Drug related problems after discharge from an Australian teaching hospital.

OBJECTIVE: To reconcile patients' medicines and to classify drug related problems identified during medication review conducted after discharge from hospital. SETTING: Patients were discharged from the cardiology unit of Westmead Hospital after recruitment into the Westmead Medicines Project which ran from 2004 to 2007. METHOD: This retrospective study involved an analysis of drugs, diseases and drug related problems in medication review reports available for 76 out of 85 patients who received a Home Medicines Review (HMR). Data sources for medication reconciliation and analyses also included hospital discharge summaries (n = 70) and GP referrals for HMR (n = 44). Comprehensive clinical profiles were constructed for the 76 subjects whose drug related problems were identified, coded, and then classified from their HMR reports. MAIN OUTCOME MEASURES: Number, type, distribution and international classification of drugs, diseases and drug-related problems. RESULTS: Patients were prescribed drugs for a broad range of cardiovascular, circulatory, endocrine, respiratory and digestive system diseases. Mean number of drugs per patient in discharge summaries: 8.7 ± SD 3.3 (range 3-19); in GP referrals: 8.9 ± SD 4.3 (range 2-23); and in HMR reports: 10.8 ± SD 4.0 (range 3-24). Mean number of diseases per patient in discharge summaries: 4.1 ± SD 2.9 (range 1-11); and in HMR reports: 4.7 ± SD 2.6 (range 1-12). A total of 398 drug related problems were identified for 71 (93.3%) patients with mean 5.6 ± SD 4.3 problems (range 1-21). The most frequently recorded problems were the patients' uncertainty about drug aim: n = 128 (32.0%); potential interactions n = 89 (22.4%); and adverse reactions n = 60 (15.1%). CONCLUSION: This study showed that patients recently discharged from a tertiary care hospital had a significant number of drug related problems. Classification of drugs and diseases revealed a broad range of non-cardiovascular medicines and conditions in the patients from an acute care cardiology unit. We found that home medicines review provided continuity of care and an opportunity for medication reconciliation which revealed marked differences in number of drugs, between hospital discharge and medicines review. The patients' uncertainly about their drugs and their diverse range of co-morbidities indicated the need for timely counselling by pharmacists in the community.

Quality patient care and pharmacists' role in its continuity--a systematic review.

BACKGROUND: Continuity of care is important for the delivery of quality health care. Despite the abundance of research on this concept in the medical and nursing literature, there is a lack of consensus on its definition. As pharmacists have moved beyond their historical product-centered practice, a source of patient-centered research on continuity of care for practice application is required. OBJECTIVE: To determine the scope of research in which pharmacists were directly involved in patients' continuity of care and to examine how the phrase continuity of care was defined and applied in practice. METHODS: A working definition of continuity of care and a tool for relevance quality assessment of search articles were developed. MEDLINE, International Pharmaceutical Abstracts, EMBASE, and the Cochrane Collaboration evidence-based medicine reviews and bibliographies were searched (1996-March 2008). Reporting clarity was assessed by the Consolidated Standards of Reporting Trials checklist and outcomes were grouped by economic, clinical, and/or humanistic classification. RESULTS: The search yielded 21 clinical and randomized controlled trials, including 11 pharmacist-only and 10 multidisciplinary studies. A broad range of research topics was identified and detailed analysis provided ready reference for considerations of research replication or practice application. Studies revealed a range of research aims, settings, subject characteristics, attrition rates and group sizes, interventions, measurement tools, outcomes, and definitions of continuity of care. Research focused on patients with depression (n = 4), cardiovascular disease (n = 4), diabetes (n = 2), and dyslipidemia (n = 1); specific drugs included non-tricyclic antidepressants, cardiovascular drugs, and benzodiazepines. From the proposed endpoints of economic cost (n = 6) and clinical (n = 14) and humanistic (n = 16) outcomes, 15 studies reported statistically significant results. CONCLUSIONS: Medication management at primary, secondary, and tertiary levels of care indicated an expanded role and collaboration of pharmacists in continuity of care. However, the exclusion of disadvantaged patients in 19 studies is at odds with continuity of care for these patients, who may have been the most in need for the same reason that they were excluded.

