Risk assessments of drug-related problems for cardiac surgery patients.

OBJECTIVES: Patients undergoing cardiac surgery are considered at high risk for developing drug-related problems (DRPs) due to comorbidities and complexity of drug treatment. This study aimed to identify DRPs in patients undergoing cardiac surgery and to develop and implement a framework to reduce potential risks associated with drug treatment. STUDY DESIGN: Prospectively designed quasi-experimental study. METHODS: This study consisted of observational (risk assessment and framework development) and interventional (framework implementation) periods and was conducted at a department of cardiovascular surgery in a university hospital. An expert panel evaluated the causes of DRPs. Then a framework was developed in consensus to identify safeguards to be implemented during the interventional period. RESULTS: A total of 200 patients (100 patients per study period) were included. During the observational period, a total of 275 DRPs and 487 causes were identified; 74.5% of DRPs were not solved. For the risk analysis, 487 causes were evaluated and only 32.6% were considered acceptable risk. By implementing the framework in the interventional period, 215 DRPs and 304 causes were identified and 386 interventions were recommended by a clinical pharmacist. A total of 342 (88.6%) interventions were accepted by a health care team, and 128 (59.5%) DRPs were completely solved. For the risk analysis, 304 causes were evaluated and 84.9% were considered acceptable risk ( P < .001 compared with the observational period). CONCLUSIONS: It is possible to reduce risk levels or prevent occurrence of DRPs by implementing a framework for risk management developed by a multidisciplinary care team in areas such as cardiac surgery where time is limited.

Drug-related problems at the heart of cardiac surgery.

OBJECTIVES: Optimal perioperative success in cardiac surgery requires precise management of drug treatment. This study aimed to determine the prevalence, types and associated factors of drug-related problems (DRPs) during the entire hospital stay. METHODS: A prospective observational study was conducted at the department of cardiovascular surgery in a university hospital between November 2019 and March 2020. Patients with planned elective cardiac surgery, aged ≥18 years, were included. A clinical pharmacist collaboratively reviewed medications on a daily basis and identified DRPs. RESULTS: A total of 100 patients (60 male) were included; median (range) age was 62 (19-86) years, and median (IQR) length of stay in hospital was 15 (9) days. A total of 275 DRPs were identified (median (IQR) 3 (2-4)). The number of patients who had at least one DRP was 47 preoperatively, 55 in the postoperative intensive care unit, 100 in the postoperative ward, and 16 at discharge. In order to reduce bias because of the small sample size, Firth's logistic regression analysis was conducted. Statistically significant variables according to univariate analysis were included into a logistic regression model. Therefore the length of hospital stay (OR 1.14, 95% CI 1.03 to 1.26, p=0.008), living arrangements (living alone) (OR 4.24, 95% CI 1.41 to 12.73, p=0.009), number of medications at admission (OR 1.32, 95% CI 1.09 to 1.59, p=0.002), and having coronary artery bypass graft surgery (OR 2.87, 95% CI 1.07 to 7.70, p=0.03) were associated with an increased risk for DRPs in the final model. CONCLUSION: Hospital stay carries an increased risk for DRPs, especially at the postoperative stage. Modifiable risk factors for DRPs can be managed by required interventions performed by a multidisciplinary healthcare team.

Impact of chronic total occlusion in a non-infarct-related coronary artery on contrast-associated nephropathy in acute ST-elevation myocardial infarction.

OBJECTIVES: Co-existing chronic total occlusion (CTO) in a non-infarct-related artery (IRA) might serve as an important trigger of adverse outcomes in ST-segment elevation myocardial infarction (STEMI). Therefore, we planned to analyse the potential impact of non-IRA CTO on the evolution of contrast-associated nephropathy (CAN) in STEMI patients managed with primary percutaneous coronary intervention (P-PCI). METHODS: A total of 537 subjects with STEMI undergoing P-PCI during the first 12 h after the onset of their symptoms were enrolled in this retrospective study. The subjects were categorised based on the angiographic presence of non-IRA CTO. Moreover, the subjects were also divided into 2 groups based on their CAN status following P-PCI (CAN (+) and CAN (-)). RESULTS: Co-existing non-IRA CTO was demonstrated in 86 subjects (16%). During the hospitalisation period, we identified 81 (15.1%) subjects with CAN. Subjects with non-IRA CTO had a significantly higher incidence of CAN compared with those without (56 [12.4%] vs 25 [29.1%], respectively, p < 0.001). In a logistic regression analysis, an existing non-IRA CTO (odds ratio: 2.840, 95%CI: 1.451-5.558, p = 0.002), as well as age, haemoglobin, diabetes mellitus, creatinine, and white blood cell count, were independent of predictors of CAN. CONCLUSION: In STEMI patients managed with P-PCI, a co-existing non-IRA CTO had an independent association with the evolution of CAN.

