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Arasi F, Bennett E, Rokoduru A, Kaspar A. Assessment of knowledge, attitude and practice for oxygen therapy among medical staff at the Colonial War Memorial Hospital in Fiji. Intern Med J 2024; 54:657-663. [PMID: 37615066 DOI: 10.1111/imj.16210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Oxygen therapy (OT) is a commonly prescribed essential medicine for people of all ages in the management of hypoxia. The adverse effects of inappropriate OT supplementation may be underestimated by health professionals and lead to poor health outcomes among hospitalised patients. Knowledge, attitude and practice (KAP) assessments of medical staff members to OT guidelines are essential to ensure optimal patient care. AIMS To perform a KAP assessment of OT administration among doctors and nurses employed at the national hospital of Fiji in 2021. METHODS Prospective cross-sectional study design. KAP assessment was performed with an online questionnaire and clinical observation. RESULTS The study population (N = 116) consisted of doctors (20.7%) and nurses (79.3%) representing the acute medical, burns, cardiac care, intensive care, surgical and postanaesthetic recovery units. Overall, the proportion of participants who obtained a good score (>70%) was 87% for knowledge, 87.93% for attitudes and 84% for practice. Best knowledge scores were obtained for general OT indications (71%) and scenarios where immediate oxygen application is required (70%). Lowest knowledge scores were for OT contraindications (14%) and oxygen saturation for acute myocardial infarction (32%), asthma (36%) and healthy newborns (43%). The most positive attitudes were in response to the statement that OT guidelines are essential (96%). A total of 78 (80.4%) patients were being cared for with good OT practice. CONCLUSIONS Good KAP scores were obtained for medical staff in Fiji regarding OT administration. Ongoing professional education activities should include updated training of OT contraindications and optimal oxygen saturation levels for special patient groups.
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Affiliation(s)
- Fa'amuamua Arasi
- Department of Anaesthesia & Intensive Care, Colonial War Memorial Hospital, Suva, Fiji
- Department of Anaesthesia, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
- Surgical Unit, Tupua Tamasese Meaole Hospital, Ministry of Health, Apia, Samoa
| | - Elizabeth Bennett
- Department of Anaesthesia & Intensive Care, Colonial War Memorial Hospital, Suva, Fiji
- Department of Anaesthesia, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Avelina Rokoduru
- Pacific Sexual and Reproductive Health Research Centre, Fiji National University, Suva, Fiji
| | - Annette Kaspar
- Surgical Unit, Tupua Tamasese Meaole Hospital, Ministry of Health, Apia, Samoa
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Andison M. Digital Health Safety Matters: A Promising Practice Study into the Adoption of Patient Safety Guidelines in Australia. Stud Health Technol Inform 2024; 310:334-338. [PMID: 38269820 DOI: 10.3233/shti230982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
A foundation for digitally enabling healthier living is the safe development and use of technology. The practice of digital health safety has emerged from patient harm attributed to failing technologies. The study aimed to investigate how to adopt and implement digital health safety guidelines at scale. Data was collected through an online survey, semi-structured interviews, focus groups, document review, and data mining of artefacts. The findings of this study capture the emerging practice from Australia in a way that offers insights into the problem of practice, patient safety practice, safety culture, and socio-technical factors. The research findings contribute to better understanding of the complexities of balancing digital innovation with patient safety. The four recommendations from the study and the provision of a logic model will support the audience to implement actions toward a safer digital health ecology.
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Affiliation(s)
- Melissa Andison
- eHealth Queensland, Australasian Institute of Digital Health Member and British Computer Society Fellow, Australia
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Huang JL, Xin X, Ma MJ, Ning Z, Xiao ST, Chen PP. A qualitative study on the clinical safety and user experiences of female condoms for anal intercourse among men who have sex with men in Shanghai, China. Front Public Health 2023; 11:1243891. [PMID: 38074717 PMCID: PMC10701689 DOI: 10.3389/fpubh.2023.1243891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/19/2023] [Indexed: 12/18/2023] Open
Abstract
Objective This qualitative study aimed to understand the clinical safety, efficacy, and receptiveness of using the female condom (FC) during anal intercourse among men who have sex with men (MSM). Methods Subjects for this study were recruited from a two-group crossover trial among MSM in Shanghai. The trial consisted of two phases, each including the use of condoms (FC vs. male condom), questionnaires, and in-depth one-on-one interviews. The two phases were separated by a washout period of 4 weeks. The minimum sample size for this study was determined in accordance with the principle of "information saturation." The qualitative data were organized and analyzed using ATLAS.ti version 7. Results A total of 26 participants from the MSM population were recruited for this study, with 10 assuming the insertive role (i.e., "1"), 8 assuming the receptive role (i.e., "0"), and 8 being versatile (i.e., "0.5"). Each participant completed the crossover trial comprising two phases. The cumulative usage of FCs and male condoms (MCs) amounted to 115 and 127 times, respectively. During the reported sexual encounters, no participants reported incidents of condom rupture, slippage, or other malfunctions. A few participants reported experiencing slight chafing pain, primarily put forward by "0" participants. Apart from those reports, no instances of bleeding, swelling, or allergic reactions were reported. The efficiency of FC in disease prevention, the sexual partner's willingness to use FC, the freshness of FC, and positive sexual experiences were the main reasons for the consistent use of FC for anal sex. Discomfort and pain during sexual activity, the loose design and thick material of FCs, and difficulties in placing FCs were the major obstacles to FC use among MSM. The elements referring to the forehead exhibited varied in importance among "1,", "0," and "0.5" participants. Regarding the willingness to use the FC in the future anal intercourse, 61.54% of participants expressed a positive inclination, 23.08% were uncertain, and 15.38% stated that they would not. "A better sense of security during anal sex" was the main factor affecting willingness among "0" participants and "the sexual pleasure that the FC brought" among "1" participants. Improving the design and technology of FCs and increasing the frequency of use and practice might improve the use skills, which will favor the willingness to use FCs among the MSM population. Conclusion FCs received positive user feedback from study participants, but distinctions were found in individuals in different sexual roles. Large-scale quantitative studies are needed to evaluate the clinical safety of the FC and its effectiveness in preventing the transmission of STDs during anal intercourse.
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Affiliation(s)
- Jia-Lu Huang
- School of Public Health, Dali University, Dali, China
| | - Xin Xin
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
- Pudong New Area Center for Disease Control and Prevention, Shanghai, China
- Pudong Institute of Preventive Medicine, Fudan University, Shanghai, China
| | - Ming-Jun Ma
- School of Public Health, Dali University, Dali, China
| | - Zhen Ning
- Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
| | - Shao-tan Xiao
- Pudong New Area Center for Disease Control and Prevention, Shanghai, China
- Pudong Institute of Preventive Medicine, Fudan University, Shanghai, China
| | - Pan-pan Chen
- Department of Epidemiology, School of Public Health, Fudan University, Shanghai, China
- Pudong New Area Center for Disease Control and Prevention, Shanghai, China
- Pudong Institute of Preventive Medicine, Fudan University, Shanghai, China
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de Almeida-Junior S, Ferraz MVF, de Oliveira AR, Maniglia FP, Bastos JK, Furtado RA. Advances in the phytochemical screening and biological potential of propolis. Fundam Clin Pharmacol 2023; 37:886-899. [PMID: 37038052 DOI: 10.1111/fcp.12898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 02/13/2023] [Accepted: 04/05/2023] [Indexed: 04/12/2023]
Abstract
Propolis is a natural resinous product collected from different parts of plants by bees and mixed with their salivary secretions. The occurrence of more than 180 different chemotypes has flavonoids, phenolic acids, esters, and phenolic aldehydes, as well as balsamic resins, beeswax, pollen, and essential and aromatic oils, among others. Its biological potential documented throughout the world justifies the need, from time to time, to organize reviews on the subject, with the intention of gathering and informing about the update on propolis. In this review (CRD42020212971), phytochemical advances, in vitro, in vivo, and clinical biological assays of pharmacological interest are showcased. The focus of this work is to present propolis clinical safety assays, antitumor, analgesic, antioxidant, anti-inflammatory, and antimicrobial activities. This literature review highlights propolis' promising biological activity, as it also suggests that studies associating propolis with nanotechnology should be further explored for enhanced bioprocessing applications.
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Affiliation(s)
- Silvio de Almeida-Junior
- Biosciences and Health Laboratory, State University of Minas Gerais, Belo Horizonte, Brazil
- Postgraduate Program in Health Promotion, University of Franca, Franca, Brazil
| | - Matheus Vitor Ferreira Ferraz
- Department of Fundamental Chemistry, Federal University of Pernambuco, UFPE, Recife, Brazil
- Heidelberg Institute for Theoretical Studies, Heidelberg, Germany
| | - Alex Roberto de Oliveira
- Postgraduate Program in Animal Science, Animal Science Laboratory, University of Franca, Franca, Brazil
| | | | - Jairo Kenupp Bastos
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Ricardo Andrade Furtado
- Postgraduate Program in Health Promotion, University of Franca, Franca, Brazil
- Postgraduate Program in Animal Science, Animal Science Laboratory, University of Franca, Franca, Brazil
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Wright A, Snyder OL, He H, Christenson LK, Fleming S, Weiss ML. Procoagulant Activity of Umbilical Cord-Derived Mesenchymal Stromal Cells' Extracellular Vesicles (MSC-EVs). Int J Mol Sci 2023; 24:ijms24119216. [PMID: 37298168 DOI: 10.3390/ijms24119216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/11/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023] Open
Abstract
Many cell types, including cancer cells, release tissue factor (TF)-exposing extracellular vesicles (EVs). It is unknown whether MSC-EVs pose a thromboembolism risk due to TF expression. Knowing that MSCs express TF and are procoagulant, we hypothesize that MSC-EVs also might. Here, we examined the expression of TF and the procoagulant activity of MSC-EVs and the impact of EV isolation methods and cell culture expansion on EV yield, characterization, and potential risk using a design of experiments methodology. MSC-EVs were found to express TF and have procoagulant activity. Thus, when MSC-derived EVs are employed as a therapeutic agent, one might consider TF, procoagulant activity, and thromboembolism risk and take steps to prevent them.
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Affiliation(s)
- Adrienne Wright
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS 66506, USA
- Midwest Institute of Comparative Stem Cell Biotechnology, Kansas State University, Manhattan, KS 66506, USA
| | - Orman Larry Snyder
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS 66506, USA
- Midwest Institute of Comparative Stem Cell Biotechnology, Kansas State University, Manhattan, KS 66506, USA
| | - Hong He
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS 66506, USA
- Midwest Institute of Comparative Stem Cell Biotechnology, Kansas State University, Manhattan, KS 66506, USA
| | - Lane K Christenson
- Department of Cell Biology and Physiology, University of Kansas Medical Center, Kansas City, KS 66160, USA
| | - Sherry Fleming
- Division of Biology, Kansas State University, Manhattan, KS 66506, USA
| | - Mark L Weiss
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS 66506, USA
- Midwest Institute of Comparative Stem Cell Biotechnology, Kansas State University, Manhattan, KS 66506, USA
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Zhang M, Huang F, Jiang F, Mai M, Guo X, Zhang Y, Xu Y, Zu H. Clinical efficacy and safety of low-dose doxepin in Chinese patients with generalized anxiety disorder: A before-after study. Medicine (Baltimore) 2022; 101:e31201. [PMID: 36281170 PMCID: PMC9592331 DOI: 10.1097/md.0000000000031201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/15/2022] [Indexed: 11/15/2022] Open
Abstract
Clinical and animal studies have reported that low-dose doxepin may have positive effects on generalized anxiety disorder (GAD); however, its effectiveness and clinical safety are less well understood. This study is a before-after study and aims to investigate the effectiveness and side effects of low-dose doxepin by evaluating Hamilton Anxiety Scale (HAMA) scores, hormones, blood glucose, serum lipids, body weight, and body mass index (BMI) in patients with GAD. Forty-nine patients (20 males and 29 females) with GAD were randomly assigned to receive low-dose doxepin (6.25 mg-12.5 mg per day) for 12 weeks between February 2015 and March 2016. HAMA scores, fasting blood glucose (FBG) body weight, BMI, and some serum biochemical indexes, such as adrenocorticotropic hormone (ACTH), free triiodothyronine (FT3), total cholesterol (TC), triglyceride (TG), and low-density lipoprotein cholesterol (LDLC), and FBG, were assessed during pretreatment and post-treatment. Mean scores of HAMA decreased from 19.50 ± 1.22 to 8.50 ± 3.61 after low-dose doxepin treatment (P < .01). The serum levels of ACTH (4.33 ± 2.14 vs 6.12 ± 3.02 pmol/L), FT3 (4.78 ± 0.51 vs 5.15 ± 0.52 pg/mL), TC (4.55 ± 1.01 vs 5.93 ± 1.66 mmol/L), TG (1.69 ± 1.51 vs 3.39 ± 2.86 mmol/L), and LDLC (2.43 ± 0.88 vs 3.76 ± 1.25 mmol/L), and FBG (5.06 ± 0.43 vs 5.78 ± 0.81 mmol/L) were higher than that pretreatment with a significant difference (P < .01). Bodyweight (62.00 ± 7.45 vs 64.00 ± 6.44 kg, P = .23) and BMI (23.70 ± 2.35 vs 24.48 ± 2.11 kg/m2, P = .14) had no difference after treatment. These results suggest that low-dose doxepin has beneficial clinical efficacy and safety. Low-dose doxepin can ameliorate anxiety in GAD patients and has some effects on neuroendocrine systems and the metabolic activity of serum glucose and lipid.
