Drug dosage in patients with renal failure optimized by immediate concurrent feedback

OBJECTIVE: To examine the impact of immediate concurrent feedback on dose adjustment in patients with renal failure. DESIGN: Prospective 12-month study in patients with various degrees of renal failure, with comparison to a retrospective control group. SETTING: A 39-bed unit of a university hospital providing primary and tertiary care. PATIENTS: Patients with renal failure (estimated creatinine clearance < or = 50 mL/min) receiving at least 1 pharmacologically active drug. INTERVENTIONS: Education of physicians and immediate concurrent feedback on the ward giving estimated creatinine clearance and dose recommendations for renally eliminated drugs adjusted to individual renal function. MEASUREMENTS AND MAIN RESULTS: The percentage of dosage regimens adjusted to renal function and cost assessment of drug therapy were calculated. Overall, 17% of the patients had at least 1 estimated creatinine clearance < or = 50 mL/min. In the intervention group, the dose of 81% of renally eliminated drugs was adjusted to renal function, compared with 33% in the control group ( P <.001). The mean difference in cost between standard and adjusted dose of renally eliminated drugs in the intervention and control groups was 5.3 +/- 12.3 and 0.75 +/- 2.8 Swiss francs (approximately US$3.5 and US$0.5), respectively ( P <.001), accounting for 16.5% and 2.8%, respectively, of daily medication costs of all drugs. CONCLUSIONS: The proportion of doses of renally eliminated drugs adjusted to renal function can be substantially increased by immediate concurrent feedback. This saves drug costs and has the potential to prevent adverse drug reactions.     

The epidemiology of red cell transfusion

Background and Objectives Understanding of the clinical usage of red cells is limited despite its importance in transfusion practice improvement and planning for blood supply requirements. Previous studies have described red cell use based upon ICD and hospital discharge codes; however, such approaches are open to misclassification. This study addresses this limitation by undertaking an epidemiological analysis of red cell use using case note review. Materials and Methods Patient, disease and contextual factors were extracted from the medical records of a randomly selected sample of hospital patients in Northern Ireland who received a red cell transfusion during 2005 (n = 1474). Results Transfused patients received a total of 3804 units (median of two units per transfusion episode). Most transfusions occurred in a medical setting (71%). Patients undergoing treatment for gastrointestinal conditions were responsible for the majority of the demand (29% of transfusion episodes; 34% of red cell units). The presence of bleeding and abnormal tests of coagulation were associated with receiving larger transfusions (≥ 3 units), while patients undergoing orthopaedic surgery and those with a haemoglobin level over 7 g/dl had the lowest risk of receiving ≥ 3 units in any one transfusion episode. Conclusion The majority of red cells are now prescribed in a medical setting. With an ageing population and increasing therapeutic interventions, the demand for blood is likely to increase despite efforts to reduce usage by eliminating inappropriate transfusions through education and behaviour change. The post‐transfusion target (and therefore the number of units to transfuse) for any given clinical situation as well as guidance on a ‘safe’ transfusion threshold should be considered in future guidelines.     

Oxygen administration and monitoring for ward adult patients in a teaching hospital

Aim: The aims of this study were to describe oxygen administration and respiratory monitoring of ward patients in a tertiary teaching hospital, and to assess differences in characteristics and outcomes between patients who are receiving versus are not receiving oxygen. Methods: Prospective clinical audit of all non‐ventilated adult ward patients in a tertiary teaching hospital in Melbourne, Victoria on 26 August 2009. Results: All 323 eligible patients were audited (medical 218, surgical 105). At assessment, 76 patients (24%) were on oxygen therapy and of these, 57 patients (74%) received oxygen by nasal prongs. Overall, oxygen saturation was documented in 301 (93.2%) patients and respiratory rate (RR) documented in 283 patients (87.6%). Patients receiving oxygen had a lower median SpO₂ (94% vs 96%, P < 0.0001), higher median RR (20/min vs 18/min, P < 0.0005); and were older (68.8 v 63.1 years, P= 0.0094). The in‐hospital mortality of patients receiving oxygen therapy was 15.8% compared with 5.3% for those not on oxygen (P < 0.0056). Conclusion: Oxygen is administered to one‐quarter of ward patients in our hospital. Oxygen saturation and RR are not documented in approximately 10% of patients. Oxygen therapy in ward patients identifies individuals with increased mortality. Continuing educational interventions to increase awareness of the high‐risk status of these patients and strategies to detect patients at risk of hypoxaemia are needed.     

