Outpatient Initiation of Insulin: A Nurse Practitioner Protocol

Noninsulin dependent diabetes (type II diabetes) is a chronic disease characterized by hyperglycemia. Clients can generally be controlled by diet and exercise or a combination of diet, exercise, and oral hypoglycemic agents. When this therapy is not effective in controlling the hyperglycemia, the health care provider must choose to initiate insulin therapy. Outpatient initiation of insulin is an alternative to hospitalization in the type II diabetic client. Clinical guidelines for the initiation of insulin on an outpatient basis and management of the diabetic client are presented.     

Impact of Vendor Computerized Physician Order Entry in Community Hospitals

BACKGROUND

It is uncertain if computerized physician order entry (CPOE) systems are effective at reducing adverse drug event (ADE) rates in community hospitals, where mainly vendor-developed applications are used.

OBJECTIVE

To evaluate the impact of vendor CPOE systems on the frequency of ADEs.

DESIGN AND PATIENTS

Prospective before-and-after study conducted from January 2005 to September 2010 at five Massachusetts community hospitals. Participants were adults admitted during the study period. A total of 2,000 charts were reviewed for orders, medication lists, laboratory reports, admission histories, notes, discharge summaries, and flow sheets.

MAIN MEASURES

The primary outcome measure was the rate of preventable ADEs. Rates of potential ADEs and overall ADEs were secondary outcomes.

KEY RESULTS

The rate of preventable ADEs decreased following implementation (10.6/100 vs. 7.0/100 admissions; p?=?0.007) with a similar effect observed at each site. However, the associated decrease in preventable ADEs was balanced against an increase in potential ADEs (44.4/100 vs. 57.5/100 admissions; p?p?=?0.03), which was driven by non-preventable events (4.0/100 vs. 11.7/100 admissions; p?CONCLUSIONS Adoption of vendor CPOE systems was associated with a decrease in the preventable ADE rate by a third, although the rates of potential ADEs and overall ADEs increased. Our findings support the use of vendor CPOE systems as a means to reduce drug-related injury and harm. The potential ADE rate could be reduced by making refinements to the vendor applications and their associated decision support.     

Role of Sun Exposure in Melanoma

BACKGROUND: Malignant melanoma is the third most common skin cancer in the United States. It is commonly thought that sun exposure is causative in these tumors. Recently, however, the significance of the role of sun exposure in melanoma has come into question. Some have suggested that other factors, such as genetics, play a larger role, and that sun protection may even be harmful. OBJECTIVE AND METHODS: To investigate the role of sun exposure in melanoma etiology. An extensive review of basic science and clinical literature on this subject was conducted. RESULTS: Although exceptions exist, sun exposure likely plays a large role in most melanomas. The pattern of this exposure, however, is not fully known, and controversy exists, especially in the use of sunscreens. Sun exposure may interact with genetic factors to cause melanomas, and sun protective measures appear to be prudent. CONCLUSIONS: The cause of melanoma is probably variable and multifactorial. Sun exposure may play a primary or supporting role in most melanoma tumors.     

Metastatic Cutaneous Squamous Cell Carcinoma: An Update

BACKGROUND: Squamous cell carcinoma (SCC) is the second most common type of skin cancer in the United States. Cutaneous SCC has the potential to metastasize and cause morbidity and mortality. OBJECTIVE: Our purpose was to review and summarize the literature on metastatic cutaneous SCC, including risk factors for metastasis, data from clinical studies, and current management. RESULTS: Multiple studies confirm that even well-differentiated and small tumors (<2 cm) may metastasize. Over the past two decades, additional literature on the risk factors for metastatic cutaneous SCC, including immunosuppression, has been published. In addition, new staging systems have been proposed that may influence management of these tumors. Chemotherapy regimens are numerous, but remain limited in ability to improve overall survival. CONCLUSION: Although we know more about the risk factors, survival for patients with metastatic cutaneous SCC depends on extent of nodal involvement. Therefore, emphasis should remain on prevention and aggressive treatment of cutaneous SCC and vigilant observation for signs and symptoms of metastasis.