Patterns and changes in prescriber attitudes toward PDA prescription-assistive technology

Context

Medication error prevention is a priority for the U.S. healthcare system in the 21st century. Use of technology is considered by some as critical to achieve this goal. Knowledge of the attitudinal barriers to such adoption, however, is limited.

Objective

To determine the attitudes of frontline prescriber clinicians towards technology in general, and PDAs specifically, before and after introduction of a PDA in the clinical setting of medication prescribing.

Design

A pre- and post-intervention web-based survey, 12-14 months apart.

Setting

Academic tertiary care children's hospital.

Participants

Total of 244 prescriber clinicians.

Intervention

Distribution of a PDA with pediatric-specific medication prescribing information after completion of an on-line medication safety certification and other safety focused educational sessions.

Main outcome measures

Ratings (5-point Likert scale) reflecting perceptions and attitudes towards technology in general and technology in medical settings along with self-reported usage of the PDA for Rx.

Results

Early Adopters and Late Adopters were identified statistically, and the group membership reflected their prior exposure to and ownership of other technologies. Early Adopters tended to be younger and less experienced clinically (e.g., residents) and more frequent owners and users of technology. Early Adopters expressed significantly more favorable attitudes toward technology and PDAs on both pre- to post-intervention survey occasions. They also utilized the PDA for Rx more often than LAs. Interestingly, PDA use for Early Adopters was based on its ease of use, while PDA use among later adopters was based on its clinical usefulness.

Conclusions

Provision of point of care information using PDAs and a user-friendly, pediatric-specific medication information software package did not positively affect the attitudes of prescriber clinicians among those already favorable toward technology. However, a significant change was found among those with initially less favorable attitudes. Organizations need to understand the nature of both Early and Late Adopters and plan appropriately for managing the respective needs and expectations when potentially beneficial technologies are introduced. In order to ensure the success of an implementation, the training and supportive interventions need to be carefully designed and specifically catered to the personality-based outcome expectations of the prescriber.     

A national survey of how acupuncture is currently used in midwifery care at Swedish maternity units

Objective

it is not known how acupuncture is used in midwifery care in Sweden and what kind of requirements health-care providers have for midwives and acupuncture training programmes. The aims of this study were to survey indications for the use of acupuncture in midwifery care in Sweden, and to examine the criteria and requirements used for purchase of acupuncture education programmes.

Design

a postal survey using a structured questionnaire.

Setting

45 maternity units in Sweden.

Participants

the midwife-in-charge of the units.

Measurements and findings

the most common indications for the use of acupuncture were relaxation, pain relief, retained placenta, after pains, milk stasis during lactation, hyperemesis and pelvic instability. Specific requirement for acupuncture education were provision of a short course during weekdays including a follow-up course.

Key conclusion

acupuncture is widely used for many indications in Swedish maternity units despite weak or no evidence to support effectiveness in midwifery care. Requirements for acupuncture education did not seem to be in accordance with what might be expected for this type of qualified intervention.

Implications for practice

the use of acupuncture in midwifery care should not persist until systematic evaluation of the effect of this method is carried through.     

National survey of how acupuncture education is organised for Swedish midwives

Objective

in Sweden, acupuncture education is required before midwives can use the method in clinical practice. Courses in acupuncture are usually organised by private individuals or companies, and each health facility decides on the adequacy of the educational package. Therefore, there is no overall standard or quality control for free-standing courses of acupuncture education for midwives. The aim of this study was to survey the education given to Swedish midwives in the use of acupuncture treatment in the obstetric area.

Design

a postal survey using a structured questionnaire.

Setting

organisers of acupuncture education.

Participants

18 acupuncture instructors.

Measurements and findings

acupuncture courses were usually organised outside universities and colleges. The courses were similar in terms of extent and content, and were mainly based on a Western medical approach. The recommended indications were extensive despite a lack of scientific evidence. The most common instructor profile was a midwife without any academic degree.

Key conclusions and implications for practice

courses differed considerably in the extent to which they were research based. Continuing professional education for midwives should be given at the same academic level, at least, as basic midwifery education.     

Progestin treatment for the prevention of preterm birth

Progestin supplementation appears to be a promising approach to both preventing initiation of preterm labor and treating it once it is already established, given the role of progesterone in maintaining pregnancy, as well as support from basic and clinical research. Progesterone and 17α-hydroxyprogesterone acetate slow the process of cervical ripening, and this is the rationale for prophylactic long-term progestin supplementation mostly studied so far. However, progesterone (but not 17α-hydroxyprogesterone acetate) also inhibits myometrial activity even after the cervix has already ripened. Moreover, these effects depend greatly on the vehicle used and the route of administration. Understanding different mechanisms of action, as well as the importance of progestin formulation, vehicle and route of administration, is the key to finding the optimal progestin treatment for prevention of preterm birth.     

