Spray Your Valentine With Liquid Trust!

Hurry there's still time to get your liquid "trust-spray" for Valentines Day! The world's first OTC oxytocin product, formulated to enhance people's trust in you for only $29.95! From their web site we read, "Liquid Trust Enhanced has been specially designed to give a boost to the dating and relationship area of your life. This upgraded formula still contains the same great Oxytocin formula, but now includes the powerful pheromones Androstenone and Androsterone. For the first time, you can create a TRUSTING and PASSIONATE atmosphere...It all starts with Trust." Check it out @: www.VeroLabs.com. 

Yeah I didn't believe it when I first saw it either. As per Dr. Buhler's Physiology of Female Hormones lecture; Oxytocin is an endogenous neurohypophysial hormone released from the posterior pituitary of both men and women and acts to contract the smooth muscles in the uterus and pelvic floor region during coitus and child birth.

Oxytocin comes from the Greek; okytokos, meaning swift birth. (Martini, 2006). Before the modern understanding of oxytocin, it was common practice to let a first born twin; suckle at the mother’s breast; speeding the birth of the second child, assisting the expulsion of the placenta (after birth), and promoting the pre-pregnancy uterine size and tone. (Tortora, 2003). We now know that this is due to the hormone oxytocin. A synthetic oxytocin (Pitocin) is used exogenously and is indicated for use in producing rhythmic uterine contractions in full-term labor, control of postpartum bleeding, and induction of postpartum milk let down. 

Apparently it has the added (alternate) effect of bonding and increasing the trust in people near its release. It is thought to play a role in augmenting the pair bonding between mates and therefore helps determine long-term monogamy. Quote taken from a study of neuron transmission in prairie voles, "Other neurotransmitters are known to support social affiliation, including the neuropeptides oxytocin and vasopressin, and monogamous prairie voles have a higher density of oxytocin receptors in the nucleus accumbens compared to more promiscuous vole species." (Edwards, 2006) This study concluded that there was a significant correlation between the prairie voles that had more oxytocin receptors and those which lived monogamous lives! 

And so what about that Vero Labs claim of 'liquid trust' in a bottle, could there be something to it? Though the FDA approved an over the counter nasal oxytocin spray (that has since been removed) available to assist new mothers in stimulating the milk let down reflex; they only approved a 0.5 mg strength, one that their own literature states was a sub-physiological dose. The possibility that a perfume, like the one sold by Vero Labs, being substantially less than the concentration of this OTC nasal spray, could provide the behavior modifying results of making people trust in others as they are claiming, is rather slim. Happy Valentine's Day!

References:

1. Martini, F. (2006). Fundamentals of Anatomy & Physiology Seventh Edition. Pearson Education Inc. San Francisco, CA.

2. Kosfeld, M; et al. (2005). Oxytocin Increases Trust in Humans. Nature. vol. 435, pp. 673-676.

3. Uvnäs-Moberg, et al. (1999). Oxytocin as a possible mediator of SSRI-induced antidepressant effects. Psychopharmacology. vol. 142, pp. 95 – 101

4. http://arbl.cvmbs.colostate.edu/hbooks/pathphys/endocrine/hypopit/oxytocin.html

5. Tortora, G., Grabowski, S. (2003). Principles of Anatomy and Physiology Tenth Edition. John Wiley & Sons, Inc. New York, NY.

Prescribing Pharmacists

The next time you go to the hospital or clinic it might be a pharmacist that writes you a prescription for your medication. Ever since the clinical pharmacy movement started in the 1970s, the role of pharmacists has slowly taken on new roles and more responsibilities in addition to filling and dispensing drug orders, that in some cases includes prescribing. Many times it is the pharmacist who is consulted by nurses and doctors to choose an appropriate agent for complicated inpatient (or outpatient) issues. Pharmacists have been prescribing in Australia and Great Britain for many years now under the supervision of an already established prescriber, a practice which they call secondary prescribing. The Department of Health in the UK stated that as of the end of 2004, the first year that legislation allowed it, there were around 

1000 pharmacist prescribers. The Royal Pharmaceutical Society of Great Britain states, "Regulations to allow independent prescribing (without the supervision of a doctor/ mentor) by pharmacists came into effect in May 2006. Pharmacist independent prescribers can prescribe for any clinical condition but they must only prescribe within their professional and clinical competence." (see #1. below) Of the numerous studies examining the proficiency of, and need for pharmacist prescribers, the consensus has been that allowing this responsibility to pharmacists; improves patient care, frees physicians for more pressing cases, and saves a great amount of money for the healthcare industry and its patients. 

