A retrospective study of drug‐related problems in Australian aged care homes: medication reviews involving pharmacists and general practitioners

Background Drug‐related problems (DRPs) in Australian aged care homes have been studied previously. However, little is known about the acceptance and implementation of pharmacists' recommendations by general practitioners (GPs) to resolve DRPs. Objectives The primary objective of this study was to investigate the number and nature of DRPs identified by accredited clinical pharmacists. The secondary objective was to study the GP acceptance and implementation of pharmacist recommendations to resolve DRPs. Methods This was a retrospective study of 500 randomly selected, de‐identified medication reviews performed by 10 accredited clinical pharmacists over 6 months across 62 aged care homes. The DRPs identified by pharmacists were subsequently classified by the drugs involved, types of problem (indication, effectiveness and safety) and medical diagnoses of the patient. GP written feedback on the medication review reports determined implementation of pharmacists' recommendations to resolve the DRPs. Results A total of 1433 DRPs were identified in 480 of the 500 residents. Potential DRPs were frequently classified as risk of adverse drug reactions, need for additional monitoring and inappropriate choice of a drug. Alimentary, cardiovascular, central nervous system and respiratory drugs were most frequently implicated, accounting for more than 75% of the DRPs. GPs' acceptance and implementation of pharmacists recommendations were 72.5% (95% CI; 70.2, 74.8) and 58.1% (95% CI; 55.5, 60.6), respectively. Conclusions Over 96% of the residents had potential DRPs identified by pharmacists. GP acceptance of pharmacists' recommendations was independent of the drug category, but not independent of the disease category.     

Factors leading to self-extubation of endotracheal tubes in the intensive care unit

Aim and objective:  To discuss the factors leading to self-extubation of endotracheal tubes (ETTs) and explore the differences between the groups of patients who did and did not self-remove their ETTs.
Background:  Self-extubation of ETTs has been reported to occur in 4·2% of severely ill patients and is associated with adverse medical effects.
Design:  A case-control study.
Methods:  One hundred and thirty-nine subjects were recruited from a teaching hospital in southern Taiwan based on purposive sampling. The rate of self-extubation of ETTs was 6·4%. Analysis of the two groups demonstrated that significant variables were identified and fell into three categories: (1) the department to which the patient was admitted ( p  < 0·001), (2) whether the patient met the criteria for extubation ( p  < 0·001) and (3) the patient age ( p  < 0·05). Based on multiple logistic regression analysis, whether the patient met the criteria for extubation was a main variable that was associated with self-extubation of the ETT. Among the 44 patients who had self-extubation of their ETT, 28 met the criteria to be extubated, 70% and 81·8% of whom were not sedated, and self-extubation of their ETT was conscious of the act. Of the patients who attempted to self-remove their ETT, 80% were successful and 93·2% did not incur any adverse medical effects.
Conclusion:  The medical doctor and nurse should fully evaluate a patient's oxygenation status, decrease the length of the extubation training session for patients and extubate patients promptly when extubation criteria are met.
Relevance to clinical practice:  Adopting a proactive approach to patient extubation will improve the overall quality of care.     

A multi-intervention approach on drug therapy can lead to a more appropriate drug use in the elderly. LIMM-Landskrona Integrated Medicines Management

Rationale, aims and objectives  To evaluate if an integrated medicines management can lead to a more appropriate drug use in elderly inpatients.
Method  The study was an intervention study at a department of internal medicine in southern Sweden. During the intervention period pharmacists took part in the daily work at the wards. Systematic interventions aiming to identify, solve and prevent drug-related problems (DRPs) were performed during the patient's hospital stay by multidisciplinary teams consisting of physicians, nurses and pharmacists. DRPs identified by the pharmacist were put forward to the care team and discussed. Medication Appropriateness Index (MAI) was used to evaluate the appropriateness in the patients' drug treatment at admission, discharge and 2 weeks after discharge. In total 43 patients were included, 28 patients in the intervention group and 25 patients in the group which was used as control.
Results  For the intervention group there was a significant decrease in the number of inappropriate drugs compared with the control group ( P  = 0.049). Indication, duration and expenses were the MAI-dimensions with most inappropriate ratings, and the drugs with most inappropriate ratings were anxiolytics, hypnotics and sedatives.
Conclusion  This kind of systematic approach on drug therapy can result in a more appropriate drug use in the elderly.     

