Which drugs cause preventable admissions to hospital? A systematic review.

AIMS: Previous systematic reviews have found that drug-related morbidity accounts for 4.3% of preventable hospital admissions. None, however, has identified the drugs most commonly responsible for preventable hospital admissions. The aims of this study were to estimate the percentage of preventable drug-related hospital admissions, the most common drug causes of preventable hospital admissions and the most common underlying causes of preventable drug-related admissions. METHODS: Bibliographic databases and reference lists from eligible articles and study authors were the sources for data. Seventeen prospective observational studies reporting the proportion of preventable drug-related hospital admissions, causative drugs and/or the underlying causes of hospital admissions were selected. Included studies used multiple reviewers and/or explicit criteria to assess causality and preventability of hospital admissions. Two investigators abstracted data from all included studies using a purpose-made data extraction form. RESULTS: From 13 papers the median percentage of preventable drug-related admissions to hospital was 3.7% (range 1.4-15.4). From nine papers the majority (51%) of preventable drug-related admissions involved either antiplatelets (16%), diuretics (16%), nonsteroidal anti-inflammatory drugs (11%) or anticoagulants (8%). From five studies the median proportion of preventable drug-related admissions associated with prescribing problems was 30.6% (range 11.1-41.8), with adherence problems 33.3% (range 20.9-41.7) and with monitoring problems 22.2% (range 0-31.3). CONCLUSIONS: Four groups of drugs account for more than 50% of the drug groups associated with preventable drug-related hospital admissions. Concentrating interventions on these drug groups could reduce appreciably the number of preventable drug-related admissions to hospital from primary care.

Interventions in primary care to reduce medication related adverse events and hospital admissions: systematic review and meta-analysis.

OBJECTIVE: To identify and evaluate studies of interventions in primary care aimed at reducing medication related adverse events that result in morbidity, hospital admission, and/or mortality. METHODS: Fourteen electronic databases were systematically searched for published and unpublished data. Bibliographies of retrieved papers were searched and experts and first authors contacted in an attempt to locate additional studies. There were no restrictions on language of publication. All interventions applied in primary care settings which aimed to improve patient safety by reducing adverse events resulting from medication overuse or misuse were considered. Randomised controlled trials, controlled trials, controlled before and after studies, and interrupted time series studies were eligible for inclusion. Study quality assessment and data extraction were undertaken using the Cochrane Effective Practice and Organisation of Care data collection checklist and template. Meta-analysis was performed using a random effects model. RESULTS: 159 studies were initially identified, of which 38 satisfied our inclusion criteria. These were categorised as follows: 17 pharmacist-led interventions (of which 15 reported hospital admissions as an outcome); eight interventions led by other primary healthcare professionals that reported preventable drug related morbidity as an outcome; and 13 complex interventions that included a component of medication review aimed at reducing falls in the elderly (the outcome being falls). Meta-analysis found that pharmacist-led interventions are effective at reducing hospital admissions (OR 0.64 (95% CI 0.43 to 0.96)), but restricting analysis to the randomised controlled trials failed to demonstrate significant benefit (OR 0.92 (95% CI 0.81 to 1.05)). Pooling the results of studies in the other categories did not demonstrate any significant effect. CONCLUSIONS: There is relatively weak evidence to indicate that pharmacist-led medication reviews are effective in reducing hospital admissions. There is currently no evidence for the effectiveness of other interventions which aim at reducing admissions or preventable drug related morbidity. More randomised controlled trials of primary care based pharmacist-led interventions are needed to decide whether or not this intervention is effective in reducing hospital admissions.

Non-legislative interventions for the promotion of cycle helmet wearing by children.