Assessment of the Appropriateness of Prescriptions in a Geriatric Outpatient Clinic

Objectives: Appropriateness of the geriatric outpatients' medications needs special attention due to risks of falls, fractures, depression, hospital admissions and mortality. This study aimed to identify current practice on medication usage by using the 2nd version of "Screening Tool of Older People's Potentially Inappropriate Prescriptions" and "Screening Tool to Alert Doctors to Right Treatment" criteria and affecting factors for the Turkish population. Materials and Methods: This cross-sectional study was conducted between September 2015 and May 2016 at a university research and training hospital's geriatric outpatient clinic. Patients aged ≥65 years and had ≥5 different prescribed medications (considered as polypharmacy) were recruited. The main outcome measure was the frequency of inappropriate medications identified by clinical pharmacist in the outpatient clinic according to the 2nd version of the criterion sets. Results: A total of 700 patients (440 female) were included in this study. According to the results, 316 patients (45.1%) with at least one potentially inappropriate medication and 668 patients (98.3%) with at least one potential prescription omission were detected. Potentially inappropriate medications were associated with the number of medications used per patient [odds ratio (OR): 1.20 p<0.001], living alone (OR: 4.12 p=0.02), and having congestive heart failure (OR: 2.41 p<0.001). Twenty-two (27.5%) out of 80 criteria and 4 (11.8%) out of 34 criteria did not apply to the study population. Conclusion: Detecting inappropriate medications to maintain treatment effectiveness is necessary to provide the optimum therapy. Despite the awareness of polypharmacy in outpatient clinics it is still one of the important causes of inappropriate prescription followed by vaccination rate. Therefore, with the contribution of clinical pharmacist using these available criteria is important, moreover modification of these criteria according to the local needs to be considered to achieve better outcomes.

How we Provide Nutritional Treatment in Hospitalized Patients?

BACKGROUND: In this study, we aimed to evaluate enteral nutrition (EN), parenteral nutrition (PN) and supplemental parenteral nutrition (SPN) in terms of achieving nutritional goals. METHODS: Patients receiving either EN, PN, or SPN treatment followed up by the clinical nutrition team between January and December 2017 at the university research and training hospital were included in the study. Daily nutritional requirements were calculated according to the recommendations. Total energy intake during nutritional treatment (NT) and all metabolic, mechanical, technical complications of NT were recorded. RESULTS: A total of 603 inpatients were included in the study. The nutritional goal was achieved in the majority of the SPN group patients (87.5%) statistically significant relation was found between the achievement of the target (or not) and PN access route (peripheral or central) (P < .001). However, none of the complications found statistically related to achieving the target, including gastrointestinal complications of EN (P = .46), metabolic complications of EN (P = .07), mechanical complications of EN (P = .79), metabolic complications of PN (P = .89), gastrointestinal complications in SPN group (P = .45), and metabolic complications in SPN group (P = .68). CONCLUSION: Nutritional goals could be achieved with SPN without increasing complications in the majority of patients. Commencement of SPN should be considered for positive outcomes in patients who failed to achieve desired nutritional outcomes.

