Prevalence and predictors of potential drug-drug interactions in Regione Emilia-Romagna, Italy.

BACKGROUND AND OBJECTIVE: Drug-drug interactions (DDIs) are preventable medication errors associated with potentially serious adverse events and death. Several studies have examined the prevalence of potential DDIs among ambulatory patients in various countries. Limited recent data on the prevalence of potential DDIs in Italy are available in the medical literature. The objective of this study was to estimate the prevalence of clinically important potential DDIs among the approximately 4 million residents of Regione Emilia-Romagna (RER), Italy, and to examine possible predictors of potential DDI exposure. METHODS: A retrospective follow-up study of 2004 outpatient prescription data from RER was conducted. A previously published list of clinically important potential DDIs was refined to include only pairs of drugs in which both drugs were reimbursed by the 2004 Italian National Formulary. A potential DDI was defined as the presence of a minimum 5-day overlap in days supply for drugs in an interacting pair. The 1-year period prevalence of each potential DDI was quantified. A logistic regression analysis was conducted to examine patient characteristics as predictors of potential DDIs. RESULTS AND DISCUSSION: The list of clinically important potential DDIs included 12 drug pairs that could be captured using the RER database. These 12 potential DDIs occurred 8894 times in the RER population in 2004. The most commonly identified potentially interacting medication pairs were warfarin and non-steroidal anti-inflammatory drugs (6824 cases), theophylline/aminophylline and ciprofloxacin/fluvoxamine (930), and warfarin and barbiturates (567). Odds of exposure were highest among those aged 65 years or older, males, and those with more chronic conditions. Odds of exposure increased 1.39 times with each addition of a prescription medication. CONCLUSION: A substantial number of clinically important potential DDIs were identified, particularly among warfarin users. Awareness of the most prevalent potential DDIs can help practitioners prevent concomitant use of these dangerous medication combinations.

Cholecysto-urachal fistula.

The urachus is an embryonic remnant that connects the primitive bladder to the allantois. Multiple urachal anomalies have been described, including the urachal sinus, urachal cyst, patent urachus, and urachal diverticulum. We describe an unusual case in which a patient with urinary tract infection and dysuria was ultimately found to have urinary gallstones from a urachal connection with the gallbladder.

Documenting and comparing medical students' clinical experiences.

CONTEXT: The decentralization of clinical teaching networks over the past decade calls for a systematic way to record the case-mix of patients, the severity of diseases, and the diagnostic procedures that medical students encounter in clinical clerkships. OBJECTIVE: To demonstrate a system that documents medical students' clinical experiences across clerkships. DESIGN AND SETTINGS: Evaluation of a method for recording student-patient clinical encounters using a pocket-sized computer-read patient encounter card at a US university hospital and its 16 teaching affiliates during academic years 1997-1998 through 1999-2000. PARTICIPANTS: A total of 647 third-year medical students who completed patient encounter cards in 3 clerkships: family medicine, pediatrics, and internal medicine. MAIN OUTCOME MEASURES: Number of patient encounters, principal and secondary diagnoses, severity of diseases, and diagnostic procedures as recorded on patient encounter cards; concordance of patient encounter card data with medical records. RESULTS: Students completed 86 011 patient encounter cards: 48 367 cards by 582 students in family medicine, 22 604 cards by 469 students in pediatrics, and 15 040 cards by 531 students in internal medicine. Significant differences were found in students' case-mix of patients, the level of disease severity, and the number of diagnostic procedures performed across the 3 clerkships. Stability of the findings within each clerkship across 3 academic years and the 77% concordance of students' reports of principal diagnosis with faculty's confirmation of diagnosis support the reliability and validity of the findings. CONCLUSIONS: An instrument that facilitates students' documentation of clinical experiences can provide data on important differences among students' clerkship experiences. Data from this instrument can be used to assess the nature of students' clinical education.

Early commitment of neural substrates for face recognition.