Providers Do Not Verify Patient Identity during Computer Order Entry

Introduction:  Improving patient identification (ID), by using two identifiers, is a Joint Commission safety goal. Appropriate identifiers include name, date of birth (DOB), or medical record number (MRN).
Objectives:  The objectives were to determine the frequency of verifying patient ID during computerized provider order entry (CPOE).
Methods:  This was a prospective study using simulated scenarios with an eye-tracking device. Medical providers were asked to review 10 charts (scenarios), select the patient from a computer alphabetical list, and order tests. Two scenarios had embedded ID errors compared to the computer (incorrect DOB or misspelled last name), and a third had a potential error (second patient on alphabetical list with same last name). Providers were not aware the focus was patient ID. Verifying patient ID was defined as looking at name and either DOB or MRN on the computer.
Results:  Twenty-five of 25 providers (100%; 95% confidence interval [CI] = 86% to 100%) selected the correct patient when there was a second patient with the same last name. Two of 25 (8%; 95% CI = 1% to 26%) noted the DOB error; the remaining 23 ordered tests on an incorrect patient. One of 25 (4%, 95% CI = 0% to 20%) noted the last name error; 12 ordered tests on an incorrect patient. No participant (0%, 0/107; 95% CI = 0% to 3%) verified patient ID by looking at MRN prior to selecting a patient from the alphabetical list. Twenty-three percent (45/200; 95% CI = 17% to 29%) verified patient ID prior to ordering tests.
Conclusions:  Medical providers often miss ID errors and infrequently verify patient ID with two identifiers during CPOE.     

Standardized antibacterial honey (Medihoney™) with standard therapy in wound care: randomized clinical trial

Title.  Standardized antibacterial honey (Medihoney™) with standard therapy in wound care: randomized clinical trial.
Aim.  This paper is a report of a study to compare a medical grade honey with conventional treatments on the healing rates of wounds healing by secondary intention.
Background.  There is an increasing body of evidence to support the use of honey to treat wounds, but there is a lack of robust randomized trials on which clinicians can base their clinical judgement.
Method.  A sample of 105 patients were involved in a single centre, open-label randomized controlled trial in which patients received either a conventional wound dressing or honey. Data were collected between September 2004 and May 2007.
Results.  The median time to healing in the honey group was 100 days compared with 140 days in the control group. The healing rate at 12 weeks was equal to 46·2% in the honey group compared with 34·0% in the conventional group, and the difference in the healing rates (95% confidence interval, CI) at 12 weeks between the two groups was 12·2% (−13·6%, 37·9%). The unadjusted hazard ratio (95% CI) from a Cox regression was equal to 1·30 (0·77, 2·19), P  = 0·321. When the treatment effect was adjusted for confounding factors (sex, wound type, age and wound area at start of treatment), the hazard ratio increased to 1·51 but was again not statistically significant.
Conclusion.  Wound area at start of treatment and sex are both highly statistically significant predictors of time to healing. These results support the proposition that there are clinical benefits from using honey in wound care, but further research is needed.     