Evaluation of the effect of antibiotics used during parenteral nutrition treatment on Candidemia

SUMMARY OBJECTIVE: Parenteral nutrition is an important risk factor for candidemia. In this risk analysis study, the effect of previous antibiotic administration apart from the length of hospital stay, duration of Parenteral nutrition treatment, and Candida score parameters on developing candidemia was evaluated in the non-neutropenic patients receiving Parenteral nutrition treatment. METHODS: In this double center, retrospective, and cross-sectional study, the data of patients who received Parenteral nutrition treatment were collected. Patients with or without candidemia after the initiation of Parenteral nutrition treatment were compared in terms of demographic features, Candida score, length of hospital stay, duration of Parenteral nutrition treatment, and previous use of antibiotics. Then, predictor factors affecting the probability of candidemia during Candida growth time were determined by the Cox regression analysis. RESULTS: A total of 148 patients (59.5% males) were included and 16 (10.81%) of these had candidemia after initiation of parenteral nutrition treatment. The median (min-max) duration of parenteral nutrition treatment was 11 (4-72) days and the Candida growth time was 13 (7-29) days. Statistically significant differences were found between patients with or without candidemia groups in terms of length of hospital stay (p<0.001), duration of parenteral nutrition treatment (p<0.001), and Candida score (p<0.001). To determine the effect of these variables and antibiotics on candidemia, length of hospital stay [Hazard Ratio 1.030; p=0.021] and piperacillin-tazobactam (Hazard Ratio 5.626; p=0.030) were found significant and independent risk factors on the development of candidemia. CONCLUSION: There are some well-known risk factors including length of hospital stay, duration of Parenteral nutrition treatment, and Candida score; the potential impact of piperacillin-tazobactam administration should also be considered since they may be effective on the development of candidemia.

Impact of Clinical Pharmacist-led Interventions in Turkey

Detecting drug-related problems (DRPs) is important in pharmaceutical care in for better therapeutic outcomes. Clinical pharmacists-led comprehensive medication management plays a crucial role in the rational use of drugs by preventing, identifying, and resolving DRPs. In this review, we aimed to determine the effect of interventions on patient outcomes performed by clinical pharmacists in Turkey. A systematic literature search was performed on PubMed, Google Scholar, EMBASE, Cochrane Library, and Turkish databases (ULAKBIM, Dergipark). The main categories were "clinical pharmacist", "intervention", and "Turkey". Two reviewers reviewed each article independently. Two independent reviewers screened all records and extracted data; disagreements were resolved through a consensus. Randomized controlled studies, pre- to post-intervention comparison studies, and cross-sectional studies including pharmacist-led interventions were included in the review. This review included 15 articles evaluating clinical pharmacist interventions. Ten studies (66.7%) focused on DRPs and pharmacist interventions to these problems, while the remaining 5 (33.3%) studies focused on patient education and adherence issues. Studies were conducted in oncology (33.3%), geriatrics (20.0%), chest diseases (13.3%), psychiatry (6.7%), cardiology (6.7%), and infectious diseases (6.7%) clinics. When results of studies are reviewed, most of the interventions were made at the prescriber level followed by the drug level and patient level. Problems were solved in 54.2-93.2% of DRPs, and adherence, patient knowledge, or skills were improved in most of the studies. Most of the studies were carried out within the scope of a postgraduate or doctorate thesis and yet various positive outcomes such as the prevention of side effects, increased quality of life, and decreased duration of hospital stay were observed with high positive rates of interventions, which indicate that other healthcare workers are ready to collaborate with the clinical pharmacists in Turkey.

Evaluation of the effect of antibiotics used during parenteral nutrition treatment on Candidemia.

OBJECTIVE: Parenteral nutrition is an important risk factor for candidemia. In this risk analysis study, the effect of previous antibiotic administration apart from the length of hospital stay, duration of Parenteral nutrition treatment, and Candida score parameters on developing candidemia was evaluated in the non-neutropenic patients receiving Parenteral nutrition treatment. METHODS: In this double center, retrospective, and cross-sectional study, the data of patients who received Parenteral nutrition treatment were collected. Patients with or without candidemia after the initiation of Parenteral nutrition treatment were compared in terms of demographic features, Candida score, length of hospital stay, duration of Parenteral nutrition treatment, and previous use of antibiotics. Then, predictor factors affecting the probability of candidemia during Candida growth time were determined by the Cox regression analysis. RESULTS: A total of 148 patients (59.5% males) were included and 16 (10.81%) of these had candidemia after initiation of parenteral nutrition treatment. The median (min-max) duration of parenteral nutrition treatment was 11 (4-72) days and the Candida growth time was 13 (7-29) days. Statistically significant differences were found between patients with or without candidemia groups in terms of length of hospital stay (p<0.001), duration of parenteral nutrition treatment (p<0.001), and Candida score (p<0.001). To determine the effect of these variables and antibiotics on candidemia, length of hospital stay [Hazard Ratio 1.030; p=0.021] and piperacillin-tazobactam (Hazard Ratio 5.626; p=0.030) were found significant and independent risk factors on the development of candidemia. CONCLUSION: There are some well-known risk factors including length of hospital stay, duration of Parenteral nutrition treatment, and Candida score; the potential impact of piperacillin-tazobactam administration should also be considered since they may be effective on the development of candidemia.

