Reducing the use of H2-receptor antagonists in the long-term-care setting.

OBJECTIVES: To examine the patterns of H2 blocker use in the long-term-care setting and to assess the effect of educational interventions designed to improve H2 blocker utilization patterns. DESIGN: Time-series quasi-experimental study and retrospective chart review. SETTING: A large academically-oriented long-term-care facility. PATIENTS: Institutionalized elderly patients with a mean age of 88 years receiving H2 blocker therapy. INTERVENTIONS: Two interventions involving group discussions with the medical staff, supporting educational materials, and physician-specific listings of patients receiving H2 blockers were employed sequentially over a 32-month period. RESULTS: Each intervention resulted in substantial reductions in medication use (59.6% and 32.1%, respectively). Indications for H2 blocker use were determined retrospectively for patients identified as receiving therapy prior to the interventions (n = 110). Forty-one percent were found to be receiving therapy for reasons unsubstantiated by the medical literature. These patients were more likely to be discontinued from therapy than those receiving therapy for substantiated indications (P less than 0.01), consistent with the primary focus of the educational interventions. CONCLUSIONS: These results suggest that the excessive use of H2 blocker therapy in the long-term care setting responds to educational interventions with therapeutically appropriate reductions in utilization. Repeated interventions are necessary to maintain such reductions over time although there may be some reduction in the effectiveness of the intervention with repetition.     

Advances in analytical techniques for neutron capture therapy: thin layer chromatography matrix and track etch thin layer chromatography methods for boron-10 analysis

A new track etch autoradiographic technique for quantitating boron-10 containing compounds used for neutron capture therapy is described. Instead of applying solutions of Cs2B12H11SH and its oxidation products directly to solid-state nuclear track detectors, diethylaminoethyl cellulose thin layer chromatography (TLC) plates are utilized as sample matrices. The plates are juxtaposed with Lexan polycarbonate detectors and irradiated in a beam of thermal neutrons. The detectors are then chemically etched, and the resultant tracks counted with an optoelectronic image analyzer. Sensitivity to boron-10 in solution reaches the 1 pg/microliter level, or 1 ppb. In heparinized blood samples, 100 pg boron-10/microliter are detected. This TLC matrix method has the advantage that sample plates can be reanalyzed under different reactor conditions to optimize detector response to the boron-10 carrier material. Track etch/TLC allows quantitation of the purity of boron neutron capture therapy compounds by utilizing the above method with TLC plates developed in solvent systems that resolve Cs2B12H11SH and its oxidative analogs. Detectors irradiated in juxtaposition to the thin layer chromatograms are chemically etched, and the tracks are counted in the sample lane from the origin of the plate to the solvent front. A graphic depiction of the number of tracks per field yields a quantitative analysis of compound purity.     

Thyroxine replacement in post-radioiodine hypothyroidism

Thyroxine replacement dose in 70 patients with post-radioiodine (for Graves' thyrotoxicosis) hypothyroidism was compared with that in 34 patients with autoimmune hypothyroidism matched for age and sex and diagnosed during the same period. Median replacement dose in the post-radioiodine group (100 micrograms daily) was significantly lower (P = 0.006) than in the autoimmune hypothyroid group (137.5 micrograms daily). Furthermore there was marked variation in the time elapsing from onset of post-radioiodine hypothyroidism to achievement of a given maintenance dose. These findings may be explained by persistence of non-TSH mediated thyroid function, after radioiodine therapy for Graves' thyrotoxicosis. The observations indicate the potential risk of overtreatment with thyroxine in post-radioiodine hypothyroidism unless the dose is carefully titrated against serum TSH levels. Final thyroxine requirements may not be evident in the initial phase of treatment and patients with apparently low maintenance thyroxine requirements require long-term follow up.     

A menopause center: bridging the midlife gap.

As women 40-60 years of age become the fastest growing segment of the population, it is time for women's health care providers to identify the health care needs of these women and provide the appropriate services. In 1985, Northwestern Memorial Hospital developed the Menopause Center to address these concerns. The objectives of the Menopause Center are to inform women of the natural bodily changes menopause creates, dispel common myths about the menopause, identify risk factors for osteoporosis and heart disease, provide information regarding hormone replacement therapy, and provide a forum for women experiencing the menopause to share information.     

Down's syndrome

We discuss the ethical, psychosocial, economic, and medical dimensions of the treatment and management of a child with Down's syndrome and a congenital heart defect.     

Solitary bronchioloalveolar carcinoma: CT criteria

The computed tomographic (CT) scans of 30 patients with solitary bronchioloalveolar carcinoma were reviewed. Common features at CT included the peripheral or subpleural location of a pulmonary mass (25 cases), pseudocavitation (18 cases), heterogeneous attenuation (17 cases), irregular margins forming a star pattern (22 cases), and pleural tags (21 cases). Using these CT criteria, four independent observers attempted to identify cases of bronchioloalveolar carcinoma from a larger sample of lung cancers and benign lesions by categorizing a series of test cases into four probability categories. Although the bronchioloalveolar carcinomas were correctly ranked in the two highest probability categories 75% of the time (in 45 of 60 cases), there was considerable overlap with other lung lesions, particularly with adenocarcinoma and large cell undifferentiated carcinoma. However, even though the typical features of bronchioloalveolar carcinoma are not invariable or highly specific, they are characteristic enough to suggest the diagnosis.