Decentralized pharmacy operations utilizing the unit dose concept. II. Drug information services and utilization in a decentralized pharmacy substation.
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Evaluation of mobile decentralized pharmaceutical services in a community teaching hospital.
Mobile decentralized pharmaceutical services were compared with the previous centralized unit dose drug distribution services in a community teaching hospital. Medication order turnaround time, pharmacist workload activities, number of drug information requests, dose-activity index, and quality of drug distribution and drug administration record keeping were compared under the two systems. The number of drug therapy problems identified and resolved by decentralized pharmacists also was determined. Medication order turnaround time decreased from a mean of 198 minutes to 64 minutes in the centralized and decentralized systems, respectively. The number of drug information requests increased from 0.0055 to 0.05 requests per patient day. The percentage of requests related to adverse drug reactions, drug interactions, therapeutics, pharmacokinetics, and pharmacology increased in the decentralized system. The dose-activity index was 63.5% and 56.9% for centralized and decentralized systems, respectively, with the mean number of doses handled per patient day at 14.4 and 10.7. Decentralized pharmacists spent substantially more time than centralized pharmacists performing educational, therapy-related, and dispensing activities and less time performing clerical and verification activities. Decentralized pharmacists detected a large number of drug therapy problems that probably would have gone undetected in the previous system. The decentralized system met 31 of the 32 quality assurance standards, compared with 20 standards met for the centralized system. The implementation of mobile decentralized services provided greater opportunities for use of the pharmacists' clinical skills and reduced the time allocated to traditional functions.
Drug Information Services↗
Effects of parasympathetic decentralization on some nerve-mediated functions in the feline urinary bladder.
Isolated detrusor muscle from control cats and cats parasympathetically decentralized for 3 and 10 weeks responded to electrical field stimulation by tetrodotoxin-sensitive, frequency-dependent contractions. There were no significant differences in the frequencies producing 50% response. However, the amplitude of the scopolamine-resistant contraction was distinctly lower in decentralized bladder preparations than in controls. Decentralized detrusor muscle (10 weeks) showed no increased response to alpha-adrenoceptor stimulation (phenylephrine, clonidine, noradrenaline), but the sensitivity to carbachol (at 3 and 10 weeks) was significantly decreased compared with controls. The release of [3H]noradrenaline was decreased by carbachol 10(-7) to 10(-5) M both in controls and in decentralized (10 weeks) detrusor muscle, the decrease being significantly more pronounced in the decentralized group at carbachol concentrations of 10(-7) and 10(-6) M. There were no differences between controls and decentralized bladders of muscarinic receptor concentration, but decentralization significantly reduced the affinity for the radioligand used to label the receptors. Thus, the main changes caused by parasympathetic decentralization of the feline bladder seem to be a reduced post-junctional, but an increased prejunctional response to muscarinic receptor stimulation.
Animals↗
Decrease in transmitter output and synaptic ultrastructure at lobster neuromuscular terminals with decentralization.
The effects of decentralization on the physiology and ultrastructure of neuromuscular terminals were examined by transecting the single excitor axon to the distal accessory flexor muscle in the walking legs of lobsters (Homarus americanus). Decentralization caused a reduction in the amplitude of the excitatory junctional potential without altering the resting potential or input resistance of the muscle fiber thereby suggesting a reduction in transmitter release. Confirmation was obtained by recording of synaptic currents at focal sites which showed failure of transmission and a reduced amplitude on decentralized fibers compared to their intact counterparts on the contralateral leg. The mean quantal content of synaptic transmission decreased approximately 2-7-fold at these decentralized sites compared to their intact counterparts. The ultrastructure of these identified sites was examined with serial section electron microscopy. There are few if any qualitative changes in synaptic ultrastructure between decentralized and control terminals. However, quantitatively there were changes in synaptic ultrastructure which were progressive in nature depending on the severity of the reaction to decentralization. Thus terminals showing a moderate decline in quantal content were characterized by a reduction in the number of presynaptic dense bars and synapses. Terminals showing a severe drop in transmitter release showed in addition to the above changes, a reduction in the size of synapses and terminals. These results show a progression in the loss of the structural parameters controlling transmitter release. Finally synaptic vesicles and mitochondria did not reveal any consistent or marked change with decentralization.
Animals↗
Educational decentralization and deployment of physician's assistants.