The etiology and age-related properties of patients with delirium in coronary intensive care unit and its effects on inhospital and follow up prognosis.

Background and purpose: Delirium is a syndrome frequently encountered in intensive care and associated with a poor prognosis. Intensive care delirium is mostly based on general and palliative intensive care data in the literature. In this study, we aimed to investigate the incidence of delirium in coronary intensive care unit (CICU), related factors, its relationship with inhospital and follow up prognosis, incidence of age-related delirium and its effect on outcomes. Methods: This study was conducted with patients hospitalized in CICU of a tertiary university hospital between 01 August 2017 and 01 August 2018. Files of all patients were examined in details, and demographic, clinic and laboratory parameters were recorded. Patients confirmed with psychiatry consultation were included in the groups of patients who developed delirium. Patients were divided into groups with and without delirium developed, and baseline features, inhospital and follow up prognoses were investigated. In addition, patients were divided into four groups as <65 years old, 65-75 yo, 75-84 yo and> 85 yo, and the incidence of delirium, related factors and prognoses were compared among these groups. Results: A total of 1108 patients (mean age: 64.4 ± 13.9 years; 66% men) who were followed in the intensive care unit with variable indications were included in the study. Of all patients 11.1% developed delirium in the CICU. Patients who developed delirium were older, comorbidities were more frequent, and these patients showed increased inflammation findings, and significant increase in inhospital mortality compared to those who did not develop delirium (p<0.05). At median 9-month follow up period, rehospitalization, reinfarction, cognitive dysfunction, initiation of psychiatric therapy and mortality were significantly higher in the delirium group (p<0.05). When patients who developed delirium were divided into four groups by age and analyzed, incidence of delirium and mortality rate in delirium group were significantly increased by age (p<0.05). Conclusion: Development of delirium in coronary intensive care unit is associated with increased inhospital and follow up morbidity and mortality. Delirium is more commonly seen in geriatric patients and those with comorbidity, and is associated with a poorer prognosis. High-risk patients should be more carefully monitored for the risk of delirium.

The Inflammation-Based Glasgow Prognostic Score as a Prognostic Factor in Patients with Intensive Cardiovascular Care Unit.

Background: The Glasgow prognostic score (GPS), which is obtained from a combination of C-reactive protein (CRP) and serum albumin level, predicts poor prognoses in many cancer types. Systemic inflammation also plays an important role in pathogenesis of cardiovascular diseases. In this study, we aimed to investigate the effect of inflammation-based GPS on in-hospital and long-term outcomes in patients hospitalized in intensive cardiovascular care unit (ICCU). Methods: A total of 1004 consecutive patients admitted to ICCU were included in the study, and patients were divided into three groups based on albumin and CRP values as GPS 0, 1, and 2. Patients' demographic, clinic, and laboratory findings were recorded. In-hospital and one-year mortality rates were compared between groups. Results: Mortality occurred in 109 (10.8%) patients in in-hospital period, 82 (8.1%) patients during follow-up period, and thus, cumulative mortality occurred in 191 (19.0%) patients. Patients with a high GPS score had a higher rate of comorbidities and represented increased inflammatory evidence. In the multivariate regression model there was independent association with in-hospital mortality in GPS 1 patients compared to GPS 0 patients (Odds ratio, (OR); 5.52, 95% CI: 1.2⁻16.91, p = 0.025) and in GPS 2 patients compared to GPS 0 patients (OR; 7.01, 95% CI: 1.39⁻35.15, p = 0.018). A higher GPS score was also associated with a prolonged ICCU and hospital stay, and increased re-hospitalization in the follow-up period. Conclusion: Inflammation based GPS is a practical tool in the prediction of worse prognosis both in in-hospital and one-year follow-up periods in ICCU patients.

Australian prostate-specific antigen outcome and toxicity following radiation therapy for localized prostate cancer.

