Methods for causality assessment of adverse drug reactions: a systematic review

Adverse drug events resulting in admission to the intensive care unit in oncology patients: Incidence, characteristics and associated cost

Purpose:

Describe the incidence, characteristics and cost of adverse drug events that necessitate admission to the intensive care unit in oncology patients.

Methods:

This was a prospective observational 5-months study at a medical/surgical intensive care unit of a comprehensive teaching cancer center. Patients admitted to the intensive care unit were screened to determine whether the admission was due to an adverse drug event. The adverse drug events were characterized based on the suspected medication, system involved and preventability. Patient demographics, length of stay, mortality and the total patient charges during their intensive care unit stay were recorded.

Results:

During the study period, 249 patients were screened and an adverse drug event was the primary cause of 57 (22.9%) admissions. The most common medications associated with an adverse drug event requiring intensive care unit admission were antineoplastics ( n = 37), analgesics ( n = 9) and anticoagulants ( n = 4). Ten adverse drug events were considered preventable. The average length of stay for patients with adverse drug events resulting in intensive care unit admission was 6.2 days ±9.8 (SD) and the mortality rate was 28.1%. Hematological malignancy was independently associated with adverse drug events resulting in intensive care unit admission. The average patient charges for the intensive care unit stay was US$11,692 ± 17,529 (SD), which corresponded to about US$1.5 million in annual patient charges for a 12-bed intensive care unit at a cancer institution.

Conclusions:

Adverse drug events resulting in intensive care unit admission in oncology patients are common and often associated with significant morbidity, mortality, and cost.

Comparative analysis of pharmacovigilance methods in the detection of adverse drug reactions using electronic medical records

OBJECTIVE

Medication  safety requires that each drug be monitored throughout its market life as early detection of adverse drug reactions (ADRs) can lead to alerts that prevent patient harm. Recently, electronic medical records (EMRs) have emerged as a valuable resource for pharmacovigilance. This study examines the use of retrospective medication orders and inpatient laboratory results documented in the EMR to identify ADRs.

METHODS

Using 12 years of EMR data from Vanderbilt University Medical Center (VUMC), we designed a study to correlate abnormal laboratory results with specific drug administrations by comparing the outcomes of a drug-exposed group and a matched unexposed group. We assessed the relative merits of six pharmacovigilance measures used in spontaneous reporting systems (SRSs): proportional reporting ratio (PRR), reporting OR (ROR), Yule's Q (YULE), the χ(2) test (CHI), Bayesian confidence propagation neural networks (BCPNN), and a gamma Poisson shrinker (GPS).

RESULTS

We systematically evaluated the methods on two independently constructed reference standard datasets of drug-event pairs. The dataset of Yoon et al contained 470 drug-event pairs (10 drugs and 47 laboratory abnormalities). Using VUMC's EMR, we created another dataset of 378 drug-event pairs (nine drugs and 42 laboratory abnormalities). Evaluation on our reference standard showed that CHI, ROR, PRR, and YULE all had the same F score (62%). When the reference standard of Yoon et al was used, ROR had the best F score of 68%, with 77% precision and 61% recall.

CONCLUSIONS

Results suggest that EMR-derived laboratory measurements and medication orders can help to validate previously reported ADRs, and detect new ADRs.

Nurses' spontaneous reporting of adverse drug reactions: expert review of routine reports

AIM

The aims of this study were to analyse spontaneously reported adverse drug reactions according to their previous description, seriousness, causality and the reporting professional.

BACKGROUND

Previous findings showed that fewer nurses than physicians and pharmacists report adverse drug reactions. This is not attributed to any lack of ability in identifying adverse drug reactions.

METHOD

Adverse drug reactions received by the Central Portugal Regional Pharmacovigilance Unit, between 2001 and 2011, were studied. Certain and probable adverse drug reactions were included to test differences between professional groups for serious and non-serious adverse drug reactions.

RESULTS

The Central Portugal Regional Pharmacovigilance Unit received 1014 adverse drug reactions. Fifty-four nurses reported 66 adverse drug reactions, whereas 232 physicians and 145 pharmacists reported 589 and 357 adverse drug reactions, respectively. Considering the number of practising professionals, it was estimated that 0.55% of nurses, 3.96% of physicians and 7.08% of pharmacists have reported an adverse drug reaction. Of the 633 adverse drug reactions assessed as certain or probable, 46 (21 serious), 387 (192 serious) and 198 (77 serious) were reported from nurses, physicians and pharmacists, respectively. There were no differences in the reporting of serious adverse drug reactions among nurses, physicians and pharmacists.

CONCLUSIONS

Nurses are able to identify serious adverse drug reactions although they report less than other professionals.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurses need to increase their involvement in spontaneous reporting schemes by taking responsibility for routinely reporting suspected adverse drug reactions.

An updated method improved the assessment of adverse drug reaction in routine pharmacovigilance

OBJECTIVE

Updating a logistic causality assessment method to improve its agreement with consensual expert judgment (CEJ).