Identification of a high risk subgroup of patients with silent ischaemia after myocardial infarction: a group for early therapeutic revascularisation?

Asymptomatic ("silent") ischaemia has been shown to be of prognostic significance in patients with stable and unstable angina and more recently in patients recovering after myocardial infarction. No therapeutic regimen has yet been shown to improve the prognosis of patients with silent ischaemia after infarction, which can be found in as many as a third of these patients. Attempts to achieve therapeutic revascularisation in all these patients may be undesirable, but early revascularisation could be especially beneficial in some selected high risk patients. Two hundred and fifty consecutive clinically stable survivors of myocardial infarction who had predischarge submaximal exercise tests were followed up for a year. Silent ischaemia was found in 27% of these patients; 15% had symptomatic ischaemia. Patients with a positive exercise test were prescribed a beta blocker before discharge. Mortality in patients with silent (9.4%) and symptomatic (5.4%) ischaemia in the first year after infarction was not significantly different. Patients with symptomatic ischaemia were more likely to have undergone coronary artery bypass grafting in the first year. Patients with silent ischaemia were, however, significantly more likely to die than patients with a negative exercise test (relative odds 12:1). Patients with silent ischaemia and an abnormal blood pressure response or who could not complete a submaximal exercise protocol were at particularly high risk, being 32 times more likely to die than those with a negative test (95% confidence interval from 3.3 to 307 times more likely). First year mortality in this group was 22%. The benefits of therapeutic revascularisation in this high risk group need to be studied.     

Identification of a high risk subgroup of patients with silent ischaemia after myocardial infarction: a group for early therapeutic revascularisation?

Asymptomatic ("silent") ischaemia has been shown to be of prognostic significance in patients with stable and unstable angina and more recently in patients recovering after myocardial infarction. No therapeutic regimen has yet been shown to improve the prognosis of patients with silent ischaemia after infarction, which can be found in as many as a third of these patients. Attempts to achieve therapeutic revascularisation in all these patients may be undesirable, but early revascularisation could be especially beneficial in some selected high risk patients. Two hundred and fifty consecutive clinically stable survivors of myocardial infarction who had predischarge submaximal exercise tests were followed up for a year. Silent ischaemia was found in 27% of these patients; 15% had symptomatic ischaemia. Patients with a positive exercise test were prescribed a beta blocker before discharge. Mortality in patients with silent (9.4%) and symptomatic (5.4%) ischaemia in the first year after infarction was not significantly different. Patients with symptomatic ischaemia were more likely to have undergone coronary artery bypass grafting in the first year. Patients with silent ischaemia were, however, significantly more likely to die than patients with a negative exercise test (relative odds 12:1). Patients with silent ischaemia and an abnormal blood pressure response or who could not complete a submaximal exercise protocol were at particularly high risk, being 32 times more likely to die than those with a negative test (95% confidence interval from 3.3 to 307 times more likely). First year mortality in this group was 22%. The benefits of therapeutic revascularisation in this high risk group need to be studied.     

One drug or two? Step‐down therapy after i.v. antibiotics for community‐acquired pneumonia

