Quantification of the alcohol withdrawal syndrome in 487 alcoholic patients

While the alcohol withdrawal syndrome (AWS) is frequently encountered in a number of medical settings, its clinical management is inconsistent. Appropriate management of the AWS can be enhanced by objectively quantifying principal symptoms. The modified or Milwaukee Selective Severity Assessment (MSSA) measures 10 symptoms of the AWS, providing clinicians with a quantitative indication of the syndrome's severity. The MSSA was administered to 487 successively admitted alcoholics entering an inpatient chemical dependency treatment center. The MSSA was used to evaluate the severity, monitor progression, and determine efficacy of treatment of the AWS. The MSSA aided clinicians in deciding which patients required pharmacologic intervention for their AWS. Two groups of patients are described: 435 whose AWS was not judged to be severe enough to require medication, and 52 whose AWS was sufficiently severe to warrant pharmacologic intervention. The MSSA allowed clinicians to accurately identify patients requiring pharmacologic intervention of the AWS: only 10.6% of 487 hospitalized alcoholics required pharmacotherapy. The MSSA is a convenient, effective, and efficient tool for monitoring the AWS.     

How much will it cost? Estimation of resource needs and availability for HIV prevention,treatment and care for people who inject drugs in Asia

As countries in Asia strive to meet their universal access targets, harm-reduction programmes are yet to be scaled up to reach effective levels of coverage. Resource tracking and estimation of resource needs and gaps is critical to inform the financing decisions of major donors of harm-reduction programmes in the region. This study aimed at estimating the financial resource needs and gaps for scaling-up harm reduction in the region, building on previous research conducted by the Independent Commission on AIDS in Asia. The overall resource need for achieving universal access in the target population in 2009 was US $0.5 billion, with NSP and OST accounting for nearly 70% of the overall regional resource need. A significant resource gap, approximately 90%, of the resource need in 2009, was identified for harm reduction in the region, representing less than 2% of the overall global resource need to address AIDS. Additional resources will be required to support the introduction and scaling-up of integrated, comprehensive harm-reduction programmes that provide a full range of services to reduce HIV transmission among people who inject drugs.     

Improving clinician-patient communication of health risks when diagnostic test information is imprecise

Both clinicians and patients experience difficulty with the statistical reasoning required to make inferences about health states on the basis of information derived from diagnostic tests. This problem will grow in importance as we move into the era of personalised medicine where an increasing supply of imprecise diagnostic tests meets an increasing demand to use such tests on the part of intelligent but statistically innumerate clinicians and patients. We describe a user-friendly, interactive, graphical interface for calculating, visualising, and communicating accurate inferences about uncertain health states when diagnostic information (test sensitivity and specificity, and health state prevalence) is imprecise and ambiguous in its application to a specific patient. The software is free, open-source, and runs on all popular PC operating systems (Windows, Mac, Linux).     

Quality of drug information database research for clinical decision support

This commentary identifies studies that have compared commercially available DI databases, and discusses improvements in study methodology that might better guide clinicians in selecting resources for their practice setting. We also provide suggestions for future direction of research in this area with an eye towards clinical decision support systems (CDSS). The body of comparative research of commercially available DI databases is small, and provides little value to the average clinician when making purchasing decisions. Transparency of study methodology would allow readers to choose a database that best fits their practice needs. Future research must consider how DI resources are imbedded within CDSS, such that the alerts generated by the CDSS are consistent with the primary DI workhorse of the practice site. Cohesion between CDSS and DI resources needs to be a consideration in future DI resource comparative research.     

Obtaining and providing health information in the community pharmacy setting

Community pharmacists are a valuable information resource for patients and other healthcare providers. The advent of new information technology, most notably the Internet, coupled with the rapid availability of new healthcare information, has fueled this demand. Pharmacy students must receive training that enables them to meet this need. Community advanced pharmacy practice experiences (APPEs) provide an excellent opportunity for students to develop and master drug information skills in a real-world setting. Preceptors must ensure that students are familiar with drug information resources and can efficiently identify the most useful resource for a given topic. Students must also be trained to assess the quality of resources and use this information to effectively respond to drug or health information inquiries. This article will discuss key aspects of providing drug information in the community pharmacy setting and can serve as a guide and resource for APPE preceptors.     