STUDY DESIGN AND SETTING

A random sample of 53 drug-event pairs from a pharmacovigilance database were evaluated independently by CEJ and by a group of experts in pharmacovigilance using the logistic method. Causes of disagreement between both approaches were analyzed, and changes in the assessment of some criteria of the logistic method were proposed and tested in models. The model giving results closest to the CEJ was retained and compared with the initial version on another set of drug-event pairs.

RESULTS

Finally, only the criterion "Search for nondrug cause" was changed into "Search for other causes." The assessment not investigated, possible other cause decreased the probability of drug causation instead of being neutral, whereas the assessment not applicable, not required remained neutral. This new version presents much improved specificity (0.56 vs. 0.33), relatively good sensitivity (0.96), and positive and negative predictive values (0.92 and 0.71).

CONCLUSION

The updated logistic method presented here improves the initial version that had poor specificity and tended to overestimate drug causation. This new version presents satisfactory characteristics to be used in routine pharmacovigilance.

Enhancing communication about paediatric medicines: lessons from a qualitative study of parents' experiences of their child's suspected adverse drug reaction

Background

There is little research on parents' experiences of suspected adverse drug reactions in their children and hence little evidence to guide clinicians when communicating with families about problems associated with medicines.

Objective

To identify any unmet information and communication needs described by parents whose child had a suspected adverse drug reaction.

Methods

Semi-structured qualitative interviews with parents of 44 children who had a suspected adverse drug reaction identified on hospital admission, during in-patient treatment or reported by parents using the Yellow Card Scheme (the UK system for collecting spontaneous reports of adverse drug reactions). Interviews were conducted face-to-face or by telephone; most interviews were audiorecorded and transcribed. Analysis was informed by the principles of the constant comparative method.

Results

Many parents described being dissatisfied with how clinicians communicated about adverse drug reactions and unclear about the implications for their child's future use of medicines. A few parents felt that clinicians had abandoned their child and reported refusing the use of further medicines because they feared a repeated adverse drug reaction. The accounts of parents of children with cancer were different. They emphasised their confidence in clinicians' management of adverse drug reactions and described how clinicians prospectively explained the risks associated with medicines. Parents linked symptoms to medicines in ways that resembled the established reasoning that clinicians use to evaluate the possibility that a medicine has caused an adverse drug reaction.

Conclusion

Clinicians' communication about adverse drug reactions was poor from the perspective of parents, indicating that improvements are needed. The accounts of parents of children with cancer indicate that prospective explanation about adverse drug reactions at the time of prescription can be effective. Convergence between parents and clinicians in their reasoning for linking children's symptoms to medicines could be a starting point for improved communication.

Genetic, environmental and stochastic factors in monozygotic twin discordance with a focus on epigenetic differences

Genetic-epidemiological studies on monozygotic (MZ) twins have been used for decades to tease out the relative contributions of genes and the environment to a trait. Phenotypic discordance in MZ twins has traditionally been ascribed to non-shared environmental factors acting after birth, however recent data indicate that this explanation is far too simple. In this paper, we review other reasons for discordance, including differences in the in utero environment, genetic mosaicism, and stochastic factors, focusing particularly on epigenetic discordance. Epigenetic differences are gaining increasing recognition. Although it is clear that in specific cases epigenetic alterations provide a causal factor in disease etiology, the overall significance of epigenetics in twin discordance remains unclear. It is also challenging to determine the causality and relative contributions of environmental, genetic, and stochastic factors to epigenetic variability. Epigenomic profiling studies have recently shed more light on the dynamics of temporal methylation change and methylome heritability, yet have not given a definite answer regarding their relevance to disease, because of limitations in establishing causality. Here, we explore the subject of epigenetics as another component in human phenotypic variability and its links to disease focusing particularly on evidence from MZ twin studies.

Drug induced interstitial lung disease

With an increasing number of therapeutic drugs, the list of drugs that is responsible for severe pulmonary disease also grows. Many drugs have been associated with pulmonary complications of various types, including interstitial inflammation and fibrosis, bronchospasm, pulmonary edema, and pleural effusions. Drug-induced interstitial lung disease (DILD) can be caused by chemotherapeutic agents, antibiotics, antiarrhythmic drugs, and immunosuppressive agents. There are no distinct physiologic, radiographic or pathologic patterns of DILD, and the diagnosis is usually made when a patient with interstitial lung disease (ILD) is exposed to a medication known to result in lung disease. Other causes of ILD must be excluded. Treatment is avoidance of further exposure and systemic corticosteroids in patients with progressive or disabling disease.

Recognition of adverse drug events in older hospitalized medical patients

Objective

To assess medical teams’ ability to recognize adverse drug events (ADEs) in older inpatients.

Methods

The study cohort comprised 250 patients aged 65 years or older consecutively admitted to Internal Medicine wards of three hospitals in the Netherlands between April and November 2007. An independent expert team identified ADEs present upon admission or occurring during hospitalization by a structured retrospective patient chart review. For all ADEs identified, the expert team assessed causality, severity, preventability, and recognition by medical teams.