BACKGROUND: Helmets reduce bicycle-related head and facial injuries for bicyclists of all ages in all types of crash. We aimed to identify non-legislative interventions that are effective in promoting helmet use among children, so future campaigns can be designed on a firm evidence base. OBJECTIVES: to assess the effectiveness of non-legislative interventions (compared to a lack of interventions) in increasing helmet use among children; to identify possible reasons for differences in the effectiveness of interventions; to evaluate effectiveness with respect to social group; to identify any adverse consequences of interventions. SEARCH STRATEGY: We searched 11 electronic databases and manually searched other sources of potentially relevant data. SELECTION CRITERIA: We included randomised controlled trials, cluster randomised controlled trials and controlled before and after studies. Studies included participants aged 0 to 18 years and described interventions to promote helmet use not requiring enactment of legislation. Studies had to report at least one of the following outcomes: observed helmet wearing; self-reported helmet ownership; self-reported helmet wearing. DATA COLLECTION AND ANALYSIS: Data were extracted by two reviewers working independently. Study results were adjusted to account for clustering. A random-effects model was used to pool data in meta-analyses. Heterogeneity was explored with sub-group analyses. MAIN RESULTS: Twenty-two studies were included. The odds of observed helmet wearing were significantly greater amongst those receiving non-legislative interventions (OR 2.30, 95% CI 1.37 to 3.85). Sub-group analysis indicated the effect may be greater for community-based studies (OR 4.30, 95% CI 2.24 to 8.25) and those providing free helmets (OR 4.35, 95% CI 2.13 to 8.89) than for those providing subsidised helmets (OR 2.02, 95% CI 0.98 to 4.17) and for those set in schools (OR 1.82, 95% CI 0.94 to 3.52). We found no significant effect of non-legislative interventions in increasing self-reported helmet ownership, but they were associated with a significant increase in self-reported helmet wearing (OR 3.90, 95% CI 1.42 to 10.69), particularly amongst interventions set in schools (OR 4.73, 95% CI 1.09 to 20.49) but there was significant unexplained heterogeneity between effect sizes for these two outcomes. AUTHORS' CONCLUSIONS: Community-based studies that include the provision of free helmets alongside an educational component increase observed helmet wearing in the areas in which they are set. There is some evidence that interventions in schools and those providing subsidised helmets may increase observed helmet wearing, but possibly to a lesser extent than those set in communities and those providing free helmets.

Cycle helmet ownership and use; a cluster randomised controlled trial in primary school children in deprived areas.

AIMS: To assess the effectiveness of two different educational interventions plus free cycle helmets, in increasing cycle helmet ownership and use. METHODS: A cluster randomised controlled trial was carried out in 28 primary schools in deprived areas of Nottingham, involving 1213 year 5 schoolchildren (age 9 and 10). Children received either a helmet + educational pack (educational pack and order form for free cycle helmet) or a helmet + multifaceted intervention (educational pack, order form for free cycle helmet, school assembly, lesson devoted to cycle helmet education, and an invitation to a school based cycling event). RESULTS: The helmet + educational pack was as effective as the helmet + multifaceted intervention in terms of helmet ownership (OR 1.51, 95% CI 0.50 to 4.58) and wearing (OR 0.98, 95% CI 0.57 to 1.68). Helmet ownership significantly increased from baseline with both interventions, and wearing significantly increased from baseline with the helmet + educational pack. The interventions reduced the inequality in helmet ownership between children residing in deprived and non-deprived areas that had been present prior to the study. CONCLUSIONS: An educational pack plus a form to order a free cycle helmet is an effective way of increasing bicycle helmet ownership and use and reduces inequalities in helmet ownership among children in deprived areas. Further work is needed to determine the length of the effect of such interventions.

Inequalities in cycle helmet use: cross sectional survey in schools in deprived areas of Nottingham.