Female Urinary Incontinence at Orgasm: A Possible Marker of a More Severe Form of Detrusor Overactivity. Can Ultrasound Measurement of Bladder Wall Thickness Explain It?

IntroductionCoital incontinence (CI) during orgasm is a form of urinary incontinence possibly because of detrusor overactivity (DO), as the underlying pathophysiological condition. Women with this symptom usually show a pharmacological lower cure rate than those with DO alone. The ultrasound measurement of the bladder wall thickness (BWT) allows an indirect evaluation of detrusor muscle thickness, giving a potential index of detrusor activity.AimWe wanted to understand if CI at orgasm could be a marker of severity of DO by comparing BWT in women with both DO and CI at orgasm vs. women with DO alone. In addition we aimed to confirm if CI during orgasm is related to antimuscarinics treatment failure.MethodsThis is a prospective cohort study performed in two tertiary urogynecological referral departments, recruiting consecutive patients seeking treatment for symptomatic DO.Main Outcome MeasuresAll patients were thoroughly assessed including physical examination, urodynamic evaluation, and BWT measurement according to the International Continence Society/International Urogynecological Association and ICI recommendations. Solifenacine 5 mg once daily was then prescribed and follow-up was scheduled to evaluate treatment. Multiple logistic regression (MLR) was performed to identify risk factors for treatment failure.ResultsBetween September 2007 and March 2010, 31 (22.6%) and 106 (77.4%) women with DO with and without CI at orgasm were enrolled. Women complaining of CI at orgasm had significantly higher BWT than the control group (5.8 ± 0.6 mm vs. 5.2 ± 1.2 mm [P = 0.007]). In patients with CI at orgasm, the nonresponder rate to antimuscarinics was significantly higher than controls (P = 0.01). After MLR, CI at orgasm was the only independent predictor decreasing antimuscarinics efficacy (odds ratio [OR] 3.16 [95% CI 1.22–8.18], P = 0.02).ConclusionsWomen with DO and CI at orgasm showed a significantly higher BWT values and worse cure rates than women with DO alone. CI at orgasm could be a marker of a more severe form of DO. Serati M, Salvatore S, Cattoni E, Siesto G, Soligo M, Braga A, Sorice P, Cromi A, Ghezzi F, Cardozo L, and Bolis P. Female urinary incontinence at orgasm: A possible marker of a more severe form of detrusor overactivity. Can ultrasound measurement of bladder wall thickness explain it?.     

Great minds don't think alike: collaborative maternity care at San Francisco General Hospital

For more than 30 years the collaboration between obstetrician-gynecologists and certified nurse-midwives at San Francisco General Hospital has led to the provision of high-quality care to women and families. This enduring partnership has been sustained by shared goals and values, most notably a commitment to excellence in both providing care to the underserved and training the next generation of physicians and nurse-midwives. Success has also depended on a mutual respect for differences that has enabled the collaborative to capitalize on the distinct expertise of each partner. The balance struck between independence and interdependence of the practice groups has led to innovation and successes that might otherwise not have come to being, while also enabling the collaborative to overcome the inevitable conflicts and challenges that arise within this type of long-standing partnership. This model holds promise for replication in other settings and informs broader considerations of health policy and regulation.     

Chemotherapy for gynecologic cancers occurring during pregnancy

Chemotherapy treatment of gynecologic malignancies during pregnancy should provide maternal benefit without undue fetal harm. We review the treatment regimens for gynecologic cancers occurring during pregnancy and the effects of chemotherapy on fetal development, parturition, and lactation. Women diagnosed with a gynecologic cancer during pregnancy require individualized treatment plans from a multidisciplinary team. TARGET AUDIENCE: Obstetricians & gynecologists, family physicians. LEARNING OBJECTIVES: After completing this CME activity, physicians should be better able to specify the indications for chemotherapy in gynecologic cancers during pregnancy and postpartum periods, discuss the risks and benefits of chemotherapy for gynecologic cancer during pregnancy and postpartum periods. In addition, they should also be able to distinguish the mechanism of action of various chemotherapy agents to choose the best treatment options for patients and monitor for impacts of chemotherapy on fetal growth to determine the best treatment and management strategies.     

Farnesoid X receptor activation improves erectile function in animal models of metabolic syndrome and diabetes