A community-based educational network was established to improve the deployment of physician's assistants away from the original site of training in California's San Francisco Bay Area. The philosophy underlying the program decentralization, lessons learned during its implementation, and outcomes of the decentralization are discussed. The graduates' practice locations for a seven-year period are compared before and after the decentralization of the program. Before decentralization, 58 percent of the graduates established their first practice outside of the Bay Area. Following decentralization, 100 percent of the students trained entirely within community settings took their first jobs away from the Bay Area. Unique aspects of this decentralization experience compared with those reported previously included the lack of a required student-preceptor match at the time of entry into the program, the provision of clinical training in or near the site of student residence, and the opportunity to compare before and after effects of decentralizing educational components other than preceptorships.
California↗
Sensitivity of the nictitating membrane of the cat to succinylcholine after decentralization and denervation.
Seven days after decentralization or denervation, the nictitating membrane of the cat becomes supersensitive to succinylcholine. The supersensitivity to succinylcholine is of a moderate degree (2-3 fold) and there is little difference between the supersensitivity induced by decentralization or denervation. In this respect, it is similar to the decentralization type of supersensitivity observed for other agonists which are not taken up by the adrenergic nerve endings (e.g. acetylcholine and methoxamine). Since succinyloholine causes an apparent contraction of the nictitating membrane through its action on the extraocular muscle and no effect on the nictitating membrane itself, it is concluded that both chronic decentralization and denervation produced a decentralization type supersensitivity in the extraocular muscles. The results suggest that supersensitivity in the extraocular muscles may contribute significantly to the decentralization supersensitivity of the nictitating membrane of the cat, in vivo, especially for those agonists which cause contractions of both the nictitating membrane and the extraocular muscle.
Animals↗
Functional evidence for sprouting or decentralized parasympathetic neurons in rat urinary bladder.
The pelvic nerve, carrying parasympathetic nerve fibres, distributes bilaterally in the rat urinary bladder. Preganglionic parasympathetic denervation (decentralization) on one side and postganglionic parasympathetic denervation on the other are followed by an initial decrease in acetylcholine forming capacity and in number of acetylcholinesterase positive nerves in the bladder. However, within a few weeks a marked recovery in acetylcholine synthesis and in number of nerves, based on collateral sprouting, occurs. In this study muscle strips of the rat urinary bladder exposed to the combined surgical procedure was studied. The strips were taken from "denervated" and "decentralized" halves of the bladder. Their contractile responses to methacholine and transmural electrical field stimulation were isometrically recorded in vitro. A supersensitivity to methacholine was found to have developed, of about the same degree, in the two halves 1 week postoperatively. In the denervated halves 4 weeks postoperatively, the supersensitivity was even more marked, whereas in the decentralized halves it tended to be less than after 1 week. The responses of denervated halves to electrical stimulation were reduced 1 week postoperatively. This was also the case for decentralized halves, although the reduction was not large enough to be significant. When examined 4 weeks postoperatively the responses, in particular in denervated halves, were enlarged compared to those 1 week postoperatively. The atropine-sensitive portion of the responses increased with time. Increases in contractile responses to electrical stimulation accompanied by a tendency to desensitization to methacholine are taken as functional evidence for outgrowth of decentralized parasympathetic neurones in the decentralized halves.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
The state mental hospital in transition. Illinois state mental hospitals decentralize.
In this paper, we have looked at mental hospital decentralization as it has developed in the thirteen State of Illinois mental hospitals as of June 30, 1967. The hospitals were looked at from the most centralized to the most decentralized. This was done by relating the hospitals to five descriptive model types, described at greater length elsewhere. Hospital decentralization is portrayed as a complex and highly idiosyncratic process. Attempts to place specific hospitals at point along the decentralization continuum are thus tentative and clear rules for classifying stages of decentralization have yet to be formulated. Complicating the picture still further is that hospitals in transition change rapidly and may at even intervals of a month show dramatic change. It is expected that the trend implied is stable, however, and that ultimately all Illinois state mental hospital with possible exception of ISPI and Illinois Security Hospital, will be located at the decentralized model. This is seen as necessary if they are to survive as viable treatment institutions.
Commitment of Persons with Psychiatric Disorders↗
Time course of the development of pre- and postjunctional supersensitivity in the rabbit ear artery after decentralization.