Permanent and transient changes in the reflectance of CO2 laser-irradiated dental hard tissues at lambda = 9.3, 9.6, 10.3, and 10.6 microns and at fluences of 1-20 J/cm2.

BACKGROUND AND OBJECTIVE: Effective use of lasers for preventive dental treatments requires accurate knowledge of the amount and distribution of laser energy deposited during irradiation. At CO2 wavelengths, the reflection losses are considerable and reduce the laser energy absorbed by the tissue surface. STUDY DESIGN/MATERIALS AND METHODS: The specular and diffuse reflectance of enamel and dentin were measured at the 10.6-, 10.3-, 9.6-, and 9.3-microns wavelengths of the CO2 laser. Changes in reflectance during and after laser irradiation were investigated. RESULTS: The low-fluence reflectance (< 1 J/cm2) of calcified dental tissues at CO2 wavelengths varies between 9% and 50%. Permanent and transient changes in the reflectance are induced at higher irradiation intensities. CONCLUSION: These changes resulted in increased energy coupling during irradiation.

Nasogastric enteral feeding in the management of hyperemesis gravidarum.

OBJECTIVE: To report our experience in treating hyperemesis gravidarum with nasogastric enteral feeding. METHODS: Seven women (ages 17-36 years, mean 27 years) presented with intractable nausea, vomiting, dehydration, and weight loss (mean 13 lb) and were hospitalized for management of symptoms and nutritional support. An 8-Fr Dobbhoff nasogastric feeding tube was placed and nutritional supplement was administered as a continuous infusion, starting at a rate of 25 mL/hour. The rate of infusion was increased in an incremental fashion until daily caloric requirements were met. RESULTS: Nausea and vomiting improved within 24 hours after nasogastric tube placement. Enteral feedings were well tolerated, and all patients were discharged from the hospital within 8 days. Enteral feedings were continued, in an outpatient setting, for a mean of 43 days (range 5-174). Ultimately, all patients resumed oral feeding and discontinued enteral feeding. Subsequently, all patients gave birth to full-term, normal-weight babies. CONCLUSION: Enteral feeding via nasogastric tube seems to be effective in relieving intractable nausea and vomiting and in providing adequate nutritional support. Enteral nutrition should be considered as an alternative to total parenteral nutrition in the management of hyperemesis gravidarum.

Scanning electron microscope observations of CO2 laser effects on dental enamel.

Studies of the effects of carbon dioxide (CO2) lasers on dental enamel have demonstrated that surface changes can be produced at low fluences (< 10 J/cm2) if wavelengths are used which are efficiently absorbed by the hard tissues. In this study, scanning electron microscopy (SEM) was used to characterize the wavelength dependence of surface changes in dental enamel after exposure to an extensive range of CO2 laser conditions. Bovine and human enamel were irradiated by a tunable, pulsed CO2 laser (9.3, 9.6, 10.3, 10.6 microns), with 5, 25, or 100 pulses, at absorbed fluences of 2, 5, 10, or 20 J/cm2, and pulse widths of 50, 100, 200, 500 microseconds. SEM micrographs revealed evidence of melting, crystal fusion, and exfoliation in a wavelength-dependent manner. Crystal fusion occurred at absorbed fluences as low as 5 J/cm2 per pulse at 9.3, 9.6, and 10.3 microns, in contrast to no crystal fusion at 10.6 microns (< or = 20 J/cm2). Longer pulses at constant fluence conditions decreased the extent of surface melting and crystal fusion. The total number of laser pulses delivered to the tissue did not significantly affect surface changes as long as a minimum of 5 to 10 pulses was used. Within the four easily accessible wavelengths of the CO2 laser, there are dramatic differences in the observed surface changes of dental hard tissue.

