Inappropriate use of proton pump inhibitors in a local setting

INTRODUCTION

There are growing concerns that the use of proton pump inhibitors (PPIs) may be inappropriate in instances that do not conform to evidence-based indications. This point-prevalence study aimed to investigate the frequency, indications and appropriateness of use of PPIs in hospitalised patients on a randomly chosen day.

METHODS

On a randomly chosen day, all inpatients were documented, and those on any form of PPIs on that day were determined. Indications for maintaining these patients on PPIs were obtained from the electronic medical records, which were then recorded and cross-referenced against a list of accepted indications adapted from the US Food and Drug Administration (FDA)-approved list.

RESULTS

In all, 1,025 inpatients were documented. Of the 477 (46.5%) inpatients using PPIs, only 219 (45.9%) fulfilled the FDA-approved indications, while the majority (n = 258, 54.1%) did not. Overall, PPIs were not strictly indicated for use in 206 (43.2%) inpatients, according to FDA criteria. Of the 477 inpatients on PPIs, 52 (10.9%) had borderline indications based on expert consensus/guidelines other than FDA criteria.

CONCLUSION

Although the use of PPIs is prevalent in hospitals, less than half of the hospitalised patients using PPIs in our study had evidence-based indications that supported such use. The overuse of PPIs has a negative impact on healthcare costs and may lead to adverse effects. Steps to curb the inappropriate use of PPIs should address factors such as indications for the initiation of PPIs, and reassessment of the need for ongoing PPI use in inpatients upon discharge and during outpatient reviews.     

Clopidogrel and proton pump inhibitor (PPI) interaction: separate intake and a non-omeprazole PPI the solution?

Background

Dual therapy with aspirin and clopidogrel increases the risk of gastrointestinal bleeding. Therefore, co-therapy with a proton pump inhibitor (PPI) is recommended by most guidelines. However, there are warnings against combining PPIs with clopidogrel because of their interactions with cytochrome P450 isoenzyme 2C19 (CYP2C19).

Methods

The effects of the combined or separate intake of 20 mg of omeprazole and 75 mg of clopidogrel on the clopidogrel-induced inhibition of platelet aggregation were measured in four healthy subjects whose CYP2C19 exon sequences were determined. The effects of co-therapy with 10 mg of rabeprazole were also examined.

Results

Two subjects showed the wild-type CYP2C19 sequence. The concurrent intake of omeprazole had no effect on clopidogrel-induced platelet inhibition in these subjects. Two subjects were heterozygous for the *2 allele, with predicted reduced CYP2C19 activity. One of them was a clopidogrel non-responder. In the second heterozygous subject, omeprazole co-therapy reduced the clopidogrel anti-platelet effect when taken simultaneously or separately. However, the simultaneous intake of rabeprazole did not reduce the clopidogrel effect.

Conclusion

The clopidogrel-PPI interaction does not seem to be a PPI class effect. Rabeprazole did not affect the clopidogrel effect in a subject with a clear omeprazole-clopidogrel interaction. The separate intake of PPI and clopidogrel may not be sufficient to prevent their interaction.

     

Medical complications and outcomes at an onsite rehabilitation unit for older people

Background

The rehabilitation of older patients in Ireland after an acute medical event occurs at dedicated onsite hospital units or at offsite centres. Information on medical complications and outcomes is inadequate.

Aims

Enumeration of medical complications of patients admitted to a dedicated onsite rehabilitation unit for older people, and the extent of co-morbidity in the population with the effects that this had on the evolution of medical complications.

Methods

A retrospective analysis of patients admitted to a 58-bed onsite unit over a 1-year period was performed. Information collating co-morbidities, medical complications and functional outcomes was recorded.

Results

Medical complications occurred in almost 95 % of patients, where full data were available. Over one-third required intravenous therapy.

Conclusion

Twenty-four hour medical cover is required for older patients managed at onsite rehabilitation units. Further studies on offsite medical rehabilitation facilities for older patients are required.     

Undergraduate medical education in substance use in Ireland: a review of the literature and discussion paper

Background

Medical complications of substance use are a considerable cause of morbidity and the role of the physician in the care of such problems has consistently been demonstrated. Appropriate knowledge and skills are necessary to carry out this role.

Aims

To review the literature on training undergraduate medical students in identifying and managing substance misuse and to discuss the implications of this literature for Irish medical education.