AIMS: To describe cycle helmet owning and wearing among children in a deprived area and to investigate the association between helmet ownership and wearing and socioeconomic deprivation. METHODS: Cross sectional survey in 28 primary schools in deprived areas of Nottingham; 1061 year 5 schoolchildren were studied. RESULTS: All year 5 children attending school on the day of the survey completed the questionnaire (87% of children registered at participating schools). Children residing in a deprived area were less likely to own a bike and more likely to ride it four days a week or more. Half the children owned a helmet (52%), but only 29% of these always wore their helmet. Children in deprived areas were less likely to own a helmet, but those that owned a helmet were not less likely to always wear one. Family encouragement and parental warning of dangers of not wearing a helmet were associated with increased helmet ownership rates. Family encouragement and best friends wearing a helmet were associated with higher rates of helmet wearing. CONCLUSIONS: Programmes aimed at preventing head injury among child cyclists will need to address the inequality in helmet ownership that exists between children residing in deprived and non-deprived areas. Strategies to increase family encouragement to wear a helmet may be useful, as may those recognising the importance of the attitudes and behaviours of peers, such as peer education programmes. Further work is required to assess how exposure to risk of cycling injury varies with deprivation.

To test or not to test: are Hispanic men at highest risk for HIV getting tested?

This study examined how HIV testing history and future testing intentions were related to sexual risk and perceptions of risk in a community sample of 1,052 Hispanic men. This sample is noteworthy in its diverse representation of Hispanics, its high ratio of participants born outside the USA, and its inclusion of heterosexuals and men who have sex with men (MSM). We used area-based sampling to recruit participants at public venues. Data were collected via anonymous, structured interviews from December 1999 to February 2001. Lifetime testing rates were high (76%), but only 45% had been tested in the last 12 months. Results indicate that men at highest risk-those who were MSM, had more partners and had STDs-were more likely to have been tested, and to have been tested recently, than men with lower risk. Being MSM and having been previously tested predicted future testing intentions. Inconsistent condom users with more than five partners were less likely to intend to be tested than men with more than five partners who used condoms consistently. Studying men who have successfully routinized HIV prevention practices (including testing) will assist in the development of interventions for those who remain at risk.

Clinical outcomes and resource utilization associated with haemophilia care in Europe.

We conducted a multicentre, cross- sectional study of 1042 haemophilia subjects across Europe to compare various health outcomes associated with on-demand vs. prophylactic factor-substitution therapy. Demographic, medical history, and healthcare resource utilization data were analysed along with the number of bleeding events over the past 6 months. Treatment-cost data were also examined to provide preliminary information for future economic studies. A logistic regression analysis, controlling for other statistically significant covariates, showed that patients treated on demand were 3.4 times more likely to have had a joint bleed over the previous 6 months than those treated with prophylaxis. Multiple regression analyses further confirmed these findings, because on-demand subjects had, on average, 5.15 more joint bleeds over the reporting period than patients treated with prophylaxis. Notably, these findings were even more dramatic for younger haemophilia patients when our study sample was stratified by age. Due to the high cost of factor replacement, healthcare costs were significantly higher for subjects treated prophylactically. While hospital costs for prophylaxis subjects were, on average, lower, statistically significant cost savings for prophylactic subjects were not noted. These results suggest that clinicians and health policy decision-makers should consider the advantages of prophylactic therapy for haemophilia patients in formulating treatment protocols and allocating health resources.

Quality-of-life differences between prophylactic and on-demand factor replacement therapy in European haemophilia patients.

The European Study on the Clinical Outcomes and Resource Utilization associated with Haemophilia Care was designed to compare various health outcomes associated with on-demand and prophylactic factor substitution methods in European haemophilia patients. While the primary objective of this research is to conduct an economic analysis, an important component of this study is to evaluate quality-of-life differences that may exist between patients who utilize these two styles of therapy. Quality-of-life research has emerged as a primary measure of health outcomes because it allows the augmentation of traditional clinical indicators of health with data gathered from the patient's perspective. A total of 1033 haemophilia patients from 16 European haemophilia treatment centres were enrolled in this study. The SF-36, a multidimensional quality-of-life instrument, was administered to all participants. This instrument measures eight health-related quality-of-life dimensions: physical functioning, physical role limitations, bodily pain, general health, vitality, social functioning, emotional role limitations, and mental health. All haemophilia subjects enrolled in the study scored significantly lower than the population normative means in the three physical dimensions and in the general health dimension. HIV-negative haemophiliac subjects differed significantly by factor substitution type in a multivariate analysis examining all eight health dimensions. Univariate analyses testing each dimension separately indicated that patients treated prophylactically reported significantly less bodily pain, better general health, and scored significantly higher in the physical functioning, mental health, and social functioning dimensions. While these results suggest that health-related quality-of-life may be better for haemophilia patients treated prophylactically, future prospective studies that gather periodic quality-of-life data over time should be conducted.