Nature of light scattering in dental enamel and dentin at visible and near-infrared wavelengths.

The light-scattering properties of dental enamel and dentin were measured at 543, 632, and 1053 nm. Angularly resolved scattering distributions for these materials were measured from 0° to 180° using a rotating goniometer. Surface scattering was minimized by immersing the samples in an index-matching bath. The scattering and absorption coefficients and the scattering phase function were deduced by comparing the measured scattering data with angularly resolved Monte Carlo light-scattering simulations. Enamel and dentin were best represented by a linear combination of a highly forward-peaked Henyey-Greenstein (HG) phase function and an isotropic phase function. Enamel weakly scatters light between 543 nm and 1.06 µm, with the scattering coefficient (µ(s)) ranging from µ(s) = 15 to 105 cm(-1). The phase function is a combination of a HG function with g = 0.96 and a 30-60% isotropic phase function. For enamel, absorption is negligible. Dentin scatters strongly in the visible and near IR (µ(s)≅260 cm(-1)) and absorbs weakly (µ(a) ≅ 4 cm(-1)). The scattering phase function for dentin is described by a HG function with g = 0.93 and a very weak isotropic scattering component (˜ 2%).

Proton-induced physicochemical calcium release from ceramic apatite disks.

When bone is cultured in acid medium there is net calcium efflux (JCa) and proton influx (JH) relative to the mineral. The acid medium appears to induce physicochemical mineral dissolution as well as cell-mediated bone resorption. To determine the independent effect of acid medium on physicochemical dissolution, we utilized cell-free synthetic ceramic apatite (CAP) disks, which contain carbonate (5.5%) in an apatite structure chemically similar to mammalian bone. CAP disks were cultured in control (Ctl, pH approximately equal to 7.44) or acid (Met, pH approximately equal to 7.11) medium for 48 h and compared to similarly treated neonatal (4-6 days old) mouse calvariae. Medium was changed and analyzed at 3, 24, and 48 h. At 3, 24, and 48 h there was significantly greater JCa from the CAP disks and calvariae incubated in Met compared to Ctl; over the entire 48 h time period there was a greater progressive increase in JCa from the CAP disks than the calvariae incubated in Met. There was no significant JCa at 3, 24, or 48 h from CAP disks or calvariae incubated in Ctl. At 3 h there was significantly greater JH into the CAP disks and calvariae incubated in Met compared to Ctl; JH was greater into the CAP disks than the calvariae. Utilizing a synthetic model of bone mineral we demonstrated that acid medium induces physicochemical calcium efflux and proton influx relative to the mineral.

Dependence of in vitro demineralization of apatite and remineralization of dental enamel on fluoride concentration.

The anti-caries activity of fluoride is contributed to in several ways. Two major aspects of fluoride action are (i) the inhibition of demineralization at the crystal surfaces within the tooth, and (ii) the enhancement of subsurface remineralization resulting in arrestment or reversal of caries lesions. Fluoride present in the aqueous phase at the apatite crystal surface may play a determining role in the inhibition of enamel or dentin demineralization. In one part of the present study, the initial dissolution rate of synthetic carbonated-apatite in acetate buffers was measured with fluoride present in the buffer in the 0-2.6 mmol/L (0-50 ppm) range. Inhibition of demineralization was shown to be a logarithmic function of the fluoride concentration in solution. In the second part of the present study, an in vitro pH-cycling model was used for determination of the effect on net de/remineralization of enamel by treatment solutions containing fluoride in the 0-26 mmol/L (0-500 ppm) range. The net mineral loss was shown to be negatively related to the logarithm of the fluoride concentration. These studies have demonstrated an exponential quantitative relationship between fluoride concentration and inhibition of apatite demineralization or enhancement of remineralization. The clinical implications are (i) that simply increasing fluoride concentration may not necessarily give increased cariostatic benefit, and (ii) that improving the means of delivery of relatively low fluoride concentrations for longer times should be more appropriate for enhancing clinical efficacy.