Methods

A search of the literature was performed using keywords; “substance-related disorders”, “undergraduate” and “curriculum”. All abstracts were reviewed and the full text of relevant abstracts was studied and references reviewed for further articles.

Results

Despite an increase in prevalence of the problem of drug and alcohol use in Ireland and the UK, this has not been reflected in undergraduate medical curricula. In the UK, minimal time is devoted to formal teaching of medical undergraduates in the area of substance misuse and many doctors do not have the appropriate knowledge, skills, attitudes and confidence to treat patients with such problems. In Ireland, no data has reported formal undergraduate teaching hours in the area of drug and alcohol misuse. Internationally, substance abuse curricula have been developed and implemented in medical schools in the United States and Australia.

Conclusion

While substance misuse is increasing in prevalence, this is not reflected in the composition of medical curricula, especially in Ireland. International best practice whereby undergraduate curricula that adequately address substance misuse and related issues are systematically developed and implemented, is recommended for adoption by Irish medical schools.     

Frequency and risk factors associated with emergency medical readmissions in Galway University Hospitals

Background

Unplanned readmissions of medical hospital patients have been increasing in recent years. We examined the frequency and associates of emergency medical readmissions to Galway University Hospitals (GUH).

Method

Readmissions during the calendar year 2006 were examined using hospital in-patient enquiry data. Associations with clinical and demographic factors were determined using univariate and multivariate analyses.

Results

The medical emergency readmission rate to GUH, after correction for death during the index admission, was 19.5%. Age 65 years or more, male gender, length of stay more than 7 days and primary diagnoses of chronic obstructive pulmonary disease, myocardial infarction, alcohol-related disease and heart failure during the index admission were significantly associated with readmission in univariate and multivariate analyses.

Conclusion

The medical emergency readmission rate in GUH is comparable to other acute hospitals in Ireland and Britain. Further evaluation is needed to estimate the proportion of readmissions that are potentially avoidable.     

Monitoring Clostridium difficile infection in an acute hospital: prevalence or incidence studies?

Background

Surveillance of Clostridium difficile infection (CDI) is an essential component of a CDI preventative programme.

Aims

The aim of this study was to evaluate two methods of CDI surveillance.

Methods

Prevalence of CDI, antibiotic use and associated co-morbidity was assessed weekly on two wards over 6?weeks. In addition, CDI incidence surveillance was performed on all new CDI cases over a 13-week period. Cases were assessed for CDI risk factors, disease severity, response to treatment and outcome at 6?months.

Results

Clostridium difficile infection prevalence was 3.5% (range 2.9?C6.1%) on the medical ward and 1.1% (range 0?C3.5%) on the surgical ward. Patients on the medical ward were older and more likely to be colonised with MRSA; however, recent antibiotic use was more prevalent among surgical patients. Sixty-one new CDI cases were audited. Patients were elderly (mean age 71?years) with significant co-morbidity (median age adjusted Charlson co-morbidity score 5). CDI ribotypes included 027 (29 cases) 078 (5) and 106 (4). Eight patients developed severe CDI, seven due to 027. Antibiotic use was common with 56% receiving three or more antibiotics in the preceding 8?weeks. Twenty-four patients had died at 6?months, five due to CDI.

Conclusion

Clostridium difficile infection prevalence gives a broad overview of CDI and points to areas that require more detailed surveillance and requires little time. However, patient-based CDI incidence surveillance provides a more useful analysis of CDI risk factors, disease and outcome for planning preventative programmes and focusing antibiotic stewardship efforts.     

A national survey of clubs medical personnel,facilities and protocols in Irish Rugby Union

Background

Rugby Union is one of the most popular sports in Ireland. Participation in all sports carries risk, and there is an onus on governing bodies and those involved in sport to minimise this risk using injury prevention and management programmes.

Aims

The aim of this study was to evaluate the current status of medical personnel, facilities and equipment in Rugby Union clubs in Ireland.

Methods

A nationwide cross sectional survey of affiliated clubs in Ireland was undertaken at the beginning of the 2011–2012. Clubs were surveyed on a range of variables including their medical personnel, facilities, equipment, policies and concussion.

Results

47.7 % of those surveyed responded. The majority reported involvement of appropriate medically qualified personnel, having a dedicated medical area/room, a first aid kit and defibrillator, and a demand for first aid courses.