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Affiliation(s)
- Mengqi Zhang
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Fengmin Huang
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Feiyu Jiang
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Meiting Mai
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Xiaorou Guo
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Ying Zhang
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
| | - Ying Xu
- Department of Geriatric Cognitive Disorders, Shanghai Jinshan Zhongren Geriatric Nursing Hospital, Shanghai, China
| | - Hengbing Zu
- Department of Neurology, Jinshan Hospital, Fudan University, Shanghai, China
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Halawany HS, Abraham NB, Al-Badr AH, Al-Khalifa KS. Perceptions of Patient Safety Competence Using the Modified Version of the Health Professional Education in Patient Safety Survey (H-PEPSS) Instrument Among Dental Students in Riyadh, Saudi Arabia. Adv Med Educ Pract 2022; 13:1019-1028. [PMID: 36105768 PMCID: PMC9466956 DOI: 10.2147/amep.s369291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/29/2022] [Indexed: 06/15/2023]
Abstract
AIM To investigate dental students' self-reported confidence in learning about various domains of patient safety during their clinical training years. METHODS The Health Professional Education in Patient Safety Survey (H-PEPSS) was distributed to the fourth- and fifth-year undergraduate students, interns and postgraduate dental students. The survey explores how the seven domains of the Canadian Patient Safety Institute Safety Competencies Framework and wider cases of patient safety issues are presented in dental education, as well as participants' self-reported comfortability regarding revealing about patient safety issues. A comparison of the patient safety domains scores were assessed through learning scenarios (classroom and clinical), gender, level of study and type of institution. RESULTS Out of 409 participants, 359 undergraduate dental students and 131 postgraduate dental students responded to the survey. Irrespective of the groups, all dental students were most confident regarding their learning aspects about skills pertaining to clinical safety and effective communication and least confident in learning related to managing safety risks. All the patient safety factors irrespective of the scenario, scored above 75% and thus interpreted as good competence. Statistically significant differences were reported among the genders in the classroom scenario for learning about communicating effectively with the patients regarding patient safety issues (p < 0.05). Male dental students, undergraduates and those in the private institution were significantly less confident about recognizing and reporting to immediate risks in the clinical scenario compared to their respective counterparts (p < 0.05). CONCLUSION Based on the results, the dental students are quite confident with regard to the learning aspects of clinical patient safety, nevertheless, their confidence in learning certain patient safety aspects warrants further improvement. This implies a need to address the impact of regular interventions, extra motivation and repeated mentoring in both the classroom and clinical scenarios on improving dental students' confidence about patient safety.
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Affiliation(s)
- Hassan Suliman Halawany
- Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
| | - Nimmi Biju Abraham
- School of Oral Health, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Abid Hamoud Al-Badr
- Department of Periodontics and Community Dentistry, College of Dentistry, King Saud University, Riyadh, Saudi Arabia
| | - Khalifa S Al-Khalifa
- Department of Preventive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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Fishbane S, Ganz T, Pratt RD. Ferric pyrophosphate citrate for parenteral administration of maintenance iron: structure, mechanism of action, clinical efficacy and safety. Curr Med Res Opin 2022; 38:1417-1429. [PMID: 35726771 DOI: 10.1080/03007995.2022.2092373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Anemia is a common complication in patients with hemodialysis-dependent chronic kidney disease (HDD-CKD). Anemia is principally the result of erythropoietin deficiency, inflammation, and iron deficiency. High molecular weight iron oxide nanoparticles (IONP) are routinely administered intravenously to replace iron losses and, although effective, there are lingering concerns about possible safety issues. Ferric pyrophosphate citrate (FPC, Triferic, Triferic AVNU [Triferic and Triferic AVNU are the proprietary name for ferric pyrophosphate citrate. Triferic and Triferic AVNU are registered trademarks of Rockwell medical Inc.]) is a complex iron salt that donates iron directly to plasma transferrin. FPC is devoid of any carbohydrate moiety and is administered via the dialysate or intravenously during each hemodialysis session to replace iron and maintain hemoglobin. Controlled clinical trials of up to 48 weeks in duration have demonstrated the efficacy of regular administration of dialysate FPC for maintaining hemoglobin levels and iron balance in HDD-CKD patients. Clinical data also suggest that dialysate FPC may reduce the dose requirements for and use of erythropoiesis-stimulating agents and IONPs in HDD-CKD patients. Safety data from clinical studies and post-marketing surveillance show that FPC is well tolerated and not associated with an increased risk of infection, inflammation, iron overload, or serious hypersensitivity reactions. FPC represents an effective and well-tolerated choice for iron replacement and maintenance of hemoglobin in the long-term management of HDD-CKD patients.
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Affiliation(s)
- Steven Fishbane
- Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY, USA
| | - Tomas Ganz
- University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA
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Elnour AA, Ahmed IM, Khalid AK, Elmustafa M. Validation and comparison between two warfarin dosing clinical algorithms and warfarin fixed dosing in specialized heart center: cross-sectional study. Pharm Pract (Granada) 2022; 20:2722. [PMID: 36733524 PMCID: PMC9851814 DOI: 10.18549/pharmpract.2022.3.2722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
Abstract
Background Warfarin is well known as a narrow therapeutic index that has prodigious variability in response which challenges dosing adjustment for the maintenance of therapeutic international normalized ratio. However, an appreciated population not on new oral anticoagulants may still need to be stabilized with warfarin dosing. Objective The current study's main objective was to validate and compare two models of warfarin clinical algorithm models namely the Gage and the International Warfarin Pharmacogenetics Consortium (IWPC) with warfarin 5 mg fixed standard dosing strategy in a sample of Sudanese subjects. Method We have conducted a cross-sectional study recruited from the out-patient clinic at a tertiary specialized heart center. We included subjects with unchanged warfarin dose (stabilized), and with therapeutic international normalized ratio. The predicted doses of warfarin in the two models were calculated by three different methods (accuracy, clinical practicality, and the clinical safety of the clinical algorithms). Main outcome measure The primary outcomes were the measurements of the clinical (accuracy, practicality, and safety) in each of the two clinical algorithms models compared to warfarin 5 mg fixed standard dose strategy. Results We have enrolled 71 Sudanese subjects with mean age (51.7 ± 14 years), of which (49, 69.0%) were females. There was no significant difference between the warfarin 5 mg fixed standard dose strategy and the predicted doses of the two clinical algorithm models (MAE 1.44, 1.45, and 1.49 mg/day [P =0.4]) respectively. In the clinical practicality, all of the three models had a high percent of subjects (95.0%, 51.9%, and 66.7%) in the ideal dose range in middle dose group (3-7 mg/ day) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithm models respectively. However, a small percent of subjects was exhibited in the warfarin low dose group ≤ 3 mg/day (0.0%, 15.0%, and 10.0%) and warfarin high dose group ≥ 7 mg/day (0.0%, 33.3%, and 33.3%) for warfarin 5 mg fixed standard dosing strategy, Gage, and IWPC clinical algorithms respectively. In terms of clinical safety, the percent of subjects with severely over-prediction were 28.2%, 22.5%, and 22.5% for warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively. While the percent of severely under-prediction was 12.7%, 7.0%, and 5.6% for the warfarin 5 mg fixed standard dosing, Gage, and IWPC, respectively. Conclusion The Gage and IWPC clinical algorithm models were accurate, more clinically practical, and clinically safe than warfarin 5 mg standard dosing in the study population. The cardiologist can use either models (Gage and IWPC) to stratify subjects for accurate, practical, and clinically safe warfarin dosing..
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Affiliation(s)
- Asim Ahmed Elnour
- PhD, MSc. Program of Clinical Pharmacy, College of Pharmacy, Al Ain University (AAU), Abu Dhabi campus, Abu Dhabi-United Arab Emirates (UAE). AAU Health and Biomedical Research Center, Al Ain University, Abu Dhabi, United Arab Emirates.
| | - Islam Mohammed Ahmed
- PhD student, MSc, B Pharm. Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani-Sudan. b. Faculty of Pharmacy, Managel University for Science and Technology, Managel-Sudan.
| | - Al-Kubaissi Khalid
- PhD, MSc. Department of Pharmacy Practice & Pharmacotherapeutics, College of Pharmacy-University of Sharjah, Sharjah-United Arab Emirates.
| | - Mohamed Elmustafa
- PhD, Msc. Department of Pharmacology, Faculty of Pharmacy, University of Gezira, Wad Medani-Sudan.
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Patel SS, Rauscher M, Kudela M, Pang H. Clinical Safety Experience of TAK-003 for Dengue Fever: A New Tetravalent Live Attenuated Vaccine Candidate. Clin Infect Dis 2022; 76:e1350-e1359. [PMID: 35639602 PMCID: PMC9907483 DOI: 10.1093/cid/ciac418] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/12/2022] [Accepted: 05/20/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND An unmet medical need remains for an effective dengue tetravalent vaccine that can be administered irrespective of previous dengue exposure. TAK-003, a dengue tetravalent vaccine, has demonstrated efficacy in an ongoing phase 3 trial in children and adolescents living in dengue-endemic areas, with an acceptable safety profile in both dengue-naive and dengue-exposed individuals. METHODS Safety findings are presented herein from an integrated analysis of data for healthy 4-60-year-olds from two phase 2 and three phase 3 double-blind, placebo-controlled clinical trials of TAK-003 (TAK-003, n = 14 627; placebo, n = 7167). Safety evaluation included analyses of postinjection reactogenicity, unsolicited adverse events (AEs), serious AEs (SAEs), and deaths. Subgroup analyses were performed by age group, baseline serostatus, and gender. RESULTS The most common local and systemic AEs were injection site pain (43% for TAK-003 and 26% for placebo) and headache (34% and 30%, respectively). Injection site AEs were mostly mild and resolved within 1-3 days. Unsolicited AEs and AEs leading to discontinuation occurred with similar frequency across both groups, while SAEs were fewer for TAK-003 recipients (6% vs 8% for placebo). Four of the 5 vaccine-related SAEs (which included hypersensitivity, dengue fever, and dengue hemorrhagic fever) occurred in the placebo group. No deaths were considered vaccine-related. Subgroup analyses showed no differences in safety by baseline serostatus or by gender, albeit analysis by age indicated greater local reactogenicity rates for adolescents (46% for TAK-003 and 28% for placebo) and adults (56% and 19%, respectively) than for children (37% and 25%, respectively). CONCLUSIONS No important safety risks were identified, and TAK-003 was well tolerated irrespective of age, gender, or baseline dengue serostatus in recipients aged 4-60 years.
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Affiliation(s)
- Sanjay S Patel
- Correspondence: Sanjay S. Patel, PhD, Thurgauerstrasse 130, 8152 Glattpark-Opfikon (Zurich), Switzerland ()
| | | | - Maria Kudela
- Present affiliation: Pfizer, Cambridge, Massachusetts, USA
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Luis Máximo Daneluti A, Offenbecker Guerra L, Valéria Robles Velasco M, do Rosário Matos J, Rolim Baby A, Kalia YN. Preclinical and clinical studies to evaluate cutaneous biodistribution, safety and efficacy of UV filters encapsulated in mesoporous silica SBA-15. Eur J Pharm Biopharm 2021; 169:113-124. [PMID: 34637918 DOI: 10.1016/j.ejpb.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/23/2021] [Accepted: 10/05/2021] [Indexed: 11/25/2022]
Abstract
Innovative technologies have been designed to improve efficacy and safety of chemical UV filters. Encapsulation can enhance efficacy and reduce transdermal permeation and systemic exposure. The aims of this work were (i) to determine the cutaneous biodistribution of avobenzone (AVO), oxybenzone (OXY), and octyl methoxycinnamate (OMC) incorporated in mesoporous silica SBA-15 and (ii) to perform preclinical (in vitro) and (iii) clinical safety studies to demonstrate their innocuity and to evaluate sun protection factor (SPF) in humans. Skin penetration studies showed that deposition of OXY and AVO in porcine and human skin after application of stick formulation with incorporated filters (stick incorporated filters) was significantly lower than from a marketed (non-encapsulated) stick. Cutaneous deposition and transdermal permeation of OXY in and across human skin were 3.8-and 13.4- fold lower, respectively, after application of stick entrapped filters. Biodistribution results showed that encapsulation in SBA-15 decreased AVO and OXY penetration reaching porcine and human dermis. Greater deposition (and permeation) of OXY in porcine skin than in human skin, pointed to the role of follicular transport. Stick incorporated filters had good biocompatibility in vivo and safety profiles, even under sun-exposed conditions. Entrapment of UV filters improved the SPF by 26% and produced the same SPF profile as a marketed stick. Overall, the results showed that SBA-15 enabled safety and efficacy of UV filters to be increased.