Results

The medical teams did not recognize 19.9 % of all ADEs present upon admission {60.4 ADEs [95 % confidence interval (CI) 51.5–70.8] per 100 hospitalizations} and 20.3 % of all ADEs occurring during the hospital stay [47.2 ADEs (95 % CI 39.4–56.5) per 100 hospitalizations]. Unrecognized ADEs were significantly more often ADEs with possible causality (p=0.014, df=1), ADEs caused by medication errors (p<0.001, df=1), and ADEs not manifesting as new symptoms (p<0.001, df=1). The medical teams did not recognize 23.2 % of mild to moderately severe ADEs and 16.5 % of severe, life-threatening, or fatal ADEs. The recognition of ADEs varied with event type.

Conclusions

The recognition of ADEs by medical teams was substantial for those ADEs with evident causality and with clinically apparent and severe consequences. ADEs mimicking underlying pathologies with a lower severity went unrecognized much more often, as did those resulting only in abnormal laboratory values. Tools to improve the recognition of ADEs by medical teams should, therefore, focus on those ADEs that are more challenging to detect.

Causality methods in cosmetovigilance: comparison of Colipa and PLM versus global introspection

The European Cosmetics Regulation requires a post-marketing system for detection of undesirable effects on human health of cosmetic products. Colipa, the European Cosmetic, toiletry and perfumery association, provided guidelines for causality assessment of these effects. In addition another causality method originally designed for causality rating in Post Launch Monitoring (PLM) of novel foods has been employed to assess causality of cosmetic products. In this study these two causality schemes for consumer cosmetic products were validated against clinical assessment, using the method of global introspection (GI) in 100 reported cases. Causality assessments were performed by three experienced assessors in pharmacovigilance. In the event of discordance between the assessors, an adapted Delphi method was used. The overall Spearman correlation coefficient was 0.74 for comparison of Colipa versus GI, whereas this was 0.50 for PLM versus GI. According to current guidelines, the sensitivity was 0.95 for both the Colipa and PLM method, specificity was 0.84 for Colipa and 0.40 for PLM. From these results it can be concluded the performance of the Colipa causality method yielded better correlation to GI than PLM causality method. The factor identified from comparison of these two schemes as having greatest impact was the course of the reaction.

Use of an abnormal laboratory value-drug combination alert to detect drug-induced thrombocytopenia in critically Ill patients

PURPOSE

The aim of this study was to assess the performance of a commercially available clinical decision support system (CDSS) drug-laboratory result alert in detecting drug-induced thrombocytopenia in critically ill patients.

MATERIALS AND METHODS

Adult patients admitted to the medical and cardiac intensive care unit during an 8-week period and identified by 1 of 3 signals in the CDSS, TheraDoc, were eligible. Alerts were generated when the patient had a low platelet count and was ordered a potentially causal drug. Patients were evaluated in real time for the occurrence of an adverse drug reaction using 3 causality instruments. Positive predictive values were calculated for the alert.

RESULTS

Sixty-four patients with a mean age of 54 years met the inclusion criteria, generating 350 alerts. Positive predictive values were 0.36, 0.83, and 0.40 for signals 1, 2, and 3, respectively. Overall, there were 137 adverse drug reactions identified in the 350 alerts, with heparin, vancomycin, and famotidine as the 3 most common potential causes.

CONCLUSIONS

A commercial CDSS drug-laboratory alert is effective at identifying drug-induced thrombocytopenia in the intensive care unit and may improve patient safety. Compared with previous studies, the combination alert performs better than alerts based exclusively on laboratory values and should be considered to reduce alert fatigue.

Potentially inappropriate medication use in Indian elderly: comparison of Beers' criteria and Screening Tool of Older Persons' potentially inappropriate Prescriptions

AIM

To compare Beers' criteria (BC) and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) for prevalence, specificity, sensitivity and predictors for potentially inappropriate medication (PIM) use.

METHODS

Patients aged ≥ 60 years from medicine wards of a tertiary care hospital were included. Comparisons between BC and STOPP were made using Pearson's χ(2) -test for categorical variables and Mann-Whitney U-test for continuous variables. Specificity and sensitivity were assessed by using 2 × 2 contingency table. Bivariate analysis and subsequent multivariate logistic regression was used to identify the predictors of PIM use.

RESULTS

In the 540 patients included, prevalence of PIM use as per BC and STOPP was 24.6% and 13.3%, respectively. Sensitivity and specificity of BC in detecting PIM was 0.65 and 0.53, respectively. Considering the diagnoses/conditions, sensitivity and specificity of BC was 0.12 and 0.48, respectively, whereas independent of diagnoses/conditions, corresponding values were 0.75 and 0.54. PIM as per BC and STOPP accounted for 11 and 6 adverse drug reactions (ADR), respectively. Medications not listed in BC or STOPP were more likely to be associated with ADR. Multiple diseases (≥ 4) and use of more drugs during hospital stay (10-14) predicted PIM use as per BC, whereas age (60-74 years) predicted PIM use as per STOPP.