Conclusions

This survey provided key information on the current medical status of clubs in Ireland to the governing body. Many clubs have adequate medical resources in place, however a large number do not have medical professionals working with them or own basic medical equipment. The results of this study have lead to the development and implementation of a rugby specific injury prevention and management programme for medical and non-medical personnel at all levels of the game in Ireland.     

The quality of information on three common ENT procedures on the Internet

Background

The Internet hosts a large number of high-quality medical resources and poses seemingly endless opportunities to inform, teach, and connect professionals and patients alike. However, it is difficult for the lay person to distinguish accurate from inaccurate information.

Aim

This study was undertaken in an attempt to assess the quality of information on otolaryngology available on the Internet.

Methods

Sixty appropriate websites, using search engines Yahoo and Google, were evaluated for completeness and accuracy using three commonly performed ENT operations: tonsillectomy (T), septoplasty (S), and myringoplasty (M).

Results

A total of 60 websites were evaluated (NT?=?20, NM?=?20, NS?=?20). A total of 86.7% targeted lay population and 13.3% targeted the medical professionals. 35% of the sites included all critical information that patients should know prior to undergoing surgery and over 94% of these were found to contain no inaccuracies. Negative bias towards medical profession was detected in 3% of websites.

Conclusions

In the current climate, with informed consent being of profound importance, the Internet represents a useful tool for both patients and surgeons.     

In-situ emergency pediatric surgery in the intensive care unit

Background

The role of surgery in the intensive care unit (ICU) remains unclear. Although previous studies have not shown any increase in morbidity when operating on patients in the ICU for surgical procedures; there remains a reluctance to operate on sick patients in the ICU.

Aim

We did a retrospective study of critically ill children and neonates who underwent in-situ surgery (ISS) to further evaluate its safety and potential. Surgery was aided with the use of operative loupes and high-intensity headlight.

Methods

The medical records of all patients who had undergone surgical procedures in the pediatric ICU over an 11-year period from January 1998 till December 2008 were retrospectively reviewed. We reviewed our experience looking specifically at wound infection rates along with other morbidities in 543 patients.

Results

Our morbidities were comparable with that of operations performed in the operating theater, with low wound infection rates (1 %) for all surgeries undertaken in the pediatric ICU.

Conclusion

ISS avoids the risks of transfer to the operative theater and the potential delays in theater access. Our results suggest that ISS in a tertiary-level pediatric surgical hospital is safe and does not impact adversely on clinical outcome.     

Electronic clinical decision support systems attitudes and barriers to use in the oncology setting

Background

There is little evidence regarding attitudes to clinical decision support systems (CDSS) in oncology.

Aims

We examined the current usage, awareness, and concerns of Irish medical oncologists and oncology pharmacists in this area.

Methods

A questionnaire was sent to 27 medical oncologists and 34 oncology pharmacists, identified through professional interest groups. Respondents ranked concerns regarding their use of a CDSS on a scale from 1 to 4, with 4 being most important.

Results

Overall, 67% (41/61) responded, 48% (13/27) of oncologists and 82% (28/34) of pharmacists surveyed. Concerns included ??difficulty defining complex clinical situations with a set of rules?? (mean?±?SD) (3.2?±?0.9), ??ensuring evidence base is up to date and relevant?? (3.2?±?0.9) and ??lack of clinically relevant suggestions?? (2.9?±?0.9). Ninety-three percent reported using a CDSS but 54% were unaware of this.

Conclusion

While there are benefits to using a CDSS, concerns must be addressed through user education. This may be a starting point for a user-centred design approach to the development of future local systems through a consultative process.     

A series of patients on anti-TNF therapy referred to a multidisciplinary lung cancer service

Background

Biological therapies have significantly improved the quality of life of patients with aggressive collagen vascular diseases. Blocking TNF activity may potentially confer a higher malignant potential for patients.

Aims

To identify patients to whom anti-TNF therapies were recently prescribed and were referred to a multidisciplinary lung cancer service.

Methods

Retrospective review of patients over an 18-month period who were referred to a multidisciplinary lung cancer service.

Results

Three patients who underwent recent anti-TNF therapies and presented with solid organ tumours. All had significant additional risks for cancer including smoking and family history and active connective tissue diseases with a past history of immunosuppressive therapies.