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Affiliation(s)
| | | | | | | | - André Rolim Baby
- Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo
| | - Yogeshvar N Kalia
- School of Pharmaceutical Sciences, University of Geneva; Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva.
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12
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Güner MD, Ekmekci PE, Kurtoglu B. Variability of Pharmacogenomics Information in Drug Labels Approved by Different Agencies and Its Ethical Implications. Curr Drug Saf 2021; 17:47-53. [PMID: 34315387 DOI: 10.2174/1574886316666210727155227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/28/2020] [Accepted: 05/03/2021] [Indexed: 11/22/2022]
Abstract
AIMS The aim of this study was to determine if there are discrepancies among various agency-approved labels for the same active ingredient and where the labels approved by the Turkish Medicines and Medical Devices Agency (TMMDA) stand regarding the inclusion of PGx and discuss these ethical implications. BACKGROUND The efficacy and safety of drugs can be improved by rational prescription and personalization of medicine for each patient. Pharmacogenomics information (PGx) in drug labels (DL) is one of the important tools for the personalization of medications because genetic differences may affect both drug efficacy and safety. Providing adequate PGx to patients has ethical implications. OBJECTIVE To evaluate PGx in the DLs approved by TMMDA and other national agencies provided by the Pharmacogenomics Knowledgebase. METHODS DL annotations from the Pharmacogenomics Knowledgebase and DLs approved by the TMMDA were analyzed according to information and action levels, which are "testing required", "testing recommended", "actionable", and "informative". RESULTS There are 381 drugs listed in PharmGKB drug label annotations with pharmacogenomics information and 278 of these have biomarkers. A total of 242 (63.5%) drugs are approved and available in Turkey. Of these, 207 (85.5%) contain the same information as in or similar to that in the labels approved by the other agencies. The presence and level of information varied among the DLs approved by different agencies. The inconsistencies may have an important effect on the efficacy and the safety of drugs. CONCLUSION These findings suggest a need for the standardization of PGx information globally because it may not only affect the efficacy and safety of medications but also essential ethical rules regarding patient rights by violating not sufficiently sharing all available information.
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Affiliation(s)
- Müberra Devrim Güner
- Department of Medical Pharmacology, TOBB Economics and Technology, University School of Medicine, Ankara 06560, Turkey
| | - Perihan Elif Ekmekci
- Department of History of Medicine and Ethics, TOBB Economics and Technology, University School of Medicine, Ankara 06560, Turkey
| | - Berra Kurtoglu
- Department of Medicine, TOBB Economics and Technology, University School of Medicine, Ankara 06560, Turkey
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13
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Alberto EC, Jagannath S, McCusker ME, Keller S, Marsic I, Sarcevic A, O’Connell KJ, Burd RS. Classification strategies for non-routine events occurring in high-risk patient care settings: A scoping review. J Eval Clin Pract 2021; 27:464-471. [PMID: 33249690 PMCID: PMC7961264 DOI: 10.1111/jep.13456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Non-routine events (NREs) are atypical or unusual occurrences in a pre-defined process. Although some NREs in high-risk clinical settings have no adverse effects on patient care, others can potentially cause serious patient harm. A unified strategy for identifying and describing NREs in these domains will facilitate the comparison of results between studies. METHODS We conducted a literature search in PubMed, CINAHL, and EMBASE to identify studies related to NREs in high-risk domains and evaluated the methods used for event observation and description. We applied The Joint Commission on Accreditation of Healthcare Organization (JCAHO) taxonomy (cause, impact, domain, type, prevention, and mitigation) to the descriptions of NREs from the literature. RESULTS We selected 25 articles that met inclusion criteria for review. Real-time documentation of NREs was more common than a retrospective video review. Thirteen studies used domain experts as observers and seven studies validated observations with interrater reliability. Using the JCAHO taxonomy, "cause" was the most frequently applied classification method, followed by "impact," "type," "domain," and "prevention and mitigation." CONCLUSIONS NREs are frequent in high-risk medical settings. Strengths identified in several studies included the use of multiple observers with domain expertise and validation of the event ascertainment approach using interrater reliability. By applying the JCAHO taxonomy to the current literature, we provide an example of a structured approach that can be used for future analyses of NREs.
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Affiliation(s)
- Emily C. Alberto
- Division of Trauma and Burns, Children’s National Hospital, Washington, DC, USA
| | - Swathi Jagannath
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Maureen E. McCusker
- Office of Institutional Research and Decision Support, Virginia Commonwealth University, Richmond, VA, USA
| | - Susan Keller
- Department of Nursing Science Professional Practice and Quality, Children’s National Hospital, Washington, DC, USA
| | - Ivan Marsic
- Department of Electrical and Computer Engineering, Rutgers University, Piscataway, NJ, USA
| | - Aleksandra Sarcevic
- College of Computing and Informatics, Drexel University, Philadelphia, PA, USA
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children’s National Hospital, Washington, DC, USA
| | - Randall S. Burd
- Division of Trauma and Burns, Children’s National Hospital, Washington, DC, USA
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14
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McVey L, Alvarado N, Keen J, Greenhalgh J, Mamas M, Gale C, Doherty P, Feltbower R, Elshehaly M, Dowding D, Randell R. Institutional use of National Clinical Audits by healthcare providers. J Eval Clin Pract 2021; 27:143-150. [PMID: 32307857 DOI: 10.1111/jep.13403] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 01/26/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Healthcare systems worldwide devote significant resources towards collecting data to support care quality assurance and improvement. In the United Kingdom, National Clinical Audits are intended to contribute to these objectives by providing public reports of data on healthcare treatment and outcomes, but their potential for quality improvement in particular is not realized fully among healthcare providers. Here, we aim to explore this outcome from the perspective of hospital boards and their quality committees: an under-studied area, given the emphasis in previous research on the audits' use by clinical teams. METHODS We carried out semi-structured, qualitative interviews with 54 staff in different clinical and management settings in five English National Health Service hospitals about their use of NCA data, and the circumstances that supported or constrained such use. We used Framework Analysis to identify themes within their responses. RESULTS We found that members and officers of hospitals' governing bodies perceived an imbalance between the benefits to their institutions from National Clinical Audits and the substantial resources consumed by participating in them. This led some to question the audits' legitimacy, which could limit scope for improvements based on audit data, proposed by clinical teams. CONCLUSIONS Measures to enhance the audits' perceived legitimacy could help address these limitations. These include audit suppliers moving from an emphasis on cumulative, retrospective reports to real-time reporting, clearly presenting the "headline" outcomes important to institutional bodies and staff. Measures may also include further negotiation between hospitals, suppliers and their commissioners about the nature and volume of data the latter are expected to collect; wider use by hospitals of routine clinical data to populate audit data fields; and further development of interactive digital technologies to help staff explore and report audit data in meaningful ways.
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Affiliation(s)
- Lynn McVey
- School of Healthcare, University of Leeds, Leeds, UK
| | | | - Justin Keen
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Joanne Greenhalgh
- School of Sociology and Social Policy, University of Leeds, Leeds, UK
| | - Mamas Mamas
- School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Chris Gale
- School of Medicine, University of Leeds, Leeds, UK
| | | | | | - Mai Elshehaly
- Faculty of Engineering and Informatics, University of Bradford, Bradford, UK
| | - Dawn Dowding
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Rebecca Randell
- Faculty of Health Studies, University of Bradford, Bradford, UK
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15
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Long BR, Veron P, Kuranda K, Hardet R, Mitchell N, Hayes GM, Wong WY, Lau K, Li M, Hock MB, Zoog SJ, Vettermann C, Mingozzi F, Schweighardt B. Early Phase Clinical Immunogenicity of Valoctocogene Roxaparvovec, an AAV5-Mediated Gene Therapy for Hemophilia A. Mol Ther 2020; 29:597-610. [PMID: 33309883 PMCID: PMC7854299 DOI: 10.1016/j.ymthe.2020.12.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/27/2020] [Accepted: 12/05/2020] [Indexed: 12/13/2022] Open
Abstract
Evaluation of immune responses to adeno-associated virus (AAV)-mediated gene therapies prior to and following dose administration plays a key role in determining therapeutic safety and efficacy. This report describes up to 3 years of immunogenicity data following administration of valoctocogene roxaparvovec (BMN 270), an AAV5-mediated gene therapy encoding human B domain-deleted FVIII (hFVIII-SQ) in a phase 1/2 clinical study of adult males with severe hemophilia A. Patients with pre-existing humoral immunity to AAV5 or with a history of FVIII inhibitors were excluded from the trial. Blood plasma and peripheral blood mononuclear cell (PBMC) samples were collected at regular intervals following dose administration for assessment of humoral and cellular immune responses to both the AAV5 vector and transgene-expressed hFVIII-SQ. The predominant immune response elicited by BMN 270 administration was largely limited to the development of antibodies against the AAV5 capsid that were cross-reactive with other common AAV serotypes. No FVIII inhibitor responses were observed within 3 years following dose administration. In a context of prophylactic or on-demand corticosteroid immunosuppression given after vector infusion, AAV5 and hFVIII-SQ peptide-specific cellular immune responses were intermittently detected by an interferon (IFN)-γ and tumor necrosis factor (TNF)-α FluoroSpot assay, but they were not clearly associated with detrimental safety events or changes in efficacy measures.
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Affiliation(s)
| | - Philippe Veron
- University Pierre and Marie Curie and INSERM U974, Paris, France; Genethon, 91000, Evry, France; Université Paris-Saclay, Univ Evry, INSERM, Genethon, Integrare Research Unit UMR_S951, 91000 Evry, France
| | - Klaudia Kuranda
- University Pierre and Marie Curie and INSERM U974, Paris, France
| | - Romain Hardet
- University Pierre and Marie Curie and INSERM U974, Paris, France
| | | | | | | | - Kelly Lau
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | - Mingjin Li
- BioMarin Pharmaceutical Inc., Novato, CA, USA
| | | | | | | | - Federico Mingozzi
- University Pierre and Marie Curie and INSERM U974, Paris, France; Genethon, 91000, Evry, France; Université Paris-Saclay, Univ Evry, INSERM, Genethon, Integrare Research Unit UMR_S951, 91000 Evry, France
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16
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Abstract
Genome editing tools have already revolutionized biomedical research and are also expected to have an important impact in the clinic. However, their extensive use in research has revealed much unpredictability, both off and on target, in the outcome of their application. We discuss the challenges associated with this unpredictability, both for research and in the clinic. For the former, an extensive validation of the model is essential. For the latter, potential unpredicted activity does not preclude the use of these tools but requires that molecular evidence to underpin the relevant risk:benefit evaluation is available. Safe and successful clinical application will also depend on the mode of delivery and the cellular context.
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Affiliation(s)
- Lydia Teboul
- The Mary Lyon Centre, Medical Research Council Harwell Institute, Harwell Campus, Didcot OX11 0RD, Oxon, UK.
| | - Yann Herault
- Université de Strasbourg, CNRS, INSERM, IGBMC, PHENOMIN-Institut Clinique de la Souris, Celphedia, Strasbourg 67404, France
| | - Sara Wells
- The Mary Lyon Centre, Medical Research Council Harwell Institute, Harwell Campus, Didcot OX11 0RD, Oxon, UK
| | - Waseem Qasim
- Great Ormond Street Institute of Child Health, NIHR Biomedical Research Centre, London WC1N 1EH, UK.
| | - Guillaume Pavlovic
- Université de Strasbourg, CNRS, INSERM, IGBMC, PHENOMIN-Institut Clinique de la Souris, Celphedia, Strasbourg 67404, France.
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17
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Aranaz Ostáriz V, Gea Velázquez de Castro MT, López Rodríguez-Arias F, Valencia Martín JL, Aibar Remón C, Requena Puche J, Díaz-Agero Pérez C, Compañ Rosique AF, Aranaz Andrés JM. Risk Analysis for Patient Safety in Surgical Departments: Cross-Sectional Design Usefulness. Int J Environ Res Public Health 2020; 17:ijerph17072516. [PMID: 32272647 PMCID: PMC7177398 DOI: 10.3390/ijerph17072516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/27/2022]
Abstract
(1) Background: Identifying and measuring adverse events (AE) is a priority for patient safety, which allows us to define and prioritise areas for improvement and evaluate and develop solutions to improve health care quality. The aim of this work was to determine the prevalence of AEs in surgical and medical-surgical departments and to know the health impact of these AEs. (2) Methods: A cross-sectional study determining the prevalence of AEs in surgical and medical-surgical departments was conducted and a comparison was made among both clinical areas. A total of 5228 patients were admitted in 58 hospitals in Argentina, Colombia, Costa Rica, Mexico, and Peru, within the Latin American Study of Adverse Events (IBEAS), led by the Spanish Ministry of Health, the Pan American Health Organization, and the WHO Patient Safety programme. (3) Results: The global prevalence of AEs was 10.7%. However, the prevalence of AEs in surgical departments was 11.9%, while in medical-surgical departments it was 8.9%. The causes of these AEs were associated with surgical procedures (38.6%) and nosocomial infections (35.4%). About 60.6% of the AEs extended hospital stays by 30.7 days on average and 25.8% led to readmission with an average hospitalisation of 15 days. About 22.4% resulted in death, disability, or surgical reintervention. (4) Conclusions: Surgical departments were associated with a higher risk of experiencing AEs.