CONCLUSION

Overall, BC is useful in the detection of PIM use independent of diagnoses/conditions, whereas STOPP is useful in detection of PIM use considering the diagnoses/conditions. There is a need for consensus on using the tool for detection of PIM use in Indian elderly.

Development and inter-rater reliability of the Liverpool adverse drug reaction causality assessment tool

Aim

To develop and test a new adverse drug reaction (ADR) causality assessment tool (CAT).

Methods

A comparison between seven assessors of a new CAT, formulated by an expert focus group, compared with the Naranjo CAT in 80 cases from a prospective observational study and 37 published ADR case reports (819 causality assessments in total).

Main Outcome Measures

Utilisation of causality categories, measure of disagreements, inter-rater reliability (IRR).

Results

The Liverpool ADR CAT, using 40 cases from an observational study, showed causality categories of 1 unlikely, 62 possible, 92 probable and 125 definite (1, 62, 92, 125) and ‘moderate’ IRR (kappa 0.48), compared to Naranjo (0, 100, 172, 8) with ‘moderate’ IRR (kappa 0.45). In a further 40 cases, the Liverpool tool (0, 66, 81, 133) showed ‘good’ IRR (kappa 0.6) while Naranjo (1, 90, 185, 4) remained ‘moderate’.

Conclusion

The Liverpool tool assigns the full range of causality categories and shows good IRR. Further assessment by different investigators in different settings is needed to fully assess the utility of this tool.

A review of causal inference for biomedical informatics

Causality is an important concept throughout the health sciences and is particularly vital for informatics work such as finding adverse drug events or risk factors for disease using electronic health records. While philosophers and scientists working for centuries on formalizing what makes something a cause have not reached a consensus, new methods for inference show that we can make progress in this area in many practical cases. This article reviews core concepts in understanding and identifying causality and then reviews current computational methods for inference and explanation, focusing on inference from large-scale observational data. While the problem is not fully solved, we show that graphical models and Granger causality provide useful frameworks for inference and that a more recent approach based on temporal logic addresses some of the limitations of these methods.

Complementary medicine and safety: a systematic investigation of design and reporting of systematic reviews

OBJECTIVES

The objective of this study was to examine the methods used in systematic reviews of safety across a range of complementary therapies to assess the variation in approach and the potential for developing guidance on conduct and reporting.

DESIGN

Systematic reviews focusing on safety were retrieved from NHS Evidence and searches of major databases. A pre-prepared template was used for data extraction. Information extracted included details of search strategies, sources, participants, interventions, reported adverse event/effect(s) and causality assessment. Data extraction was carried out by one researcher and a check for accuracy by a second researcher. Methods were assessed against criteria based on guidance provided by the Cochrane Adverse Effects Methods Group.

RESULTS

A total of 2563 citations were screened and 88 systematic reviews were selected for inclusion. The majority focused on the safety of herbs and nutritional supplements. Approximately half the reviews covered all aspects of safety; other reviews addressed specific adverse effects or interactions. Types of data included in the reviews did not always reflect the focus of the review. Search strategies, sources used, quality assessment and assessment of causality also varied.

CONCLUSIONS

Detailed examination and comparison of the methods has highlighted several areas in which there is potential for development of guidelines and consensus on standards. These include search strategies, sources of information, data extraction and assessment of causality. The value of systematic reviews in relation to large outcome studies requires further consideration.

Accuracy and reproducibility of two scales in causality assessment of unexpected hepatotoxicity

WHAT IS KNOWN AND OBJECTIVE

There is almost no published information about reliability of scales for causality assessment in hepatotoxicity at pharmacovigilance centres. The aim of this study was to compare two commonly used scales in cases of unexpected hepatotoxicity, in evaluating their accuracy and reproducibility at pharmacovigilance centres (in signal detection).

METHODS

Two scales [Council for International Organizations of Medical Sciences or Rousel Uclaf Causality Assessment Method (CIOMS/RUCAM) and NARANJO] were compared in 19 cases of unexpected hepatotoxicity reported during 2004-2009. Data of the cases (with initial clinical assessments) were collected by a network of medical specialists using a structured reporting form. Later, two independent observers assessed each case using both scales. The accuracy and reproducibility of the scales were analysed by Kappa weighted (Kw) test.

RESULTS

  Both scales (CIOMS/RUCAM vs. NARANJO) showed moderate agreement with the initial clinical assessments (accuracy) for observer A (Kw: 0·56 vs. 0·60) and substantial agreement for observer B (Kw: 0·72 vs. 0·70), with high agreement between observers (Kw: 0·84 vs. 0·67). Both observers (A vs. B) found low agreement between scales (Kw: 0·21 vs. 0·50), with lower scores for the CIOMS/RUCAM scale in 11 and nine cases, respectively. For an early perception of unexpected serious reactions, the scale is more useful if it is not asked for 'previous knowledge' and if it gives higher causality score.

WHAT IS NEW AND CONCLUSION

The CIOMS/RUCAM scale showed similar accuracy, but better reproducibility (agreement between observers) than the NARANJO scale, and therefore is recommended for use at pharmacovigilance centres. Fine-tuning of the CIOMS/RUCAM method could contribute to better detection of unexpected hepatotoxicity.