Conclusions

Our series highlights the potential malignant risk of anti-TNF theraphy to a general medical audience     

Autologous stem cell transplantation in myeloma: the St James’s Hospital experience, 1997–2003

Background

High-dose treatment with autologous stem cell transplantation (ASCT) has become the standard of care for patients with myeloma below the age of 65 years.

Aims

We report an audit of 60 patients (median age: 52.5 years) who underwent ASCT in the National Bone Marrow Transplant centre in St James’s Hospital in Dublin between 1997 and 2003 inclusive.

Methods

Clinical and laboratory data were retrieved from patient medical records and hospital information management systems.

Results

Thirty-six patients had IgG, 11 IgA, 1 IgD, 9 light chain and 3 non-secretory MM. Fifty-seven (95%) patients received anthracycline-corticosteroid combination chemotherapy prior to autografting. There was no transplant-related mortality (TRM). Complete (CR) and Partial Responses (PR) were seen in 16 (29.6%) and 29 (53.7%) of those evaluable (n = 54 (90%)). The actuarial Progression-Free (PFS) and Overall Survival (OS) rates at five years are 13% and 55% respectively.

Conclusion

Centre outcome is comparable to published international series and supports the use of ASCT in the treatment of this malignancy.     

A five-year review of publication productivity among Irish orthopaedic units

Background

The academic productivity of trainees, consultants and institutions is frequently judged by the quantity of articles published in peer-reviewed medical journals.

Aim

To assess the publication history of Irish orthopaedic units over a 5-year period, and to identify patterns of publication.

Methods

A PubMed search was performed of each consultant affiliated with each orthopaedic unit in the country for between 2004 and 2008. Publications were classified by individual, institution, publication type and impact factor.

Results

Over the 5 years of the study, 239 papers were published from 19 orthopaedic units, in 69 different journals. Fifty-six consultants had at least one senior author publication, with seven consultants having more than ten. Impact factors of the journals targeted varied considerably and reveals an interesting duality among authors when opting for profile or prestige.

Conclusion

We feel this study represents a comprehensive and novel review of the state of publishing in a surgical specialty.     

Not written, not done: are we identifying elderly at-risk patients for pneumococcal vaccination?

Background

Pneumococcal disease, especially in its invasive form, is a significant cause of morbidity and mortality worldwide. However, with the advent of vaccination, invasive disease is potentially avoidable. This study aimed to assess the documentation of pneumococcal vaccination status in elderly patients by healthcare professionals in a busy teaching hospital environment.

Methods

One hundred and fifty-seven open (active) medical records of inpatients and outpatients aged over 65 years were reviewed, to examine for evidence of documentation of pneumococcal vaccination status.

Results

From the medical records, 338 patient encounters were studied. Overall, there was a mean of 2.4 ± 1.2 indications for pneumococcal vaccination, with more indications in medical than in surgical patients (P = 0.04). The rate of recording in respiratory outpatient clinics was 71.4 % in comparison to 0 % in other medical and surgical outpatient clinics. Overall the documentation rate was 2.1 %.

Conclusions

Only respiratory physicians had demonstrable evidence of actively asking about pneumococcal vaccination on a regular basis. There is considerable need for increased awareness among healthcare professionals and improvement in methods of recording vaccination status.     

Postgraduate training in Ireland: expectations and experience

Background

Postgraduate medical training in Ireland has been compared unfavourably with training abroad and blamed for an “exodus” of graduates of Irish medical schools. Exploration of features of a good training environment and development of tools to measure it have been the focus of much published research. There have been no Irish studies examining training environment using such validated tools.

Aim

The aim of this study was to use a validated tool, to examine the expectations and experience of training, amongst those training under the Royal College of Physicians of Ireland (RCPI).

Method

The Dutch Residency Education Climate Test (D-RECT) is a 50 item tool to measure postgraduate learning environments. D-RECT was sent to all new entrants to RCPI training programmes in July 2012 (n = 527) and completed in regard to expectations of training (response rate 80.6 %). In March 2013, D-RECT was sent to all RCPI trainees (n = 1,246) to complete in relation to the post held on 1 March (response rate 32.6 %). Data were analysed in SPSS version 18.

Results

Experience fell short of expectations for basic specialist training, however, scores for experience rose with greater seniority to match expectations. Positive aspects were teamwork, consultant willingness to discuss patients and respectful treatment of trainees. Areas of weakness were provision of feedback and time to learn new skills.

Conclusion

Measurement of learning environment at a national level using a quantitative tool provides useful information for quality assurance and improvement of training.     