Background: The aim of the study was to describe the oral antibiotics prescribed as step‐down therapy for patients hospitalized for community‐acquired pneumonia (CAP). Methods: A comparative audit of patient records in a Sydney teaching hospital, a district referral hospital and a regional hospital was carried out. Patients older than 15 years admitted between 1 July 2004 and 31 December 2004 with a diagnosis of CAP were identified by diagnostic code. The medical records were reviewed for patient demographics, the specialty of the attending physician, comorbidities, adverse drug events, relevant microbiological results and the antibiotic therapy prescribed for the treatment of pneumonia. Cases were randomly selected from all pneumonia admissions, with approximately equal numbers from urban and regional hospitals. One hundred and ninety‐six admissions for CAP (in 193 patients) were included in this review. Patients were predominantly cared for by respiratory physicians (62%) and geriatricians (14%). Eighty‐nine per cent of patients received dual antibiotic therapy on admission. Results: For patients commenced on two antibiotics, 62% were prescribed two oral antibiotics after completing i.v. therapy, 27% were prescribed one oral agent and 11% were prescribed no step‐down therapy. Geographic location and the presence of a documented antibiotic allergy affected prescribing practice. Neither the specialty of the attending medical officer nor the identification of a likely pathogen affected prescribing practice. Conclusion: Although most of the patients with CAP were initially prescribed two antibiotics, there was considerable variability in whether one, two or no oral agents were prescribed as step‐down therapy.     

Nursing home candidates: hospital inpatient trial to identify those appropriately assignable to less intensive care

Primary care physicians are often confronted with demands that elderly patients be institutionalized. Patients who appear to have no new medical problems present a therapeutic dilemma. Should they be admitted to a general hospital or should they be placed directly in a nursing home? This longitudinal prospective study involved 29 consecutive elderly patients judged to be in need of nursing home placement but who were without medical indications for admission. They were assessed and treated in a 30-bed ward of a general hospital. The mean length of stay was 19 days. Of the 29 patients, 8 (24 percent) benefited from the hospitalization; the outcome was placement and retention at a level of care less intensive than that in a nursing home. On admission to this special ward, the presence of 2 of the following 3 characteristics identified the patients who would benefit from this preplacement hospitalization (with 75 percent sensitivity and 86 percent specificity): 1) a score of A or B (Katz Scale) for activities of daily living; 2) a score of 3 or fewer errors on the mental status scale (Pfeiffer); and 3) the presence of family members willing to care for the patient, although unable to do so at the time of admission. These 3 factors constitute a screening tool to differentiate elderly patients who will benefit most under a regimen of intensive rehabilitation from those who will be inevitable recipients of long-term care.     

Anxiety after a heart attack.

An objective measurement of anxiety at defined intervals after the onset of acute cardiac symptoms was made in 203 men admitted to the Coronary Care Unit, Royal Infirmary of Edinburgh, and in 83 patients in a Teesside coronary survey. Of the Teesside patients, 50 were treated at home, 22 were admitted initially to a coronary care unit, and 11 were admitted directly to a general medical ward. In the Edinburgh patients the level of anxiety was high early in the illness, fell rapidly, and rose again towards the end of their stay in hospital. At 4 months it was that of a normal population. After transfer from the coronary care unit the group was not more anxious than other patients in the ward. Reaction to the illness was unrelated to its physical severity. Patients who reacted badly at the beginning were less likely to return to work. The pattern of anxiety in the Teesside patients resembled that of the Edinburgh group, and reaction to illness was largely independent of physical aspects. Treatment in hospital, either through a coronary care unit initially or in a medical ward, did not increase emotional distress. At 3 months patients treated initially in a coronary care unit were less anxious than the others. Throughout the period of study the Teesside patients were more anxious than the Edinburgh patients and outcome was not related to anxiety. Social and environmental differences may account for this.     

European Study on Orthopaedic Status of haemophilia patients with inhibitors

Development of inhibitors against factor VIII (FVIII) or factor IX (FIX) in haemophilia patients is one of the most serious complications of repeated exposure to replacement therapy and has major clinical and economic consequences. To evaluate the relationship between inhibitor status of haemophilia patients and their quality of life (QoL) and degree of arthropathy and to compare the orthopaedic status of patients with/without inhibitors. An observational, cross-sectional, case control study enrolling: group A (n = 38), males aged 14-35 years, with severe congenital haemophilia A or B who had inhibitors against FVIII/FIX >5 years; group B (n = 41), as group A, but aged 36-65 years and group C (n = 49), as group A, but without inhibitors. Socio-demographics: medical history, clinical characteristics and QoL were assessed. In groups A and B, 16% and 27% were hospitalized for orthopaedic procedures vs. 4% in group C. Patient mobility was also severely reduced in groups A and B, with 24% and 22% using wheelchairs vs. 4% in group C, and 50% and 51% needing a walking aid vs. 29% in group C. Significantly more joint pain was reported by patients in group A vs. those in group C; clinical/radiological orthopaedic scores were also worse in group A vs. group C. Significantly more joint abnormality was reported by patients in group A vs. group C. The burden of orthopaedic complications and the impact on QoL are more severe in haemophilia patients who have developed inhibitors than in those without inhibitors.     