Review article: pre-neoplastic states of the gastric mucosa--a practical approach for the perplexed clinician

The sequence leading to gastric cancer can be schematically reduced to Helicobacter pylori infection–chronic gastritis–atrophy–intestinal metaplasia–dysplasia–neoplasia. Although clinicians have not yet developed a uniform approach to the treatment of gastritis (when should H. pylori infection be treated?), the entity itself is not the subject of controversy. All other lesions are still the focus of debate. There are no guidelines for the management of patients with intestinal metaplasia; pathologists are still searching for universal diagnostic criteria for atrophic gastritis; dysplasia and early neoplasia have elicited scientific diatribes between Japanese and Western pathologists. Amidst such controversies and in the absence of guidelines to regulate the management of gastric lesions, the responsibility to provide sensible clinical advice is often bestowed upon pathologists. This review discusses whether pathologists have access to sufficient evidence to provide the requested advice, and whether a consensus on the management of gastric ‘pre-neoplastic’ states is within reach. We conclude that, although many sensible and useful definitions, criteria and classifications are being generated, the final decision on how to manage the individual patient with gastric lesions will continue to be based on the communication between pathologist and clinician.     

Pre-neoplastic states of the gastric mucosa–a practical approach for the perplexed clinician

The sequence leading to gastric cancer can be schematically reduced to Helicobacter pylori infection–chronic gastritis–atrophy–intestinal metaplasia–dysplasia–neoplasia. Although clinicians have not yet developed a uniform approach to the treatment of gastritis (when should H. pylori infection be treated?), the entity itself is not the subject of controversy. All other lesions are still the focus of debate. There are no guidelines for the management of patients with intestinal metaplasia; pathologists are still searching for universal diagnostic criteria for atrophic gastritis; dysplasia and early neoplasia have elicited scientific diatribes between Japanese and Western pathologists. Amidst such controversies and in the absence of guidelines to regulate the management of gastric lesions, the responsibility to provide sensible clinical advice is often bestowed upon pathologists.
This review discusses whether pathologists have access to sufficient evidence to provide the requested advice, and whether a consensus on the management of gastric 'pre-neoplastic' states is within reach. We conclude that, although many sensible and useful definitions, criteria and classifications are being generated, the final decision on how to manage the individual patient with gastric lesions will continue to be based on the communication between pathologist and clinician.     

中国多发性骨髓瘤创新药物可及性研究

近年来,我国政府推出多项举措,大力推动患者对创新药物的可及,但患者需求的增长以及医疗资源的有限性,也要求社会能够提供更有"价值"的医药产品和医疗服务。全球范围内创新药物上市给多发性骨髓瘤患者带来了更多的获益,但中国复发、难治多发性骨髓瘤患者的治疗选择有限,亟待创新、有效、安全的药物。本研究通过分析多发性骨髓瘤药物为代表的创新高价值药物在中国的可及性现状,探讨患者创新药物可及性所面临的主要挑战,研究多发性骨髓瘤疾病领域创新药物对患者的价值,提出推动创新药物可及性的建议。     

Towards bio-based plasticizers with reduced toxicity: Synthesis and performance testing of a 3-methylphthalate

As a very durable material, soft polyvinyl chloride (PVC) is used for many applications in the field of consumer products. To enable the desired properties, for example for medical devices, the addition of plasticizers is required. For this purpose, mostly dialkyl phthalates are used being produced on a multi-million tons scale annually. Since some of these are associated with human health effects, there is an increasing demand for the search of alternatives. Besides reduced toxicity while maintaining excellent performance features, an economic access as well as biorenewable starting materials are further criteria, which should be ideally fulfilled by such a new plasticizer generation. Targeting these demands and in contrast to most available substitutes being based on petrochemical feedstock, we developed a synthetic route starting from bio-renewable platform chemicals. In detail, a Diels-Alder reaction of 2-methylfuran and maleic anhydride and subsequent dehydration leads to three phthalate derivatives with different alcohol components bearing a methyl group at the aromatic ring. As a representative substance, di(2-ethylhexyl) 3-methylphthalate was chosen for performance tests, and this new bio-based alternative offers properties similar to known plasticizers in such initial studies.     