One Irish study made some interesting discoveries after interviewing a number of new prescribing pharmacists and the doctor/ mentors that helped them during their first two years. The article was called: Pharmacists' and mentors' views on the introduction of pharmacist supplementary prescribing: a qualitative evaluation of views and context, and was published in the International Journal of Pharmacy Practice, 2007. They found that, "all participants [pharmacists & doctors] saw it [prescribing rights for pharmacists] as the next step, a natural progression for pharmacy and something that would formalize current practice." They make the claim that prior to this official legislation pharmacists had been effectively performing this type of prescribing only without receiving the due recognition for their input into patient care. One pharmacist was quoted saying, "I would like the ability to change that of my own accord without having to go to a junior doctor who knows absolutely nothing, just tell him to sign off something I've told him to do, which to my mind is ridiculous." Moving in this direction will require pharmacists to be more proactive than reactive. Pharmacists have always been seen as the 'safety net' with regard to correcting or 'catching' prescribing issues, but expanding the role to envelop prescribing within a professional and clinical area of competence or specialty, will bring pharmacists to the forefront of patient care and responsibility. It will save time and money to involve a pharmacist at the beginning of a patients' care rather than only to come behind to fix or catch mistakes that were out of his control. Its the difference between, "offering advice and making decisions," one pharmacist reported.

Surprisingly, pharmacists have even been prescribing here in the US for some time now too. March, 1995 the Veterans Affairs Medical Centers (VAMC) received the go ahead from the FDA to issue a directive that allowed for an expanded scope of practice, including  independent prescribing privileges for Clinical Pharmacy Specialists (CPSs). In addition to the normal activities of a registered pharmacist, this new directive allows CPSs to prescribe new medications; including, initiation, continuation, termination or alteration of drug therapies, and the authority to perform, order, or review physical exams and lab tests. CPSs can now assist in emergency procedures, adverse drug reactions, patients with chronic and acute diseases, and administer medications. (See: Prescribing privileges among pharmacists in Veteran Affairs medical centers, American Journal of Health-System Pharmacists, 2001.) 

Dare I say that there is not a more exciting time to be a pharmacist since Alexander Flemming discovered the antibiotic properties of penicillin in 1928! Independent prescribing rights for pharmacists is a major advancement for the career. It will necessitate current pharmacists to embrace a changing job description with increasing roles and responsibilities and it will require students of pharmacy to be engaged and alter their goals and outlook for their career.  I believe that in a decade's time we will look back and realize that prescribing rights for pharmacists was a logical advancement and we won't be able to imaging what it was like before they could. 

References

1. http://www.rpsgb.org.uk/worldofpharmacy/currentdevelopmentsinpharmacy/pharmacistprescribing/index.html

2. http://www.ashp.org/import/news/NewsCapsules/article.aspx?id=227

3. http://www.ashp.org/import/news/HealthSystemPharmacyNews/newsarticle.aspx?id=985

4. http://www.ashp.org/import/news/HealthSystemPharmacyNews/newsarticle.aspx?id=1604

5. http://www.ualberta.ca/~csps/JPPS8(2)/L.Emmerton/pharmacists.pdf

6. http://www.shpa.org.au/pdf/positionstatement/prescribing_jun05.pdf

Clinical Pharmacy

I've recently been posed the question: "What exactly do pharmacists do in a hospital?" Clinical pharmacists have assisted hospitalists in areas of service, research and education. Here's a summary of what I've seen/read as the importance of a pharmacist-doctor team in the clinic or hospital:

SERVICE

Hospitalist-Pharmacist collaboration can improve direct patient care in the following areas:

· Medication Reconciliation

· CMS Core measures – including antibiotic selection, vaccination, and smoking cessation

· Monitoring drug therapy – including warfarin, insulin, and other drugs with a narrow therapeutic index

· Innovations in transitions of care – especially at admit and discharge to improve continuity of care

· Ensure access to needed medications after discharge

· Patient education

RESEARCH

Hospitalists and pharmacists have collaborated:

· To reduce length of stay

· To improve the discharge process

· To reduce costs (patient and hospital)

· To improve interdisciplinary training

· To improve hospital quality and patient safety

EDUCATION

Pharmacists and hospitalists have collaborated:

               ·     To provide training in palliative care

               ·     To improve interdisciplinary education, as above

               ·     To write and improve textbooks

Illinois and its Governor

I find it awfully interesting that the day after I question Rod Blagojevich's use of authority he's arrested!? (I even tried so hard to leave his name out of the case!) 'The Economist' said of him that he took office in 2002, "vowing to bring ethics reform to Illinois." What a joke that turned out to be. (see http://www.economist.com/world/unitedstates/displayStory.cfm?story_id=12757603&source=features_box2.) 

