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The impact of an Educational Program on Gentamicin Use in a Teaching Hospital
220
ONCOLOGY AND CHEMOTHERAPY
obtained by catheterization. Of these specimens 25 yielded > 100,000 colonies per ml. and were regarded as positive. These results were compared to direct counts made under the microscope. With a threshold value of 5 bacteria direct microscopy showed a sensitivity of 0.96, with a specificity of 0.89. When the threshold value was increased the specificity improved somewhat but at a significant loss in sensitivity. Similar threshold values for white blood cells showed an unacceptable sensitivity rate but recording of white blood cells was of some value since the absence of bacteria and white blood cells made infection exceedingly unlikely. In summary, the authors concluded that the "examination of fresh unspun, unstained urine in a hemocytometer counting chamber for the presence of bacteria is a simple, rapid and sensitive method to screen for significant bacteria in a pediatric outpatient clinic". T.D.A. 2 tables, 8 references
Editorial comment. This is a clean-cut study, demonstrating the benefit of careful urinalysis in accurately differentiating contaminated from infected urine. Use of a counting chamber is not new but the method is attractive and certainly costeffective. L.R.K.
The Impact of an Educational Program on Gentamicin Use in a Teaching Hospital W. JOHNSON, W. E. MITCH, A.H. HELLER AND R. SPECTOR, Division of Clinical Pharmacology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
M.
Amer. J. Med., 73: 9-14 (July) 1982 A study was designed to determine if an educational program could alter the prescribing pattern of gentamicin by physicians at a teaching hospital. Objective criteria for acceptable use were based upon the specific indications for use of gentamicin, maximum daily maintenance dose and precautions for avoiding toxicity. Gentamicin therapy was considered acceptable only if all criteria were satisfied. In addition, gentamicin use was considered unacceptable if it was continued for ~4 days after isolation of an organism resistant to gentamicin or if the drug was administered for > 10 days without evidence of persistent infection or bacterial endocarditis. The educational program directed primarily at the house staff extended for a 2-month period. Results and implications of a review of a 72-day period of gentamicin use in the hospital were presented to the house staff and discussed at several of the weekly meetings. At the meetings criteria for acceptable use of gentamicin were discussed in detail. An issue of a monthly hospital publication was devoted to these criteria and distributed to the house staff. Finally, copies of these criteria were placed in visible locations at the nursing stations. In the pre-education review period 57 of 109 courses of gentamicin (52 per cent) were acceptable. Another review 1 year after the educational program revealed 93 of 120 courses acceptable (78 per cent). Indications for gentamicin use that were found unacceptable decreased from 11 to 5 per cent and the incidence of excessive doses declined from 21 to 7 per cent. Despite improvement in dosage determination patterns the incidence of nephrotoxicity (7.5 versus 8 per cent) did not decrease. An educational program may improve the prescribing patterns of physicians and offers advantages over programs that
specifically restrict the use of certain antimicrobials within an institution. M.G.F. 3 tables, 23 references
Inhibitory Effect of Kanamycin on Catecholamine Secretion From Adrenal Medullary Cells C. SHIMIZU, s. TAKAHASHI, E. TACHIKAWA, N. E. TAKAHASHI, Departments of Pharmacology and Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
T. KASHIMOTO,
0HTSUBO AND
Res. Comm. Chem. Path. Pharm., 37: 151-154 (July) 1982 This study was undertaken to investigate the effect of kanamycin on catecholamine secretion in isolated adrenal medullary cells. Bovine adrenal medullary slices were digested first with collagenase and subsequently suspended in a Ringer's solution to yield 6 X 106 cells per tube. Basal catecholamine secretion was determined to be 0.49 ± 0.04 u. per tube. The addition of carbamylcholine (0.1 ug.) increased this to 2.68 ± 0.21 ug. catecholamine per tube. Excess potassium (56 mM.) also resulted in an increase of catecholamine secretion to a level of 1.85 ± 0.20 ug. per tube. Kanamycin then was added to the tubes of suspended cells in varying concentrations found not to affect the spontaneous secretion of catecholamine. Kanamycin did inhibit carbamylcholine and potassium-stimulated catecholamine secretion in a dose-dependent fashion. Calcium is known to participate in carbamylcholine and potassium-induced catecholamine secretion. The authors suggest that kanamycin may influence catecholamine secretion by its effect on calcium ion movement within the cells. G.F.S. 1 table, 4 references
ONCOLOGY AND CHEMOTHERAPY Treatment of Bilateral Wilms' Tumors-a 22-yr Experience B.
K. W ASILJEW, A. BESSER AND J. RAFFENSPERGER, The Department of Surgery, Children's Memorial Hospital and the Department of Surgery, Northwestern University Medical School, Chicago, Illinois
J. Ped. Surg., 17: 265-268 (June) 1982 Of 157 children with Wilms tumor bilateral masses were encountered in 14 (9 per cent). In 8 patients bilateral tumors were diagnosed at the outset, while in 6 the second tumor was discovered 3 months to 5 years later. In this latter group, however, review of the original films revealed evidence that the contralateral tumor may have been present from the beginning in 3 patients. Treatment in these 14 patients was varied. Four children underwent unilateral nephrectomy with contralateral irradiation, with or without chemotherapy. One died as a consequence of treatment and another died with persistent tumor. Seven children underwent nephrectomy with contralateral partial nephrectomy, with or without adjunctive irradiation therapy or chemotherapy. Two died of recurrent or persistent cancer. Finally, 3 patients underwent bilateral partial nephrectomy plus chemotherapy. One died of complications of drug toxicity. Over-all, 9 of the 14 patients are free of disease. T.D.A. 2 tables, 12 references
ONCOLOGY AND CHEMOTHERAPY
obtained by catheterization. Of these specimens 25 yielded > 100,000 colonies per ml. and were regarded as positive. These results were compared to direct counts made under the microscope. With a threshold value of 5 bacteria direct microscopy showed a sensitivity of 0.96, with a specificity of 0.89. When the threshold value was increased the specificity improved somewhat but at a significant loss in sensitivity. Similar threshold values for white blood cells showed an unacceptable sensitivity rate but recording of white blood cells was of some value since the absence of bacteria and white blood cells made infection exceedingly unlikely. In summary, the authors concluded that the "examination of fresh unspun, unstained urine in a hemocytometer counting chamber for the presence of bacteria is a simple, rapid and sensitive method to screen for significant bacteria in a pediatric outpatient clinic". T.D.A. 2 tables, 8 references
Editorial comment. This is a clean-cut study, demonstrating the benefit of careful urinalysis in accurately differentiating contaminated from infected urine. Use of a counting chamber is not new but the method is attractive and certainly costeffective. L.R.K.
