Public health practice and public health education: a personal view of their current relationship.

In its 1988 report, The Future of Public Health, the Institute of Medicine stated that schools of public health had become "somewhat isolated" for public health practice. Since then a great deal has been done to address this issue by the academic community, state and local public health practice agencies, foundations, and federal health agencies. This commentary reviews their most important actions and identifies some unresolved issues.     

Caring for adults with mental retardation: survey of family practice residency program directors

In their core curriculum guidelines, the Society of Teachers of Family Medicine has recognized the importance of training family physicians in caring for persons with mental retardation. We mailed surveys to all family practice residency directors in the United States, questioning them about experiences and methods used to teach residents about health care needs of adults with mental retardation and the importance of this education. We found that 84% of programs provide residents with one or more experiences, and 60% instruct residents in this area. Most directors ranked this education as very important or important. There was no relationship between type or age of residency program and likelihood that residents were educated about mental retardation. The importance of this education is discussed.     

HAART improves prognosis in HIV-associated progressive multifocal leukoencephalopathy

Introduction of highly active antiretroviral therapy (HAART) has been associated with many changes in the complications of human immunodeficiency virus (HIV) infection. A cohort of 25 HIV patients with progressive multifocal leukoencephalopathy (PML) treated with HAART experienced a median survival of >46 weeks. This is an improvement in prognosis compared with recent historic experience and correlated with HIV RNA viral load reductions. We conclude that current HIV therapy is important in improving the outlook of PML in the setting of HIV.     

Documenting the provision of pharmaceutical care

There is a growing importance and need for the documentation of the clinical work done by the pharmacist in providing pharmaceutical care. The data provided by documentation of care are critical to the effective and efficient transition from a product-based profession to a patient-care, service-based profession, especially during a period of great scrutiny of resource utilization in the hospital industry. Intervention documentation can serve both to document the provision of pharmaceutical care to individual patients and to provide critical information to managers to justify and expand the level of service provided.     

Managing drug shortages: seven years' experience at one health system.

A health system's experience in monitoring drug shortages since 1996 within the organization and since 2001 on a national level is described. Since January 1996, the Drug Information Service (DIS) at the University of Utah Hospitals and Clinics (UUHSC) has systematically prepared written bulletins to affected practitioners when drug shortages occurred. The DIS began providing information on a national level to the American Society of Health-System Pharmacists in January 2001. A total of 224 drug shortages were tracked from January 1996 to June 2002. All shortages at UUHSC were also national shortages, but only about two thirds of national shortages also affected UUHSC. The most common reasons for shortages were manufacturing problems (28%) and product discontinuation (20%). The most frequently represented pharmacologic-therapeutic categories were central nervous system agents (24%) and serums, toxoids, and vaccines (17%). Of the 119 shortages in 2001, 70 (59%) were still ongoing as of the end of June 2002. The most common potential safety problems were that clinicians might be unfamiliar with the alternative agent (54%) and that the alternative's dosage requirement was different (50%). Over half of the shortages were cost neutral, but the assessment did not include substantial potential indirect costs. Detailed information on drug shortages collected by a health system's drug information service since 1996 indicated a trend toward more frequent shortages.     

The role of hyperthermia in regional alkylating agent chemotherapy.