Let me just tell you how weird this guy is. In an interview in 2006 after the incident I mentioned in my post yesterday (see: Opinions in the Wind) he was quoted as saying, “Rather than try to get the legislature to pass something—because we attempted to and they didn’t do it—on my own, through executive order action, I forced these guys to fill prescriptions for birth control for women who come in with prescriptions from their doctors.” (see from the right http://www.lifesitenews.com/ldn/2008/dec/08120903.html & from the left http://www.windycitymediagroup.com/gay/lesbian/news/ARTICLE.php?AID=13039. Just in case anyone accused me of being imbalanced!) Last time I checked, forcing a bill into law by 'executive order action' that takes away the rights of one person (a pharmacist) to choose how they will express their ethical and religious freedom was expressly forbidden in the Constitution of the United States. Well let's see what he can do from behind bars? I hope pharmacists in Illinois unite, stand up for their right to refuse, and reverse that unconstitutional law that this power hungry Governor mandated!

Here's the official public record of the criminal complaint that lead to his arrest: http://dig.abclocal.go.com/wls/documents/blago_complaint.pdf. 

Opinions in the Wind

Pharmacy school has challenged many of the the ideas and opinions I had previously justified. If nothing else it has shown me that there is much more gray area in most issues than one might presume by looking at the surface. During an ethics case study the other day we pursued a lengthy debate about the degrees of death and the differences between euthanasia and assisted suicide. For those outside of Oregon, our state is one of the few as I understand, that allow physician assisted suicide. You can check out interesting statistics and information on our "Death With Dignity Act", at http://www.oregon.gov/DHS/ph/pas/. This act was passed by voters in October 1997 and allows for terminally ill patients to voluntarily end their lives by taking a lethal dose of medication prescribed by a physician and often filled and dispensed by a pharmacist. Last year (2007) 45 physicians prescribed 85 killer scripts, 49 of which were used to end the life of a patient.

Here's what I think I've sorted out from our deadly debate: manslaughter > euthanasia > assisted suicide > the 'Principle of Double Effect'.  The keys for understanding the differences in these is in the semantics of their definitions. The National Institutes of Health has an online medical dictionary that's really great; http://www.nlm.nih.gov/medlineplus/mplusdictionary.html. They define euthanasia as: the act of killing hopelessly sick or injured individuals in a relatively painless way for reasons of mercy. The assisted suicide entry reads: suicide by an individual facilitated by means or information provided by someone else aware of the individuals' intent. Now although the 'Principle of Double Effect' wasn't listed in this - or any other medical dictionary I checked - it is understood in the health community to be in this context, the inadvertent overdose of pain medication leading to respiratory failure and death of a patient. This 'second' or double effect of death is not considered harm to the patient when correctly administered in the proper setting, i.e. hospice or palliative care.

Let me say, right off the bat, that I do not condone Kevorkian ethics surrounding euthanasia, especially since its illegal in all 50 states; but, this issue does present a couple of interesting ethical dilemmas for me with respect to assisted suicide and double effect, which are legal. First of all, how do I feel about taking part in the conscious death of another individual? Secondly, do I or any other health care provider,  have the right to refuse care if they disagree with the ethics of what they're being asked to do?

As for the first question, if you had asked me 4 months ago, I would have said unequivocally that there is no way I would participate in the death of another person no matter the circumstance, but that was before I understood the tole (pain) that cancer, ALS and other terminal illnesses take on a person; so now, I'm not sure yet where I stand. I would condone the use of the principle of double effect but I'm going to have to ponder how I would handle being asked to fill or dispense a suicidal medication. I don't know if assisted suicide fulfills the fundamental ethical principle of beneficence or my vow to 'do no harm'.

As for the second question; there was an interesting case a while ago of a pharmacist in Illinois that refused to fill a prescription siting his right to refuse care based on a religious ethical stance that he maintained. He later found that the patient was the daughter of the State's Governor who wasn't very happy about the pharmacist causing an unnecessary emergency of finding another pharmacist to fill the prescription in the middle of the night. The Governor lobbied the state legislator and the voting block and eventually was successful in writing a bill into law that obligated every pharmacist in the state to fill every script that they receive from any licensed physician. This needless to say is a major setback for the career relegating the pharmacist to nothing more than a technician that fills an order. Personally I 'prescribe' to the libertarian model, where each provider has the right to choose his or her mode of practice and ethical justification within the limits of the board that carries their licence. 

Here's another ethical quandary I've been asked to consider. If you asked me 4 months ago how I felt about addiction, I'd probably tell you that it was wrong to be addicted to a drug and we, as doctors, need to help prevent and treat (wean) patients that struggle with this problem. Well I've found more gray area here to be weighed. We were talking in class just today about Parkinson's Disease (PD), the debilitating degenerative neurological disease that cripples its sufferers with uncontrollable tremors, rigidity, bradykinesia and a shuffling gait. One of the side effects of several of the drugs used to treat the symptoms of PD is an elevation in mood by stimulating the medial forebrain bundle, which holds the pleasure and reward center of the brain responsible for addiction. Herein lies the question, is it necessarily bad to be 'addicted' to a drug that helps control a disease state, especially one who's side effect actually makes you feel (emotionally) better? I say no, in this context, being addicted is not a harmful thing, and I would probably be happy to see a patient use his or her prescription with good compliance especially if they felt better doing it! 