Elective surgery: a comparison of in-patient versus day surgery practices in Ireland

Background

Currently, there is a paucity of research which has assessed practices at the point of care for day surgery patient.

Aim

To outline the patient journey from first referral for surgery and identify structures and processes which facilitate or constrain the provision of day surgery.

Method

A retrospective medical charts review of 200 consecutively presenting patients undergoing elective surgery in two Irish teaching hospitals. Data collection was completed from January 2009 to March 2009. This analysis spanned from first referral to the hospital until discharge and follow up.

Results

Great variability was noted in practices between the two hospitals. While some of the differences in practice become barriers to increased rates of day surgery, others did not have an impact.

Conclusion

This study echoes findings of other similar studies in that management of patients undergoing elective surgery which varies significantly across Irish hospitals.     

Modelling the impact of old and new mechanisms of entry and selection to medical school in Ireland: who gets in?

Background

Several changes to entry and selection to medical school in Ireland were introduced in 2009 including the addition of a specialised admission test the Health Professionals Admissions Test (HPAT-Ireland).

Aims

We wished to determine the impact of each aspect of the reforms by modelling outcomes if old and new mechanism had prevailed, the extent to which applicants and entrants repeated the leaving certificate, and leaving certificate and HPAT-Ireland scores of successful candidates.

Methods

The leaving certificate and HPAT scores of all medical school applicants and entrants in 2009 and 2010 were analysed.

Results

Data were available for 2,913 applicants in 2009 and 3,292 applicants in 2010. In 2009, over 33 % of students admitted to medicine would not have been admitted if the decision was based solely on their leaving certificate. The corresponding figure for 2010 was 44 %. In 2009, if entry had been based on the combined HPAT-Ireland and an un-moderated leaving certificate score, this would have affected the outcomes in 5 % of applicants or 25 % of those who secured a medical school place. The corresponding figures for 2010 are 6 and 24 %, respectively. Since 2009 applicants and entrants are far less likely to repeat the leaving certificate examination. HPAT-Ireland entry scores appear relatively stable while leaving certificate scores have varied in an upward direction.

Conclusions

All of the reforms to medical school admission have contributed significantly in determining outcomes. The addition of the HPAT-Ireland adjunct admission test equates with the impact of moderation of leaving certificate points.     

Anti-social behaviour in a large Irish teaching hospital

Background

Anti-social behaviour affects staff physically and psychologically and has financial implications. More information on its occurrence is required for effective risk management.

Aims

We undertook to audit the complete dataset on anti-social behaviour in an urban Irish hospital.

Methods

Data, collected from computerised incident reports between January 2005 and December 2008, were analysed with respect to date, location, incident type, person affected, type and severity of injury.

Results

There were 3,727 incidents over 4?years, with numbers rising annually at the approximate rate of 20%. Most involved nursing staff. Incidents occurred primarily on medical and surgical wards and were usually classified as minor. Physical or verbal assaults were most frequently reported.

Conclusion

Anti-social behaviour appears to be increasing. Certain wards and categories of healthcare professionals are at particular risk. More research is required to explain factors leading to such behaviour and optimum strategies for its active management.     

Managing chronic disease in Ireland: hospital admission rates and clinical outcomes in a large ulcerative colitis population

Background

Health care planning demands a detailed knowledge of the course of chronic diseases in the Irish population. This study describes hospital admission rates, medication use and outcomes in a large cohort of patients with ulcerative colitis attending a tertiary referral centre in Ireland.

Method

Four hundred and twenty-four patients who attended during the 18-year period from January 1991 to January 2009 were identified. Baseline demographics, hospital admission, medications required, extent of colitis and date of colectomy were recorded.

Results

More than half (55.4%) of the patients were managed exclusively in an outpatient setting throughout diagnosis and follow-up. Systemic corticosteroids, thiopurines and infliximab were required by 70, 29.5 and 5% of the patients, respectively. Overall 5-year colectomy rate due to failure of medical therapy was 15.8%. Independent predictors of colectomy were hospital admission at first presentation (odds ratio 3.6, p?p?Conclusions The majority of patients with colitis have an uncomplicated disease course and do not require thiopurines, biologic agents or hospital admission. Principal management at a primary care level may be appropriate in many cases. Colectomy rates at a specialist centre in Ireland compare favourably with international figures.