Clinical relevance of measuring colonic permeability

Background  Gastroduodenal and small intestinal permeability are increased in patients with Crohn's disease (CD) and intensive care patients. The relevance of colonic permeability has not yet been adequately investigated. The aim of this study was to investigate the clinical value of sucralose excretion as indicator for colonic permeability in these patient groups.
Design  After oral administration of four sugars and subsequent analysis of urinary excretion, gastroduodenal and intestinal permeability were calculated from saccharose excretion and lactulose/mannitol (L/M) ratio over 5 h, and sucralose excretion from 5 to 26 h in 100 healthy controls, 29 CD and 35 patients after coronary surgery (CABG).
Results  In controls, sucralose excretion was highly variable (0·67 ± 0·92%) and not related to small intestinal permeability. In CD and CABG, L/M ratio was increased (0·054 ± 0·060; 0·323 ± 0·253 vs. 0·018 ± 0·001 in controls). Sucralose excretion was increased in 77% of CABG but only in 7% of CD. There was an association between gastroduodenal and intestinal permeability in CD and CABG ( r  = 0·72, and r  = 0·51), but sucralose excretion was not related to either one of these two parameters. Other than a weak association between sucralose and length of stay in intensive care in CABG patients ( P  = 0·099), sucralose excretion was not related to clinical outcome.
Conclusions  The proposed cut-off for normal sucralose excretion is 2·11%, but its high variability and lack of association to gastrointestinal permeability or clinical outcome leave it open, if it can provide information beyond established permeability tests.     

Characterizing violence in health care in British Columbia

Title.  Characterizing violence in health care in British Columbia.
Background.  The high rate of violence in the healthcare sector supports the need for greater surveillance efforts.
Aim.  The purpose of this study was to use a province-wide workplace incident reporting system to calculate rates and identify risk factors for violence in the British Columbia healthcare industry by occupational groups, including nursing.
Methods.  Data were extracted for a 1-year period (2004–2005) from the Workplace Health Indicator Tracking and Evaluation database for all employee reports of violence incidents for four of the six British Columbia health authorities. Risk factors for violence were identified through comparisons of incident rates (number of incidents/100,000 worked hours) by work characteristics, including nursing occupations and work units, and by regression models adjusted for demographic factors.
Results.  Across health authorities, three groups at particularly high risk for violence were identified: very small healthcare facilities [rate ratios (RR) = 6·58, 95% CI =3·49, 12·41], the care aide occupation (RR = 10·05, 95% CI = 6·72, 15·05), and paediatric departments in acute care hospitals (RR = 2·22, 95% CI = 1·05, 4·67).
Conclusions.  The three high-risk groups warrant targeted prevention or intervention efforts be implemented. The identification of high-risk groups supports the importance of a province-wide surveillance system for public health planning.     

Outcome after device implantation in chronic heart failure is dependent on concomitant medical treatment

Background  Device implantation in chronic heart failure (CHF) for cardiac resynchronization therapy (CRT) with or without implantable cardioverter/defibrillator (ICD) is an established treatment option for symptomatic patients under medical baseline therapy. Although recommended, the need for optimization of medical therapy was never proven. As in 'the real world', medical therapy is not always up-titrated to the desirable dosages; this provides the opportunity to evaluate the impact of optimizing medical therapy in patients who had received a device therapy with proven effectiveness.
Materials and methods  This observational cohort study retrospectively assessed the 'real life'-effect of CRT compared with that of CRT/ICD therapy and the impact of concomitant pharmacotherapy on outcome. Outcome of patients with guideline recommended renin–angiotensin system inhibitor and ß-blocker dosages was compared with that of patients who failed to reach the desired dosages. Mean follow-up for the 205 CHF (95 CRT and 110 CRT/ICD) patients was 16·8 ± 12·4 months.
Results  In the total study cohort, 83 (41%) reached the combined primary endpoint of all-cause death or cardiac hospitalization [CRT group: 25 (26%), CRT/ICD group: 58 (52·7%), P  < 0·001]. Multiple cox regression analysis revealed non-optimized medical therapy at follow-up [HR = 2·080 (1·166–3·710), P  = 0·013] and CRT/ICD vs. CRT [HR = 2·504 (1·550–4·045), P  < 0·001] as significant predictors of the primary endpoint.
Conclusion  Our data stress the importance of professional monitoring and titration of pharmacotherapy not only in medically treated CHF patients but also in patients under device therapy by a heart failure unit or a specialized cardiologist.     