I'm certain there will be interesting cases to come that will challenge my preconceived opinions and stances as I continue my investigation into the world of pharmacy. This will be a continual forum to open some of these gray areas of pharmacy practice for the discussion and consideration of all. 

Intro to Pain

So we started a class the other day called Intro to Pain. It's taught by Dr. Jackson the pain specialist... really! I didn't believe it at first either, there really is such thing as a doctor of pain! 

Flu Season 2008

Doctor Carlson, the preceptor at my Safeway Pharmacy rotation site this fall, requested that I make a public service announcement about the flu that patients could read while waiting for their shots. With his assistance as editor I came up with this poster:

How do you spell that?...or, its all greek to me!

I remember asking my mom when I was learning to spell how to spell the letters so I could remember the word better! Like how do you spell the letter 'C' or 'S' or 'M', etc. I recall her telling me, "there is no way to spell a letter son". This memory was sparked during Dr. Pokala's description of the reason for neuronal plaque development in Alzheimer's Disease being a result of the cellular cytoskeleton breakdown due to the loss of integrity of the τ-protein. I thought to my self, "I don't remember what this Greek letter looks like, how am I going to write it in my notes? Maybe if I knew how it was spelled I could transliterate this Greek symbol into the roman alphabet." Yeah, I know I'm a little slow. I eventually came to and realized that Greek is one of the few languages I know of that gives you the option of using the symbol or spelling it out! This one's for you Mom, (τ) is spelled: tau! Oh, and if anyone else was wondering I looked them all up, here's the rest of the Greek alphabet...

alpha, beta, gamma, delta, epsilon, zeta, eta, theta, iota, kappa, lambda, mu, nu, xi, omicron, pi, rho, sigma, tau, upsilon, phi, chi, psi, omega

- The image above is a photomicrograph from: pharmalicensing.com/.../1117210578_429747d2adcec showing a tangle of τ-protein (large dark triangular structure) that may be a cause of Alzheimer's Disease!

Food Diaries

Our academic extention groups threw this newsletter PSA together in a half an hour today!

I need a Latin pseudonym...

So Paracelsus is my new hero. Dr. Harrelson (PhD. Medicinal Chemistry) lectured today about drug discovery, its history and practical use. Anyway, he mentioned that this guy Paracelsus, kind of stood up to the establishment headed by the Galen doctrine of polytherapy (throw as many herbs as you think necessary at the patient and the body will "take what it needs" to heal) by suggesting that each herb given as a remedy has what he called a 'vital spirit' or 'quintessence' that was responsible for its pharmacological benefit. He postulated that this quintessence from herbs and minerals were contaminated with impurities that inhibited their 'natural' benefit. So off he went purifying natural products by isolating their active ingredients. The now purified compounds were given to patients suffering from certain ailments and the effect or drug action was observed and recorded. This lead Paracelsus to the theory of monotherapy; or a drug intervention where only one drug is used to treat one disease state. It sounds like pretty standard stuff for our 21st century ears, but in his day this was an exciting and revolutionary theory.

All that history aside, that isn't the purpose for my posting. I'm in love with the romanticism of taking a Latin pseudonym as did so many scientists, philosophers and writers of the romantic and classical eras. It was a right of passage so to speak for the educated, no matter their native language, to understand Latin grammar and even take on a Latin pseudonym or to Latinize their given name in order to publish during the scientific revolution. Take this guy Paracelsus; his real name was, Theophrastus Philippus Aureolus Bombast Honenheim, pretty amazing in its own right but not very practical in conversation. What about Carl von Linne, known to most by Carolus Linnaeus, the Swedish botanist/ zoologist that started the whole binomial nomenclature thing! Sometimes the pseudonym would not be a Latinization of their own name but would take on an attribute or characteristic of that person. Take the Polish born renascence man, Mikolaj Kopernik who had many names, the best known of which was Nicolaus Copernicus which literally means 'one who works copper'. The famous Frenchman, Rene Descartes was known as Renatus Cartesius among academic circles. Galileo Galilei was... wait he was Italian?! (seen above right).

So I guess I feel like I want to join this uber-cool club of scientists by finding a Latinized pseudonym of my own! For those of you who know me, please suggest some original and relevant Latin names to consider. If you don't know me all that well, suggest some Latinized forms of my given name, or check out my profile and try something more character based. I'm excited to see what you all come up with!

Here's a cool list of Latinized names: http://en.wikipedia.org/wiki/List_of_Latinised_names

or: http://freereg.rootsweb.com/howto/latinnames.htm