The Synovitis,Acne, Pustulosis,Hyperostosis, And Osteitis (SAPHO) syndrome: A two-center study of 23 patients

IntroductionThe Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO) syndrome is a rare autoinflammatory disease. The clinical presentation is heterogeneous, hence the difficulty of making the diagnosis.Aim of the workTo assess clinical, laboratory parameters and radiological features, and to detail the therapeutic options of SAPHO syndrome.Patients and methodsPatients diagnosed with SAPHO syndrome were retrospectively studied from two rheumatology centres in Tunisia. The epidemiological, clinical, radiological, and therapeutic data were collected from patients’ medical records.ResultsTwenty-three patients were enrolled. The mean age was 44.7 ± 16.9 years (14–76 years). Skin involvement was found in a third of patients. Osteoarticular manifestations involved anterior chest wall damage in 56% of cases and axial skeletal lesions in 93% of patients. Ten (43%) patients had peripheral joint involvement, and one reported bone pain in the forearm. HLA-B27 was positive in a third of the patients. All patients were treated with nonsteroidal anti-inflammatory drugs (NSAIDs) with variable clinical responses. Antibiotic therapy with doxycycline was prescribed in 3 cases, with no clinical improvement. Sulfasalazine was used in 4 cases after therapeutic failure of NSAIDs. Methotrexate was prescribed in 4 cases. Tumor necrosis factor (TNF) inhibitors (Etanercept) were provided for 2 with a good clinical response, and were planned for two others. Pamidronate was given to a patient with bone involvement with pain relief and clinical improvement.ConclusionPatients with SAPHO were relatively young. Skin lesions were not common. The involvement of the anterior chest wall and the axial skeleton was predominant.     

Socio-economic disadvantage, quality of medical care and admission for acute severe asthma

Background: In asthma, socio-economic and health care factors may operate by a number of mechanisms to influence asthma morbidity and mortality.
Aim: To determine the quality of medical care including the patient perception of the doctor-patient relationship, and the level of socio-economic disadvantage in patients admitted to hospital with acute severe asthma.
Methods: One hundred and thirty-eight patients (15–50 years) admitted to hospital (general ward or intensive care unit) with acute asthma were prospectively assessed using a number of previously validated instruments.
Results: The initial subjects had severe asthma on admission (pH=7.3±0.2, PaCO2=7.1 ±5.0 kPa, n =90) but short hospital stay (3.7±2.6 days). Although having high morbidity (40% had hospital admission in the last year and 60% had moderate/severe interference with sleep and/or ability to exercise), they had indicators of good ongoing medical care (96% had a regular GP, 80% were prescribed inhaled steroids, 84% had a peak flow meter, GP measured peak flow routinely in 80%, 52% had a written crisis plan and 44% had a supply of steroids at home). However, they were severely economically disadvantaged (53% had experienced financial difficulties in the last year, and for 35% of households the only income was a social security benefit). In the last year 39% had delayed or put off GP visit because of cost. Management of the index attack was compromised by concern about medical costs in 16% and time off work in 20%.
Conclusion: Patients admitted to hospital with acute asthma have evidence of good quality on-going medical care, but are economically disadvantaged. If issues such as financial barriers to health care are not acknowledged and addressed, the health care services for asthmatics will not be effectively utilised and the current reductions in morbidity and mortality may not be maintained.     