The effect of an active on-ward participation of hospital pharmacists in Internal Medicine teams on preventable Adverse Drug Events in elderly inpatients: protocol of the WINGS study (Ward-oriented pharmacy in newly admitted geriatric seniors)

BACKGROUND

The potential of clinical interventions, aiming at reduction of preventable Adverse Drug Events (preventable ADEs) during hospital stay, have been studied extensively. Clinical Pharmacy is a well-established and effective service, usually consisting of full-time on-ward participation of clinical pharmacists in medical teams. Within the current Hospital Pharmacy organisation in the Netherlands, such on-ward service is less feasible and therefore not yet established. However, given the substantial incidence of preventable ADEs in Dutch hospitals found in recent studies, appears warranted. Therefore, "Ward-Oriented Pharmacy", an on-ward service tailored to the Dutch hospital setting, will be developed. This service will consist of multifaceted interventions implemented in the Internal Medicine wards by hospital pharmacists. The effect of this service on preventable ADEs in elderly inpatients will be measured. Elderly patients are at high risk for ADEs due to multi-morbidity, concomitant disabilities and polypharmacy. Most studies on the incidence and preventability of ADEs in elderly patients have been conducted in the outpatient setting or on admission to a hospital, and fewer in the inpatient setting. Moreover, recognition of ADEs by the treating physicians is challenging in elderly patients because their disease presentation is often atypical and complex. Detailed information about the performance of the treating physicians in ADE recognition is scarce.

METHODS/DESIGN

The design is a multi-centre, interrupted time series study. Patients of 65 years or older, consecutively admitted to Internal Medicine wards will be included. After a pre-measurement, a Ward-Oriented Pharmacy service will be introduced and the effect of this service will be assessed during a post-measurement. The primary outcome measures are the ADE prevalence on admission and ADE incidence during hospital stay. These outcomes will be assessed using structured retrospective chart review by an independent expert panel. This assessment will include determination of causality, severity and preventability of ADEs. In addition, the extent to which ADEs are recognised and managed by the treating physicians will be considered.

DISCUSSION

The primary goal of the WINGS study is to assess whether a significant reduction in preventable ADEs in elderly inpatients can be achieved by a Ward-Oriented Pharmacy service offered. A comprehensive ADE detection method will be used based on expert opinion and retrospective, trigger-tool enhanced, chart review.

Phenotype standardization for immune-mediated drug-induced skin injury

Advances in genetic research and molecular biology techniques have made it possible to begin to characterize the underlying genetic factors that predispose patients to serious forms of drug-induced skin injury (DISI). To facilitate research in this area, we have set out standardized phenotypic definitions for (i) Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), (ii) acute generalized exanthematous pustulosis (AGEP), and (iii) hypersensitivity syndrome (HSS; also known as drug reaction with eosinophilia and systemic symptoms (DRESS) and drug-induced hypersensitivity syndrome (DIHS)). A DISI Expert Working Group comprising participants with varied expertise reviewed and debated current terminology and diagnostic criteria for DISI and agreed on the minimum phenotypic criteria for selected forms of DISI (SJS/TEN, AGEP, and HSS). In addition, an algorithm has been developed to aid appropriate clinical categorization of patients with DISI. These standardized criteria will be important in facilitating adequate and accurate patient recruitment in order to advance research in pharmacogenomic, immunological, mechanistic, and epidemiological studies.

Incidence and cost estimate of treating pediatric adverse drug reactions in Lagos, Nigeria

CONTEXT AND OBJECTIVES

Adverse drug reactions (ADRs) may cause prolonged hospital admissions with high treatment costs. The burden of ADRs in children has never been evaluated in Nigeria. The incidence of pediatric ADRs and the estimated cost of treatment over an 18-month period were determined in this study.

DESIGN AND SETTING

Prospective observational study on children admitted to the pediatric wards of the Lagos State University Teaching Hospital (LASUTH) in Nigeria, between July 2006 and December 2007.

METHODS

Each patient was assessed for ADRs throughout admission. Medical and non-medical costs to the hospital and patient were estimated for each ADR by reviewing the medical and pharmacy bills, medical charts and diagnostic request forms and by interviewing the parents. Cost estimates were performed in 2007 naira (Nigeria currency) from the perspectives of the hospital (government), service users (patients) and society (bearers of the total costs attributable to treating ADRs). The total estimated cost was expressed in 2007 United States dollars (USD).

RESULTS

Two thousand and four children were admitted during the study; 12 (0.6%) were admitted because of ADRs and 23 (1.2%) developed ADR(s) during admission. Forty ADRs were suspected in these 35 patients and involved 53 medicines. Antibiotics (50%) were the most suspected medicines. Approximately 1.83 million naira (USD 15,466.60) was expended to manage all the patients admitted due to ADRs.

CONCLUSIONS

Treating pediatric ADRs was very expensive. Pediatric drug use policies in Nigeria need to be reviewed so as to discourage self-medication, polypharmacy prescription and sales of prescription medicines without prescription.

