HIV Pharmacist's Impact on Inpatient Antiretroviral Errors.

OBJECTIVES: Transitions in care between out-patient and in-patient settings provide ample opportunity for medication errors to occur in HIV-infected patients. The purpose of this study was to examine the effectiveness of an HIV pharmacist monitoring service in decreasing antiretroviral medication errors in a large south central teaching hospital in the USA. METHODS: A retrospective, observational study was conducted to examine the frequency of antiretroviral medication errors in HIV-seropositive patients with hospital admissions between 1 September 2011 and 30 September 2013 at a single tertiary care centre in Oklahoma. Patient assignment to the 12-month pre-intervention and intervention study periods was determined by admission date. Demographic, laboratory, and in-patient medication data were collected. Bivariate analyses were conducted using χ2 analysis with the Yates correction factor for continuity to examine frequencies in specific antiretroviral classes and error categories. A multivariable Poisson regression was employed to examine the frequency of medication errors before and after initiation of the pharmacist service. RESULTS: Medication errors were examined in a total of 330 patient admissions during the 2-year study period. A multivariable-adjusted decrease of 73.9% in the number of errors was observed between the pre-intervention and intervention periods (P < 0.001). Patients on protease inhibitor regimens or with impaired renal function had 2.6-fold and 2.8-fold higher numbers of errors, respectively (P < 0.001). CONCLUSIONS: HIV pharmacist monitoring can decrease medication errors in HIV-infected patients as they transition between out-patient and in-patient care. Patients receiving protease inhibitor-based therapy or with renal insufficiency are at higher risk for medication errors upon admission.

The first 1000 patients on an internet-based colorectal neoplasia database across private and public medicine in Australia: development of a binational model for the Colorectal Surgical Society of Australia and New Zealand.

BACKGROUND: Collection of multi-institutional data pertaining to the treatment of bowel cancer has been hindered by poor clinician compliance with data entry and the lack of incentive to participate. OBJECTIVE: This study aimed to establish if a novel browser-based model of data collection results in complete data capture. DESIGN: A Web-based data collection interface was custom written, offering automated reporting modules for clinical outcome to participants and an automated reporting system for outstanding data fields, and summary reporting of surgical quality outcomes. The software was combined with a clinical feedback system incorporating fortnightly data review meetings, at the time of clinical multidisciplinary meetings. PATIENTS AND SETTING: Selected were 932 consecutive patients with opt-out consent from 3 hospital sites, including public and private medicine. MAIN OUTCOME MEASURES: The primary outcomes measured were the analysis of data completeness and accuracy and ensuring that the highest-quality data were used for clinical audit of the surgical practices of Australian colorectal surgeons for the purpose of quality assurance. RESULTS: A total of 932 men and women, 22 to 94 years of age, treated for colorectal neoplasia were evaluated. We obtained 100% completion (>27,000 data points) of perioperative data registered by 8 specialist colorectal surgeons and a full-time database manager. CONCLUSIONS: Data completeness and validity are essential for clinical databases to serve the purpose of quality assurance, benchmarking, and research. The results confirm the safety and efficacy of colorectal cancer surgery in both the public and private sector in Australia. The combination of a simple multiuser interface, defined data points, automated result-reporting modules, and data-deficiency reminder module resulted in 100% data compliance in nearly 1000 clinical episodes. The unprecedented success of this model has lead to the Colorectal Surgical Society of Australia and New Zealand adopting this model for data collection for Australia and New Zealand as the binational database.

Clinical and endorectal ultrasound staging of circumferential rectal cancers.

Circumferential rectal cancers present at a more advanced stage than those located in a single quadrant. Although accurate staging is an important aspect of the preoperative management of the patient with a rectal cancer, the clinical and radiological staging of this subgroup of rectal cancer patients has been poorly studied. All patients with a rectal cancer were assessed clinically (by digital rectal examination and rigid sigmoidoscopy) before the radiological assessment by endorectal ultrasound (ERUS). Data collected included tumour height (distance from anal verge in centimetre) and tumour type (circumferential or non-circumferential). Radiological tumour staging was with the TNM system. Fifty-nine subjects (33 men, 26 women; median age 65 years (range 38-86 years)) were identified with a circumferential rectal cancer. Mean height of the cancer was 8 +/- 0.4 cm (standard error of the mean; range 2-13 cm). Forty-two cancers were palpable, and 17 cancers were impalpable. All cancers assessed clinically as circumferential were confirmed as circumferential on ERUS scanning. Tumour stage as assessed by ERUS was either T3 (n = 57) or T4 (n = 2). Nodal status was N0 (n = 29) and N1 (n = 30). All rectal cancers assessed as circumferential on clinical examination have an ERUS stage of T3 or greater.

Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following diagnostic colonoscopy.

Colonic perforation is an unusual complication of colonoscopy. We present a case of pneumothorax, pneumomediastinum, pneumoperitoneum and extensive subcutaneous emphysema resulting from a diagnostic colonoscopy. To our knowledge, only two such cases have been described previously.

