty areas.     

Paravalvular leak and other events in silzone-coated mechanical heart valves: a report from AVERT

BACKGROUND: The Artificial Valve Endocarditis Reduction Trial (AVERT) was designed to compare endocarditis rates in Silzone versus conventional valves. Recruitment ended January 21, 2000, because of higher rates of paravalvular leakage in patients receiving the Silzone prosthesis. The present analysis determined late event rates that might be used in the management of approximately 36,000 patients who have received the Silzone prosthesis. METHODS: A total of 807 patients in 19 centers in North America and Europe were randomized. Mean age was 61+/-11 years; 41% were women. Operations included aortic valve replacement in 59%, mitral valve replacement in 32%, and aortic and mitral valve replacements in 9%; 41% had concomitant operations (26% coronary artery bypass grafting). RESULTS: Major paravalvular leakage (followed by repair, explant, or mortality) occurred in 18 of 403 patients receiving Silzone valves and 4 of 404 patients without Silzone valves (2-year event-free rates: 91.1% versus 98.9% conventional, p < 0.003). Similarly, 2-year freedom from any explant was lower in the Silzone arm (19 versus 2 events; 90.1% versus 99.4%, p = 0.0002). Rates of mortality and stroke were similar during follow-up. CONCLUSIONS: Continued follow-up of AVERT supports the conclusion that the Silzone prosthesis has increased risk of paravalvular leakage requiring reoperation. Overall survival is similar in the two groups.     

Discrepancies in frozen section mucosal margin tissue in laryngeal squamous cell carcinoma

BACKGROUND: Head and neck surgeons commonly request frozen sections. Practice patterns vary from laboratory to laboratory on how the tissue is used in performing the frozen section. Some pathologists wish to see all the material submitted by consuming it completely during frozen section, whereas others reserve some for permanent section. We wished to determine whether knowledge of margin status was initially inaccurate because of reserving tissue for permanent section. METHODS: Sixty-five laryngectomies (total and partial) with margin assessment enhanced by frozen section evaluation were studied. Forty-five laryngectomy specimens, generating 249 frozen sections in which a permanent section was prepared from tissue remaining from frozen section examination, were studied. RESULTS: Five of the 249 frozen sections contained a discrepancy between the frozen section and permanent section because of insufficient leveling of the frozen section block. These five discrepancies were called negative on frozen section, but permanent section revealed dysplasia (two cases of mild dysplasia, one case with moderate dysplasia, and one case with severe dysplasia) or carcinoma in situ (one case). Twenty laryngectomies in which the frozen section tissue was consumed at the time of frozen section generated 103 frozen sections. In eight of the frozen sections involving six cases, the diagnostic tissue was not present on one or two of the frozen section levels examined. CONCLUSIONS: We conclude that in examining margins for laryngeal squamous cell carcinoma the frozen section tissue should be completely sampled by examining several levels at the time of frozen section. This requires consuming or exhausting the frozen section tissue rather than reserving any remaining frozen tissue for a paraffin-embedded permanent section.     

Phase II evaluation of low-dose oral etoposide for the treatment of relapsed or progressive AIDS-related Kaposi's sarcoma: an AIDS Clinical Trials Group clinical study.

PURPOSE: Liposomal anthracyclines and paclitaxel are considered the best available cytotoxic therapies for Kaposi's sarcoma (KS), but relapse is common. To identify new interventions for relapsed or progressive KS, a phase II study of low-dose etoposide to assess its toxicity and efficacy was conducted. PATIENTS AND METHODS: Thirty-six patients with high-risk KS were treated with oral etoposide 50 mg/d for 7 consecutive days of every 2-week cycle. All patients' disease had relapsed or progressed after prior combination chemotherapy or anthracycline therapy. For patients without a complete or partial response after two cycles of therapy and no toxicity greater than grade 2, the dose of etoposide was escalated to 100 mg/d orally on days 1 to 7 of each 14-day cycle. Treatment-related and disease-specific quality of life was evaluated using patient reports on the General Health Self-Assessment Form and a KS-specific measure. RESULTS: One patient achieved a complete response, 12 patients had a partial response (overall response rate, 36.1%), and stable disease was observed in 12 patients (33.3%). Tumor responses were seen in all disease sites. Fourteen patients had their dose escalated, of whom five responded. The median time to response was 17.7 weeks; the median duration of response was 25 weeks. The most frequent hematologic abnormality was neutropenia, which was grade 4 in seven patients and grade 3 in six. Opportunistic infections occurred in eight patients during the treatment period. Both response to treatment and toxicity influenced patient-reported quality of life. CONCLUSION: We conclude that low-dose oral etoposide at a dose of 50 mg/d is safe and effective for the treatment of refractory or progressed AIDS-related KS and has an overall positive effect on the quality of life of responding patients.     

Effects of protein kinase C activators on phorbol ester-sensitive and - resistant EL4 thymoma cells

Phorbol ester-sensitive EL4 murine thymoma cells respond to phorbol 12- myristate 13-acetate with activation of ERK mitogen-activated protein kinases, synthesis of interleukin-2, and death, whereas phorbol ester- resistant variants of this cell line do not exhibit these responses. Additional aspects of the resistant phenotype were examined, using a newly-established resistant cell line. Phorbol ester induced morphological changes, ERK activation, calcium-dependent activation of the c-Jun N-terminal kinase (JNK), interleukin-2 synthesis, and growth inhibition in sensitive but not resistant cells. A series of protein kinase C activators caused membrane translocation of protein kinase C's (PKCs) alpha, eta, and theta in both cell lines. While PKC eta was expressed at higher levels in sensitive than in resistant cells, overexpression of PKC eta did not restore phorbol ester-induced ERK activation to resistant cells. In sensitive cells, PKC activators had similar effects on cell viability and ERK activation, but differed in their abilities to induce JNK activation and interleukin-2 synthesis. PD 098059, an inhibitor of the mitogen activated protein (MAP)/ERK kinase kinase MEK, partially inhibited ERK activation and completely blocked phorbol ester-induced cell death in sensitive cells. Thus MEK and/or ERK activation, but not JNK activation or interleukin-2 synthesis, appears to be required for phorbol ester-induced toxicity. Alterations in phorbol ester response pathways, rather than altered expression of PKC isoforms, appear to confer phorbol ester resistance to EL4 cells.