Changes in the sensitivity of the rabbit ear artery to exogenous norepinephrine and potassium and to sympathetic nerve electrical stimulation were examined in vitro following decentralization which was performed by removing the unilateral preganglionic nerve proximal to the superior cervical ganglion. The contralateral side was left intact as a control. The postjunctional supersensitivity to exogenous norepinephrine and potassium had fully developed one week after the decentralization and was sustained for at least 8 weeks; the arteries decentralized for 1-8 weeks were about 2.1- and 1.3-fold supersensitive to norepinephrine and potassium, respectively, as compared with the contralateral control arteries. The frequency-response curve of the electrically stimulated decentralized artery shifted gradually to the left of the control within weeks after decentralization. Since the response to electrical stimulation was attributed to endogenous norepinephrine released from the sympathetic nerve terminals within the adventitial-medial junction, the leftward shift of the frequency-response curve in the decentralized artery probably reflects a gradual increase in the released norepinephrine per pulse by electrical stimulation, i.e., the prejunctional supersensitivity to electrical stimulation. It is concluded that the prejunctional sympathetic supersensitivity to electrical stimulation develops slower than the postjunctional nonspecific supersensitivity in the rabbit ear artery. The change in the sensitivity of the denervated postganglionic neuron, including the superior cervical ganglion is also discussed with regard to the "law of denervation supersensitivity".
Animals↗
Decentralization of the superior cervical ganglia and the immediate hypersensitivity response.
Bilateral decentralization of the superior cervical ganglia protects against pulmonary inflammation when measured 8 hr after induction of anaphylaxis in rats sensitized to the nematode, Nippostrongylus brasiliensis. Since anaphylactic shock produces immediate perturbations to the cardiovascular and respiratory systems, we examined whether bilateral decentralization of the superior cervical ganglia modified the responses of these two systems during the first 4 hr of the anaphylactic response. With the exception of the bronchioles, decentralization did not protect against anaphylaxis-associated increases in extravasation of albumin, and the small changes in respiratory function induced by anaphylaxis were unaffected by the denervation. Decentralization did not alter anaphylaxis-induced reductions in blood flow to the gastrointestinal tract; however, blood flow to the kidneys and spleen of decentralized rats was restored more rapidly to normal values. These results suggest that the protective effect of decentralization on the late phase pulmonary inflammation of anaphylaxis is unrelated to early changes in respiratory mechanics, although the protection may be facilitated by the more rapid re-establishment of normal cardiovascular homeostasis.
Analysis of Variance↗
Attitudes of pharmacists and nurses toward interprofessional relations and decentralized pharmaceutical services.
Pharmacists' and nurses' attitudes toward pharmacist-nurse relations and pharmaceutical services were surveyed before and after the implementation of satellite pharmacies at a 600-bed teaching hospital. The same questionnaire was distributed two months before decentralization (phase 1) and nine months after decentralization was completed (phase 2). Sixty questions about the pharmacy services and the drug treatment process were to be answered using a seven-point, Likert-type scale. Overall response rates for the two phases were 62% and 45%, respectively. Pharmacists' satisfaction with all measured aspects of pharmaceutical services increased after decentralization of services; nurses' satisfaction increased for all measures except pharmacist-conducted medication histories. Pharmacists' satisfaction with the nursing department was greater after decentralized services were implemented. Most aspects of role conflict, one of four measured antecedents to interdepartmental conflict, improved subsequent to decentralization of services. Because of changes in personnel between the two phases of the study, the results may represent the opinions of different people, rather than actual changes in satisfaction. The attitudes of nurses and pharmacists toward overall distributive pharmaceutical services and toward certain aspects of interprofessional relations improved after pharmaceutical services were decentralized.
Attitude of Health Personnel↗
Decentration of intraocular lenses implanted after intercapsular cataract extraction (envelope technique).
Pseudophakos decentration produces symptoms such as glare, halos, and other visual aberrations. We have reviewed 161 eyes of patients who had an intercapsular cataract extraction with intraocular lens (IOL) implantation with a follow-up of at least six months. Mean decentration was 0.54 mm. It was 0.46 mm for the lenses implanted symmetrically in the bag, 0.65 mm for those implanted in the sulcus, and 0.91 mm for those implanted asymmetrically (bag-sulcus). The differences between the lenses fixated in the bag and those asymmetrically situated were statistically significant (P less than .001). Circular looped lenses (360-degree encircling loop) decentered less (mean 0.28 mm) than modified C-loop lenses (mean decentration 0.63 mm) and modified J-loop lenses (mean decentration 0.60 mm). These differences were statistically significant (P less than .001). The differences were also significant if we considered only the lenses implanted in the bag (mean decentration 0.20 versus 0.59 and 0.54, respectively) (P less than .0001).
