Medications prescribed and occurrence of falls in general medicine inpatients.

BACKGROUND: Although falls are multifactorial, medications are a key risk factor that may be modifiable. Falls were among the most common occurrences entered into a risk identification system at the authors' hospital. OBJECTIVES: To identify whether general medicine inpatients who had experienced a fall were taking any medications known to be associated with falls. METHODS: The literature was reviewed to develop a list of high-risk medications that have been associated with falls. In a retrospective quality-improvement database-based study, information from the risk identification system was merged with data from the pharmacy dispensing system for general medicine inpatients who had experienced a fall. The primary end point was the percentage of patients with a documented fall who had a prescription for a high-risk medication. The number of such medications that had been prescribed for patients who fell was also calculated. RESULTS: Eighty-one unique medications were found to be associated with falls. During the study period (April 1, 2008, to March 31, 2009), 151 patients experienced a fall. Of those, 144 (95.4%) were taking at least one high-risk medication. The mean number of high-risk medications per patient who experienced a fall was 2.2. Of all documented falls, a new high-risk medication had been started within 7 days before the fall for 74 (49.0%) and within 24 h before the fall for 17 (11.3%). The most commonly prescribed drugs during all time periods (i.e., within 24 h or 7 days before the fall or since the patient's admission) were lorazepam and zopiclone. The pharmacy database did not track administration of medications, so it is possible that some of the drugs prescribed were not actually taken by the patient. CONCLUSION: Almost all inpatients who experienced a fall during the hospital stay had a prescription for at least one medication associated with a high risk for falls. Lorazepam and zopiclone were the drugs most commonly associated with falls in this hospital, and their use should be reviewed.

Advanced cutaneous malignant melanoma: a systematic review of economic and quality-of-life studies.

OBJECTIVE: Metastatic melanoma (MM), a major concern for health-care providers, is increasing. We systematically reviewed published articles describing the impact of interventions (drugs and screening) on quality of life (QoL) in patients with MM, and articles that measured QoL in MM. METHODS: We searched secondary databases including MEDLINE, Embase, CINAHL, Cochrane, and DARE from inception to 2006 using MESH terms "melanoma" and "metastases." Economic articles were subject to established quality assessment procedures. RESULTS: We found 13 QoL and five economic studies (three cost-effectiveness, two cost-utility; average quality = 83% +/- 7%). No strong evidence was found in this review for cost-effectiveness of interferons in Canada (incremental cost-effectiveness ratio [ICER] = $55,090/quality-adjusted life-year) or temozolomide in the United States (ICER = $36,990/Life-year gained based on nonsignificant efficacy differences). Melanoma screening was not cost-effective in the United States ($150,000-931,000/life-saved) or Germany (no survival benefit). From the 13 QoL studies,eight measured baseline QoL; six studied the same population, generating similar results using different approaches/outcomes. Tools used included GLQ-8, QLQ-C30, QLQ-36, QWB-SA, and SF-36. Baseline scores QoL scores ranged from 0.60 to 0.69. Another five studies (N = 959 patients) were randomized trials analyzing QoL in patients treated with dacarbazine alone, dacarbazine +/- interferon, dacarbazine + fotemustine, interleukin +/- histamine, and temozolomide. Little difference was found in QoL scores between drugs or between baseline and end point. CONCLUSIONS: Cost-effectiveness has not been widely demonstrated for treatment of MM. Only two studies with unimpressive results exist for treatments. Screening was not cost-effective in the United States or Germany. Generally, no significant improvements in QoL were found for any alternative for treating MM. A need exists for effective treatments that improve duration and QoL.

Risk factors for new-onset diabetes mellitus in patients receiving protease inhibitor therapy.

BACKGROUND: Metabolic complications including diabetes mellitus (DM) have been associated with protease inhibitor (PI) therapy. Risk factors for the development of DM are not well-defined. OBJECTIVES: To determine risk factors for the development of new-onset DM in patients initiated on PI therapy. METHODS: A retrospective cohort study was conducted to identify predictors of developing DM in subjects started on PI therapy between January 1997 and January 2003. Diabetes cases were defined as physician documentation of DM in the outpatient medical chart and/or those subjects receiving an antidiabetic agent. Logistic regression was used to examine the relationship between new-onset DM and demographic characteristics, and between new-onset DM and total treatment days with PI therapy. Body mass index could not be entered into the model due to missing height measurements. RESULTS: A total of 496 subjects on PI therapy were included, of which 18 (3.6%) developed DM. The mean age of the subjects was 43.4+/-9.4 years (range 19 to 77) and the mean duration of therapy was 3.0+/-1.9 years (range 0.17 to 7.9). In the multivariate model, older subjects were more likely to develop DM (OR 1.12, 95% CI 1.05 to 1.19; P=0.001). This corresponds to a 12% increased risk of DM for each one-year increase in age. Subjects that weighed more had an increased risk (OR 1.06, 95% CI 1.03 to 1.10; P=0.001), as did those belonging to a non-Aboriginal minority group when compared with Caucasians (OR 6.67, 95% CI 1.56 to 28.41; P=0.01). A longer duration of PI therapy was also significantly associated with developing DM (OR 1.52, 95% CI 1.07 to 2.17; P=0.02). CONCLUSION: A longer duration of PI therapy is associated with an increased risk of developing DM. As with HIV-negative subjects, demographic characteristics such as age, weight and ethnicity were important predictors of developing DM in the present study.