Antiplatelet drug use in a diabetic clinic

BACKGROUND: There are definite indications for antiplatelet therapy in diabetes in the presence of large-vessel disease, but in the absence of large-vessel disease, the evidence is less clear. There is also evidence that antiplatelet therapy is under-prescribed. AIM: To investigate the use of antiplatelet drugs in patients attending a diabetic clinic in a large teaching hospital. DESIGN: Retrospective case-note survey. METHODS: We examined the case-notes of 300 consecutive diabetic patients, to determine whether antiplatelet therapy was being used in appropriate patients, including those with established large-vessel disease, hypertension and nephropathy or microalbuminuria. RESULTS: The patients were of mean +/- SD age 61 +/- 13 years, diabetes duration 10 +/- 8 years, BMI 31.4 +/- 6.7 kg/m(2) and HbA(1c) 8.3 +/- 1.5%; 276 (92%) had type 2 diabetes, and 162 (54%) were male. Antiplatelet drugs were being taken by 157 (52%) who fulfilled the survey standard for treatment; a further 83 (28%) met the survey standard but were not receiving treatment, of whom 48 (16% of the total group) had no valid contraindication. DISCUSSION: A significant minority of diabetic patients are being denied antiplatelet drugs despite good indications.     

Diarrhea and metformin in a diabetic clinic

In a questionnaire-based survey of 285 randomly selected diabetic patients, diarrhea was found to occur in 8%; this was found to be similar to that in 150 nondiabetic control patients attending other medical clinics (8%). When the diabetic patients were divided into separate therapeutic groups, metformin-treated (with or without sulfonylureas) patients had a markedly greater prevalence of diarrhea (20%) than those not on this drug (6%). A majority of patients with metformin-associated diarrhea had soiling of clothes as a problem, while at least two complained of frank loss of control over their anal sphincter. These patients did not have autonomic neuropathy, and in all who stopped this drug, diarrhea settled within 2-5 days. Only 6% of insulin-dependent diabetic individuals (IDD) had diarrhea, one of whom had explosive nocturnal stools with incontinence and features diagnostic of autonomic neuropathy. Metformin is by far the commonest cause of diarrhea and incontinence in our diabetic clinic, where it is used routinely. In contrast, diarrhea due to autonomic neuropathy is rare.     

A guide to taking a patient's history

This article outlines the process of taking a history from a patient, including preparing the environment, communication skills and the importance of order. The rationale for taking a comprehensive history is also explained.     

Contraindicated medication use among patients in a memory disorders clinic

Background: Inappropriate or contraindicated use of medications in elderly patients is common and associated with poor outcomes. An important risk factor for adverse drug events is the increased sensitivity to drug effects on the central nervous system (CNS). There is a high rate of use of CNS-active drugs in patients with cognitive impairment, despite the fact that these medications may worsen cognition and be a possible “reversible” cause of memory loss.Objectives: The goals of this study were to establish the prevalence of these contraindicated medications in a population of elderly patients referred to a memory disorders clinic for evaluation and to determine if those individuals receiving contraindicated medications had specific characteristics. This included determining how many patients were concurrently being prescribed a cholinesterase inhibitor.Methods: The review included new patients consecutively evaluated for cognitive complaints in a memory disorders clinic between June 2003 and August 2004. Each patient underwent a comprehensive evaluation by a multi-disciplinary team during a 3-hour clinic appointment. A thorough history of cognitive deficits and associated symptoms was obtained by the physician, who also performed a comprehensive neurologic examination. All patients underwent neuropsychologic testing with an extensive cognitive battery. In addition, patients' electronic medical records were reviewed to determine a list of prescribed and over-the-counter medications at the time of the initial referral. Contraindicated medications were identified using the updated Beers criteria of medications that should be avoided in older patients with cognitive impairment or that have high CNS adverse effects.Results: A total of 100 patients (91 men, 9 women; mean [SD] age, 75.8 [9.7] years; 73% white) were included in the study. Eighty-six patients were determined at the time of evaluation to have some kind of cognitive impairment. They were mildly impaired, with a mean (SD) Mini-Mental State Examination score of 22.9 (5.1), based on a scale of 0 to 30. Twenty-two patients were taking ≥1 contraindicated medication that could potentially affect their cognition; the most frequently prescribed were benzodiazepines, oxybutynin, amitriptyline, fluoxetine, and diphenhydramine. Twenty-eight of the 100 patients were being treated with a cholinesterase inhibitor at the time of their evaluation; of these, 4 (14%) were also taking ≥1 medication with anticholinergic properties.Conclusions: Despite research evidence and recommendations to avoid these CNS-active medications because of their adverse effects, they continue to be prescribed in elderly patients with cognitive impairments. Further research is needed to determine strategies that will help reduce their administration in this population.     

The determination of plasma glucose in a diabetic clinic

An assessment of the Beckman Glucose Analyzer has been made and an account given of twelve months satisfactory use in a diabetic clinic.     

The role of nurse practitioners in a primary care eye clinic

This paper reports on a study conducted to audit the practice of nurse practitioners in a primary care eye clinic at St Paul's Eye Unit at the Royal Liverpool University Hospital, UK. The clinic deals with ophthalmic accidents and emergencies and routine referral patients from general practitioners. This was a prospective study of the case notes of 250 consecutive patients who attended the clinic without prior appointment. The study was completed in 1 week.     

The Medication Adherence Model: a guide for assessing medication taking

The Medication Adherence Model (MAM) was developed to describe the process of medication adherence and guide health care providers in assessing medication-taking in individuals with hypertension. The MAM was structured with the idea that two types of nonadherence contribute to inconsistent medication taking, the intentional decision to miss medications, and the unintentional interruptions that cause medications not to be taken. The three core concepts identified in the model are: (a) Purposeful Action, (b) Patterned Behavior, and (c) Feedback. Patients' initiating and sustaining medication adherence are dependent on the deliberate decision to take medications based on perceived need, effectiveness, and safety (Purposeful Action). Then they establish medication-taking patterns through access, routines, and remembering (Patterned Behavior). Individuals use information, prompts, or events (Feedback) during the appraisal process to evaluate health treatment that, in return, influences individuals' levels of Purposeful Action and Patterned Behavior (Johnson, 2002; Johnson, Williams, & Marshall, 1999). The MAM depicts the dynamic process of initiating and maintaining medication adherence from the hypertensive patient's perspective. The model describes the key components of existing cognitive and self-regulatory models, and identifies an additional behavioral component. The succinct organization of the MAM may facilitate health care providers' ability to evaluate and individualize interventions for promoting medication taking.     

Attitudes of patients with schizophrenia toward taking medication

The attitude of 50 hospitalized persons with schizophrenia toward taking their medication was examined. Both open-ended and fixed-response estimates of attitude were made. Insight also was measured, and the relationships between insight and attitude and between hallucinations and insight were analyzed. Patients were able to provide information about beliefs and feelings about taking medication and about insight toward illness and treatment. Attitudes varied, and both strongly positive and strongly negative beliefs about taking medication were held simultaneously. Some of the implications for nursing are explained.