Comprehensive pharmaceutical care to prevent drug-related readmissions of dependent-living elderly patients: a randomized controlled trial.

BACKGROUND: Elderly patients are vulnerable to adverse drug reactions (ADRs). Drug-related readmissions (DRRs) can be a major consequence of ADR. Therefore, this study aimed to investigate the effects of a ward-based, comprehensive pharmaceutical care service on the occurrence of DRRs as the endpoint in dependent-living elderly patients. METHODS: A randomized, controlled trial was performed at a German University Hospital. Patients fulfilling the following criteria were eligible: admission to a cooperating ward, existing drug therapy at admission, 65 years of age and older, home-care or nursing home residents in ambulatory care, and a minimum hospital stay of three days. Patients received either standard care (control group) or pharmaceutical care (intervention group). Follow-up consultations were conducted for each patient at 1, 8, 26, and 52 weeks after discharge. The time to DRR was defined as the primary outcome measure and was analysed using the log-rank test. The Cox-proportional hazard model was used for risk factor analysis. RESULTS: Sixty patients (n = 31 intervention group, n = 29 control group) participated in the study. For patients in the intervention group, the median time to DRR was prolonged; however, the level of statistical significance was not reached (log-rank test P = 0.068; HR = 3.28, P = 0.086). When the risk factors 'age' or 'length of stay on the ward' were added to the Cox proportional hazard model, patients in the control group exhibited a significantly higher risk of experiencing a DRR than patients of the intervention group (HR = 4.62; P = 0.028 including age and HR = 5.76; P = 0.033 including length of stay on the ward). CONCLUSIONS: Our findings demonstrate the successful implementation of ward-based, comprehensive pharmaceutical care for dependent-living elderly. Despite a low participation rate, which led to an underpowered study, the results provide a preliminary efficacy signal and effect size estimates to power a definitive trial. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01578525 , prospectively registered April 13, 2012.

Risk factors for morbidity after appendectomy.

INTRODUCTION: The aim of the present study was to evaluate the risk factors for postoperative complications after an appendectomy with special regard to both the time period from hospital admission to operation and night time surgery. PATIENTS AND METHODS: Patients who underwent an appendectomy due to acute appendicitis and were admitted to the University Hospital Aachen between January 2003 and January 2014 were included in this retrospective analysis. Regarding the occurrence of postoperative complications, patients were divided into the following two groups: the group with complications (group 1) and the group without complications (group 2). RESULTS: Of the 2136 patients who were included in this study, 165 patients (group 1) exhibited complications, and in 1971 patients (group 2), no complications appeared. After a univariate logistic regression analysis, six predictors for postoperative complications were found and are described as follows: (1) complicated appendicitis (odds ratio (OR) 4.8 (3.46-6.66), p < 0.001), (2) operation at night (OR 1.62 (1.17-2.24), p = 0.004), (3) conversion from laparoscopic to open access (OR 37.08 (12.95-106.17), p < 0.001), (4) an age > 70 years (OR 6.00 (3.64-9.89), p < 0.001), (5) elevated CRP (OR 1.01 (1.01-1.01), p < 0.001) and (6) increased WBC count (OR 1.04 (1.01-1.07), p = 0.003). After multivariate logistic regression analysis, a significant association was demonstrated for complicated appendicitis (1.88 (1.06-3.32), p < 0.031), conversion to open access (OR 16.33 (4.52-58.98), p < 0.001), elevated CRP (OR 1.00 (1.00-1.01), p = 0.017) and an age > 70 years (OR 3.91 (2.12-7.21), p < 0.001). The time interval between hospital admission and operation was not associated with postoperative complications in the univariate and multivariate logistic regression analyses, respectively. However, the interaction between complicated appendicitis and the time interval to operation was significant (OR 1.024 (1.00-1.05), p = 0.028). CONCLUSION: Based on our findings, surgical delay in the case of appendicitis and operation at night did not increase the risk for postoperative complications. However, the mean waiting time was less than 12 h and patients aged 70 years or older were at a higher risk for postoperative complications. Furthermore, for the subgroup of patients with complicated appendicitis, the time interval to surgery had a significant influence on the occurrence of postoperative complications. Therefore, the contemporary operation depending on the clinical symptoms and patient age remains our recommendation.

[Knowledge, attitude and opinion of patients regarding the new German legislation on advance care planning : Results of a survey in a department of general internal medicine]. / Wissen, Haltung und Meinung von Patienten zum neuen Patientenverfügungsgesetz : Ergebnisse einer Umfrage in einer allgemeininternistischen Abteilung.