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Affiliation(s)
- Verónica Aranaz Ostáriz
- Hospital Universitario Sant Joan d’Alacant. Ctra, N-332, s/n, Sant Joan d´Alacant, 03550 Alicante, Spain; (M.T.G.V.d.C.); (A.F.C.R.)
- Correspondence: ; Tel.: +34-676707517
| | | | | | - José Lorenzo Valencia Martín
- Hospital Universitario Ramón y Cajal, IRYCIS. M-607, km 9100, 28034 Madrid, Spain; (J.L.V.M.); (C.D.-A.P.); (J.M.A.A.)
| | - Carlos Aibar Remón
- Hospital Clínico Universitario Lozano Blesa, Avda. San Juan Bosco, 15, 50009 Zaragoza, Spain;
| | - Juana Requena Puche
- Hospital General Universitario de Elda, Ctra, Sax-La Torreta, s/n, Elda, 03600 Alicante, Spain;
| | - Cristina Díaz-Agero Pérez
- Hospital Universitario Ramón y Cajal, IRYCIS. M-607, km 9100, 28034 Madrid, Spain; (J.L.V.M.); (C.D.-A.P.); (J.M.A.A.)
| | - Antonio Fernando Compañ Rosique
- Hospital Universitario Sant Joan d’Alacant. Ctra, N-332, s/n, Sant Joan d´Alacant, 03550 Alicante, Spain; (M.T.G.V.d.C.); (A.F.C.R.)
| | - Jesús María Aranaz Andrés
- Hospital Universitario Ramón y Cajal, IRYCIS. M-607, km 9100, 28034 Madrid, Spain; (J.L.V.M.); (C.D.-A.P.); (J.M.A.A.)
- Center for Biomedical Research in the Epidemiology and Public Health Network (CIBERESP), 28029 Madrid, Spain
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18
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Abstract
There are limitations to the sensitivity and specificity of conventional two-dimensional echocardiograms in making an accurate diagnosis in certain patient populations. This led to the development of specific contrast-enhancing agents with the following characteristics: small enough to cross the pulmonary capillary bed, remain stable throughout the length of the procedure, do not dissolve in blood, and rapidly cleared from the body with low toxicity. Unfortunately, the use of contrast echocardiography has not taken off as expected. The low take-up rate among clinicians can largely be attributed to the black box warning by the United States Food and Drug Administration in 2007, after the coincidental occurrence of four patient deaths and about 190 severe cardiopulmonary reactions shortly after contrast agent administration. In this article, we address the clinical safety of contrast agents, share our institution's experience in using it and elaborate on the clinical indications of contrast echocardiography.
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Affiliation(s)
- Siang Chew Chai
- Department of Cardiology, Changi General Hospital, Singapore
| | - Puay Joo Tan
- Department of Cardiology, Changi General Hospital, Singapore
| | - Khim Leng Tong
- Department of Cardiology, Changi General Hospital, Singapore
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19
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Affiliation(s)
- Fran Pollner
- Department of Pharmacology and Physiology and Department of Family Medicine, Georgetown University Medical Center, Washington, DC
| | - Bonnie O'Connor
- Department of Pediatrics, Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Adriane Fugh-Berman
- Department of Pharmacology and Physiology and Department of Family Medicine, Georgetown University Medical Center, Washington, DC
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20
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Eltorai AS. Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors. J Eval Clin Pract 2019; 25:739-743. [PMID: 30548370 DOI: 10.1111/jep.13086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/07/2018] [Accepted: 11/09/2018] [Indexed: 12/18/2022]
Abstract
RATIONALE AIMS AND OBJECTIVES Pulmonary aspiration is a feared complication of anaesthesia that is associated with significant morbidity and mortality. Within the small existing body of literature on medical malpractice claims related to periprocedural aspiration, very little information is available regarding the case-specific factors that were alleged to contribute to each aspiration event. METHODS This study searched an extensive nationwide database of medical malpractice claims and identified 43 relating to periprocedural pulmonary aspiration. RESULTS The most common mechanism of causation cited in these claims (37%) was the failure to secure the airway with an endotracheal tube (ETT) when an elevated aspiration risk existed, most commonly because endotracheal intubation was not originally selected as part of the anaesthetic plan. The second most common alleged category of causation (33%) was the failure to perform a proper rapid-sequence induction and/or place a nasogastric tube (NGT) for decompression prior to induction. An equal amount of cases resulted in defendant versus plaintiff verdicts (44.2% each), while a settlement was reached in the remaining 11.6% of cases. CONCLUSION These findings are generalizable to clinical practice improvement on a broader scale. They demonstrate the need to develop reliable, high-sensitivity tests for detecting elevated risk before clinicians can be expected to take special steps to protect susceptible patients, and they also show that medical malpractice can be alleged because of failure to uphold currently accepted standards of care even when the published evidence for those standards is weak. This study demonstrates that careful review of medical malpractice litigation can elucidate common contributory factors and facilitate improvements in clinical practice and decision-making.
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Affiliation(s)
- Ashley Szabo Eltorai
- Department of Anesthesiology, Cardiac Division, Yale University School of Medicine, New Haven, Connecticut
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21
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Amer YS, Wahabi HA, Abou Elkheir MM, Bawazeer GA, Iqbal SM, Titi MA, Ekhzaimy A, Alswat KA, Alzeidan RA, Al-Ansary LA. Adapting evidence-based clinical practice guidelines at university teaching hospitals: A model for the Eastern Mediterranean Region. J Eval Clin Pract 2019; 25:550-560. [PMID: 29691950 DOI: 10.1111/jep.12927] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 12/15/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Clinical practice guidelines (CPGs) are significant tools for evidence-based health care quality improvement. The CPG program at King Saud University was launched as a quality improvement program to fulfil the international accreditation standards. This program was a collaboration between the Research Chair for Evidence-Based Healthcare and Knowledge Translation and the Quality Management Department. This study aims to develop a fast-track method for adaptation of evidence-based CPGs and describe results of the program. METHODS Twenty-two clinical departments participated in the program. Following a CPGs awareness week directed to all health care professionals (HCPs), 22 teams were trained to set priorities, search, screen, assess, select, and customize the best available CPGs. The teams were technically supported by the program's CPG advisors. To address the local health care context, a modified version of the ADAPTE was used where recommendations were either accepted or rejected but not changed. A strict peer-review process for clinical content and methodology was employed. RESULTS In addition to raising awareness and building capacity, 35 CPGs were approved for implementation by March 2018. These CPGs were integrated with other existing projects such as accreditation, electronic medical records, performance management, and training and education. Preliminary implementation audits suggest a positive impact on patient outcomes. Leadership commitment was a strength, but the high turnover of the team members required frequent and extensive training for HCPs. CONCLUSION This model for CPG adaptation represents a quick, practical, economical method with a sense of ownership by staff. Using this modified version can be replicated in other countries to assess its validity.
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Affiliation(s)
- Yasser S Amer
- Clinical Practice Guidelines Unit, Quality Management Department, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.,Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.,Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University Medical Council, Alexandria University, Alexandria, Egypt.,Guidelines International Network, Adaptation Working Group (Steering)
| | - Hayfaa A Wahabi
- Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.,Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Manal M Abou Elkheir
- Pharmacy Services, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Ghada A Bawazeer
- Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.,Pharmacy Services, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Shaikh M Iqbal
- Pediatrics Department, King Khalid University Hospital, King Saud University, Hospital, Riyadh, Saudi Arabia.,Department of Pediatrics and Child Health, University of Manitoba, College of Medicine, Manitoba, Canada
| | - Maher A Titi
- Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.,Patient Safety Unit, Quality Management Department, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Aishah Ekhzaimy
- Medicine Department, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Khalid A Alswat
- Medicine Department, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Rasmieh A Alzeidan
- Cardiac Sciences Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Lubna A Al-Ansary
- Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.,Guidelines International Network, Adaptation Working Group (Steering).,Family and Community Medicine Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Health Metrics and Measurement, World Health Organization, Geneva, Switzerland
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22
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Mondoux S, Shojania KG. Evidence-based medicine: A cornerstone for clinical care but not for quality improvement. J Eval Clin Pract 2019; 25:363-368. [PMID: 30977249 DOI: 10.1111/jep.13135] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/10/2019] [Indexed: 11/28/2022]
Abstract
Quality improvement (QI) as a clinical improvement science has been criticized for failing to deliver broad patient outcome improvement and for being a top-down regulatory and compliance construct. These critics have argued that the focus of QI should be on increasing adherence to clinical practice guidelines (CPGs) and, as a result, should be consolidated into research structures with the science of evidence-based medicine (EBM) at the helm. We argue that EBM often overestimates the role of knowledge as the root cause of quality problems and focuses almost exclusively on the effectiveness of care while often neglecting the domains of safety, efficiency, patient-centredness, and equity. Successfully addressing quality problems requires a much broader, systems-based view of health-care delivery. Although essential to clinical decision-making and practice, EBM cannot act as the cornerstone of health system improvement.
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Affiliation(s)
- Shawn Mondoux
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Kaveh G Shojania
- Centre for Quality Improvement and Patient Safety and the Department of Medicine, University of Toronto, Toronto, Canada
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Zeeshan MF, Yousufi Z, Khan D, Malik FR, Ashfaq F, Batool F, Atta L, Tariq H, Huma Z, Ghafoor R, Jamil A, Qazi U. Informed consent practice for obstetric and gynaecologic procedures: A patients' perspective from a developing country. J Eval Clin Pract 2019; 25:491-497. [PMID: 30815974 DOI: 10.1111/jep.13106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/10/2019] [Accepted: 01/13/2019] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To assess the surgical informed consent (SIC) practices for obstetric and gynaecological (OB-GYN) procedures at different hospitals in Pakistan. METHODS Study was conducted in five hospitals (three public and two private) of Peshawar, Pakistan. A pretested structured tablet-based questionnaire was administered from October 2016 through January 2017 among post-op OB-GYN patients. RESULTS About 27% of the patients (significantly more in private hospitals, P = 0.001) did not remember a formal consent administration. Most patients (80%) felt they had no choice about signing the consent. About 65% (mostly in public as compared with private hospitals) mentioned that they would have signed it regardless of the specifics in it (P < 0.001). Patients had increased odds to recall consent if they felt empowered, odds ratio (OR) = 4.5; had an opportunity to ask questions, OR = 7.2; wanted more explanation, OR = 2.8; and had consent administered in their mother tongue, OR = 6.9. DISCUSSION Patients' recall of key elements of consent was low. The time spent with the patient for consenting was much shorter than recommended. The printed consent forms were mostly not available in patients' mother tongue. CONCLUSIONS Consent practice for OB-GYN procedures was suboptimal in studied hospitals. Patients' attitude toward informed consent practices largely reflected providers' focus on obtaining a legally valid signed consent as opposed to administering a consent that empowers patients to make an informed decision in the absence of any external pressure.
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Affiliation(s)
- Muhammad F Zeeshan
- Prime Institute of Public Health, Riphah International University, Islamabad, Pakistan.,Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Zainab Yousufi
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Durdana Khan
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Farhat R Malik
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Fizza Ashfaq
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Fatima Batool
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Lyaba Atta
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Hira Tariq
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Zille Huma
- Department of Health, Khyber Pakhtunkhwa, Pakistan
| | - Rahat Ghafoor
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Ayisha Jamil
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Umair Qazi
- Prime Institute of Public Health, Riphah International University, Islamabad, Pakistan
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Challen R, Denny J, Pitt M, Gompels L, Edwards T, Tsaneva-Atanasova K. Artificial intelligence, bias and clinical safety. BMJ Qual Saf 2019; 28:231-237. [PMID: 30636200 PMCID: PMC6560460 DOI: 10.1136/bmjqs-2018-008370] [Citation(s) in RCA: 302] [Impact Index Per Article: 60.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 11/23/2018] [Accepted: 12/06/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Robert Challen
- EPSRC Centre for Predictive Modelling in Healthcare, University of Exeter College of Engineering Mathematics and Physical Sciences, Exeter, UK .,Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Joshua Denny
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Martin Pitt
- NIHR CLAHRC for the South West Peninsula, St Luke's Campus, University of Exeter Medical School, Exeter, UK
| | - Luke Gompels
- Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Tom Edwards
- Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Krasimira Tsaneva-Atanasova
- EPSRC Centre for Predictive Modelling in Healthcare, University of Exeter College of Engineering Mathematics and Physical Sciences, Exeter, UK
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Abstract
Methoxyflurane is an inhaled analgesic administered via a disposable inhaler which has been used in Australia for over 40 years for the management of pain associated with trauma and for medical procedures in children and adults. Now available in 16 countries worldwide, it is licensed in Europe for moderate to severe pain associated with trauma in conscious adults, although additional applications are being made to widen the range of approved indications. Considering these ongoing developments, we reviewed the available evidence on clinical usage and safety of inhaled analgesic methoxyflurane in trauma pain and in medical procedures in both adults and children. Published data on methoxyflurane in trauma and procedural pain show it to be effective, well tolerated, and highly rated by patients, providing rapid onset of analgesia. Methoxyflurane has a well-established safety profile; adverse events are usually brief and self-limiting, and no clinically significant effects on vital signs or consciousness levels have been reported. Nephrotoxicity previously associated with methoxyflurane at high anesthetic doses is not reported with low analgesic doses. Although two large retrospective comparative studies in the prehospital setting showed inhaled analgesic methoxyflurane to be less effective than intravenous morphine and intranasal fentanyl, this should be balanced against the administration, supervision times, and safety profile of these agents. Given the limitations of currently available analgesic agents in the prehospital and emergency department settings, the ease of use and portability of methoxyflurane combined with its rapid onset of effective pain relief and favorable safety profile make it a useful nonopioid option for pain management. Except for the STOP! study, which formed the basis for approval in trauma pain in Europe, and a few smaller randomized controlled trials (RCTs), much of the available data are observational or retrospective, and further RCTs are currently underway to provide more robust data.