Urinary excretion of metformin in diabetic patients with and without tuberculosis

BackgroundPatients with concurrent diabetes mellitus (DM) and tuberculosis (TB) pose an increased risk of treatment failure in TB and management of DM is complicated. Anti-diabetic and anti-TB drugs may interact with on another other when co-administered. The role of anti-TB drugs on the excretion of metformin in urine has not been studied. Therefore, we carried out a study in DM patients with and without TB to compare the percentage of metformin excreted in urine.MethodsA total of 52 DMTB and 17 DM patients were recruited in this study from the Chennai Corporation Centres. DM and DM - TB patients were administered the prescribed anti-TB and anti-diabetic drugs (metformin (MET), glipizide (GLP),glimepiride (GLM),glibenclamide (GLB),rifampicin (RMP),isoniazid (INH), pyrazinamide (PZA) and ethambutol (EMB). DM and DMTB patients received metformin (MET) alone and in combination with sulphonylureas as diabetic drugs. The urine samples were collected from 0 to 8 hours after drug administration. Urine MET excreted in DM and DMTB patients were estimated by high performance liquid chromatography (HPLC) and percent dose was calculated.ResultsThe percent dose of MET excreted in urine in DMTB patients was significantly higher when compared to DM patients. There is significant difference in the percent dose of MET excreted among DM patients with and without sulphonylureas, values being 23.3 and 17.7% respectively (p = 0.044).ConclusionThis is the first study to report on the percent dose of MET excretion in urine in patients with DM and DMTB receiving MET along with anti-TB drugs.     

Clinical and metabolic characteristics of newly diagnosed diabetes patients: experience of a university hospital in Tunis

PURPOSE: The aim of our retrospective study was to explore the clinical and metabolic characteristics of newly diagnosed diabetes patients over the age of 30 years. METHODS: Study participants were consecutive, newly diagnosed patients with diabetes, over the age of 30 years, presenting to our university hospital department between January 1999 and June 2003. Clinical and metabolic data were collected retrospectively by medical record review. RESULTS: Three hundred seventy patients were included; mean age was 54.1+/-14.0 years; 49% were women and a family history of diabetes was reported in 52% of patients. Patients presented with acute complications in 40% of cases. Symptoms of polyuria-polydipsia and weight loss were present at diagnosis in 87% and 76% of cases respectively. 58% of our patients were obese or overweight (BMI> or =25 kg/m(2)), hypertension was present in 22%, hypertriglyceridemia in 27% and high LDL cholesterol in 27%. Neuropathy was diagnosed in 24%, nephropathy in 13%, coronary heart disease in 9%, retinopathy in 8% of cases, stroke in 3% and peripheral arterial disease in 2%. Insulin was prescribed initially in 47% of cases. CONCLUSIONS: Our results demonstrate that clinical symptoms and acute ketosis are the most common presenting features of diabetes mellitus in adults at the hospital level. Associated chronic complications are frequent.     

Added value of pharmacist-acquired drug histories in an orthopaedic ward

In Belgian hospitals, drug histories of patients taken on admission are generally collected by medical trainees, physicians and nurses. As errors in drug histories may lead to medication errors and adverse drug events, we aimed at comparing the data obtained by a clinical pharmacist with those obtained by the nurses in a surgical orthopaedic ward. In this four months study, 50 patients, with a mean age of 66 years, were included. Out of these 50 drug histories, 107 differences were found when comparing the data gathered by the nurses with the data of the pharmacist. On average, there were 2.1 discrepancies per patient. Omission of a drug and incorrect or unknown dose accounted for 80.3% of the discrepancies, while allergy and/or intolerance, incorrect frequency and addition of a drug accounted for respectively 11.2%, 4.8% and 3.7%. Interestingly, six drug categories represented almost 55% of the drug-related discrepancies.These were, in order of importance: anxiolytic and neuroleptics, antacids and proton pump inhibitors (PPI's), painkillers, antidepressants, aspirin and eye drops. Finally, 27% of the discrepancies concerned "over the counter" drugs. From this study we were able to conclude that the clinical pharmacist performed more complete and more accurate drug histories than nurses in the surgical orthopaedic care unit, especially in patients taking multiple drugs. These results suggest that drug histories taken by a pharmacist may lead to a reduction of potential adverse drug events during hospitalisation.