Interleukin-18 levels are associated with low-density lipoproteins size

Introduction  Both low-density lipoproteins (LDL) size and serum interleukin (IL)-18 levels have been shown to be predictors of cardiovascular morbidity and mortality. However, it is still unknown whether IL-18 levels are independently associated with LDL size.
Methods  In this cross-sectional study including 53 premenopausal women (18–45 years), LDL size (by gradient gel electrophoresis), serum IL-18, high-sensitivity C-reactive protein (hs-CRP), serum lipids, insulin sensitivity (S_I, by frequently sampled intravenous glucose tolerance test) were measured.
Results  LDL size correlated with IL-18 ( r  = −0·38, P  = 0·006), hs-CRP ( r  = −0·40, P  = 0·003), S_I ( r  = 0·36, P  = 0·011), serum triglycerides ( r  = −0·32, P  = 0·018) and high-density lipoproteins (HDL)-cholesterol ( r  = 0·40, P  = 0·003). When these variables were entered into a regression model, serum IL-18 (β = −0·26, P  = 0·04), triglycerides (β = −0·29, P  = 0·02) and HDL-cholesterol (β = 0·34, P  = 0·01) levels were independently associated with LDL size, accounting for 42% of the variance ( P  < 0·001). Serum hs-CRP levels and S_I were not significant independent predictors of LDL size in this model.
Conclusions  This is the first report showing that elevated IL-18 levels are associated with reduced LDL size, independent of other inflammatory and metabolic risk factors. Future prospective studies are needed to evaluate the predictive role of IL-18 as an inflammatory marker of LDL size and the development of subclinical and/or clinical atherosclerosis.     

Appropriate prescribing in the elderly: an investigation of two screening tools, Beers criteria considering diagnosis and independent of diagnosis and improved prescribing in the elderly tool to identify inappropriate use of medicines in the elderly in primary care in Ireland

Background:  Elderly patients are particularly vulnerable to inappropriate prescribing, with increased risk of adverse drug reactions and consequently higher rates of morbidity and mortality. A large proportion of inappropriate prescribing is preventable by adherence to prescribing guidelines, suitable monitoring and regular medication review. As a result, screening tools have been developed to help clinicians improve their prescribing.
Objectives:  To compare identification rates of inappropriate prescribing in elderly patients in primary care using two validated screening tools: Beers' criteria and improved prescribing in the elderly tool (IPET); to calculate the net ingredient cost (NIC) per month (€) of the potentially inappropriate medicines in this population of patients.
Method:  A consecutive cohort of 500 patients 65 years of age and over were recruited prospectively from primary care over a 6 month period in a provincial town in Ireland. Patients' medical records (electronic and paper) were screened and all relevant information concerning current illnesses and medications was recorded on a standardized data collection form to which Beers' criteria [considering diagnosis (CD) and independent of diagnosis (ID)] and IPET tools were applied. The NIC was calculated from an edition of the Irish monthly index of medical specialities published concurrently with the data collection.
Results:  Beers' criteria identified a total of 69 medicines that were prescribed inappropriately (eight CD and 61 ID) in 65 patients (13%), costing €824·88 per month while IPET identified 63 potentially inappropriate medicines in 52 (10·4%) patients costing €381·28 per month.
Conclusions:  Potentially inappropriate medications are prescribed in a significant proportion of elderly people in primary care, with significant economic implications.     

Thiopurine S-methyltransferase (TPMT) genetic polymorphisms in Mexican newborns

Background:  Thiopurine S -methyltransferase (TPMT) is involved in the toxicity and therapeutic efficacy of thiopurine drugs, and its gene exhibits genetic polymorphisms that differ across diverse populations. Four TPMT polymorphisms ( TPMT *2, *3A, *3B and *3C) account for 80–95% of alleles that cause reduced enzyme activity. To date, only a single study in the Mexican population involving 108 individuals has been performed, but the regional and ethnic origin of this population was not described. Accordingly, information about the TPMT polymorphism in the Mexican population is limited.
Objective:  To determine the TPMT allele and genotype frequencies in a sample of newborns from Mexico City.
Methods:  Three hundred and sixty DNA samples from unrelated, anonymous individuals were obtained from dried blood spots collected on filter paper as part of the Newborn Screening National Program. Allele-specific polymerase chain reaction for the TPMT *2 allele and PCR restriction fragment length polymorphism for TPMT *3A, TPMT *3B, TPMT *3C alleles were used to determine the respective allelic and genotypic frequencies.
Results and Discussion:  Of 720 TPMT alleles analysed, 49 (6·81%) were deficiency alleles. The most common deficiency allele was TPMT *3A (5·69%), followed by TPMT *3C (0·56%), TPMT *3B (0·28%) and TPMT *2 (0·28%). Fourty-five newborns were heterozygous for one mutant allele (12·5%) and two showed a genotype with two deficiency alleles (0·56%). Despite its unique ethnic composition, our Mexican population exhibited variant allele frequencies that were similar to some Caucasian populations.
Conclusion:  Our data suggest that approximately 1 in 180 persons born in Mexico City might have low or undetectable TPMT enzyme activity, a frequency that, overall, is somewhat higher than that reported for Caucasian populations generally (1 in 300).     