Adverse events associated with acupuncture: a prospective survey

OBJECTIVE

The objective of this study was to investigate the adverse events associated with acupuncture using a standard record form in order to identify the risks of acupuncture therapy and assess their causes.

METHODS

Thirteen (13) Oriental medicine doctors volunteered to report the number of acupuncture treatment sessions administered and patients encountered every week. When adverse events occurred, these doctors reported it using a record form that we created. The record form contained six major items to be filled out: patient, acupuncture treatment, adverse event, causality, person reporting the incident, and acupuncturist.

RESULTS

In 5 weeks, the 13 Oriental medicine doctors in our study conducted 3071 acupuncture treatment sessions on 2226 patients. A total of 99 adverse events were reported, which is a rate of 3.2 events per 100 treatments. Common adverse events were hemorrhage (32%), hematoma (28%), and needle site pain (13%). Of the 99 treatments during which an adverse events occurred, 64 treatments were ended, and 62 of the adverse events diminished or disappeared. Of the 35 remaining cases of adverse events in which treatment was continued, 28 patients had their adverse events diminish or disappear. Causality assessment suggested that 47% of adverse events were certainly caused by acupuncture, 45% were probably/likely caused by acupuncture, 7% were possibly caused by acupuncture, and only 1% of events were unassessable/unclassifiable.

CONCLUSIONS

Although acupuncture was associated with adverse events, there were no serious adverse events experienced by patients this study. If acupuncture treatment is administered by a practitioner with enough experience and is conducted in accordance with established guidelines, it is a safe treatment method.

Comparison of three methods (consensual expert judgement, algorithmic and probabilistic approaches) of causality assessment of adverse drug reactions: an assessment using reports made to a French pharmacovigilance centre

BACKGROUND

Different methods have been proposed for assessing a possible causal link between a drug treatment and an adverse event in individual patients. They approximately belong to three main categories: expert judgement, operational algorithms and probabilistic approaches.

OBJECTIVE

To compare, in a set of actual drug adverse event reports, three different methods for assessing drug causality, each belonging to one of the three main categories: expert judgement, the algorithm used by the French pharmacovigilance centres since 1985, and a novel method based on the logistic function.

METHODS

Fifty drug-event pairs were randomly sampled from the database of the Bordeaux pharmacovigilance centre, France. To serve as the gold standard, the probability for drug causation, from 0 to 1, was first determined for each drug-event pair by a panel of senior experts until consensus was reached. Causality was then assessed by members of the Bordeaux pharmacovigilance centre by using the French algorithm and the logistic method. Results expressed as a probability with the logistic method and as a score from 0 to 4 with the French algorithm were then compared with consensual expert judgement, as were the sensitivity, specificity and positive and negative predictive values.

RESULTS

Probabilities ranged from 0.08 to 0.99 (median 0.58; mean 0.60) for experts versus 0.18-0.88 (median 0.73; mean 0.67) for the logistic method. Consensual expert judgement was not discriminant (p = 0.50) in ten cases. For the algorithm, only three of five causality scores were found, doubtful scores being clearly predominant (74%) followed by possible (16%) and probable (10%) scores. Sensitivity and specificity were 0.96 and 0.42, respectively, for the logistic method versus 0.42 and 0.92 for the algorithm. Positive and negative predictive values were 0.78 and 0.83, respectively, for the logistic method versus 0.92 and 0.42 for the algorithm.

CONCLUSIONS

Agreement between the three approaches was poor, and only satisfactory for drug events judged as drug-induced by consensual expert judgement. The logistic method showed high sensitivity at the expense of poor specificity. Conversely, the algorithm had poor sensitivity but good specificity. The comparatively good sensitivity and positive predictive values of the logistic method suggest that it may be more useful in the routine or automated assessment of case reports of suspected but still unknown adverse drug reactions. With a substantial rate of false positives relative to true negatives (low specificity), the logistic method does not replace, but can be complemented by, critical clinical assessment of individual cases in evaluating drug-related risk.

Systematic review of topical vasoconstrictors in endoscopic sinus surgery

OBJECTIVE

The objective of this study is to systematically review the literature and examine the safety for the use of topical vasoconstrictors in endoscopic sinus surgery.

STUDY DESIGN

Systematic review clinical trials.

METHOD

A systematic literature search was performed in MEDLINE, EMBASE, The Cochrane Library, and National Guideline Clearinghouse, and references in the selected articles.

RESULTS

The search criteria captured 42 manuscripts with relevant titles. A systematic review on the topical use of phenylephrine was found; however, no other systematic review, meta-analyses, or clinical guidelines were identified. Six randomized clinical trials or comparative studies, as well as multiple case reports and review articles were also identified. The literature supports the safety of oxymetazoline and epinephrine when used judiciously in carefully selected patients undergoing endoscopic sinonasal surgery; however, topical phenylephrine is not recommended because of its risk profile.

CONCLUSION

In sinus or nasal surgery, topical vasoconstrictors should be used in a manner that minimizes the risk of cardiovascular morbidity.

