Physician motivations for nonscientific drug prescribing

Although there is increasing concern about inappropriate physician prescribing and how to devise programs to improve drug therapy decisions, little research has been published documenting the reasons for such misprescribing. We analyzed the motivations reported by 141 physicians who were part of a large multi-state randomized controlled trial of 'academic detailing.' The physicians were identified from state Medicaid prescribing records as moderate to high prescribers of cerebral or peripheral vasodilators, propoxyphene, or cephalexin, and were visited by clinical pharmacists serving as outreach educators in a medical school-based prescribing improvement program. Physicians' motivations for their prescribing patterns were discussed in an informal, interactive manner; all responses were recorded in detail by the pharmacists immediately following each visit. Of the 110 responses elicited, the most common reason offered by physicians for use of these medications was patient demand (51 statements, or 46%). Physicians also frequently attributed their prescribing of these drugs to intentional use of placebo effect (24%). An equally common reason was prescribers' assertion that their own clinical experience indicated that these drugs were actually therapies of choice in the conditions presented (26%), despite evidence from the research literature that this was not the case. Such indications included the use of the 'vasodilators' for senile dementia or peripheral vascular disease, cephalexin for viral upper respiratory infections, and propoxyphene instead of acetaminophen or aspirin for mild pain. Greater attention must be paid to physicians' attitudes and motivations concerning suboptimal prescribing if programs are to succeed in replacing these practices with more rational clinical decision-making.     

Aspergillus pancarditis following bone marrow transplantation for chronic myelogenous leukemia

A 34-year-old man with chronic myelogenous leukemia developed hemoptysis, pain in the left side of the chest, and a systolic heart murmur eight weeks following an allogeneic bone marrow transplant. His clinical status deteriorated, and he died ten weeks after transplantation. Autopsy revealed unsuspected disseminated aspergillosis, including the unusual finding of Aspergillus pancarditis and pericarditis. Cardiac aspergillosis is a uniformly lethal disease in immunocompromised persons and must be aggressively diagnosed following early symptoms.     

A high percentage yield of tyrosine hydroxylase-positive cells from rat E14 mesencephalic cell culture.

In the ventral mesencephalon of the E14 rat fetus, 90% of the dopaminergic, tyrosine hydroxylase positive (TH+) cells are localized in 1.0 mm3 of tissue. This same ventral mesencephalic region also contains 90% of the dopamine content of the E14 ventral brainstem (2.2 +/- 0.3 nmol/mg protein). When cells were prepared for culturing from this localized area, and plated at a density of 2.5 x 10(5) cells/cm2, 17-21% of the cells were TH+, at 4 and 12 h, and at 1, 5, 7 and 10 days after plating. The percentage of TH+ cells was also 17-21% when examined at 4 h, 12 h or 5 days after plating at densities ranging from 7.8 x 10(3) to 2.5 x 10(5) cells/cm2. However, cell survival at a density of less than 6.2 x 10(4) cells/cm2 was poor after 5 days in culture. Based on the degree of neurite elongation and complexity, cell maturation appeared to be complete at 5 days in culture (DIV5), and appeared to be maintained at this level up to DIV10. By DIV14, neurite retraction was evident, and the cells were more rounded. These signs may indicate the inception of senescence in the cultures. A benztropine-sensitive, concentration-dependent dopamine uptake mechanism was demonstrated in the cultures at DIV7, and DA could be released from preloaded cells using 50 mM K+. Five morphological subtypes of TH+ cells were identified in the cultures. This primary culture of the ventral mesencephalic, dopaminergic area, with a high percentage of TH+ cells, is suitable for use in acute biochemical and cellular studies, between DIV 5 and DIV10.     

Comparison of Roche RIA, Roche EIA, Hybritech EIA, and Abbott EIA methods for measuring carcinoembryonic antigen

Using 600 clinical specimens, we compared the concordance of four methods for carcinoembryonic antigen: the Roche RIA (I); the Roche EIA (II); Hybritech EIA (III); and Abbott EIA (IV). EDTA-treated plasma was used for Methods I and II and serum for Methods III and IV. However, no significant difference was found between results for serum and plasma in Method II. The normal reference interval (in micrograms/L) was I (222 specimens), 1.94 +/- 1.54; II (57 specimens), 0.8 +/- 0.5; III (100 specimens), 2.94 +/- 2.47; and IV (614 specimens), less than 5.0. The precision of all four methods was acceptable. Concordance among all of the methods exceeded 90%.     

Short-term respiratory effects of cleaning exposures in female domestic cleaners.

Symptoms of obstructive lung disease in domestic cleaners have been related to the use of bleach and other irritant cleaning products. The short-term effects of cleaning exposures on respiratory symptoms and peak expiratory flow (PEF) were investigated in domestic cleaners with respiratory disorders. In a panel study, 43 female domestic cleaners with a recent history of asthma and/or chronic bronchitis completed a 2-week diary, collecting information on respiratory symptoms, PEF and cleaning exposures. Mixed regression models were used to assess daily changes in symptoms and PEF associated with specific cleaning exposures. The probability of having work-related asthma was individually assessed by a computerised diagnostic system and an occupational asthma expert. Lower respiratory tract symptoms were more common on working days and were predominantly associated with exposure to diluted bleach, degreasing sprays/atomisers and air fresheners. Associations with upper respiratory tract symptoms and PEF were less apparent. Eleven (30%) subjects scored positively for work-related asthma. It is concluded that exposure to certain irritant cleaning products aggravates lower respiratory tract symptoms in female domestic cleaners with asthma or chronic bronchitis.     

Strategies for screening blood for human immunodeficiency virus antibody. Use of a decision support system

A decision analytic model was used to examine alternative strategies to screen donated blood for human immunodeficiency virus (HIV) using data from the literature and from 1987 blood-screening programs in areas with high and low prevalence of HIV. Sensitivity analyses incorporated uncertainties about HIV infection and test performance. Current screening strategies are estimated to allow 20.5 infected units per million donated units to be transfused at a cost of $16,850 per HIV-positive unit detected in high-prevalence areas and 4.7 infected units per million donated units to be transfused at a cost of $32,275 per HIV-positive unit detected in low prevalence areas, with nine false-positive notifications of uninfected patients per million units screened and 14.9 discarded, noninfected units per HIV-positive unit in low-prevalence areas. Testing donated blood for HIV can be improved by individualizing screening strategies for areas with different prevalences of HIV. Efforts to further reduce transfusion-associated HIV should focus on improved test performance in early stages of infection, reduction of unnecessary transfusions, donor recruitment in lower-risk groups, and public health measures to reduce HIV infection among the general population.