The objective of the present study was to examine prostate-specific antigen relapse free survival (PSA-RFS) and morbidity following 'conventional' radical radiation therapy for prostate cancer in two Australian regional treatment services. Four hundred and eighty men with clinically localized prostate cancer were treated between 1993 and 1997 at Liverpool and Westmead Hospitals using a standardized 4-field, CT-planned radiotherapy technique. Principal endpoints were PSA-RFS (American Society for Therapeutic Radiology and Oncology guidelines definition) and late rectal and urinary morbidity (Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer criteria). The median follow up of patients from the end of RT was 55 months. Prospectively, they were divided into three prognostic categories: (i) high risk T3 or 4 and/or PSA > 20 ng/mL and/or Gleason score 8-10 (40% of cohort); (ii) intermediate risk T1 or 2 and PSA 10-20 ng/mL and/or Gleason score 7 (33% of cohort); and (iii) low risk T1 or 2 and PSA < 10 ng/mL and Gleason score < 6 (27% of cohort). The 5-year actuarial PSA-RFS was 53% for the whole patient group. The 4-year rates were 32, 56 and 75% for high, intermediate and low risk groups, respectively. On multivariate analysis, T-stage, Gleason score, pre-RT-PSA were strong independent predictors of PSA-defined outcome. Late (grade 2) rectal and urinary morbidity occurred at some point in time in the post-RT period in 8.0 and 5.8% of patients, respectively. These results confirm that low Gleason score, low T stage, presenting PSA < 10 ng/mL and nadir < 1 ng/mL remain the strongest predictors of a good outcome. Long-term toxicity was very acceptable. However, further improvement in outcome is desirable, and with the adoption of new technology allowing escalation of radiotherapy doses such an expectation might be achieved.

Cutaneous head and neck squamous cell carcinoma metastatic to cervical lymph nodes (nonparotid): a better outcome with surgery and adjuvant radiotherapy.

OBJECTIVE: The aim of this study is to report on the experience of treating cutaneous squamous cell carcinoma (SCC) metastatic to cervical (nonparotid) lymph nodes at the Head and Neck Unit, Westmead Hospital, Sydney, Australia. STUDY DESIGN: Retrospective chart review. METHODS: Patients diagnosed with previously untreated metastatic cutaneous SCC to cervical lymph nodes (levels I-V) and treated with radiotherapy, surgery, or surgery and adjuvant radiotherapy were identified. Relapse and outcome was analyzed using Cox regression analysis. RESULTS: Between 1980 and 2000, 74 patients were treated with curative intent. There were 59 males and 15 females, with a median age of 66 (range 37-93) years. Median duration of follow up was 48 (range 12-187) months. Fifty-two were treated with neck dissection and radiotherapy, 13 with neck dissection alone, and 9 with only radiotherapy. Most patients (85%) had an identifiable index lesion. Level I (38%) and II (36%) lymph nodes were the most often involved. In total, 25 (34%) patients developed recurrent disease, predominantly locoregional (22 of 25). Median time to recurrence was 5.2 (2-34.3) months. Increasing nodal size (> or =3 cm) (P =.01), metastatic spread to multiple nodes (P =.05), and the presence of extranodal spread (P =.01) all predicted for worse survival. Patients undergoing combined modality treatment had a lower relapse rate (15%) and a significantly better disease free survival (P =.001) compared with single modality treatment. CONCLUSION: Metastatic cutaneous SCC is uncommon but potentially lethal. Surgery and adjuvant radiotherapy remain the best practice and provide the best chance of achieving locoregional control.

Metastatic cutaneous squamous cell carcinoma to the parotid: the role of surgery and adjuvant radiotherapy to achieve best outcome.

