Cigarette smoking and the risk of supraventricular and ventricular tachyarrhythmias in high-risk cardiac patients with implantable cardioverter defibrillators

Introduction: Nicotine elevates serum catecholamine concentration and is therefore potentially arrhythmogenic. However, the effect of cigarette smoking on arrhythmic risk in coronary heart disease patients is not well established.
Methods and Results: The risk of appropriate and inappropriate defibrillator therapy by smoking status was analyzed in 717 patients who received an implantable cardioverter defibrillator (ICD) in the Multicenter Automatic Defibrillator Implantation Trial-II. Compared with patients who had quit smoking before study entry (past smokers) and patients who had never smoked (never smokers), patients who continued smoking (current smokers) were significantly younger and generally had more favorable baseline clinical characteristics. Despite this, the adjusted hazard ratio (HR) for appropriate ICD therapy for fast ventricular tachycardia (at heart rates ≥180 b.p.m) or ventricular fibrillation was highest among current smokers  (HR = 2.11 [95% CI 1.11–3.99])  and intermediate among past smokers  (HR = 1.57 [95% CI 0.95–2.58])  , as compared with never smokers (P for trend = 0.02). Current smokers also exhibited a higher risk of inappropriate ICD shocks  (HR = 2.93 [95% CI 1.30–6.63])  than past  (HR = 1.91 [95% CI 0.97–3.77])  and never smokers (P for trend = 0.008).
Conclusions: In patients with ischemic left ventricular dysfunction, continued cigarette smoking is associated with a significant increase in the risk of life-threatening ventricular tachyarrhythmias and inappropriate ICD shocks induced by rapid supraventricular arrhythmias. Our findings stress the importance of complete smoking cessation in this high-risk population.     

Perceptions and attitudes of rehabilitation medicine physicians on complementary and alternative medicine in Australia

Background:  The growing demand for complementary and alternative medicine (CAM) is undeniable. We report a first study about the attitudes and behaviour of Australian rehabilitation physicians to CAM.
Methods:  A prospective cross-sectional survey was undertaken to document the prevalence of, knowledge about and referrals to CAM therapies and their perceived effectiveness, by a sample of Australian rehabilitation physicians.
Results:  Thirty-six out of 94 actively practising rehabilitation physicians from the Australasian Faculty of Rehabilitation Medicine, the Royal Australasian College of Physicians, replied to the survey, a response rate of 38%, and 85% reported familiarity with CAM, the most familiar therapies being acupuncture (80%), yoga (74%) and Tai-Chi (72%). CAM referral was reported in 84%, 38% personally used CAM, 94% of patients enquired about CAM therapies, 32% of respondents routinely enquired about CAM use. Age, sex and year of Fellowship were not associated with familiarity, personal use or frequency of patient enquiry about CAM. Those who reported to be very familiar with CAM were more likely to routinely enquire about CAM use ( P  = 0.028) and be more confident in prescribing certain CAM therapies ( P  < 0.05).
Conclusion:  Australian rehabilitation physicians report similar CAM referral rates to Canadian physiatrists and Australian general practitioners. The most commonly prescribed therapies were acupuncture, yoga and Tai-Chi. Almost all patients use CAM therapies, but only a minority of rehabilitation physicians enquires about CAM use on a regular basis. The latter may avoid potentially harmful drug interactions, as well as improve the quality of the physician–patient relationship.     

Diagnostic quality in rural health centres in Burkina Faso

Summary
objective   To study the quality of diagnostic practice in rural Burkina Faso.
method   In 9 health centres of 3 districts, 313 outpatient consultations were observed, and 417 diagnoses by 15 nurses were analysed. Criteria for evaluation of patient history and clinical examination were based on the diagnostic guidelines distributed by the Ministry of Health.
results   In only 20% of the diagnoses the nurses took a sufficient history and in only 40% they conducted a sufficient clinical examination. In 21% patients underwent no clinical examination at all. Only 12% of all diagnoses were based on sufficient history-taking and adequate clinical examinations. The individual elements of clinical examination were performed correctly in 82% of cases. The variation between nurses was immense, but no correlation could be found with regard to their basic training. However, nurses who had received the diagnostic guidelines examined patients more carefully than those who had not. Larger numbers of patients per day are not associated with shorter nurse-patient contact, and neither is sufficiency of patient history associated with duration of the consultation.
conclusion  The low diagnostic quality of the outpatient consultations in the studied area indicates that this issue has been neglected in national public health initiatives. But examination skills are good and diagnostic guidelines may have had a positive effect on the diagnostic quality.     

Under-detection of depressed mood in older inpatients and related over-prescription of depression-associated medications

Background:   Aging is associated with increased prevalence of depression and with increased use of medications. The aims of this study were to determine the rate of recognition of depressive symptoms and the prevalence of depressed mood among aged inpatients, as well as to assess the use of medications known to enhance depression in this population.
Methods:   A cross-sectional study of cognitively intact patients aged 65 and over, in a general medical ward, was undertaken. Depressed mood was identified using the Geriatric Depression Screening Scale. Data on diagnoses, prescribed medications, psychiatry consultations and medication changes were abstracted from medical charts. Two years following the index hospitalization, data on diagnoses during subsequent admissions were abstracted from computerized records.
Results:   The study sample comprised 183 elderly patients. 27.3% of them displayed depressed mood. None were diagnosed as suffering from depression, referred to psychiatric consultation, or prescribed antidepressant medication. All patients but one received depression-enhancing medications. Only in four cases were these medications stopped, without attributing the cessation to awareness of the mood disturbance and the potential association with the stopped medication. During the subsequent two years, a state of depression was recorded in only three additional patients.
Conclusion:   Under-recognition of depressed mood leads to inappropriate management of aged inpatients. Initiation or continuation of depression-associated medications, resulting from under-recognition of depression, may contribute to the prevalence and augment the severity of this disorder.     