Consistency between causality assessments obtained with two scales and their agreement with clinical judgments in hepatotoxicity

PURPOSE

Reliability and usefulness of scales for causality assessment in hepatotoxicity have not been fully explored. The goal of this study was to examine consistency between causality assessments obtained with two commonly used scales and their agreement with initial clinical assessments in hepatotoxicity reported in Serbia, and to review usefulness of these scales.

METHODS

We compared the two scales (CIOMS/RUCAM and NARANJO) in 80 cases reported during 1995-2009. The initial clinical assessments performed at the time of reporting served as a control for comparison with the subsequent causality assessments. The agreement between obtained causality assessments and the initial clinical assessments were analysed by Kappa weighted (K(w)) statistical test.

RESULTS

In the 80 cases, the NARANJO scale showed better agreement with the initial clinical assessments (K(w): 0.62) than the CIOMS/RUCAM scale (K(w): 0.50) with moderate mutual agreement (K(w): 0.58). Results for 69 cases reported before the start of the study showed the same. In 11 cases reported in 2009 (after the start of the study) the CIOMS/RUCAM scale showed better agreement with the initial clinical assessments (K(w): 0.80) than the NARANJO scale (K(w): 0.70) with perfect mutual agreement (K(w): 1.0).

CONCLUSION

The two scales showed good similarity and the same was true when their outcomes were compared with the clinical judgments provided by the reporting physicians. Both scales may be useful in pharmacovigilance and clinical practice, but the CIOMS/RUCAM scale provides more specific data. Our results also confirmed that the quality of data and documentation influence the reliability of the method.

Chronic pruritus in the absence of specific skin disease: an update on pathophysiology, diagnosis, and therapy

Chronic pruritus is a major and distressing symptom of many cutaneous and systemic diseases and can significantly impair the patient's quality of life. Pruritus perception is the final result of a complex network involving dedicated nerve pathways and brain areas, and an increasing number of peripheral and central mediators are thought to be involved. Itch is associated with most cutaneous disorders and, in these circumstances, its management overlaps with that of the skin disease. Itch can also occur without associated skin diseases or primary skin lesions, but only with nonspecific lesions secondary to rubbing or scratching. Chronic itch with no or minimal skin changes can be secondary to important diseases, such as neurologic disorders, chronic renal failure, cholestasis, systemic infections, malignancies, and endocrine disorders, and may also result from exposure to some drugs. The search for the cause of pruritus usually requires a meticulous step-by-step assessment involving careful history taking as well as clinical examination and laboratory investigations. Few evidence-based treatments for pruritus are available. Topical therapy, oral histamine H(1) receptor antagonists, and phototherapy with UV radiation can target pruritus elicitation in the skin, whereas antiepileptic drugs, opioid receptor antagonists, and antidepressants can block signal processing in the CNS.

Adverse events of moxibustion: a systematic review

OBJECTIVES

The aim of this review was to identify adverse events of moxibustion as reported in the medical literature.

METHODS

Computerised literature searches were carried out in 14 databases. All articles reporting adverse effects of any type from moxibustion in humans were included, regardless of study design and publication language. The related journals and references in all located articles were manually searched for further relevant articles. Data were extracted and evaluated according to predefined criteria by three independent reviewers.

RESULTS

Adverse events related to moxibustion treatment were reported in 4 randomised clinical trials, 1 controlled clinical trial, 2 uncontrolled observational studies, 13 case reports, and 1 prospective study. The most common effects identified in this review were allergic reactions, burns, and infections such as cellulitis and hepatitis C. Allergic reactions were reported in six case reports (four case reports related to infections and two related to burns). The other articles were case reports of xerophthalmia, xeroderma, hyperpigmented macules, ptosis and eversion of the eyelids. In clinical trials, various adverse events such as rubefaction, blistering, itching sensations, discomfort due to smoke, general fatigue, stomach upsets, flare-ups, headaches, and burns were reported. Tenderness and pressure in the epigastric region or in one of the hypochondriac regions, unpleasant odour with or without nausea and throat problems, abdominal pain, premature birth, premature rupture of the membrane and bleeding due to excess pressure on the anterior placenta were reported in pregnant women.

CONCLUSION

Moxibustion is not entirely risk free, as it has several kinds of potential adverse events such as allergy, burn and infection. Currently, the incidence of such events is not known. In the interest of patient safety, sufficiently large prospective studies should be considered to clarify this issue.

Assessing safety of herbal products for menopausal complaints: an international perspective

Future research of herbal products for menopausal women should include long-term safety assessments because women may use these products for prolonged periods of time. Growing numbers of women take prescription medications and concurrently use herbal products for alleviation of menopausal symptoms. Because of possible herb-drug interactions, both drug and supplement manufacturers should provide basic pharmacokinetic data to reduce the risk of adverse interactions. In addition, herbal products produced to high quality standards are essential for ensuring consumer safety. Regulatory frameworks must be in place to ensure that herbal ingredients' identities have been verified, that they have been properly quantified per unit dose, that the product is within tolerance limits for contaminants, that the product's safety and effectiveness under the recommended conditions of use have been assessed before sale to the public, and that a system is in place to detect and deal with adverse reactions when they arise. This article explores these and related concerns.