BACKGROUND: In September 2009 a new legislation for advance care planning was introduced in Germany with the important characteristics of bindingness and unlimited validity for individual directives. Knowledge regarding this act and the attitude towards its characteristics among patients is unclear. AIM OF THIS STUDY: Analysis of knowledge, attitude and opinion of patients in a general internal medical department regarding advance care planning in general and the recent German legislation. METHODS: A total of 200 consecutive patients in an internal medicine ward were interviewed with the help of a questionnaire regarding their attitude to and knowledge on advance care planning in general and the current legislation. RESULTS: Approximately 40 % of the patients had issued some form of directive (either advance care directive or health care proxy) and only 7.5 % were advised by their physicians to make an advance directive. Patients with no directive were not willing to deal with dying and death, were not well-informed about directives or assumed that relatives or physicians would make an appropriate decision. Characteristics of the new legislation were controversially assessed; only 21 % of the patients wished to have a literal implementation of their directive. Regarding the content of an advance directive, more than 80 % of the patients voted for pain control in the palliative setting. CONCLUSION: The proportion of patients with a directive regarding advance care planning is only slowly increasing. Many patients are not well-informed, do not want to deal with dying or would like to delegate decisions to relatives and physicians. The present characteristics of the German legislation are controversially assessed and often do not represent the wishes of the patients.

The ratio of abdominal circumference and body weight--an objective parameter for the daily ward round in a NICU?

OBJECTIVE: Feeding tolerance and the degree of abdominal distension are important factors on the ward round on a NICU. They are basis for systematic changes in enteral feeds and an early indicator of clinical deterioration. Our aim was to examine the ratio of abdominal circumference(AC) to body weight (BW) as an additional variable for abdominal distension and its relationship to feeding, the increase of feeds and CPAP. HYPOTHESIS: The AC/BW ratio of premature infants decreases in serial measurements with increasing body weight during the fi rst 28 days of life. Higher amount of enteral nutrition and CPAP cause an increase. PATIENTS AND METHODS: In 30 premature infants(mean: 27.5 weeks, SD 2.2; 16 male, 2 200 measurements),daily measurement and recording during the fi rst 28 days of life: AC (cm), BW (g),enteral/parenteral amount of fluid intake, type of formula, composition of macronutrients (breastmilk, type of formula), gastric residual volume,CPAP therapy. RESULTS: Increase of AC ratio mean value from 19.9, SD 3.2 (d1) to 25.0, SD 5.2 (d6), followed by continuous decrease to 19.9, SD 4.4 (d28). Weeks of gestation, total amount of enteral feeding had a significant eff ect (p < 0.05). With increasing total amount of enteral feeding, the AC/BW ratio decreased. Changes in enteral feeding volume,CPAP had no significant eff ect. CONCLUSION: Our aim was to provide longitudinal data from VLBW infants and to assess whether AC/BW ratio is affected by feeding, increase in feds and CPAP. In future the ratio may be a more objective parameter to avoid withholding feds or to detect early clinical deterioration.

Practical skills training influences knowledge and attitude of dental students towards emergency medical care.

BACKGROUND: Medical emergencies in dental practice are generally perceived as being rare. Nonetheless, recent studies have shown that incidents occur on a regular basis. Therefore, patients have the right to expect necessary skills to manage life-threatening situations from every dentist. OBJECTIVE: To observe students' attitude and self-assessment towards emergency medical care (EMC) and its practical appliance. MATERIAL AND METHODS: Students of dentistry took part in small group sessions for adult and paediatric basic life support. Participants filled out pre-post questionnaires regarding knowledge and attitude towards EMC (6, respectively, 10-point Likert scale). Additionally, feedback was asked for the quality of course and tutors. RESULTS: Forty dental students in their last 2 years of study registered for the EMC courses. The majority had never attended any first-aid course; the mean age was 25% and 75% were women. A comparison between pre- and post-evaluation showed that the participation in practical training easily enhances the students' awareness of EMC importance as well as self-confidence in managing emergencies. After the course, 71% shared the opinion that retraining should be obligatory for all medical personnel. At the same time, students' self-assessment of confidence for specific tasks got significant upgrades in every aspect. CONCLUSION: The evaluation data clearly show the participants' needs to deal with topics of EMC within the curriculum of dentistry. The proposed course is able to change participants' attitudes towards EMC and its importance for their daily practice. The considerable enhancement of self-confidence in performing EMC-techniques might also lead to more willingness to manage emergency situations.