An Evaluation of an Adapted U.S. Model of Pharmaceutical Care to Improve Psychoactive Prescribing for Nursing Home Residents in Northern Ireland (Fleetwood Northern Ireland Study)

OBJECTIVES: To test the effect of an adapted U.S. model of pharmaceutical care on prescribing of inappropriate psychoactive (anxiolytic, hypnotic, and antipsychotic) medications and falls in nursing homes for older people in Northern Ireland (NI).
DESIGN: Cluster randomized controlled trial.
SETTING: Nursing homes randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11).
PARTICIPANTS: Residents aged 65 and older who provided informed consent (N=334; 173 intervention, 161 control).
INTERVENTION: Specially trained pharmacists visited intervention homes monthly for 12 months and reviewed residents' clinical and prescribing information, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to improve the prescribing of these drugs. The control homes received usual care.
MEASUREMENTS: The primary end point was the proportion of residents prescribed one or more inappropriate psychoactive medicine according to standardized protocols; falls were evaluated using routinely collected falls data mandated by the regulatory body for nursing homes in NI.
RESULTS: The proportion of residents taking inappropriate psychoactive medications at 12 months in the intervention homes (25/128, 19.5%) was much lower than in the control homes (62/124, 50.0%) (odds ratio=0.26, 95% confidence interval=0.14–0.49) after adjustment for clustering within homes. No differences were observed at 12 months in the falls rate between the intervention and control groups.
CONCLUSION: Marked reductions in inappropriate psychoactive medication prescribing in residents resulted from pharmacist review of targeted medications, but there was no effect on falls.     

Understanding the oldest old in northern Japan: An overview of the functional ability and characteristics of centenarians

Aim:   To increase knowledge of the functional ability of centenarians by examining the situation of Japanese centenarians residing in an urban region in northern Japan.
Methods:   Questionnaires focused on functional ability, demographics, housing and care needs were received from 56 centenarians and 104 control subjects: 56 aged 80–89 and 48 aged 90–99.
Results:   Centenarian physical capabilities, care needs and health history were diversified. Centenarians most commonly resided with family in the community and were likely to utilize informal and insurance care services. Gender differences in functional ability by age groups known as gender cross-over were observed in control subjects but reduced in centenarians. A few who reported physical limitations were not entitled to receive nationally subsidized care services suggesting inaccuracies may have occurred during certification determination.
Conclusion:   Centenarians in northern Japan represent a heterogeneous cohort suggesting multiple paths to the attainment of advanced old age. This is the first study designed to provide a solid knowledge base of actual circumstances experienced by centenarians specifically in northern Japan.     

Polypharmacy management among Australian veterans: improving prescribing through the Australian Department of Veterans' Affairs' prescriber feedback programme

Background:  Older patients are potentially at risk from the effects of polypharmacy (PP) and/or drug–drug interactions.
Aims:  To examine the effects of a targeted patient-specific prescriber feedback programme on patients prescribed more than 19 individual medications over the 3-month study period.
Methods:  The Commonwealth Department of Veterans' Affairs commissioned a review of Repatriation Pharmaceutical Benefit Scheme claims data to identify patients potentially at risk of drug injury through either PP (≥20 unique medications during 3 months) or clinically significant drug interactions (DI). Dispensing information for the patient at risk, relevant clinical guidelines and a personalized covering letter were mailed to the main prescribing general practitioner of the identified veteran patient. The claims data were then re-analysed after the programme.
Results:  There was a significant reduction in the mean number of unique medications prescribed over a 3-month period 1 year after the prescriber feedback (mean change = −2.22; 95% confidence interval −3.54 to −0.90; P  = 0.0013) for patients identified with ongoing PP. There was also a significant reduction in the number of DI pairs (mean change = −0.73; 95% confidence interval −0.77 to −0.69; P  < 0.0001) for the patients identified with an ongoing DI. The number of patients dispensed one or more DI pairs decreased from 836 to 318 after the feedback.
Conclusion:  A targeted prescriber feedback programme can influence general practitioner prescribing at an individual patient level and, therefore, contribute to the quality use of medicines.     

Inappropriate medication prescribing for elderly ambulatory care patients

BACKGROUND: Inappropriate medication use in elderly patients has been linked to a large share of adverse drug reactions and to excess health care utilization. METHODS: Trends in the prevalence of potentially inappropriate drug prescribing at ambulatory care visits by elderly persons from 1995 to 2000 were examined with data from office-based physicians in the National Ambulatory Medical Care Survey and from hospital outpatient departments in the National Hospital Ambulatory Medical Care Survey. Explicit criteria were used to identify potentially inappropriate prescribing. Multivariate regression was used to identify related factors. RESULTS: In 1995 and 2000, at least 1 drug considered inappropriate by the Beers expert panel was prescribed at 7.8% of ambulatory care visits by elderly patients. At least 1 drug classified as never or rarely appropriate by the Zhan expert panel was prescribed at 3.7% and 3.8% of these visits in 1995 and 2000, respectively. Pain relievers and central nervous system drugs were a large share of the problem. The odds of potentially inappropriate prescribing were higher for visits with multiple drugs and double for female visits. The latter was due to more prescribing of potentially inappropriate pain relievers and central nervous system drugs. CONCLUSIONS: Potentially inappropriate prescribing at ambulatory care visits by elderly patients, particularly women, remains a substantial problem. Interventions could target more appropriate drug selection by physicians when prescribing pain relievers, antianxiety agents, sedatives, and antidepressants to elderly patients. Such behavior could eliminate a large portion of inappropriate prescribing for elderly patients and reduce its higher risk for women.