BACKGROUND: Australia has the highest incidence of cutaneous squamous cell carcinoma in the world. The majority of lesions occur in the head and neck with metastases to the parotid gland lymph nodes reflecting an uncommon, but aggressive, manifestation. Parotidectomy +/- neck dissection followed by adjuvant radiotherapy should be considered as best practice. METHODS: Between 1983 and 2000, seventy-four patients were treated for metastatic cutaneous squamous cell carcinoma to the parotid with surgery and adjuvant radiotherapy at Westmead Hospital, Sydney. Relevant data were extracted from patient files and a prospectively maintained database. Patterns of relapse and outcome were analysed. RESULTS: Median age at diagnosis was 65 years (34-93 years) in 63 men and 11 women. Median follow-up duration was 41 months (12-188 months). All patients underwent parotidectomy with 52 undergoing a simultaneous neck dissection. Twelve patients required sacrifice of the facial nerve (4) or one or more branches (8). All received adjuvant radiotherapy to the parotid region with 56 also receiving radiotherapy to the ipsilateral neck. Despite treatment, 24% developed locoregional recurrence, with a median time to relapse of 7.5 months. The most common site for recurrence was the treated parotid region and upper neck. Most relapsed patients died. No variable independently predicted for locoregional recurrence on multivariate analysis. The 5-year absolute and cause-specific survival rates were 58% and 72%, respectively. CONCLUSION: Parotid gland lymph node metastases from cutaneous squamous cell carcinoma are associated with a high rate of recurrence and cause-specific mortality despite current best practice (surgery and high dose adjuvant radiotherapy). The role of more aggressive surgery, altered fractionation or chemotherapy to enhance locoregional control remains unclear.

Squamous cell carcinoma of the lip: is there a role for adjuvant radiotherapy in improving local control following incomplete or inadequate excision?

BACKGROUND: The treatment of squamous cell carcinoma of the lip with surgery is usually curative but incomplete/inadequate excision may be associated with recurrence and poor outcome. There is no consensus in the literature on the definition of an adequate excision margin. METHODS: Patients treated for squamous cell carcinoma of the lip at Westmead Hospital, Sydney, between 1980 and 2000 were eligible for inclusion. Polytomous logistic regression analysis was undertaken to assess for predictors of recurrence. Recurrence-free and overall survival were calculated using Kaplan-Meier survival curves. RESULTS: A total of 130 patients was identified. Median age at diagnosis was 64 years (23-97 years). Most lesions (90%) were located on the lower lip in 96 (74%) male patients. Median follow-up duration was 54 months (0-189 months). Most patients -presented with T1 lesions (75%). Initial treatment was surgery (39%), radiotherapy (48%) or both (13%). Twenty-seven per cent of excised lesions had a close (< or =2 mm) or positive margin. A total of 40 patients (31%) had recurrence (18% lymph nodes, 11% lip and 2% both). In the surgery group recurrence was significantly more likely with close or positive margins (P = 0.05). The 2 year -recurrence-free survival was 82% and 54% for radiotherapy and surgery, respectively (P < 0.001). The 2 year overall survival was similar (90% radiotherapy vs 100% surgery; P = 0.58). CONCLUSION: Incomplete or inadequate excision of some lip cancers results in local recurrence. If re-excision is not feasible -surgeons should consider the role of adjuvant radiotherapy in improving local control.

"Well, have I got cancer or haven't I?" The psycho-social issues for women diagnosed with ductal carcinoma in situ.

OBJECTIVES: To explore women's experience of being diagnosed with ductal carcinoma in situ (DCIS) in relation to the following: response to the diagnosis; understanding about the diagnosis; satisfaction with information; satisfaction with the level of involvement in treatment decision-making and satisfaction with support services. DESIGN: An explorative descriptive qualitative design was used to facilitate an in-depth exploration of women's experiences. SETTING AND PARTICIPANTS: Five focus group interviews were conducted in New South Wales (NSW), Australia, involving 26 women diagnosed with DCIS. RESULTS: DCIS is a non-invasive breast disease, that in most cases will not recur if treated, and cannot of itself metastasize to other parts of the body. However, this study found that women were confused about whether or not they had cancer that could result in death. Women's confusion was compounded by the use of the term "carcinoma" and by the recommendation of treatments such as mastectomy. Women's confusion was not alleviated by appropriate information, with most women reporting dissatisfaction with the information they received specifically about DCIS. CONCLUSIONS: This study identifies that a diagnosis of DCIS has a significant psychological impact on women. The communication challenges highlighted in this study are not only relevant to DCIS but to any other disease in which the natural history is uncertain and the evidence about treatment effectiveness is still emerging. Further research is needed in areas such as DCIS to explore the difficulties experienced in doctor-patient communication and their impact on patient outcomes, and how to optimize doctor-patient communication.