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Affiliation(s)
- Keith M Porter
- Trauma Department, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Sara Dickerson
- Medical Affairs, Mundipharma International Limited, Cambridge, UK,
| | - Paul M Middleton
- Emergency Medicine Research Unit, Liverpool Hospital, Sydney, NSW, Australia
- Distributed Research in Emergency and Acute Medicine (DREAM) Collaboration, Sydney, NSW, Australia
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Hunt KV, Harding AM, Taylor SE, Curtain C. Evaluation of medication dose omissions amongst inpatients in a hospital using an electronic Medication Management System. J Eval Clin Pract 2018; 24:688-694. [PMID: 29786928 DOI: 10.1111/jep.12944] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/18/2018] [Indexed: 12/13/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Whilst many dose omissions cause no patient harm, inappropriate dose omissions have been associated with increased length of hospital stay, risk of sepsis, and mortality. This study aimed to comprehensively describe the prevalence and nature of omitted doses overall and of high risk medication dose omissions in an organization using an electronic Medication Management System. METHODS A retrospective cross-sectional study was undertaken in an Australian tertiary referral health service. All routinely documented electronic inpatient dose administration records from 1st July 2014 to 30th June 2015 were included. Period prevalence and characteristics of dose omissions overall and of high-risk medication dose omissions were determined. RESULTS During the study period, 3.3 million inpatient doses were scheduled for administration, with doses endorsed as "not given" comprising 6.2% of all scheduled doses. Non-valid dose omissions (medication not available or no justification documented) comprised 1.2% of scheduled doses. Patient refusal accounted for one third of all dose omissions, while for 12% no explanation was provided and 7% were endorsed "medication not available". High-risk medications accounted for 20% of all dose omissions. One in 20 antimicrobial doses scheduled were omitted, and of these, 17% were due to patient refusal. CONCLUSION The period prevalence of dose omissions in this large study after electronic Medication Management System implementation is similar to that found when paper charts were used. Although most dose omissions appear appropriate, many orders were not given due to patient refusal or with no documented justification. Interventions to minimize unintentional dose omissions are indicated.
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Affiliation(s)
- Katherine V Hunt
- Pharmacy Department, Austin Health, Studley Rd, Heidelberg, Victoria, Australia, 3084
| | - Andrew M Harding
- Pharmacy Department, Austin Health, Studley Rd, Heidelberg, Victoria, Australia, 3084
| | - Simone E Taylor
- Pharmacy Department, Austin Health, Studley Rd, Heidelberg, Victoria, Australia, 3084
| | - Colin Curtain
- Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
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27
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Taghizadeh-Ghehi M, Ahmadvand A. Comments on "Strategies for reduction in the duration of intravenous drug use: Interest of drug tracers as quality indicators to improve intravenous to oral switch". J Eval Clin Pract 2018; 24:454-455. [PMID: 29193482 DOI: 10.1111/jep.12853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 10/30/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Maryam Taghizadeh-Ghehi
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Ahmadvand
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
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Corey GR, Loutit J, Moeck G, Wikler M, Dudley MN, O'Riordan W; SOLO I and SOLO II investigators. Single Intravenous Dose of Oritavancin for Treatment of Acute Skin and Skin Structure Infections Caused by Gram-Positive Bacteria: Summary of Safety Analysis from the Phase 3 SOLO Studies. Antimicrob Agents Chemother 2018; 62:e01919-17. [PMID: 29358292 DOI: 10.1128/AAC.01919-17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 01/09/2018] [Indexed: 01/01/2023] Open
Abstract
Oritavancin is a lipoglycopeptide with bactericidal activity against Gram-positive organisms. Its rapid concentration-dependent bactericidal activity and long elimination half-life allow single-dose treatment of acute bacterial skin and skin structure infections (ABSSSI). SOLO I and SOLO II were randomized, double-blind studies evaluating the efficacy and safety of a single 1,200-mg intravenous (i.v.) dose of oritavancin versus twice-daily i.v. vancomycin for 7 to 10 days in ABSSSI patients. Safety data from both studies were pooled for safety analysis. The database comprised pooled safety data for 976 oritavancin-treated patients and 983 vancomycin-treated patients. The incidences of adverse events, serious adverse events, and discontinuations due to adverse events were similar for oritavancin (55.3, 5.8, and 3.7%, respectively) and vancomycin (56.9, 5.9, and 4.2%, respectively). The median time to onset (3.8 days versus 3.1 days, respectively) and the duration (3.0 days for both groups) of adverse events were also similar between the two groups. The most frequently reported events were nausea, headache, and vomiting. Greater than 90% of all events were mild or moderate in severity. There were slightly more infections and infestations, abscesses or cellulitis, and hepatic and cardiac adverse events in the oritavancin group; however, more than 80% of these events were mild or moderate. Subgroup analyses did not identify clinically meaningful differences in the incidence of adverse events attributed to oritavancin. A single 1,200-mg dose of oritavancin was well tolerated and had a safety profile similar to that of twice-daily vancomycin. The long elimination half-life of oritavancin compared to that of vancomycin did not result in a clinically meaningful delay to the onset or prolongation of adverse events. (This study has been registered at ClinicalTrials.gov under registration no. NCT01252719 and NCT01252732.).
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Murphy K, Coombes I, Moudgil V, Patterson S, Wheeler A. Clozapine and concomitant medications: Assessing the completeness and accuracy of medication records for people prescribed clozapine under shared care arrangements. J Eval Clin Pract 2017; 23:1164-1172. [PMID: 28471043 DOI: 10.1111/jep.12743] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/24/2017] [Accepted: 02/24/2017] [Indexed: 12/18/2022]
Abstract
RATIONALE, AIM, AND OBJECTIVE The objective of the study is to assess the completeness and accuracy of medication records held by stakeholders (secondary care, general practice, and community pharmacy) for clozapine consumers managed in a shared care programme. METHODS This was an exploratory, descriptive study examining secondary and primary care medication records in a large, urban, public mental health service setting in Queensland, Australia. Consumers (18-65 years old) prescribed clozapine under shared care management with capacity to consent were eligible (n = 55) to participate. Information from medication and dispensing records was used by a pharmacist to compile a best possible medication history for each consumer. Discrepancies were identified through reconciliation of stakeholder records with the history. Discrepancies were defined as an omission, addition, or administration discrepancy (difference in dose, frequency, or clozapine brand). RESULTS Thirty-five (63.6%) consumers consented for records to be reviewed. Overall, 32 (91.4%) consumers had at least 1 discrepancy in their records with a mean of 4.9 discrepancies per consumer. Of 172 discrepancies, 127 (73.8%) were omissions. Primarily, concomitant medicines were omitted in 19/35 (54%) of secondary care records while clozapine was omitted in 13/32 (40.6%) of community pharmacies records. CONCLUSIONS Discrepancies were highly prevalent in the shared care medication records of clozapine consumers of this service. Where there is incomplete and inaccurate medication information, there is a risk of suboptimal clinical decision making, increasing the likelihood of adverse drug events. This study demonstrates a need for improved documentation and timely access to accurate and complete medication records for shared care stakeholders. Expanding the pharmacist's role in this setting could improve medication accuracy in documentation and related communication.
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Affiliation(s)
- Kate Murphy
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Queensland, Australia.,Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Ian Coombes
- Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Vikas Moudgil
- Metro North Mental Health, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Susan Patterson
- Metro North Hospital and Health Service, Herston, Queensland, Australia
| | - Amanda Wheeler
- Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
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30
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Bellandi T, Tartaglia R, Forni S, D'Arienzo S, Tulli G. Adverse events in cardiac surgery, a mixed methods retrospective study in an Italian teaching hospital. J Eval Clin Pract 2017; 23:839-847. [PMID: 28371005 DOI: 10.1111/jep.12727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Adverse events (AEs) are a major concern in surgery, but the evidence in cardiac surgery is limited, especially on the contributory factors. According to the data of the National Outcomes Program, a unit was selected to conduct a mixed methods investigation into the incidence, type, and cause of AE, given its mortality rate that was double the national average on coronary artery bypass grafting, valve reparation, and replacement. METHODS A retrospective investigation on the performance of a cardiac surgery, combining the routinely collected data on process and outcome measures with a 2-stage structured review of 280 medical records performed by 3 expert clinicians, with the support of a methodologist. RESULTS At least one risk had been verified in 137 of 280 cases (48.9%, 95% CI, 43.1-54.8). The total number of AE was 42, with an incidence of 15% (95% CI, 10.8-20.2) and a preventability of 80.9% (95% CI, 69.1-92.8). In 11.9% of AE, the consequence is death, disability in 40.5%, and extended hospital stay in 69% of the cases. Adverse events are associated with problems in care management at the ward (89/137, 64.9%, 95% CI, 56.9-72.9), followed by surgical complications (46/137, 33.6%, 95% CI, 25.7-41.5) and infection/sepsis (32/137, 23.4%, 95% CI, 16.3-30.4). An active error was made by the health care workers in 31 of 42 cases with AE, either during the decision making or during the execution of an action. A total of 36 AEs were due to deficiencies attributed to organizational factors and 31 were linked to poor teamwork. CONCLUSIONS The mixed methods approach demonstrated how a deep understanding of AE and poor performance may emerge thanks to the combination of routinely available data and experts' evaluations. The main limitation of this study is its focus on the cardiac surgery rather than on the entire process of care. The evaluation could have been integrated with on-site observations and the analysis of reported incidents.
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Affiliation(s)
- Tommaso Bellandi
- Department of Health, Tuscany Region, Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Riccardo Tartaglia
- Department of Health, Tuscany Region, Centre for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Silvia Forni
- Osservatorio per la qualità e l'equità, Agenzia Regionale di Sanita della Toscana, Florence, Italy
| | - Sara D'Arienzo
- Osservatorio per la qualità e l'equità, Agenzia Regionale di Sanita della Toscana, Florence, Italy
| | - Giorgio Tulli
- Osservatorio per la qualità e l'equità, Agenzia Regionale di Sanita della Toscana, Florence, Italy
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Vicente Oliveros N, Gramage Caro T, Pérez Menendez-Conde C, Álvarez-Díaz AM, Martín-Aragón Álvarez S, Bermejo Vicedo T, Delgado Silveira E. Effect of an electronic medication administration record application on patient safety. J Eval Clin Pract 2017; 23:888-894. [PMID: 28418101 DOI: 10.1111/jep.12753] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES To evaluate the effect of an electronic medication administration record (eMAR) application on the rate of medication errors in medication administration recording (ME-MAR). METHODS A before-and-after, quasiexperimental study was conducted in a university hospital that implemented the eMAR application in March 2014. Data collection was conducted in April 2012 (pre-) and June 2014 (post-) by two pharmacists. The ME-MARs were analysed by the staff involved to identify their cause. The two pharmacists independently classified the ME-MARs. In the case of disagreement, a research team examined the ME-MARs and categorized them by consensus. Three classifications were used: A classic medication error taxonomy and 2 technology-induced error taxonomies. RESULTS The pharmacists analysed 2835 (pre-) and 2621 (post-) medication administration records (MAR), respectively. Overall, the ME-MAR rate decreased from 48.0% (pre-) to 36.9% (post-) (P < .05). The same types of ME-MAR were observed in both phases except for "MAR with incomplete information," which was not observed in the postimplementation phase. In both phases, the most frequent ME-MAR was "MAR at the wrong time" (MAR before or after medication administration) (31.6% vs 30.2%). The main cause of ME-MARs in both phases was the failure to follow work procedures. The potential future risk of ME-MARs significantly decreased after the eMAR implementation (P < .05). All ME-MARs were "use errors" because of human factors. New ME-MARs (1.24%; n = 12) were observed in the postimplementation phase. CONCLUSION Use of the eMAR application significantly reduces the rate of ME-MAR and their potential risk. The main cause of ME-MAR was the failure to follow work procedures.
