Acute neurocognitive response to methylphenidate among survivors of childhood cancer: a randomized, double-blind, cross-over trial

OBJECTIVE: To investigate the acute efficacy and adverse side effects of methylphenidate (MPH) among survivors of childhood cancer [acute lymphoblastic leukemia (ALL) or brain tumor (BT)] with learning impairments. METHODS: Participants (N = 122) completed a two-day, in-clinic, double-blind, cross-over trial during which they received MPH (0.60 mg/kg of body weight) and placebo that were randomized in administration order across participants. Performance was evaluated using measures of attention, memory, and academic achievement. RESULTS: A significant MPH versus placebo effect was revealed on a measure of attention, cognitive flexibility, and processing speed (Stroop Word-Color Association Test). Male gender, older age at treatment, and higher intelligence were predictive of better medication response. No significant differences were found for number or severity of adverse side effects as a function of active medication. CONCLUSIONS: MPH shows some neurocognitive benefit and is well tolerated by the majority of children surviving ALL and BT.     

Parenteral Protein Decision Support System Improves Protein Delivery in Preterm Infants: A Randomized Clinical Trial

Background

Management of neonatal parenteral protein intake for preterm infants is challenging and requires daily modifications of the dose to account for the infant's postnatal age, birth weight, current weight, and the volume and protein concentration of concurrent enteral nutrition. The objective of this study was to create and evaluate the Parenteral Protein Calculator (PPC), a clinical decision support system to improve the accuracy of protein intake for preterm infants who require parenteral nutrition (PN).

Materials and Methods

We integrated the PPC into the computerized provider order entry system and tested it in a randomized controlled trial (routine or PPC). Infants were eligible if they were ≤3 days old, had a birth weight ≤1500 g, and had no inborn error of metabolism. The primary outcome was the appropriate total protein intake, defined as target protein dose ±0.5 g/kg.

Results

We randomly allocated 42 infants for 221 PN days in the control group and 211 in the PPC group. Total protein intake in the PPC group was more accurate as compared with the control group (appropriate protein dosing: odds ratio = 5.8; 95% CI, 2.7–12.4). Absolute deviation from protein target was 0.41 g/kg (0.24–0.58) lower in the PPC group.

Conclusion

The PPC improved appropriate protein dosing for premature infants receiving PN. Further studies are needed to test whether clinical decision support systems will reduce uremia and improve growth and to replicate similar findings in the cases of other PN nutrients.     

Patient preferences for managing asthma: results from a discrete choice experiment

Effective control of asthma requires regular preventive medication. Poor medication adherence suggests that patient preferences for medications may differ from the concerns of the prescribing clinicians. This study investigated patient preferences for preventive medications across symptom control, daily activities, medication side-effects, convenience and costs, using a discrete choice experiment embedded in a randomized clinical trial involving patients with mild-moderate persistent asthma. The present data were collected after patients had received 6 weeks' treatment with one of two drugs. Three choice options were presented, to continue with the current drug, to change to an alternative, hypothetical drug, or to take no preventive medication. Analysis used random parameter multinomial logit. Most respondents chose to continue with their current drug in most choice situations but this tendency differed depending on which medication they had been allocated. Respondents valued their ability to participate in usual daily activities and sport, preferred minimal symptoms, and were less likely to choose drugs with side-effects. Cost was also significant, but other convenience attributes were not. Demographic characteristics did not improve the model fit. This study illustrates how discrete choice experiments may be embedded in a clinical trial to provide insights into patient preferences.     

Discontinuation of Antidepressant Medication Among Latinos in the USA

Despite recent growth in the variety of antidepressant medications available, many patients discontinue medication prematurely for reasons such as nonresponse, side effects, stigma, and miscommunication. Some analysts have suggested that Latinos may have higher antidepressant discontinuation rates than other US residents. This paper examines Latino antidepressant discontinuation, using data from a national probability survey of Latinos in the USA. In this sample, 8% of Latinos had taken an antidepressant in the preceding 12 months. Among those users, 33.3% had discontinued taking antidepressants at the time of interview, and 18.9% had done so without prior input from their physician. Even controlling for clinical and other variables, patients who reported good or excellent English proficiency were less likely to stop at all. Patients were also less likely to stop if they were older, married, had public or private insurance, or had made eight or more visits to a nonmedical therapist.     