The Impact of an Educational Program on Gentamicin Use in a Teaching Hospital W. JOHNSON, W. E. MITCH, A.H. HELLER AND R. SPECTOR, Division of Clinical Pharmacology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
M.
Amer. J. Med., 73: 9-14 (July) 1982 A study was designed to determine if an educational program could alter the prescribing pattern of gentamicin by physicians at a teaching hospital. Objective criteria for acceptable use were based upon the specific indications for use of gentamicin, maximum daily maintenance dose and precautions for avoiding toxicity. Gentamicin therapy was considered acceptable only if all criteria were satisfied. In addition, gentamicin use was considered unacceptable if it was continued for ~4 days after isolation of an organism resistant to gentamicin or if the drug was administered for > 10 days without evidence of persistent infection or bacterial endocarditis. The educational program directed primarily at the house staff extended for a 2-month period. Results and implications of a review of a 72-day period of gentamicin use in the hospital were presented to the house staff and discussed at several of the weekly meetings. At the meetings criteria for acceptable use of gentamicin were discussed in detail. An issue of a monthly hospital publication was devoted to these criteria and distributed to the house staff. Finally, copies of these criteria were placed in visible locations at the nursing stations. In the pre-education review period 57 of 109 courses of gentamicin (52 per cent) were acceptable. Another review 1 year after the educational program revealed 93 of 120 courses acceptable (78 per cent). Indications for gentamicin use that were found unacceptable decreased from 11 to 5 per cent and the incidence of excessive doses declined from 21 to 7 per cent. Despite improvement in dosage determination patterns the incidence of nephrotoxicity (7.5 versus 8 per cent) did not decrease. An educational program may improve the prescribing patterns of physicians and offers advantages over programs that
specifically restrict the use of certain antimicrobials within an institution. M.G.F. 3 tables, 23 references
Inhibitory Effect of Kanamycin on Catecholamine Secretion From Adrenal Medullary Cells C. SHIMIZU, s. TAKAHASHI, E. TACHIKAWA, N. E. TAKAHASHI, Departments of Pharmacology and Internal Medicine, School of Medicine, Iwate Medical University, Morioka, Japan
T. KASHIMOTO,
0HTSUBO AND
Res. Comm. Chem. Path. Pharm., 37: 151-154 (July) 1982 This study was undertaken to investigate the effect of kanamycin on catecholamine secretion in isolated adrenal medullary cells. Bovine adrenal medullary slices were digested first with collagenase and subsequently suspended in a Ringer's solution to yield 6 X 106 cells per tube. Basal catecholamine secretion was determined to be 0.49 ± 0.04 u. per tube. The addition of carbamylcholine (0.1 ug.) increased this to 2.68 ± 0.21 ug. catecholamine per tube. Excess potassium (56 mM.) also resulted in an increase of catecholamine secretion to a level of 1.85 ± 0.20 ug. per tube. Kanamycin then was added to the tubes of suspended cells in varying concentrations found not to affect the spontaneous secretion of catecholamine. Kanamycin did inhibit carbamylcholine and potassium-stimulated catecholamine secretion in a dose-dependent fashion. Calcium is known to participate in carbamylcholine and potassium-induced catecholamine secretion. The authors suggest that kanamycin may influence catecholamine secretion by its effect on calcium ion movement within the cells. G.F.S. 1 table, 4 references
ONCOLOGY AND CHEMOTHERAPY Treatment of Bilateral Wilms' Tumors-a 22-yr Experience B.
K. W ASILJEW, A. BESSER AND J. RAFFENSPERGER, The Department of Surgery, Children's Memorial Hospital and the Department of Surgery, Northwestern University Medical School, Chicago, Illinois
J. Ped. Surg., 17: 265-268 (June) 1982 Of 157 children with Wilms tumor bilateral masses were encountered in 14 (9 per cent). In 8 patients bilateral tumors were diagnosed at the outset, while in 6 the second tumor was discovered 3 months to 5 years later. In this latter group, however, review of the original films revealed evidence that the contralateral tumor may have been present from the beginning in 3 patients. Treatment in these 14 patients was varied. Four children underwent unilateral nephrectomy with contralateral irradiation, with or without chemotherapy. One died as a consequence of treatment and another died with persistent tumor. Seven children underwent nephrectomy with contralateral partial nephrectomy, with or without adjunctive irradiation therapy or chemotherapy. Two died of recurrent or persistent cancer. Finally, 3 patients underwent bilateral partial nephrectomy plus chemotherapy. One died of complications of drug toxicity. Over-all, 9 of the 14 patients are free of disease. T.D.A. 2 tables, 12 references