The impact of pharmacoeconomics on the practitioner and the patient: a conflict of interests?

It is very easy to polarise the debate between clinicians and economists by asserting that clinicians regard the needs of individual patients as paramount, whereas economists are more interested in the priorities of society as a whole. Economists have criticised clinicians for failing to recognise the scarcity of resources relative to wants and also for being unable to appreciate the diversity of individual preferences. Furthermore, economists will assert that the wants of patients are not the same as their needs. A clinician may use degree of illness as a guide to relative need for treatment, whereas an economist would ask for information about response to treatment, explicitly acknowledging that the most severely ill patient may not derive the greatest benefit from treatment. We believe that the key to this problem lies in the differences in the definition of terms by the 2 sides, and in fact that there is some confusion over the primacy of the individual versus society. Both clinicians and economists are liable to assert that healthcare resources should be distributed equitably. However, clinicians have a somewhat imprecise appreciation of the concept of equity, whereas economists have developed a set of explicit definitions of equity, which clearly show the consequences of shifting the balance of resources to achieve equitable distribution. Inevitably, this leads to diversion of resources from one segment of society to another. At present, any transfer of resources is liable to be viewed as a sacrifice of an individual patient's needs in the interests of society as a whole. This paper shows that clinicians already accept that there is a conflict of interests between the wants of individuals and the needs of society. We believe that progress can only be made by increasingly explicit debate about the merits of different treatments. Economists have developed the theoretical framework; it is up to clinicians to turn theory into practice.     

Status quo of resource allocation of Chinese grass-roots food and drug administrations: from 2011 to 2016

County grass-root food and drug administrations (CGFDA) undertake the front-line supervision of food and drug safety, whose resource allocation is vitalto the regulation efficiency and performance. In this article, we aimed to analyze the status quo of resource allocation of CGFDA from the aspects of regulatory organization, staff, funding and equipment using officialpanel data from 2011 to 2016. The results illustrated that the total amount of regulatory resources of CGFDA was increased annually, reaching a rather large scale. However, many problems still existed in its allocation. Therefore, a series of measures should be taken to optimize the resource allocation of CGFDA, such as improving the network of institutional CGFDA, increasing the recruitmentrequirements on educational level and major, reallocating the structure of resources and guaranteeing the resource demand in less-developed areas.     

Changing oral contraceptives from prescription to over-the-counter status: an opinion statement of the Women's Health Practice and Research Network of the American College of Clinical Pharmacy

Addressing the issue of unintended pregnancy is a national priority. One proposed strategy to reduce unintended pregnancy is to improve access to oral contraceptives by changing them to over-the-counter (OTC) status. Existing data indicate that oral contraceptives meet safety criteria required of OTC products. Available literature demonstrates that women can self-screen for contraindications to oral contraceptives and can do this as well as clinicians, and experience with OTC emergency contraception suggests that OTC oral contraceptives would not increase sexual risk-taking behavior. Women support OTC access to oral contraceptives, but express an interest in accessing pharmacist counseling. On the basis of these data, the Women's Health Practice and Research Network of the American College of Clinical Pharmacy supports changing oral contraceptives to OTC status under two conditions: that they are sold where a pharmacist is on duty and that there are mechanisms in place to cover OTC contraceptives through Medicaid. Future research should address the issues of out-of-pocket costs to individuals, label-comprehension studies, and models for pharmacist reimbursement for time spent counseling on contraception.     

Prediction of neutropenia

Newer treatment strategies for the management of febrile neutropenic patients are being developed. These include: (a) hospital based oral therapy; (b) early discharge after initial stabilization in-hospital, and (c) out-patient therapy. All strategies are likely to be more successful in patients with short-lived neutropenia (< or = 7 days) than in those with more prolonged neutropenia. Although risk-prediction rules and clinical criteria can help clinicians identify 'low-risk' neutropenic patients, the overall ability of clinicians to accurately predict the subsequent duration of neutropenia once a neutropenic patient becomes febrile needs to be improved upon considerably. One attempt to do so is the survey being conducted by the Infection Study Section of the Multinational Association of Supportive Care in Cancer (MASCC). Development of an accurate rule for the prediction of neutropenia will enable more appropriate, risk-based therapy to be administered to febrile neutropenic patients, and will represent a significant advance in the management of such patients.     

