[Translated article] Implementation of the standardized process of drug therapy evaluation in inpatients and outpatients.

OBJECTIVES: The Pharmacotherapeutic follow-up program (PFU) carried out by the clinical pharmacist can be categorized within 3 fundamental activities; identification, resolution and prevention of adverse drug events. These must be adjusted to the requirements and resources of each institution, developing procedures to increase PFU efficiency and to guarantee patient safety. The clinical pharmacists of UC-CHRISTUS Healthcare Network developed a Standardized Pharmacotherapeutic Evaluation Process (SPEP). The main goal of our study is to evaluate the impact of this tool through the pharmacist evaluation number and pharmacist interventions number. Secondarily to determine the potential and direct cost savings associated with the pharmacist interventions in an Intensive care unit (ICU). METHODS: A quasi-experimental study evaluated the frequency and type of pharmacist evaluation and pharmacist interventions performed by clinical pharmacists in adult patients units of UC-CHRISTUS Healthcare Network, before and after the implementation of SPEP. The distribution of variables was evaluated using the Shapiro-Wilk test and the association between the use of SPEP and the pharmacist evaluation and pharmacist interventions number was performed using the Chi-square test. The cost evaluation associated with pharmacist interventions in the ICU was carried out using methodology proposed by Hammond et al. RESULTS: A total number of 1781 patients was evaluated before and 2129 after the SPEP. The pharmacist evaluation and pharmacist interventions number in the before-SPEP period were 5209 and 2246. In the after-SPEP period were 6105 and 2641, respectively. The increase in both the pharmacist evaluation and pharmacist interventions number was significant only in critical care patients. The potential cost saving in after-SPEP period in the ICU was USD 492,805. Major adverse drug events prevention was the intervention that generated the most savings with a reduction of 60.2%. The total direct savings for sequential therapy was USD 8072 in the study period. CONCLUSIONS: This study shows a clinical pharmacist developed tool called SPEP that increased the pharmacist evaluation and pharmacist interventions number in multiple clinical scenarios. These were significant only in critical care patients. Future investigations should make effort to evaluate the quality and clinical impact of these interventions.

[Can we improve management and control of chronic diseases?]. / Podemos mejorar el tratamiento y el control de las enfermedades crónicas?

OBJECTIVE: To evaluate the effectiveness of interventions aimed at improving the quality and outcome of chronic disease management. METHODS: Systematic review of the literature. INCLUSION CRITERIA: Clinical trials in English and Spanish that assess the effectiveness of 1 or more strategies for improving quality and outcome in asthma, diabetes, hypertension, and congestive heart failure. Interventions were classified in line with a conceptual model in 6 categories: organizational changes, community participation, information systems, clinical practice design, decision-making support, and self-management. The outcomes considered were: health service utilization, chronic disease management, clinical outcomes, quality of life, satisfaction, and self-management indicators. RESULTS: Thirty seven studies with 38 interventions were included. The most common interventions were those that investigated changes in health care design, followed by those analysing information systems and decision-making support. The most complex interventions, in terms of the overall number of strategies, including support for self-management, showed more likelihood of positive effects in clinical management and clinical outcomes. Few interventions achieved improvements in use of health care services, though patients perceived substantial improvements. CONCLUSIONS: In order to improve quality and effectiveness of chronic disease management, it is necessary to take a systematic view including proactive health care systems and patients taking an active role in managing their disease. These programmes should combine, at the least, organizational strategies, design of clinical practice and patient self-management.

Selective allergy to sheep's and goat's milk proteins.