Ethnographic study of factors influencing compliance to intermittent preventive treatment of malaria during pregnancy among Yao women in rural Malawi

In Africa today one of the main strategies to reduce malaria infection during pregnancy is the promotion of intermittent preventive treatment (IPT). To date only a few studies have investigated the factors affecting compliance to IPT. This medical anthropology study aims to describe these factors from the perspective of pregnant women in rural Malawi. We examine women's knowledge and perceptions about the use of medication in pregnancy and the timing and motivation concerning use of antenatal clinic (ANC) services. In addition, the circumstances and interaction at the ANC and the IPT implementation process are described. The data were collected by applying an ethnographic approach, including focus group discussions (n=8), in-depth interviews (n=34), drug identification exercises, participant observation and a 'knowledge, attitudes and practices' survey (n=248). This study discovered several factors affecting IPT. These were: unclear messages about IPT with sulfadoxine-pyrimethamine (SP) from nurses; timing of SP-1; periodic shortages of SP; women's limited understanding of IPT-SP; tendency for late enrolment; and nurses' underperformance. The results of this study show that understanding of the multiple contexts affecting malaria prevention is important, and that ethnographic research is useful for discovering and solving problems beyond the scope of many other research approaches.     

Repeated measures analyses of dose timing of antiretroviral medication and its relationship to HIV virologic outcomes

Medication adherence is a critical predictor of the effectiveness of antiretroviral medications in the treatment of HIV/AIDS. Studies of adherence, however, have focused primarily on the per cent of prescribed doses taken (per cent adherence). In the Adherence and Efficacy of Protease Inhibitor Therapy study, we collected detailed adherence data including dose timing information as well as data regarding patients' virologic responses. For 48 weeks, adherence data and virologic outcomes were collected every 4 weeks, and demographics and other measures were collected at baseline and at weeks 8, 24, and 48. We constructed eight different dose timing error (DTE) measures and evaluated their associations with virologic outcomes using longitudinal analyses. Repeated measures mixed effect models were fitted to evaluate the predicting power of each of the DTE measures. Among 52 036 electronically measured doses obtained from 122 patients, DTE measures significantly predicted virologic outcomes. Of the eight different DTE measures, the six DTE measures were significantly predictive of virologic outcomes even after controlling for per cent adherence. In conclusion, we identified several measures of DTE that explain HIV virologic outcomes not captured by traditional adherence measures. Investigations of adherence to antiretrovirals would benefit from measuring not only per cent adherence but dose timing adherence.     

护理人员风险意识及护理风险相关因素调查分析

目的：了解护理风险现状,探索护理风险发生的规律、特点和高危因素。方法：对30所医院的4957名医护人员进行问卷调查,建立数据库,所得资料运用SPSS11.0软件统计分析,采用Logistic回归分析、χ^2检验,并建立风险重要性因素象限推导模型。结果：新职工及工作5年内人员为护理风险高危人群;外科、妇产科、小儿科、急诊科为护理风险的高危科室;管理制度、风险教育、规程执行等变量与风险发生呈负相关;职业保险、风险组织、风险教育等9项因素为优先解决的问题。结论：加强风险管理,完善职业保险是防范护理风险的关键和根本。     

Minimizing side-effects: the clinical impact of nurse-administered 'side-effect' checklists

BACKGROUND: For those with chronic illness, the adverse effects of medication are important causes of morbidity and distress which may not always receive due attention. Guidelines and checklists may be one strategy to focus professionals' attention on long-term problems. Therefore, client-centred 'side-effect' evaluation checklists were developed to be administered and actioned by nurses. AIM: The purpose of this study was to explore the clinical impact of these checklists on long-term users of antipsychotic medication. METHODS: This study was undertaken with clients with enduring mental illness, in Community Mental Health Teams. In the first phase, 40 nurse-client interactions were observed. Following introduction of the evaluation checklists, 20 nurse-client interactions were observed with the checklists and 20 nurse-client interactions were observed for comparison. In addition, the views of professionals, service users and user groups on the value of the checklists were sought. FINDINGS: Amongst the 20 clients in the intervention group, the checklists highlighted several problems, two of which were urgent. In the intervention group, the mean number of problems actioned per client increased from 0.35 (range=0-4) with no checklists to 3 (range=0-6) with the checklists. The majority (51 of 59) of actions taken to alleviate adverse effects of medication concerned physical health problems. Nurses offered appropriate advice or encouraged clients to contact the relevant agencies. No such changes were observed in the comparator group. There were no differences between groups in the number of referrals to prescribers. IMPLICATIONS: The usefulness of the evaluation checklists for detecting unattended problems, in conjunction with the responses of service users, suggests that it may be clinically effective to establish procedures to systematically monitor people with serious mental illness for adverse drug reactions (ADRs). However, larger studies are needed to confirm this.