Laminar disorganisation of mitral cells in the olfactory bulb does not affect topographic targeting of primary olfactory axons.

Primary olfactory neurons expressing the same odorant receptor protein typically project to topographically fixed olfactory bulb sites. While cell adhesion molecules and odorant receptors have been implicated in guidance of primary olfactory axons, the postsynaptic mitral cells may also have a role in final target selection. We have examined the effect of disorganisation of the mitral cell soma layer in mutant mice heterozygous for the beta-subunit of platelet activating factor acetylhydrolase (Lis1(-/+)) on the targeting of primary olfactory axons. Lis1(-/+) mice display abnormal lamination of neurons in the olfactory bulb. Lis1(-/+) mice were crossed with the P2-IRES-tau:LacZ line of transgenic mice that selectively expresses beta-galactosidase in primary olfactory neurons expressing the P2 odorant receptor. LacZ histochemistry revealed blue-stained P2 axons that targeted topographically fixed glomeruli in these mice in a manner similar to that observed in the parent P2-IRES-tau:LacZ line. Thus, despite the aberrant organisation of postsynaptic mitral cells in Lis1(-/+) mice, primary olfactory axons continued to converge and form glomeruli at correct sites in the olfactory bulb. Next we examined whether challenging primary olfactory axons in adult Lis(-/+) mice with regeneration would affect their ability to converge and form glomeruli. Following partial chemical ablation of the olfactory neuroepithelium with dichlobenil, primary olfactory neurons die and are replaced by newly differentiating neurons that project axons to the olfactory bulb where they converge and form glomeruli. Despite the aberrant mitral cell layer in Lis(-/+) mice, primary olfactory axons continued to converge and form glomeruli during regeneration. Together these results demonstrate that the convergence of primary olfactory axons during development and regeneration is not affected by gross perturbations to the lamination of the mitral cell layer. Thus, these results support evidence from other studies indicating that mitral cells do not play a major role in the convergence and targeting of primary olfactory axons in the olfactory bulb.

Swelling at the angle of the mandible: imaging of the pediatric parotid gland and periparotid region.

The pediatric parotid gland and periparotid region are subject to a variety of lesions and are most often evaluated with ultrasonography (US), contrast material-enhanced computed tomography (CT), and magnetic resonance (MR) imaging. US may be used to assess the size of the parotid gland, distinguish diffuse from focal disease, assess vascularity and adjacent vascular structures, distinguish cystic from solid lesions, and guide fine-needle aspiration. However, further evaluation with CT or MR imaging may be needed to better define the nature and extent of disease. CT is the imaging modality of choice for most pediatric parotid disease (including acute inflammation, abscess, calculi, and major salivary duct obstruction) and most solid masses and may obviate sedation. However, a mass associated with facial nerve symptoms should be evaluated with MR imaging because it is the only modality that can consistently demonstrate the facial nerve. Findings at US, CT, and MR imaging allow localization of parotid lesions and may suggest a specific cause. Clinical information, familiarity with normal parotid anatomy at various stages of its development, and knowledge of the imaging characteristics of parotid and periparotid lesions are essential for appropriate radiologic evaluation. This information can be used to guide therapy and plan a surgical approach.

Hypovolemic shock after air reduction of intussusception.

A 7-month-old white baby girl developed hypovolemic shock requiring resuscitation secondary to an air enema reduction of intussusception. The implications of this case for standardization of the management techniques in this setting are emphasized.