5-aminosalicyclic acid and olsalazine inhibit tumor growth in a rodent model of colorectal cancer.

The ability of 5-aminosalicylic acid and olsalazine to inhibit colonic aberrant crypts and tumors was investigated in 1,2-dimethylhydrazine-treated rats. The effect of these drugs on the rates of tumor apoptosis and proliferation was studied as potential mechanisms for their action. 5-Aminosalicylic acid reduced the number of aberrant crypt foci by over one third, while olsalazine had no effect on this parameter. However, both agents effectively reduced tumor number and load, increased the rate of tumor apoptosis, and reduced the rate of tumor cell proliferation. In conclusion, 5-aminosalicylic acid and olsalazine are both ultimately effective chemopreventive agents in this model; however, only 5-aminosalicylic acid inhibited the formation of aberrant crypt foci. The inhibitory effect of these agents in tumors is related to the inhibition of proliferation and the induction of apoptosis.

Methods for measuring and monitoring medication regimen adherence in clinical trials and clinical practice.

Researchers and clinicians have used numerous methods in their attempts to adequately assess patient compliance (adherence) with medication regimens and to identify noncompliant patients. Large variations have been reported in the extent of noncompliance in individual patients and large populations. In addition, nonadherence has often been poorly defined. Direct measures of adherence include drug assays of blood or urine, use of drug markers with the target medication, and direct observation of the patient receiving the medication. Indirect measures of adherence imply that the medication has been used by the patient; these measures include various forms of self-reporting by the patient, medication measurement (pill count), use of electronic monitoring devices, and review of prescription records and claims. Compliance measures should be assessed on the basis of their validity (sensitivity and specificity or statistical correlation) and the reference standard used. Many early studies used pill counts as a reference standard, but electronic monitoring devices such as the Medication Event Monitoring System have replaced pill counts as the reference standard. The choice of a method for measuring adherence to a medication regimen should be based on the usefulness and reliability of the method in light of the researcher's or clinician's goals. Specific methods may be more applicable to certain situations, depending on the type of adherence being assessed, the precision required, and the intended application of the results.

Effectiveness of prostaglandin E2 intracervical gel (Prepidil), with immediate oxytocin, versus vaginal insert (Cervidil) for induction of labor.

OBJECTIVE: Our purpose was to compare the effectiveness of labor induction with use of prostaglandin E2 either as an intracervical gel (Prepidil), with immediate oxytocin, or as a sustained-release vaginal insert (Cervidil) with subsequent oxytocin as needed. STUDY DESIGN: Hospitalized patients at >/=37 weeks' gestation requiring labor induction and having an unfavorable cervix (Bishop score

The case for sunscreens. A review of their use in preventing actinic damage and neoplasia.

BACKGROUND: Recent controversy surrounding sunscreens has stimulated a reexamination of their use. The purposes of this article are to weigh the evidence regarding the value of sunscreens in preventing actinic damage and neoplasia and to evaluate the merit of objections that have been raised against their use for this purpose. Scientific aspects of damage from UV light, neoplasia, and sunscreens are reviewed. The value of sunscreen use in preventing actinic damage is discussed and a number of sunscreen controversies are revisited. OBSERVATIONS: The evidence favors the safety and efficacy of sunscreens for the prevention of actinic damage, melanoma, and nonmelanoma skin cancer. CONCLUSION: Sunscreens continue to be a practical and useful tool for the prevention of actinic damage and neoplasia.

Off-label prescribing during pregnancy.

Obstetricians frequently prescribe drugs for indications other than those on the product label. Reasons for such off-label use during pregnancy include prevention of repetitive abortion, inhibition of premature labor, reduction of fetal or neonatal infection, reduction in development of preeclampsia and its complications, and ripening of the cervix or induction of labor. A physician has a legal right to prescribe for off-label indications despite regulatory, manufacturer, and cost constraints. Such prescribing habits would not be considered experimental if based on sound scientific evidence. Adequate and well-controlled studies are difficult, however, to perform during pregnancy. Evidence of widespread use and support from another qualified clinician are methods of justifying off-label prescribing. Each patient is entitled to know why she and her fetus would benefit from the treatment and whether any unnecessary risk is anticipated. Legible documentation of these discussions in the medical records is important.

Patterns of uterine activity. Using oxytocin after intracervical PGE2.