Addressing the health technology assessment of biosimilar pharmaceuticals

Abstract

The growing number of biosimilars presents challenges to regulatory and health technology assessment (HTA) systems. This paper illustrates these challenges by focusing on biosimilars used in the oncological setting. In particular, discordances between data required by regulatory and HTA authorities potentially deprive patients of effective treatments and hinder optimal resource allocation. Regulatory and HTA authorities need to harmonize requirements to foster the development and widespread use of biosimilars, which potentially release considerable resources. The authors believe that often-inappropriate methodology creates a very real chance that HTA authorities will reject some biosimilars. This would effectively extend patent protection and, in the absence of competitor pressure from biosimilars, result in prices remaining unnecessarily high. The authors propose that HTA organizations should accept pharmacokinetic and pharmacodynamic equivalence between the brand and the biosimilar as a proxy of biological comparability. HTA organizations should then adopt, in the absence of compelling reasons otherwise, cost-minimization analysis (CMA) as the basis of the cost-effectiveness deliberations. In the absence of adequate studies demonstrating equivalent efficacy, a prerequisite of CMA, HTA organizations should require threshold analysis. Once approved, biosimilar manufacturers and regulators should maintain rigorous pharmacovigilance to exclude immunoreactivity or other rare adverse events. Furthermore, cancer centres and trusts should regularly audit and publish the impact of biosimilars on clinical outcomes and resource use. When appropriate, regulatory and HTA authorities should demand revised cost-effectiveness analyses from biosimilar manufacturers. This approach would hone the accuracy of the cost-effectiveness analyses, protect patients and allow health services rapid access to low cost treatments.     

Value of specialized preanesthetic clinic for cardiac and major vascular surgery patients

In a complicated and specialized population, such as patients undergoing cardiac and major vascular procedures, patients, clinicians, and hospitals may be best served and resources conserved with a specialized preanesthesia clinic. A specialized preanesthesia clinic for cardiac and major vascular procedures has a focused staff usually consisting of practitioners with cardiac and major vascular surgical care experience designed to address the patient evaluation, the information gathering, the necessary consultations, the required testing, and specific needs for the day of cardiac and major vascular surgery. Specialized preanesthesia clinics increase patient satisfaction and may also provide cost containment by decreasing the amount of indiscriminate ordering of expensive preoperative tests and potentially may decrease patient litigation. Resident trainee education can also be enhanced by a specialized preanesthesia clinic for cardiac and major vascular rotations. The ultimate goal of a specialized preanesthesia clinic is to ensure a safe and efficient perioperative cardiac and major vascular surgical experience in complicated patients undergoing complex procedures.     

A review of the use of CAM therapy and the sources of accurate and reliable information

OBJECTIVE: To describe how pharmacists can answer the call by the Institute of Medicine (IOM) of the National Academies to become more involved in evaluating complementary and alternative medicine (CAM) and to suggest resources pharmacists can access to be better prepared to advise their patients about these therapies. SUMMARY: Information published by the IOM in January 2005 clearly indicates that the American public considers CAM therapies increasingly to be .conventional. lifestyle choices rather than .alternative. practices. Some managed care organizations (MCOs) have offered CAM services for at least 8 years, and one of the nation.s largest MCOs created a network of CAM providers in 2003 with a 30% discount on provider fees. Pharmacists report an increase in questions regarding the use of herbal products and dietary supplements. As experts in drug-drug interactions, there is the expectation that pharmacists are a source of information for drug-herb interactions. Yet some surveys show pharmacists are uncomfortable answering questions about these products because, although there is an increase in the integration of CAM and conventional medicine, there are few scientific studies available to guide the clinical decisions that are necessary. The Office of Dietary Supplements (ODS) and the National Center for Complementary and Alternative Medicine (NCCAM) have increased funding of CAM research. There is a particular need for clinicians to become involved in assessing the safety and efficacy of these products. At least one health plan has created, through its pharmacy and therapeutics committee, a scientifically based, pocket-sized CAM guide that clinicians rated as somewhat to very helpful as a counseling aid. CONCLUSION: With the increasing volume of information on CAM aimed at consumers by the press, television, Internet, and other media, it is critical for pharmacists to remain current in their knowledge. Pharmacists should know what the IOM is saying about CAM and develop relationships with the CAM providers in their communities. Pharmacists should know what reliable information resources are available and be able to evaluate the literature to help patients and providers interpret what they read and hear. It is important for pharmacists to have access to and be involved in ongoing evaluation of CAM therapies being used by so many people.     