Aged↗
Marked antiinflammatory effects of decentralization of the superior cervical ganglia.
Intravenous challenge with parasite antigens in Nippostrongylus brasiliensis-sensitized rats resulted in anaphylactic shock and, in some animals, death. Surviving animals showed significant drop in mean arterial blood pressure, cardiac output, and blood flow to the trachea, bronchioles, and mesentery. After anaphylaxis, changes in the cellular and protein composition in bronchoalveolar lavage fluids (BALF) were assessed. 8 h after antigen challenge, there was significant influx of inflammatory cells and an increase in the levels of histamine and serum-derived immunoglobulins (IgG and IgM) in BALF. Chemotactic activity for neutrophils was also present in BALF. Once we established this anaphylaxis-induced model of pulmonary inflammation, we sought to determine whether or not the superior cervical ganglia (SCG) modulate this inflammation. We performed bilateral superior cervical ganglionectomy or decentralization of the SCG. Our results show that decentralization significantly reduced mortality (by 68%) after anaphylaxis. Furthermore, the increases in levels of serum-derived proteins, histamine, and influx of cells (especially neutrophils) observed in BALF after anaphylaxis were attenuated by both decentralization and ganglionectomy. By contrast, hemodynamic parameters in the respiratory tract and the presence of neutrophil chemotactic activity in BALF were not influenced by decentralization. Thus, the severity of pulmonary inflammation initiated by systemic anaphylaxis is depressed by bilateral ganglionectomy or decentralization of SCG.
Animals↗
Evidence from lack of decentralization-induced supersensitivity that beta 2-adrenoceptors of the cat nictitating membrane are non-innervated.
The right superior of cervical sympathetic trunk of cats was sectioned preganglionically under anaesthesia. Six days later the blood pressure, heart rate and contractions of the left (control) and right (decentralized) nictitating membranes were recorded under chloralose anaesthesia (80 mg kg-1). The alpha-adrenoceptor-mediated contractile responses of the nictitating membrane to intravenous adrenaline were greater on the decentralized side than the control side, with a significant shift of the dose-response curve to the left. After phentolamine (8 mg kg-1 i.v.), adrenaline administered intra-arterially exerted beta-adrenoceptor-mediated relaxation of the nictitating membranes. However, there was no difference in the sensitivity or magnitude of responses between decentralized and control sides. In a separate series of experiments, the alpha-adrenoceptor-mediated contractile responses of the nictitating membrane to intra-arterial noradrenaline displayed supersensitivity on the decentralized side, the dose-response curve being significantly shifted to the left. In the same animals, the beta-adrenoceptor-mediated relaxation responses to intra-arterial isoprenaline were non-significantly greater on the decentralized side, presumably because of raised tone. However, when expressed as a percentage of the maximum relaxation, there was no difference in sensitivity. This study shows that the alpha-adrenoceptor-mediated contractile response of the nictitating membrane displays supersensitivity after preganglionic section of the sympathetic innervation. This is presumably because of an up-regulation arising from loss of sympathetic traffic onto the receptor. The relaxation response is mediated via adrenoceptors of the beta 2-subtype and shows no supersensitivity. This suggests that these receptors are not under the influence of the sympathetic innervation.
Animals↗
Time and cost requirements for decentralized pharmacist activities.
Time and cost requirements for pharmaceutical services in patient-care areas at a 548-bed university hospital were studied. The study was conducted in 1987 and 1988 to (1) define the clinical and distributive activities of decentralized pharmacists, (2) develop time standards for each activity, (3) determine whether the time requirements of decentralized pharmacists depend on the type of patient involved, (4) determine the actual costs of decentralized pharmacist services for various types of patient, and (5) compare costs with reimbursement for clinical pharmacy services. Time standards were established based on data from seven patient categories representing a cross section of the institution's patients. The mean frequency of each activity and the total time and cost per patient day for all activities were determined. Pharmacist time spent daily in each patient-service category ranged from 2.3 hr for low-intensity medical care to 20.8 hr for trauma-burn intensive care. Decentralized pharmacists spent approximately 50% of their time on clinical activities in all patient-service categories. The daily cost per patient day for clinical activities was lowest for low-intensity medical care and highest for adult intensive care. The institution's daily charge for clinical activities ($10/admission and $10/day) exceeded the cost of clinical services during the study period. The decentralized pharmacist time requirement per patient day, and thus the costs of delivering pharmaceutical services, varied by patient-service category. The provision of clinical services generated a profit. A pharmacy workload analysis system that can identify costs and correlate them with patient types can be valuable in hospital pharmacy management.