OBJECTIVE: To compare patterns of uterine activity from low-dose oxytocin begun immediately or six hours after intracervical placement of prostaglandin E2 (PGE2) gel for the induction of labor. STUDY DESIGN: A total of 50 nonlaboring women at term with an unfavorable cervix (Bishop score < or = 4) were given a 0.5-mg dose of PGE2 gel. Each was then randomized either to be observed or to receive a low dose of oxytocin (2 mU/min, increased by 2 mU/min at 30-minute intervals, as necessary). After the six-hour observation, the patient was reexamined, and a low dose of oxytocin was either begun or continued. An adequate sample size (21 per group) was calculated for evaluating uterine activity changes. Comparisons were made using chi 2 testing, Student's t test and analysis of variance, as appropriate. RESULTS: There were no differences between the two groups in maternal race, gestational age, predose Bishop score, predose uterine activity or indication for induction. Uterine contractions became more frequent (P < .01) and were judged to be more intense (P < .02) and earlier when oxytocin was used immediately after PGE2 placement. No uterine hyperstimulation or abnormal fetal heart rate pattern was observed that required discontinuation of the oxytocin. The percentages of cases delivering vaginally within 24, 36 and 48 hours were greater when oxytocin was begun immediately in nullipara (P < .01). CONCLUSION: Low-dose oxytocin may be started immediately after instilling intracervical PGE2, with shortened time until the onset of adequate contractions.

A cost-minimization analysis of intracervical prostaglandin E2 for cervical ripening in an outpatient versus inpatient setting.

This investigation was undertaken to compare the cost impact of prostaglandin E2 gel delivered intracervically in an outpatient versus an inpatient setting. Eligible pregnant women with a singleton gestation that was beyond 37 weeks gestational age and who had an unfavorable cervix (Bishop score < or = 4) received a single dose of 0.5 mg of prostaglandin E2 intracervically as an outpatient or one or more doses as an inpatient the day before a scheduled induction of labor. After gel placement, the outpatient group was monitored for 2 hours with electronic fetal monitoring before being sent home, while the inpatient group was monitored for 2 hours in a labor and delivery unit and then sent to the maternity unit overnight. The outpatient (n = 40) and inpatient (n = 36) groups were not different in terms of maternal age, race, parity, gestational age, maternal weight, predose Bishop score, or indication for delivery. Patients in the outpatient group incurred significantly less costs ($3835.00 +/- 2172.00 vs $5049.00 +/- 2060.00) and time (74.4 +/- 33.1 hours vs 100.3 +/- 41.6 hours) in the hospital than did patients in the inpatient group. Multiparous patients in the outpatient group, compared with those in the inpatient group, spent fewer total hours in the hospital (56.6 +/- 19.3 vs 90.3 +/- 41.0 hours) and had a lower hospital cost ($2891.00 +/- 1236.00 vs $4704.00 +/- 2100.00). The only difference between the nulliparous groups favored outpatient therapy because of less intrapartum expenses ($730.00 +/- 405.00 vs $1036.00 +/- 487.00). There were no differences between the inpatient and outpatient groups for the frequencies of failed inductions, abnormal fetal heart rate patterns, and cesarean sections. No adverse maternal or neonatal effects with therapy were encountered in either setting. Substantial cost savings were found with prostaglandin E2 therapy in an outpatient rather than an inpatient setting for patients who required an induction of labor and were candidates for outpatient cervical ripening.

Sun exposure, sunscreens, and skin cancer prevention: a year-round concern.

OBJECTIVE: To review the role of sunlight in skin aging and skin cancer formation, and to provide guidelines on the use of sunscreens to minimize the adverse effects of sun damage. DATA SOURCES: A MEDLINE search of applicable articles on ultraviolet (UV) radiation, melanoma, sunscreens, and skin cancer, evaluating both human and animal studies. Published and unpublished original research as well as clinical experience were also used. DATA SYNTHESIS: The interaction of UV radiation and skin type plays a central role in melanoma formation. Mortality from melanoma is highest in geographic locations near the equator, where UV intensity is greatest. The incidence of melanomas in light-complected individuals (skin types I-III) is several times higher than those with darker skin types (types IV-VI), even in similar geographic regions. The UVB portion of the spectrum appears to be primarily responsible for skin cancer formation and photoaging, while short wave UVA rays play a significant contributing role. Regular sunscreen use has been shown to reduce the formation of precancerous actinic keratoses (AK) lesions by 36%. A dose-response relationship has also been found between the amount of sunscreen used and AK formation. CONCLUSIONS: Sunscreens have now been shown to reduce the carcinogenic effects of sunlight in humans. Patients should be advised of the long-term consequences of sun exposure and the benefits of regular sunscreen use.

Caffeine phenotyping of cytochrome P4501A2, N-acetyltransferase, and xanthine oxidase in patients with familial adenomatous polyposis.

Patients with familial adenomatous polyposis (FAP) and age and sex matched controls were tested for cytochrome P4501A2 (CYP1A2), N-acetyltransferase, and xanthine oxidase activities using caffeine urinary metabolites as a discriminator. FAP patients showed significant underactivity of N-acetyltransferase (which inactivates some carcinogens) and significant overactivity of CYP1A2 (which activates some carcinogens). Xanthine oxidase activity, which can generate free radicals and cause cellular damage, was significantly increased in the FAP patients. All but one of the FAP patients had undergone colectomy. A separate group of six patients was therefore assessed before and at an average time of eight weeks after colectomy. No effect on enzyme activity was seen. The differences in enzyme activities detected in this study could produce an excess of active carcinogenic metabolites in the bile of FAP patients and contribute to the high risk for intestinal cancer in FAP.