1280份住院病历抗菌药物不合理应用分析

目的了解住院患者抗菌药物的应用情况,保证住院患者合理应用抗菌药物,以达到最佳疗效,提高安全、有效、经济、合理的用药水平。方法随机抽取2011年第四季度归档病历1280份,对其中不合理应用抗菌药物的病历进行分类统计并分析。结果不合理应用抗菌药物共91份,不合理率为7．11％。结论临床医师在抗菌药物的应用方面存在的问题仍然比较多,临床医师应当进一步学习抗菌药物的知识,努力提高抗菌药物的合理应用水平,医院应加强临床药师的力量,以协助临床医师合理用药。     

A review of alternative approaches to healthcare resource allocation

The resources available for healthcare are limited compared with demand, if not need, and all healthcare systems, regardless of their financing and organisation, employ mechanisms to ration or prioritise finite healthcare resources. This paper reviews alternative approaches that can be used to allocate healthcare resources. It discusses the problems encountered when allocating healthcare resources according to free market principles. It then proceeds to discuss the advantages and disadvantages of alternative resource allocation approaches that can be applied to public health systems. These include: (i) approaches based on the concept of meeting the needs of the population to maximising its capacity to benefit from interventions; (ii) economic approaches that identify the most efficient allocation of resources with the view of maximising health benefits or other measures of social welfare; (iii) approaches that seek to ration healthcare by age; and (iv) approaches that resolve resource allocation disputes through debate and bargaining. At present, there appears to be no consensus about the relative importance of the potentially conflicting principles that can be used to guide resource allocation decisions. It is concluded that whatever shape tomorrow's health service takes, the requirement to make equitable and efficient use of finite healthcare resources will remain.     

The longitudinal stability of the addiction severity index

The Addiction Severity Index (ASI) is a structured interview widely used by substance abuse clinicians and researchers for client screening, determining treatment needs, and assessing treatment outcomes. Previous researchers have evaluated inter-rater agreement, test-retest reliability, and concurrent validity. The present report describes the stability of ASI scores in longitudinal work. In the context of an ongoing treatment outcome evaluation study involving seven assessors, inter-rater agreement, inter-rater reliability, as well as intra- and inter-rater accuracy were assessed repeatedly during a 2-year period. The results show the scores derived from the ASI to be stable across assessors and over time. The relationship between stable scores and resources required for training are discussed.     

Depression following traumatic brain injury: epidemiology, risk factors and management

It is important for clinicians to recognize major depression following traumatic brain injury (TBI) because of its association with poor global and psychosocial outcome, postconcussive symptoms and cognitive deficits. The purpose of this review is to provide an up-to-date selective review of the current understanding of epidemiology, risk factors and management of major depression following TBI. Many studies of prevalence of depression following TBI have not used accepted structured criteria for the diagnoses, but those that did found wide ranges of rates, from 17% to 61%. The risk factors for development of depression following TBI are poorly understood, but past psychiatric history, frontal lesions and atrophy, and family dysfunction have been shown in more than one study to play important roles. There are few controlled trials of the treatment of major depression in patients with TBI using accepted diagnostic criteria for major depression, as well as defined criteria for response and remission. As such, it is important for clinicians to use best practice guidelines for the treatment of major depression in the absence of TBI.