Centralized Hospital Services↗
The Kerala Decentration Meter. A new method and devise for fitting the optical of spectacle lenses in the visual axis.
Centring of spectacle lenses is much neglected field of ophthalmology. The prismatic effect caused by wrong centring results in a phoria on the eye muscles which in turn causes persistent eyestrain. The theory of visual axis, optical axis and angle alpha is discussed. Using new methods the visual axis and optical axis of 35 subjects were measured. The results were computed for facial asymmetry, parallax error, angle alpha and also decentration for near vision. The results show that decentration is required on account of each of these factors. Considerable correction is needed in the vertical direction, a fact much neglected nowadays; and vertical decentration results in vertical phoria which is more symptomatic than horizontal phorias. Angle Alpha was computed for each of these patients. A new devise called 'The Kerala Decentration Meter' using the pinhole method for measuring the degree of decentration from the datum centre of the frame, and capable of correcting all the factors described above, is shown with diagrams.
Asthenopia↗
In vivo measurement of posterior chamber intraocular lens decentration and tilt.
We report what to our knowledge is the first extensive in vivo clinical study of intraocular lens decentration and tilt. Measurements of posterior chamber intraocular lenses, all implanted by the same surgeon in 89 eyes, showed that decentration and tilt consistently differed between right and left eyes. Lenses tended to decenter superotemporally and tilt with their superonasal edges tipped forward. Decentration magnitude relative to the cornea light reflex axis and line of sight averaged 0.64 mm, with decentration increasing slightly with increased axial length. Average tilt was 6.75 degrees, and the average tilt-induced astigmatism was 0.27 diopter. Tilt magnitude decreased with increased axial length, as did tilt-induced astigmatism and plus sphere.
Adult↗
Distribution of neuropeptide-like immunoreactivity in intact and chronically decentralized middle cervical and stellate ganglia of dogs.
Neuropeptide-like immunoreactivity to antisera raised against Leu- and Met-enkephalin, vasoactive intestinal peptide (VIP), neuropeptide Y (NPY) and substance P (SP) have been studied immunohistochemically in middle cervical and stellate ganglia of dogs. To investigate the relationship of the peptides to one another as well as to preganglionic and postganglionic neurons, intact and chronically decentralized middle cervical and stellate ganglia were studied. Ganglia were processed for immunohistochemistry in unoperated dogs and in dogs two weeks after unilateral ganglionic decentralization. The immunoreactivity for each peptide had a characteristic distribution in the ganglia. These distributions differed from one another and from the distribution of cardiac postganglionic sympathetic neurons. Camera lucida drawings of peptide distributions were made to compare different peptides and counts were made to determine the percentages of cells immunoreactive for a given peptide. The results demonstrated that enkephalin-like immunoreactivity in axons was present in both the stellate and middle cervical ganglia, but was heaviest in the caudal 2/3 of the stellate ganglia. Enkephalin-like immunoreactive fibers formed pericellular baskets around stellate ganglion neurons. VIP-like immunoreactive cell bodies and processes were distributed sparsely, but widely, in the stellate ganglia and to a lesser extent in the middle cervical ganglia. One of two commercial antisera to SP resulted in immunoreactive staining of cell bodies and processes in the stellate ganglia. SP-like immunoreactivity in neurons represented about 10% or less of the cells in the stellate ganglia. At least 80-85% of the neurons in the stellate and middle cervical ganglia were immunoreactive for NPY antisera. Decentralization eliminated enkephalin-like immunoreactive staining in the middle cervical and stellate ganglia, but not the VIP-, NPY- and SP-like immunoreactive staining of neurons in these ganglia. In summary, the enkephalin-like immunoreactive axons in the thoracic autonomic ganglia appear to be derived from extrinsic neurons, most likely from preganglionic spinal neurons. VIP-, SP- and NPY-like immunoreactivity were not significantly affected by decentralization. The results provide anatomical evidence for substrates related to neuropeptidergic synaptic mechanisms in thoracic autonomic ganglia.
Animals↗