We present evidence of a striking failure of plasticity in the neural substrates of face recognition, which suggests that the distinction between faces and other objects, and the localisation of faces relative to other objects, is fully determined prior to any postnatal experience. A boy who sustained brain damage at 1 day of age has the classic lesions and behavioural profile of adult-acquired prosopagnosia. He has profoundly impaired face recognition, whereas his recognition of objects is much less impaired. This implies that the human genome contains sufficiently explicit information about faces and nonface objects, or visual features by which they can be distinguished, that experience with these categories is not necessary for their functional delineation and differential brain localisation.

Impact of a DRG-based hospital financing system on quality and outcomes of care in Italy.

OBJECTIVE: To examine potential changes in quality of care associated with a recent financing system implementation in Italy: in 1995, hospital financing reform implemented in Italy included the introduction of a DRG-based hospital financing system with the goals of controlling the growth of hospital costs and making hospitals more accountable for their productivity. DATA SOURCES: Hospital discharge abstract data from 1993 through 1996 for all hospitals (N=32) in the Friuli-Venezia-Giulia region of Italy. Regional population data were used to calculate rates. STUDY DESIGN: Changes between 1993 and 1996 in hospital admissions, length of stay, mortality rates, severity of illness, and readmission rates were studied for nine common medical and surgical conditions: appendicitis, diabetes mellitus, colorectal cancer, cholecystitis, bronchitis/chronic obstructive pulmonary disease (COPD), bacterial pneumonia, coronary artery disease, cerebrovascular disease, and hip fracture. PRINCIPAL FINDINGS: The total number of ordinary hospital admissions decreased from 244,581 to 204,054 between 1993 and 1996, a population-based decrease of 17.3 percent (p<.001). The mean length of stay decreased from 9.1 days to 8.8 days, resulting in a 21.1 percent decrease in hospital bed days (p<.001). Day hospital use increased sevenfold from 16,871 encounters in 1993 to 108,517 encounters in 1996. The largest decrease in hospital admissions among study conditions was a 41 percent decrease for diabetes (from 2.25 per 1,000 in 1993 to 1.31 in 1996, p<.001). For eight of the nine conditions, severity of illness increased. Differences between severity-adjusted expected and observed in-hospital mortality rates were small. CONCLUSIONS: Observed trends showed a decrease in ordinary hospital admissions, an increase in day hospital admissions, and a greater severity of illness among hospitalized patients. There was little or no change in mortality and readmission rates. Administrative data can be used to track changes in patterns of care and to identify potential quality problems deserving further review.

Effect of isotonic exercise training on left ventricular volume during upright exercise.

To determine the changes in left ventricular volume and their time course during exercise we studied 30 runners. Left ventricular end-diastolic and end-systolic volumes were measured from biapical two-dimensional echocardiograms recorded during graded upright bicycle exercise. The validity of this echocardiographic technique was assessed by comparing measurements at rest and exercise with results obtained by gated equilibrium radionuclide angiography in 10 patients with coronary artery disease. Although the absolute volume measurements were lower by echocardiography, ejection fraction was not significantly different and the directional changes in volume during exercise were comparable. In the runners, resting left ventricular end-diastolic volume measurements by echocardiography correlated with their maximum bicycle exercise endurance times (r = .80). Left ventricular end-diastolic volume, stroke volume, and ejection fraction increased during exercise with the most marked changes occurring in the first half of exercise. Systolic blood pressure/end-systolic volume (SBP/ESV) also increased during exercise, but the largest change occurred during the second half of exercise. Left ventricular volumes were larger in the 12 competitive marathon runners (maximum exercise duration greater than or equal to 27 min) as compared with the 18 noncompetitive runners (exercise duration less than or equal to 23 min): resting end-diastolic volume 130 +/- 29 (SD) ml vs 87 +/- 20 ml (p less than .001), respectively. During exercise the competitive runners exhibited a larger increase in end-diastolic volume and the noncompetitive athletes showed a greater increase in SBP/ESV. Therefore, highly trained competitive marathon runners make greater use of the less energy-consuming Frank-Starling mechanism to accomplish high levels of isotonic exercise performance as compared with less well-trained runners.