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Corny J, Perreau S, Thivilliers AP, Leplay C, Chevalier D, Beaussier H, Bézie Y. Strategies for reduction in the duration of intravenous drug use: Interest of drug tracers as quality indicators to improve intravenous to oral switch. J Eval Clin Pract 2017; 23:848-852. [PMID: 28271587 DOI: 10.1111/jep.12728] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 01/02/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Intravenous (IV) to oral (PO) drug switch is a challenge for tertiary care institutions for several reasons: catheter-related infections, patient's pain and discomfort or higher costs, and overuse of IV drugs considered as an irrational use of medicines. The objective was to evaluate yearly acetaminophen and proton-pump inhibiters' (PPIs) IV/PO ratios from 2011 to 2015 and to determine their correlation with all drugs IV/PO ratios and their relevance as drug tracers. A secondary objective was to estimate costs savings associated with a IV to PO switch improvement. METHODS Data on IV and PO consumptions and impact on costs were presented to physicians yearly, followed by the development of a computerized tool and pharmaceutical validation of prescriptions. Intravenous and PO drug consumptions were extracted yearly for all drugs, acetaminophen, and PPIs from 2011-01-01 to 2015-12-31. Acetaminophen and PPIs' IV/PO ratios were compared to IV/PO consumptions for all drugs. Costs savings associated with this switch were calculated yearly by multiplying the difference in average cost per dose by the total number of doses delivered (fixed purchase prices, euros) for both routes. RESULTS All drugs IV/PO ratio decreased every year to achieve a 16.3% reduction between 2011 and 2015. Acetaminophen and PPIs also decreased respectively by 35.5% and 16.5%. Same tendency of decrease of ratios year by year was noted for all drugs, PPIs, and acetaminophen. Savings for both acetaminophen and PPIs IV/PO switch were over 98 000€ for 5 years. CONCLUSIONS This study demonstrated that acetaminophen IV/PO ratio, easily produced in routine, was a relevant tracer to follow IV/PO switch improvement as it was correlated with all drugs IV/PO ratio. Direct cost savings associated with IV/PO switch improvements were consequent and illustrate well the impact of our approach on the efficiency of therapeutics' management.
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Affiliation(s)
- Jennifer Corny
- Department of Pharmacy, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Simon Perreau
- Department of Pharmacy, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | | | - Céline Leplay
- Department of Pharmacy, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Delphine Chevalier
- Department of Pharmacy, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Hélène Beaussier
- Clinical Research Center, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Yvonnick Bézie
- Department of Pharmacy, Groupe Hospitalier Paris Saint-Joseph, Paris, France
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Young NP, Elrashidi MY, Crane SJ, Ebbert JO. Pilot of integrated, colocated neurology in a primary care medical home. J Eval Clin Pract 2017; 23:548-553. [PMID: 27943579 DOI: 10.1111/jep.12667] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 10/07/2016] [Accepted: 10/10/2016] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Novel health care delivery models are needed to reduce health care use while delivering effective and safe care. We developed a model of a neurologist integrated and colocated in primary care leveraging "curbside," electronic, and traditional consultations. Our objective was to examine the impact on health care resource use of diagnostic testing and referrals for face-to-face neurological consultation and adverse outcomes associated with electronic and curbside consultations. METHODS Consecutive patients from December 1, 2014, to March 13, 2015, were included in the analysis about whom contact was made between a primary care clinician and a colocated neurologist. RESULTS Over 3.5 months of the pilot, 359 unique patients generated 429 consultations (179 curbsides, 68 electronic consultations, and 182 face-to-face visits). The integrated model resulted in avoidance of 78 face-to-face tertiary neurology consultations, 39 brain magnetic resonance imaging, 50 electromyograms, and 53 other advanced imaging studies. Earlier curbside consultation may have prevented unnecessary testing or face-to-face tertiary neurology consultations in 40 (22%) patients. Earlier face-to-face consultation may have avoided expensive testing in 31 (17%) patients. No cases met criteria for an adverse outcome. The number of referrals to tertiary neurology declined by 64%, and the total number of face-to-face visits per month declined by 25%. CONCLUSION Colocated neurology in a primary care medical home offers a promising intervention to deliver high-value care.
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Affiliation(s)
- Nathan P Young
- College of Medicine, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Muhamad Y Elrashidi
- College of Medicine, Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sarah J Crane
- College of Medicine, Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jon O Ebbert
- College of Medicine, Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,College of Medicine, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
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Turner JP, Tervonen HE, Shakib S, Singhal N, Prowse R, Bell JS. Factors associated with use of falls risk-increasing drugs among patients of a geriatric oncology outpatient clinic in Australia: a cross-sectional study. J Eval Clin Pract 2017; 23:361-368. [PMID: 27554195 DOI: 10.1111/jep.12624] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 07/11/2016] [Accepted: 07/12/2016] [Indexed: 01/01/2023]
Abstract
Older people with cancer are at increased risk of falling. Falls risk-increasing drugs (FRIDs), comprising psychotropics and medications that cause orthostatic hypotension, are a potentially modifiable risk factor for falls. The objective of this study was to determine the prevalence and factors associated with use of FRIDs in older people with cancer. Patients aged ≥70 years who presented to a hospital outpatient clinic between January 2009 and July 2010 were included in the study. Information on current medication use, falls in previous 6 months, and frailty criteria was collected. Multinomial logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (CIs) for factors associated with levels of FRID use. Overall, 76.1% (n = 293) of 383 patients used FRIDs. This comprised psychotropics (31.2%, n = 120) and medications causing orthostatic hypotension (69.9%, n = 269). In total, 24.0% (n = 92) patients reported falling in the previous 6 months. Risk factors for falling were associated with use of psychotropics but not orthostatic hypotension drugs. Patients with a history of falls had increased odds of using psychotropics (≥3 psychotropics; OR 13.50; 95%CI, 2.64-68.94). Likewise, frail patients had increased odds of using psychotropics (≥3 psychotropics; OR 27.78; 95%CI, 6.06-127.42). Risk factors for falling were associated with the use of psychotropics. This suggests that clinicians either do not recognize or underestimate the contribution of medications to falls in this high-risk patient group. Further efforts are needed to rationalize medication regimens at the time of patients' first presentation to outpatient oncology services.
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Affiliation(s)
- Justin P Turner
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Hanna E Tervonen
- School of Health Sciences, Centre for Population Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Faculty of Health Science, University of Adelaide, Adelaide, South Australia, Australia
| | - Nimit Singhal
- Department of Medical Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Robert Prowse
- Department of Geriatric and Rehabilitation Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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Beckmann K, Moore J, Wattchow D, Young G, Roder D. Short-term outcomes after surgical resection for colorectal cancer in South Australia. J Eval Clin Pract 2017; 23:316-324. [PMID: 27480799 DOI: 10.1111/jep.12612] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/30/2016] [Accepted: 06/30/2016] [Indexed: 12/24/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVE Short-term outcomes (unplanned readmission, post-surgical complication rates, 30-day and 90-day post-surgical mortality) are often used as indicators of quality of surgical care for colorectal cancer (CRC). Differences in these immediate outcomes can highlight disparities in care across patient subpopulations. This study aimed to document short-term outcomes following major surgery for CRC and to identify whether there were any sociodemographic differences across South Australia (SA). METHODS This population-based study included all CRC resections among SA residents diagnosed with CRC aged 50-79 years in 2003-2008 (n = 3940). Clinical, treatment, comorbidity and outcomes data were compiled through linkage of administrative and surveillance datasets across SA. A retrospective cohort design was used to examine short-term outcomes including post-operative complications, 28-day emergency readmission and 30-day and 90-day mortality. We used multivariable logistic regression to identify factors associated with each outcome. RESULTS Post-operative complications occurred in 28% of cases. Thirty-day and ninety-day mortality were 1.3% and 3%, respectively. Later stage, older age, multiple comorbidities and emergency admissions were associated with poorer short-term outcomes. Risk of complications was lower among patients from higher socio-economic areas (OR = 0.77, 95%CI 0.62-0.98). Risk of 30-day mortality was higher among non-metropolitan patients (OR = 2.33, 95%CI 1.22-4.46). Post-operative complications increased the risk of emergency readmission and short-term mortality. CONCLUSIONS Short-term outcomes following CRC surgery may be improved through strategies to increase earlier detection and reduce emergency admissions. Socioeconomic and regional disparities require further examination of health system factors.
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Affiliation(s)
- Kerri Beckmann
- Centre for Population Health, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - James Moore
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David Wattchow
- Department of General and Digestive Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Graeme Young
- Flinders Centre for Innovation in Cancer, Flinders University, Bedford Park, South Australia, Australia
| | - David Roder
- Centre for Population Health Research, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
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Abstract
Chronic fatigue syndrome/ Myalgic encephalomyelitis (CFS/ME) is a poorly understood seriously debilitating disorder in which disabling fatigue is an universal symptom in combination with a variety of variable symptoms. The only drug in advanced clinical development is rintatolimod, a mismatched double stranded polymer of RNA (dsRNA). Rintatolimod is a restricted Toll-Like Receptor 3 (TLR3) agonist lacking activation of other primary cellular inducers of innate immunity (e.g.- cytosolic helicases). Rintatolimod also activates interferon induced proteins that require dsRNA for activity (e.g.- 2ʹ-5ʹ adenylate synthetase, protein kinase R). Rintatolimod has achieved statistically significant improvements in primary endpoints in Phase II and Phase III double-blind, randomized, placebo-controlled clinical trials with a generally well tolerated safety profile and supported by open-label trials in the United States and Europe. The chemistry, mechanism of action, clinical trial data, and current regulatory status of rintatolimod for CFS/ME including current evidence for etiology of the syndrome are reviewed.
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Affiliation(s)
- William M Mitchell
- a Department of Pathology, Microbiology & Immunology , Vanderbilt University , Nashville , USA
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Altokhais TI, Al-Obaid OA, Kattan AE, Amer YS. Assessment of implementability of an adapted clinical practice guideline for surgical antimicrobial prophylaxis at a tertiary care university hospital. J Eval Clin Pract 2017; 23:156-164. [PMID: 27807920 DOI: 10.1111/jep.12658] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 08/28/2016] [Accepted: 08/29/2016] [Indexed: 12/24/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Surgical site infections are the most common healthcare-associated infections. Appropriate surgical antimicrobial prophylaxis (SAP), which is an integral part of surgical site infection SSI prevention, is one of the major preventable risks to surgical patient safety. Several clinical practice guidelines (CPGs) for SAP have been published. The aim of this study was to adapt a CPG for SAP and to assess its implementability. METHODS The methodology was based on two validated tools for CPGs, namely, the ADAPTE and the Guideline Implementability Appraisal (GLIA). RESULTS The ADAPTE CPG adaptation process methodology was utilized to produce an adapted CPG for SAP based on the American Society of Health System Pharmacists 2013 CPG. The finalized CPG was then assessed to identify any possible intrinsic barriers for implementation. CONCLUSIONS In conclusion, the ADAPTE tool is a practical and successful tool for production of CPGs. The GLIA tool is useful for assessing and preparing the finalized adapted CPG for the transition from the production stage to the implementation stage. GLIA could be added to the ADAPTE process either as a final step or to check the draft of the CPG before finalization.
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Affiliation(s)
- Tariq I Altokhais
- Division of Pediatric Surgery, Department of Surgery, Surgery Departmental CPG Committee, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Omar A Al-Obaid
- Division of Colorectal Surgery, Department of Surgery, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah E Kattan
- Division of Plastic Surgery, Department of Surgery, Surgery Departmental Quality Team, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Yasser S Amer
- Quality Management Department, CPG Steering Committee, Research Chair for Evidence-based Health Care and Knowledge Translation, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
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- King Saud University Medical City, Riyadh, Saudi Arabia
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Shiner B, Ronconi JM, McKnight S, Young-Xu Y, Mills PD, Watts BV. Test-retest reliability of the VA National Center for Patient Safety culture questionnaire. J Eval Clin Pract 2016; 22:985-989. [PMID: 27440380 DOI: 10.1111/jep.12589] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 05/25/2016] [Accepted: 05/25/2016] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Patient safety culture may have a significant influence on safety processes and outcomes. Therefore, it is important to have valid tools to measure patient safety culture in order to identify potential levers for cultural change that could improve patient safety. The 65-item Department of Veterans Affairs Patient Safety Culture Survey (VA PSCS) consists of 14 dimensions and is administered biannually to VA employees. Test-retest reliability of the VA PSCS has not been established. METHODS We conducted repeated administrations of the VA PSCS among 28 VA employees. We measured intraclass correlation coefficients for each item and dimension. RESULTS Test-retest intraclass correlation coefficient values were 0.7 or greater for 13 out of 14 dimensions of the VA PSCS. Employees had difficulty reliably reporting how others feel about patient safety. CONCLUSIONS In general, the VA PSCS survey showed adequate test-retest reliability. Items asking what others think or feel showed lower reliability. Further work is needed to better understand the relationship between safety culture, safety processes and safety outcomes.