Hypersensitivity reactions to penicillins: studies in a group of patients with negative benzylpenicillin G skin test

Background:  Although skin tests are usually employed to evaluate current penicillin allergy status, a negative result does not exclude hypersensitivity. There is a need for accurate in vitro tests to exclude hypersensitivity. A radioallergosorbent test (RAST) is a potentially good supplementary approach, but there is little information on the suitability of this method to diagnose penicillin hypersensitivity in subjects with a negative skin test to benzylpenicillin.
Methods:  A total of 133 patients with a negative skin test to benzylpenicillin G (PG) and all of whom developed allergic reactions to PG were studied. RAST was used to detect eight kinds of specific IgE antibodies to penicillins in serum, which included four kinds of major and minor antigenic determinants to four penicillin drugs. The combination sites for the specific IgE antibodies were studied by RAST inhibition test.
Results:  The rate of positive reactions for the specific IgE antibodies was 59·40% (79/133). Of the eight kinds of antigenic determinants, the positive rates for specific IgE against the major and minor determinants were 39·10% (52) and 42·86% (57) respectively. Of the four drugs, positive cases only to PG were 10 (7·5%), were significantly fewer than the cross-reacting positive cases (36) to PG ( P  <   0·01). In the RAST inhibition studies all drugs exhibited good inhibitory potencies, and in some instances the side-chain of the penicillins could induce specific responses with a variable degree of cross-reactivity among the different penicillins.
Conclusion:  Radioallergosorbent test is a good complementary test in persons who are skin-test negative with PG, and the sensitivity of RAST increaes with increasing specificity of IgE antibodies to be detected. 6-APA and the groups, making part of the different side-chains on penicillins, all contributed to the cross-reactivity.     

Reflecting peer-support groups in the prevention of stress and burnout: randomized controlled trial

Title.  Reflecting peer-support groups in the prevention of stress and burnout: randomized controlled trial.
Aim.  This paper is a report of a study to test the effect of participating in a reflecting peer-support group on self-reported health, burnout and on perceived changes in work conditions.
Background.  Stress-related conditions are one of the most common causes for long-term sick-leave. There is limited evidence for the effectiveness of person-directed interventions aimed at reducing stress levels in healthcare workers. Prior research in the relationship between support and burnout show somewhat inconsistent results.
Method.  A randomized controlled trial with peer-support groups as the intervention was conducted with 660 healthcare workers scoring above the 75th percentile on the exhaustion dimension of the Oldenburg Burnout Inventory. One hundred and fifty-one (22·9%) agreed to participate. The intervention started in 2002 with 51 participants (96·1% were women), 80 of whom constituted the control group. Potential differences in outcome measures 12 months after the intervention were compared using ancova , and data collected was completed in 2004. Qualitative content analyses were used to analyse reported experiences from group participation.
Results.  Statistically significant intervention effects were found for general health, perceived quantitative demands at work, participation and development opportunities at work and in support at work. Seven categories of experiences from participating were identified: talking to others in a similar situation, knowledge, sense of belonging, self-confidence, structure, relief of symptoms and behavioural change.
Conclusion.  Peer-support groups using a problem-based method could be a useful and comparatively inexpensive tool in alleviating work-related stress and burnout.