IntroductionThe farnesoid X receptor (FXR) is critically involved in the regulation of the hepato‐biliary system. Recent data suggest a role for FXR in modulating other metabolic pathways and vascular function.AimTo investigate whether long‐term administration of the selective FXR agonist INT‐747 ameliorates erectile function, we tested it in two animal models of metabolic derangements: a rabbit model of high‐fat diet (HFD)‐induced metabolic syndrome (MetS) and a rat model of streptozotocin (STZ)‐induced type 1 diabetes.MethodsHFD rabbit or STZ rats with or without chronic INT‐747 dosing (10 mg/kg/day for 12 weeks). INT‐747 addition to rabbit penile smooth muscle cells (rpSMCs).Main Outcome MeasureEffects of INT‐747 on metabolic features and erectile function in animal models and clarification of mechanism of action in isolated cells.ResultsINT‐747 dosing normalized visceral adiposity and glucose intolerance in HFD rabbits. INT‐747 increased penile FXR expression and partially restored endothelial nitric oxide synthase and dimethylarginine dimethylaminohydrolase 1 expression as well as impaired nitric oxide (NO)‐dependent relaxation (improved responsiveness to acetylcholine and electrical field stimulation). INT‐747 was also effective in regulating NO downstream events, as shown by increased sodium nitroprusside‐induced relaxation. Because phosphodiesterase type 5 and protein kinase G (PKG) were unaltered by INT‐747, we analyzed the calcium‐sensitizing RhoA/ROCK pathway. HFD increased, and INT‐747 normalized, RhoA membrane translocation/activation. RhoA/ROCK signaling inhibition by INT‐747 was confirmed in rpSMCs by confocal microscopy, MYPT1‐phosphorylation, cytoskeleton remodeling, cell migration, and smooth muscle‐related genes expression. In STZ rats, FXR penile expression was not altered but was significantly upregulated by INT‐747 dosing. In this model, INT‐747 improved penile erection induced by electrical stimulation of cavernous nerve and hypersensitivity to intracavernous injection of a ROCK‐inhibitor, Y‐27632, without improving hyperglycemia.ConclusionIn HFD rabbits, INT‐747 dosing improved glucose sensitivity and MetS‐associated erectile dysfunction, via upregulation of NO transmission and inhibition of RhoA/ROCK pathway. In STZ rats, INT‐747 restored in vivo penile erection and sensitivity to ROCK inhibition, independently of effects on glycemia. Vignozzi L, Morelli A, Filippi S, Comeglio P, Chavalmane AK, Marchetta M, Toce M, Yehiely‐Cohen R, Vannelli GB, Adorini L, and Maggi M. Farnesoid X receptor activation improves erectile function in animal models of metabolic syndrome and diabetes.     

Additive inhibitory effects of progesterone and sodium nitroprusside on uterine contractility during pregnancy

Progesterone (P4) and nitric oxide (NO) suppress uterine contractility (CTX). This study compares the effects of P4 to sodium nitroprusside (SNP, an NO donor) and their combination on human CTX of term/preterm and labor/nonlabor tissues. Uterine tissues (n = 128) from women (n = 28) undergoing Cesarean were suspended in organ baths. Tissues (n ≥ 6/group) were treated with vehicle, P4, SNP, or combinations. A subset of tissues (n ≥ 2/group) from term/preterm ± labor and nonpregnant patients was analyzed with P4 alone. Analysis of variance (ANOVA) was used for statistical differences (P < .05). The combination of P4 with SNP significantly suppresses CTX (% inhibition of -127.1 ± 14.5) to the levels lower than with either P4 (-20.1 ± 8.6) or SNP alone (-72.0 ± 11.2). Suppression of P4 is similar in term, preterm, and nonpregnant tissues, with increased sensitivity in laboring tissues. This indicates that P4 or SNP alone may be used for preterm labor and their combination may be more successful.     

Prospective, non-randomized phase 2 clinical trial of carboplatin plus paclitaxel with sequential radical pelvic radiotherapy for uterine papillary serous carcinoma

Objective

Uterine Papillary Serous Carcinoma (UPSC) is uncommon and accounts for less than 5% of all uterine cancers. Therefore the majority of evidence about the benefits of adjuvant treatment comes from retrospective case series. We conducted a prospective multi-centre non-randomized phase 2 clinical trial using four cycles of adjuvant paclitaxel plus carboplatin chemotherapy followed by pelvic radiotherapy, in order to evaluate the tolerability and safety of this approach.

Methods

This trial enrolled patients with newly diagnosed, previously untreated patients with stage 1b-4 (FIGO-1988) UPSC with a papillary serous component of at least 30%. Paclitaxel (175 mg/m²) and carboplatin (AUC 6) were administered on day 1 of each 3-week cycle for 4 cycles. Chemotherapy was followed by external beam radiotherapy to the whole pelvis (50.4 Gy over 5.5 weeks). Completion and toxicity of treatment (Common Toxicity Criteria, CTC) and quality of life measures were the primary outcome indicators.

Results

Twenty-nine of 31 patients completed treatment as planned. Dose reduction was needed in 9 patients (29%), treatment delay in 7 (23%), and treatment cessation in 2 patients (6.5%). Hematologic toxicity, grade 3 or 4 occurred in 19% (6/31) of patients. Patients' self-reported quality of life remained stable throughout treatment. Thirteen of the 29 patients with stages 1-3 disease (44.8%) recurred (average follow-up 28.1 months, range 8-60 months).

Conclusion

This multimodal treatment is feasible, safe and tolerated reasonably well and would be suitable for use in multi-institutional prospective randomized clinical trials incorporating novel therapies in patients with UPSC.