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Affiliation(s)
- Brian Shiner
- White River Junction VA Medical Center, White River Junction, USA.,Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Julia M Ronconi
- White River Junction VA Medical Center, White River Junction, USA.,Valley Medical Group, Greenfield, USA
| | | | - Yinong Young-Xu
- VA National Center for Patient Safety, Ann Arbor, USA.,Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Peter D Mills
- VA National Center for Patient Safety, Ann Arbor, USA.,Geisel School of Medicine at Dartmouth, Hanover, USA
| | - Bradley V Watts
- VA National Center for Patient Safety, Ann Arbor, USA.,Geisel School of Medicine at Dartmouth, Hanover, USA
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Moffat S, Skinner J, Fritz Z. Does resuscitation status affect decision making in a deteriorating patient? Results from a randomised vignette study. J Eval Clin Pract 2016; 22:917-923. [PMID: 27237130 PMCID: PMC5111586 DOI: 10.1111/jep.12559] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/11/2016] [Accepted: 04/12/2016] [Indexed: 12/21/2022]
Abstract
AIMS AND OBJECTIVES The aim of this paper is to determine the influence of do not attempt cardiopulmonary resuscitation (DNACPR) orders and the Universal Form of Treatment Options ('UFTO': an alternative approach that contextualizes the resuscitation decision within an overall treatment plan) on nurses' decision making about a deteriorating patient. METHODS An online survey with a developing case scenario across three timeframes was used on 231 nurses from 10 National Health Service Trusts. Nurses were randomised into three groups: DNACPR, the UFTO and no-form. Statements were pooled into four subcategories: Increasing Monitoring, Escalating Concern, Initiating Treatments and Comfort Measures. RESULTS Reported decisions were different across the three groups. Nurses in the DNACPR group agreed or strongly agreed to initiate fewer intense nursing interventions than the UFTO and no-form groups (P < 0.001) overall and across subcategories of Increase Monitoring, Escalate Concern and Initiate Treatments (all P < 0.001). There was no difference between the UFTO and no-form groups overall (P = 0.795) or in the subcategories. No difference in Comfort Measures were observed (P = 0.201) between the three groups. CONCLUSION The presence of a DNACPR order appears to influence nurse decision making in a deteriorating patient vignette. Differences were not observed in the UFTO and no-form group. The UFTO may improve the way nurses modulate their behaviours towards critically ill patients with DNACPR status. More hospitals should consider adopting an approach where the resuscitation decisions are contextualised within overall goals of care.
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Affiliation(s)
- Suzanne Moffat
- Health Sciences, University of East Anglia, Norwich, Norfolk, UK
| | - Jane Skinner
- Department of Medicine, University of East Anglia, Norwich, Norfolk, UK
| | - Zoë Fritz
- Acute Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, Cambridgeshire, UK
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Boriboonhirunsarn D, Watananirun K, Sompagdee N. Decision-to-delivery interval in pregnant women with intrapartum non-reassuring fetal heart rate patterns. J Eval Clin Pract 2016; 22:998-1002. [PMID: 27515180 DOI: 10.1111/jep.12613] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 06/29/2016] [Accepted: 06/30/2016] [Indexed: 12/22/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES It has been proposed that delivery should be accomplished within 30 minutes after diagnosis of fetal distress. The objective of this study was to determine the decision-to-delivery interval (DDI) in emergency caesarean delivery for non-reassuring fetal heart rate (FHR). METHODS A total of 272 term, singleton pregnant women who underwent an emergency caesarean section for non-reassuring FHR were included. Patient characteristics and clinical data were reviewed. The timing of the decision-to-delivery process was reviewed. RESULTS The mean age was 28.7 years; the mean gestational age at delivery was 38.4 weeks; and 93.7% were in FHR category 2. The decision for emergency caesarean delivery was made during normal office hours in 31.6%. Median time for decision-to-operating room, decision-to-incision and decision-to-delivery was 42.3, 48.5 and 56 minutes, respectively. Only 6.6% of women had a DDI of <30 minutes, whereas 30.5% had a DDI of >75 minutes. Significantly shorter intervals were observed for every endpoint among patients in FHR category 3, and they were significantly more likely to deliver within 30 minutes than were those in FHR category 2 (41.2% vs. 4.3%, P < 0.001). Similar results were observed for cases that occurred during normal and after hours. Neonatal outcomes were comparable among different DDI categories. CONCLUSION Only 6.6% of women with non-reassuring FHR achieved the 30-minute goal for caesarean delivery (median 56 minutes). Better performance was observed among patients in FHR category 3 regardless of diagnosis time, with 41.2% of these patients having a DDI of <30 minutes.
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Affiliation(s)
- Dittakarn Boriboonhirunsarn
- Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanokwaroon Watananirun
- Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nalat Sompagdee
- Department of Obstetrics and Gynaecology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Sarkies MN, Bowles KA, Skinner EH, Haas R, Mitchell D, O'Brien L, May K, Ghaly M, Ho M, Haines TP. Do daily ward interviews improve measurement of hospital quality and safety indicators? A prospective observational study. J Eval Clin Pract 2016; 22:792-8. [PMID: 27291891 DOI: 10.1111/jep.12543] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/16/2016] [Accepted: 03/16/2016] [Indexed: 11/26/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES The aim of this study was to determine if the addition of daily ward interview data improves the capture of hospital quality and safety indicators compared with incident reporting systems alone. An additional aim was to determine the potential characteristics influencing under-reporting of hospital quality and safety indicators in incident reporting systems. METHODS A prospective, observational study was performed at two tertiary metropolitan public hospitals. Research assistants from allied health backgrounds met daily with the nurse in charge of the ward and discussed the occurrence of any falls, pressure injuries and rapid response medical team calls. Data were collected from four general medical wards, four surgical wards, an orthopaedic, neurosciences, plastics, respiratory, renal, sub-acute and acute medical assessment unit. RESULTS An estimated total of 303 falls, 221 pressure injuries and 884 rapid response medical team calls occurred between 15 wards across two hospitals, over a period of 6 months. Hospital incident reporting systems underestimated falls by 30.0%, pressure injuries by 59.3% and rapid response medical team calls by 17.0%. The use of ward interview data collection in addition to hospital incident reporting systems improved data capture of falls by 23.8% (n = 72), pressure injuries by 21.7% (n = 48) and rapid response medical team calls by 12.7% (n = 112). Falls events were significantly less likely to be reported if they occurred on a Monday (P = 0.04) and pressure injuries significantly more likely to be reported if they occurred on a Wednesday (P = 0.01). CONCLUSIONS Hospital quality and safety indicators (falls, pressure injuries and rapid response medical team calls) were under-reported in incident reporting systems, with variability in under-reporting between wards and the day of event occurrence. The use of ward interview data collection in addition to hospital incident reporting systems improved reporting of hospital quality and safety indicators.
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Affiliation(s)
| | - Kelly-Ann Bowles
- Monash University/Monash Health, Cheltenham, Victoria, Australia
| | | | - Romi Haas
- Monash University/Monash Health, Cheltenham, Victoria, Australia
| | - Deb Mitchell
- Monash University/Monash Health, Cheltenham, Victoria, Australia
| | - Lisa O'Brien
- Monash University/Monash Health, Cheltenham, Victoria, Australia
| | - Kerry May
- Monash Health, Dandenong, Victoria, Australia
| | | | - Melissa Ho
- Monash University/Monash Health, Cheltenham, Victoria, Australia
| | - Terry P Haines
- Monash University/Monash Health, Cheltenham, Victoria, Australia
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Raza UA, Latif S, Naseer A, Saad M, Zeeshan MF, Qazi U. Introducing a structured prescription form improves the quality of handwritten prescriptions in limited resource setting of developing countries. J Eval Clin Pract 2016; 22:714-20. [PMID: 26991112 DOI: 10.1111/jep.12522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Incomplete or illegible prescriptions can lead to serious errors in administration of the prescribed medication, which can become hazardous. OBJECTIVE Our aim is to determine if a structured prescription form can improve the quality of handwritten prescription in terms of completeness and legibility. METHODS We conducted a prospective, non-randomized, time series study of quality of written prescriptions of general practitioners at a tertiary teaching hospital in Peshawar, Pakistan. The study involved an intervention, composed of the introduction of a pre-printed structured prescription form. The data were collected within 4 weeks including a 2-week pre-intervention phase and 2-week post-intervention phase. Completeness, quality of prescriptions and legibility were compared before and after the intervention of the pre-printed structured prescription form. RESULTS A total of 463 prescriptions were obtained (260 in the pre-intervention phase and 203 in the post-intervention phase). Between pre-intervention phase and post-intervention phase, the Pakistan Medical and Dental Council registration number presence in prescriptions improved from 73.1% to 100% (P < 0.0005). The presence of prescriber's signature improved from 92.7% to 99% (P = 0.001). Drug duration was not missing in 99.5% in post-intervention phase as compared with 90.4% in pre-intervention phase (P < 0.0005). Prescriptions with no legibility problems improved from 76.2% to 94.1% (P < 0.0005). Although not statistically significant, prescriptions in which drug dosage was not missing improved from 85% to 90.6% (P = 0.07). LIMITATIONS We have a limited single-center study. A larger study in multiple settings is needed to develop adequate evidence for such interventions. Subjective nature of prescription legibility can also be considered as a limitation. CONCLUSION Structuring a prescription form alone may improve certain aspects of quality of written prescription in terms of completeness and legibility.
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Affiliation(s)
- Usman Ahmad Raza
- Prime Institute of Public Health, Riphah International University, Islamabad, Pakistan
| | - Sana Latif
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Anum Naseer
- Peshawar Medical College, Riphah International University, Islamabad, Pakistan
| | - Maryam Saad
- Prime Institute of Public Health, Riphah International University, Islamabad, Pakistan
| | | | - Umair Qazi
- Prime Institute of Public Health, Riphah International University, Islamabad, Pakistan. .,Department of Surgery, Johns Hopkins University, Baltimore, Maryland, USA.
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Bernard L, Roche B, Batisse M, Maqdasy S, Terral D, Sautou V, Tauveron I. Development of a cross-disciplinary continuous insulin infusion protocol for non-critically ill patients in a French university hospital. J Eval Clin Pract 2016; 22:683-9. [PMID: 26853219 DOI: 10.1111/jep.12517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2015] [Indexed: 01/18/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES In non-critically ill patients, the use of an insulin syringe pump allows the management of temporary situations during which other therapies cannot be used (failure of subcutaneous injections, awaiting advice from the diabetes team, emergency situations, prolonged corticosteroid therapy, initiation of an artificial nutrition, need for a fasting status, etc.). To manage the risks related to this «never event», the use of a standard validated protocol for insulin administration and monitoring is an essential prerequisite. To this end, a multidisciplinary approach is recommended. METHOD With the support of our subcommission «Endocrinology-Diabetology», we proceeded with a «step-by-step process» to create such a standardized protocol: (1) review of all existing protocols in our hospital; (2) overview of the literature data concerning insulin infusion protocols developed by multidisciplinary teams in France and abroad; (3) development of a standardized protocol for non-intensive care unit patients, respecting the current recommendations and adapting it to the working habits of health teams; and (4) validation of the protocol RESULTS Two protocols based on the same structure but adapted to the health status of the patient have been developed. The protocols are divided in to three parts: (1) golden rules to make the use of the protocol appropriate and safe; (2) the algorithm (a double entry table) corresponding to a dynamic adaptation of insulin doses, clearly defining the target and the 'at risk situations'; and (3) practical aspects of the protocol: preparation of the syringe, treatment initiation and traceability. The protocols have been validated by the institution. CONCLUSION Our standardized insulin infusion protocol is simple, easy to implement, safe and is likely to be applicable in diverse care units. However, the efficiency, safety and the workability of our protocols have to be clinically evaluated.