The role of hyperthermia during regional alkylating agent chemotherapy is controversial. The aim of this study was to determine the exact contribution of hyperthermia to tumor response during isolated limb infusion with l-phenylalanine mustard. Rats bearing rodent fibrosarcoma on the hindlimb underwent isolated limb infusion with saline, saline plus heat, l-phenylalanine mustard, l-phenylalanine mustard under conditions of normothermia, or l-phenylalanine mustard plus hyperthermia. Heat was administered locally using an in-line hot water circulation loop. Treatment with l-phenylalanine mustard at a concentration of 15 or 50 micrograms/mL was ineffective at producing tumor growth delay (P = 0.24 and 0.41, respectively). Furthermore, thermal enhancement of l-phenylalanine mustard activity was not seen at 15 micrograms/mL. However, administration of high-dose l-phenylalanine mustard, 50 micrograms/mL, with increasing amounts of heat yielded increasing tumor growth delay, increased regressions, and decreased proliferative index. Although l-phenylalanine mustard infusion under normothermia yielded a tumor growth delay of 7.1 days, combination l-phenylalanine mustard + hyperthermia treatment produced tumor growth delay of 27.0 days (P < 0.01; with two of five animals showing a complete response). Four hours after isolated limb infusion, 50.9% of cells in tumor treated with l-phenylalanine mustard + hyperthermia experienced apoptosis, whereas only 18.1, 16, and 4.4% of cells underwent apoptosis after treatment with l-phenylalanine mustard, saline + hyperthermia, or saline. The mean concentration of l-phenylalanine mustard within tumor relative to perfusate following isolated limb infusion was found to be similar among all groups at 0.023, 0.025, and 0.032 in animals undergoing isolated limb infusion with l-phenylalanine mustard, l-phenylalanine mustard + normothermia, and l-phenylalanine mustard + hyperthermia, respectively. These data indicate a synergistic cytotoxic effect of l-phenylalanine mustard + hyperthermia in isolated limb infusion, which is not attributable to enhanced tumor drug uptake.     

Polilactofate microspheres for Paclitaxel delivery to central nervous system malignancies.

PURPOSE: The purpose of this study was to demonstrate that surgically implanted, controlled-release, biodegradable polilactofate microspheres (Paclimer) can be used safely to bypass the blood-brain barrier and deliver paclitaxel to malignant brain tumors. EXPERIMENTAL DESIGN: The rate of paclitaxel release from Paclimer microspheres submerged in PBS was measured in vitro by high-performance liquid chromatography. In vivo studies of Paclimer were performed as intracranial implants in Fischer 344 rats in the presence or absence of 9L gliosarcoma. Mantel-Cox statistics were used to assess the efficacy of Paclimer at extending survival of tumor-bearing animals compared with control implants. Paclimer implants tagged with [(3)H]paclitaxel were used to measure biodistribution of paclitaxel from the Paclimer implant. RESULTS: Paclimer released paclitaxel at a constant rate for up to 3 months in vitro. In vivo, Paclimer implants placed intracranially in rats released active drug for up to 30 days after implantation and doubled the median survival of rats bearing established 9L gliosarcomas (median survival of paclitaxel-treated animals = 35 days; median survival of control-treated animal = 16 days; P < 0.0001). Active drug was distributed throughout the rat brain based on liquid scintillation counting and TLC. Rats implanted with Paclimer demonstrated no overt signs of neurotoxicity and exhibited local cytopathological changes consistent with exposure to an antimicrotubule agent. CONCLUSIONS: Paclimer extends survival in a rodent model of glioma with minimal morbidity and optimal pharmacokinetics.     

Consensus statement on the live organ donor

The Authors for the Live Organ Donor Consensus Group

JAMA. 2000;284:2919-2926.

Objective  To recommend practice guidelines for transplant physicians, primary care providers, health care planners, and all those who are concerned about the well-being of the live organ donor.

Participants  An executive group representing the National Kidney Foundation, and the American Societies of Transplantation, Transplant Surgeons, and Nephrology formed a steering committee of 12 members to evaluate current practices of living donor transplantation of the kidney, pancreas, liver, intestine, and lung. The steering committee subsequently assembled more than 100 representatives of the transplant community (physicians, nurses, ethicists, psychologists, lawyers, scientists, social workers, transplant recipients, and living donors) at a national conference held June 1-2, 2000, in Kansas City, Mo.

Consensus Process  Attendees participated in 7 assigned work groups. Three were organ specific (lung, liver, and kidney) and 4 were focused on social and ethical concerns (informed consent, donor source, psychosocial issues, and live organ donor registry). Work groups' deliberations were structured by a series of questions developed by the steering committee. Each work group presented its deliberations to an open plenary session of all attendees. This information was stored and shaped into a statement circulated electronically to all attendees for their comments, and finally approved by the steering committee for publication. The term consensus is not meant to convey universal agreement of the participants. The statement identifies issues of controversy; however, the wording of the entire statement is a consensus by approval of all attendees.

Conclusion  The person who gives consent to be a live organ donor should be competent, willing to donate, free from coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of the risks, benefits, and alternative treatment available to the recipient. The benefits to both donor and recipient must outweigh the risks associated with the donation and transplantation of the living donor organ.