Patient self-reporting of potential adverse drug reactions to non-steroidal anti-inflammatory drugs in Thailand

OBJECTIVES

To validate and pilot in Thailand a questionnaire to enable patients to identify and report symptoms perceived as potential ADRs from NSAIDs. To determine the questionnaire's usefulness in enabling Thai out-patients to report potential ADRs. To determine the frequency with which symptoms patients reported were recorded by health professionals and the frequency of ADRs to these drugs reported to the APRM Centre. To assess whether patients reported symptoms from non COX-selective inhibitors and COX-2 selective NSAIDs with different frequencies.

SETTING

Out-patient departments (OPD) of a University teaching hospital in North-East Thailand.

METHOD

A questionnaire which incorporated an extensive symptoms checklist, developed and validated in English, was translated, piloted and validated in Thai. This was distributed to patients receiving one of five NSAIDs. Causality assessment of the symptoms reported was undertaken by a pharmacist, using data on concomitant medicines and disease states from OPD records.

OUTCOME MEASURES

Frequency and type of symptoms reported by patients, recording of these in OPD records, reports sent to APRM Centre.

RESULTS

Piloting found that patients were able to understand the questionnaire, but were unaware of drug names. A response rate of 42% was obtained: 694 usable questionnaires were returned out of 1,654 distributed. Overall 73% of respondents reported at least one symptom perceived to be an ADR. Sixty percent of symptoms reported were classed as probably or possibly an ADR. Fewer symptoms per patient were reported by those taking COX-2 selective inhibitors (3.5) than those taking non-selective NSAIDs (5.5), although there were no differences in the frequency of GI symptoms reported between these two sub-classes, which may relate to other factors, such as age, previous GI problems and prescription of protective ulcer-healing therapy. Only 5% of symptoms were recorded in OPD records and reporting of ADRs to these drugs to the APRM Centre of the Thai FDA during the study was very limited.

CONCLUSION

Thai out-patients were willing and able to complete questionnaires regarding potential ADRs. The questionnaire could form part of routine out-patient monitoring, aiding identification of ADRs, and may help to increase ADR reporting in Thailand.

Adverse drug reactions in hospital in-patients: a prospective analysis of 3695 patient-episodes

Adverse drug reactions (ADRs) are a major cause of hospital admissions, but recent data on the incidence and clinical characteristics of ADRs which occur following hospital admission, are lacking. Patients admitted to twelve wards over a six-month period in 2005 were assessed for ADRs throughout their admission. Suspected ADRs were recorded and analysed for causality, severity and avoidability and whether they increased the length of stay. Multivariable analysis was undertaken to identify the risk factors for ADRs. The 5% significance level was used when assessing factors for inclusion in multivariable models. Out of the 3695 patient episodes assessed for ADRs, 545 (14.7%, 95% CI 13.6-15.9%) experienced one or more ADRs. Half of ADRs were definitely or possibly avoidable. The patients experiencing ADRs were more likely to be older, female, taking a larger number of medicines, and had a longer length of stay than those without ADRs. However, the only significant predictor of ADRs, from the multivariable analysis of a representative sample of patients, was the number of medicines taken by the patient with each additional medication multiplying the hazard of an ADR episode by 1.14 (95% CI 1.09, 1.20). ADRs directly increased length of stay in 147 (26.8%) patients. The drugs most frequently associated with ADRs were diuretics, opioid analgesics, and anticoagulants. In conclusion, approximately one in seven hospital in-patients experience an ADR, which is a significant cause of morbidity, increasing the length of stay of patients by an average of 0.25 days/patient admission episode. The overall burden of ADRs on hospitals is high, and effective intervention strategies are urgently needed to reduce this burden.

Complications of traditional Chinese/herbal medicines (TCM)--a guide for perplexed oncologists and other cancer caregivers

INTRODUCTION

Cancer patients often seek complementary or alternative medicines to supplement or replace treatments prescribed by licensed medical practitioners. Traditional Chinese/herbal medicine (TCM) is a popular complementary intervention among cancer patients of Asian ethnicity, many of whom take it during their conventional treatment. Few of these patients inform their doctors, however, creating a risk of unexpected sequelae arising from either pharmacologic toxicity, unsuitable dosing, interactions with anti-cancer drugs or other medications, adulteration, or idiosyncratic reactions. If unrecognized, these problems may be misattributed to conventional treatment toxicity or disease progression, and remedial action may be inappropriate or delayed.

GOALS OF WORK

The purpose of this review is to help oncologists recognize the common presentations of TCM-related problems in cancer patients-such as abnormal liver function tests, unexpectedly severe myelosuppression, hemostatic defects, renal functional impairment, or suspected drug interactions-and to teach strategies by which these problems can be anticipated, prevented, or managed.

CONCLUSION

Through sensitive understanding of the reasons favoring TCM usage, oncologists can gain the trust and respect of their TCM-using patients while ensuring the safety and efficacy of conventional anticancer treatments.