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Affiliation(s)
- Lise Bernard
- Pôle Pharmacie, CHU Clermont-Ferrand, Clermont-Ferrand, France. .,Clermont Université, Université d'Auvergne, Clermont-Ferrand, France.
| | - Béatrice Roche
- Service d'Endocrinologie-diabétologie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Marie Batisse
- Service d'Endocrinologie-diabétologie, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Clermont Université, Université Blaise Pascal, Clermont-Ferrand, France
| | - Salwan Maqdasy
- Service d'Endocrinologie-diabétologie, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Clermont Université, Université Blaise Pascal, Clermont-Ferrand, France
| | - Daniel Terral
- Service de pédiatrie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Valérie Sautou
- Pôle Pharmacie, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Clermont Université, Université d'Auvergne, Clermont-Ferrand, France
| | - Igor Tauveron
- Service d'Endocrinologie-diabétologie, CHU Clermont-Ferrand, Clermont-Ferrand, France.,Clermont Université, Université Blaise Pascal, Clermont-Ferrand, France
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Prasad GVR. Distinguishing internal property from external property in kidney transplantation. J Eval Clin Pract 2016; 22:539-43. [PMID: 27198733 DOI: 10.1111/jep.12571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 11/29/2022]
Abstract
What determines the ownership of human body parts? In this paper, I argue that this question can be informed by an exploration of the cognitive distinction between property external to the human body such as houses, cars or land, and internal property such as organs that are located within anatomical body confines. Each type of property has distinct brain representations and possibly different effects on the sense of self. This distinction may help explain the divergence in post-donation outcomes seen in different kidney donor populations. Poor outcomes in some types of kidney donors may be due not only to a failure in their proper selection by standard medical testing or post-donation care but may also be a manifestation of differing effects on sense of self resulting from transfer of their internal property. Because a kidney is internal property, a hypothesis worth exploring is that those who experience good outcomes post-donation experience dopaminergic activation and a feeling of reward, while those experiencing bad outcomes are instead overcoming cortisol or adrenergic-based stress or fear responses without a corresponding feeling of reward, disrupting of their sense of self. Discussions about the rules for internal property transfer must be based not only on values and laws designed to govern external property but also on cognitive science-based facts, values and judgments that discussions of external property do not presently accommodate. Any future system of rules for governing organ distribution requires a framework different from that of external property to prevent harm to living kidney donors.
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Affiliation(s)
- G V Ramesh Prasad
- St. Michael's Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, Canada
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Yao C, Xu Y, Chen L, Jiang H, Ki CS, Byun JS, Bian W. Effects of warm acupuncture on breast cancer-related chronic lymphedema: a randomized controlled trial. ACTA ACUST UNITED AC 2016; 23:e27-34. [PMID: 26966410 DOI: 10.3747/co.23.2788] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Effective treatment for breast cancer-related chronic lymphedema (bcrl) remains a clinical challenge. Acupuncture and moxibustion treatments have been shown to be beneficial and safe for treating bcrl. In the present randomized controlled trial, we compared the effectiveness of combined acupuncture and moxibustion ("warm acupuncture") with that of diosmin in bcrl. METHODS Breast cancer patients who met the inclusion and exclusion criteria (n = 30) were randomized to experimental and control groups (15 per group). On alternate days, patients in the experimental group received 30 minutes of acupuncture at 6 acupoints, with 3 of the needles each being topped by a 3-cm moxa stick. The control treatment was diosmin 900 mg 3 times daily. The control and experimental treatments were administered for 30 days. Outcome measures included arm circumferences (index of effectiveness), range of motion [rom (shoulder joint function)], quality of life, clinical safety, and adverse events. RESULTS Measured by the index of effectiveness, bcrl improved by 51.46% in the experimental group and by 26.27% in the control group (p < 0.00001). Effects were greatest at 10 cm above the elbow and at the wrist, where the warm needling was provided. Impairments in shoulder joint rom were minimal at baseline in both treatment groups. However, the roms of rear protraction, abduction, intorsion, and extorsion in the experimental group improved significantly; they did not change in the control group. Self-reported quality of life was significantly better with warm acupuncture than with diosmin. No adverse effects were reported during the treatment period, and laboratory examinations for clinical safety fell within the normal ranges. CONCLUSIONS Compared with diosmin, warm acupuncture treatment can effectively reduce the degree of bcrl at the specific acupoints treated and can promote quality of life. Warm acupuncture showed good clinical safety, without any adverse effects on blood or the cardiovascular system.
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Affiliation(s)
- C Yao
- Department of Breast Disease, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, P.R.C
| | - Y Xu
- Department of Breast Disease, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, P.R.C
| | - L Chen
- Department of Breast Disease, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, P.R.C
| | - H Jiang
- Department of Breast Disease, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, P.R.C
| | - C S Ki
- Hospital of the Catholic University of Daegu, Daegu, South Korea
| | - J S Byun
- Department of Internal Medicine, College of Korean Medicine, Daegu Haany University, Daegu, South Korea
| | - W Bian
- Department of Breast Disease, Affiliated Hospital of Nanjing University of Traditional Chinese Medicine, Nanjing, P.R.C
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Abstract
OBJECTIVES Although most health care interactions in the developed world occur in general practice, most of the literature on patient safety has focused on secondary care services. To address this issue, we have constructed a patient safety toolkit for English general practices. We report how practice and respondent characteristics affect scores on our safety climate measure, the PC-Safequest, and address recent concerns with high levels of workload in English general practices. METHODS We administered the PC-Safequest, a 30-item tool that was designed to measure safety climate in primary care practices, to 335 primary care staff members in 31 practices in England. Practice characteristics, such as list size and deprivation in the area the practice served, and respondent characteristics, such as whether the respondent was a manager, were also collected and used in a multilevel analysis to predict PC-Safequest scores. RESULTS Managers gave their practices significantly higher safety climate scores than did non-managers. Respondents with more years of experience had a more negative perception of the level of workload in their practice. Practices with more registered patients and in areas of higher deprivation provided lower safety climate scores. CONCLUSIONS Managers rated their practices more positively on our safety climate measure, so the differences between the perceptions of managers and other staff may need to be reduced in order to build a strong safety culture. Excessive workload for more experienced staff and lower safety climate scores for larger practices may reflect 'burnout'. Concerns that pressures in primary care could affect patient safety are discussed.
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Affiliation(s)
- Brian G Bell
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - David Reeves
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Kate Marsden
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Anthony Avery
- Division of Primary Care, University of Nottingham, Nottingham, UK
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47
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Abstract
RATIONALE, AIMS AND OBJECTIVES A current medication plan was identified as important patient safety factor. Information is needed on how many patients possess such a plan and what problems can be identified with its use. This study tried to define factors that influence accuracy of medication plans and to detect discrepancies from planned and actually administered medication in polypharmacy patients. METHODS Participants of the 'Apo-AMTS' course in Germany evaluated medication plans from their patients during performing medication reviews in community pharmacies. Discrepancies were defined as additional or missing drugs and deviations in dosage and drug names for Rx drugs and missing or additional self-medication. RESULTS Eighty per cent of the patients possessed a medication plan mainly written by general practitioners. Only 6.5% of the plans showed no discrepancies. Most discrepancies were seen on medication plans written by medical specialists and general practitioners, mainly name aberrations (41%) followed by additional drugs taken (30%) and prescribed drugs no longer taken (18%). Dosage variance was seen in 11% of all discrepancies. Deviations from the plan were observed frequently with antihypertensives (31.4%), analgesics (11.3%) and antidepressants/hypnotics as well as lipid-lowering drugs (6.7%). Four hundred thirty-three OTC drugs were not listed, mainly analgesics, mineral supplements and laxatives. CONCLUSION Many patients possess a medication plan but most of these plans showed discrepancies which limits the use as patient safety indicator. Community pharmacies offering medication reviews have an essential position to use the medication plan as a central link between patients and their prescribers, and therefore improve patient safety.
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Affiliation(s)
| | | | - Georg Hempel
- Department of Pharmaceutical and Medicinal Chemistry - Clinical Pharmacy, Westfälische Wilhelms-Universität, Muenster, Germany
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48
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Dischinger HR, Cheng E, Mann AD, Grueber TM, Hawk S, Davis LA, Prochazka AV, Hutt E, Caplan L. Decisional support to prevent adverse drug reactions of long latency: pilot randomized controlled intervention for glucocorticoid-induced diabetes. J Eval Clin Pract 2015; 21:614-9. [PMID: 25851076 DOI: 10.1111/jep.12351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2015] [Indexed: 12/15/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Long-term exposure to glucocorticoids can cause adverse drug reactions of long latency (ADRLLs), including glucocorticoid-induced diabetes mellitus (GID). Providers can monitor for GID using the glycosylated haemoglobin blood (HbA1C) test. This study examined the utility of decisional support to improve HbA1C-based screening for GID. US veterans were identified as chronic users of oral glucocorticoids (>120 days of oral glucocorticoids in the last 2 years). The primary care providers caring for these patients were the target of the intervention. Providers were randomized to receive automatic HbA1C orders for their patients receiving chronic glucocorticoid or usual care. METHODS This study was a pilot two-arm, group-randomized, controlled trial (n = 12 providers, n = 38 patients). Data collection occurred from 5 May 2013 until 10 January 2014. A pharmacist generated the order for an HbA1C through the electronic medical record. The time between the intervention start date and the date on which an HbA1C order was signed were compared using Cox proportional and hierarchical linear regression. RESULTS The time to sign HbA1C orders (mean 12.0 days for the intervention arm; 104.0 days for control arm) was associated with significant differences favouring the intervention [HR (Hazard Ratio) 50.2, P < 0.001, confidence interval (CI) 6.3 to 398.7]. For the intervention group, 95% of orders were signed, whereas only 12% of control providers signed orders (odds ratio 150, P < 0.001, CI 12.4 to 1812.9). CONCLUSIONS The results of this study strongly suggest that the clinical pharmacist-triggered order intervention is effective. This method of computerized decisional support may be useful in improving screening for GID and ADRLLs.
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Affiliation(s)
- Hannah R Dischinger
- Internal Medicine, Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA.,Research, University of Colorado School of Medicine, Denver, CO, USA
| | - Elizabeth Cheng
- Internal Medicine, Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA.,Research, University of Colorado School of Medicine, Denver, CO, USA
| | - Alyse D Mann
- Internal Medicine, Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA.,Research, University of Colorado School of Medicine, Denver, CO, USA
| | - Tiffany M Grueber
- Pharmacy, Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA
| | - Sherri Hawk
- Pharmacy, Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA
| | - Lisa A Davis
- Internal Medicine, Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA.,Research, University of Colorado School of Medicine, Denver, CO, USA.,Rheumatology, Denver Health Medical Center, Denver, CO, USA
| | - Allan V Prochazka
- Internal Medicine, Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA.,Research, University of Colorado School of Medicine, Denver, CO, USA
| | - Evelyn Hutt
- Internal Medicine, Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA.,Research, University of Colorado School of Medicine, Denver, CO, USA
| | - Liron Caplan
- Rheumatology Section, Research, Denver Veterans Affairs Medical Center (VAMC), Denver, CO, USA.,Research, University of Colorado School of Medicine, Denver, CO, USA
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49
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Abstract
RATIONALE, AIMS AND OBJECTIVES Challenging clinical encounters can often be frustrating and demoralizing not only for clinicians but also for patients. The paper's aims are twofold. The first is to analyse the nature and origins of such encounters. The second is to appraise the CALMER and REBELS models for managing them. METHODS After reviewing the medical literature on challenging clinical encounters, a clinical case is briefly reconstructed from it. The reconstructed case is then used to analyse the nature and origins of challenging encounters and to evaluate the two models for handling them. RESULTS The reconstructed clinical case is an apt example for examining and evaluating the medical literature on challenging clinical encounters. In terms of what challenging encounters are and what elicits them, the literature captures their frustrating, demoralizing, demanding and, at times, insufferable dimensions - as well as the role of patients in their origins - as the clinical case also illustrates. With respect to managing them, the CALMER and REBELS models are effective strategies for handling challenging encounters - again, as the clinical case exemplifies. CONCLUSIONS Although the clinical case supports the medical literature on challenging clinical encounters, the literature fails to provide an adequate account of their nature and origins. Specifically, challenging encounters are a type of dysfunction - not pathophysiological but existential - in a clinical setting, with their origins not only in patients but also in clinicians and health care systems. Finally, based upon the dysfunctional nature of such encounters, revisions of the CALMER and REBELS models are proposed for better managing these encounters.
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Affiliation(s)
- James A Marcum
- Department of Philosophy and Medical Humanities Program, Baylor University, Waco, TX, USA
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50
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Abstract
Methoxyflurane is a volatile, halogenated analgesic, self-administered in a controlled low dose from the Penthrox(®) inhaler for short-term pain relief. It was formerly used in significantly higher doses to produce anaesthesia, when it caused a specific type of dose-related renal tubular damage. The pathogenesis of the renal damage and clinical use of methoxyflurane are discussed here with evidence that a low but effective analgesic dose is not associated with the risk of renal adverse effects. The maximum dose employed to produce analgesia is limited to methoxyflurane 6 mL/day and 15 mL/week, producing a minimum alveolar concentration (MAC) of 0.59 MAC-hours. Renal damage is due to the metabolism of methoxyflurane and release of fluoride ions. Exposure of humans to methoxyflurane ≤2.0 MAC-hours, resulting in serum fluoride ≤40 µmol/L, has not been associated with renal tubular toxicity. The safety margin of analgesic use of methoxyflurane in the Penthrox ((®)) inhaler is at least 2.7- to 8-fold, based on methoxyflurane MAC-hours or serum fluoride level, with clinical experience suggesting it is higher. It is concluded from clinical experience in emergency medicine, surgical procedures and various experimental and laboratory investigations that the analgesic use of methoxyflurane in subanaesthetic doses in the Penthrox inhaler does not carry a risk of nephrotoxicity.
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