BACKGROUND: Cow's milk proteins are amongst the most common causes of food allergy in infants, and caseins are probably the main allergens. The existence of a high degree of cross-reactivity between milk caseins from different animals has been reported. We describe a 2-year-old boy who experienced allergic reactions after eating and touching sheep's cheese, but who tolerated cow's milk and cow's milk dairy products. He had never ingested milk or milk derivatives from sheep or goat. METHODS: Skin prick tests were carried out using whey fractions of cow's milk, whole milk and casein from goat, sheep and cow. We also performed skin prick tests with enzymes used in cheese production. Prick-by-prick tests with cheese made from cow, sheep and goat and their corresponding whole milk were also performed. Total serum IgE and specific IgE to cow's milk proteins, whole cow's milk and sheep's milk were determined. Specific IgE against casein and whole milk from the three different species were determined by ELISA. Inhibition of IgE binding to bovine casein was tested for casein and whole milk from all three species. The proteins of three types of casein and whole milk from cow, sheep and goat were separated by SDS-PAGE and were incubated with the patient's serum. RESULTS: Skin tests were positive to sheep's milk and goat and sheep casein and were negative to all cow's milk proteins and whole cow's and goat's milk. Prick-by-prick tests were positive to goat's and sheep's cheese and were negative to cow's cheese. In ELISA-inhibition, sheep's milk and goat and sheep casein were able to inhibit > 50 % of specific IgE binding to sheep casein. The results of immunoblotting showed that the patient's circulating IgEs recognized only one band in the lanes corresponding to sheep and goat casein. CONCLUSIONS: We report a patient with allergy to sheep's and goat's milk proteins but not to cow's milk proteins. Sheep casein was probably the main allergen causing sensitization in this patient. The results suggest that sheep casein shows a high degree of cross-reactivity with goat casein but not with cow casein. Our patient presented allergic symptoms caused by sheep and goat milk and cheese proteins. However, he was able to tolerate cow's milk and cow's milk dairy products without any ill effects.

Occupational rhinoconjunctivitis from white pepper.

A 44-year-old subject developed rhinoconjunctivitis symptoms when she was exposed to white pepper while working in the food industry. A positive skin prick test for white and black pepper extracts (1:10 w/v) were obtained. Specific IgE antibodies to white and black pepper were demonstrated by ELISA. The immunoblot analysis showed two IgE-reactive protein bands able to bind to IgE from white pepper extract of 11.8 kDa and 13.6 kDa and one band from black pepper extract of 11.8 kDa. IgE binding to blotted white and black pepper extract were inhibited by preincubation of patient serum with black pepper extract. A conjunctival provocation test was positive with a white pepper extract dilution of 1:100 w/v. We describe a patient with occupational rhinoconjunctivitis caused by hypersensitivity to white pepper.

[Mortality and quality of life of patients beyond 65 years one year after ICU discharge]. / Mortalidad y calidad de vida al año del alta de una unidad de cuidados intensivos en pacientes mayores de 65 años.

BACKGROUND: Intensive care in elderly patients is a subject of controversy, because they generally present a high rate of mortality and short expectation of life. Due to the increasing life expectancy, more elderly patients will be treated in Intensive Care Unit (ICU) with an increasing consume of resources. The present study considers the mortality and quality of life (QOL) of patients beyond 65 years after ICU, and theirs predictors. PATIENTS AND METHOD: Retrospective study of patients >= 65 years admitted in multidisciplinaire ICU. Mortality and QOL (with modified EuroQOL Instrument) one year after discharge were studied. To determine mortality and QOL one year independent predicting factors, multiple logistic regression models were used. RESULTS: Of 313 patients studied, 95 (30%) died in ICU, 32 (10%) in hospital and 34 (11%) died after discharge. The independent predicting factors of mortality one year after ICU discharge were: organ failure (p < 0.000; odds ratio [OR], 2.9), cardiac surgery (p < 0.0000; OR, 0.15) and respiratory disease (p < 0.01; OR, 2.8). Of the 152 surviving patients, 21% got worse their previous QOL and only 17% were severely discapitated. The independent predicting factors of QOL one year after ICU discharge were: prior QOL (p < 0.0002; OR, 10.2) and age (p < 0.002; OR, 0.09). CONCLUSION: Despite the high one year after ICU discharge mortality rate (51%), 83% of the survivors were able to live independently. Due to dependence between mortality and multiorganic failure during ICU stay and not age, this latter cannot be the determining factor of the care level.

[Survival and quality of life of patients with multiple organ failure one year after leaving an intensive care unit]. / Supervivencia y calidad de vida de los pacientes con fracaso multiorgánico al año del alta de una unidad de medicina intensiva.

BACKGROUND: The patients' mortality with multiple organ failure (MOF) is very high and patients who consume the most resources are those with uncertain prognosis. In order to use the limited resources adequately, it is necessary to know the cost-benefit relationship of their treatment and in this study cost, mortality, quality of life (QOL) of survivors who developed MOF has been investigated. PATIENTS AND METHODS: Mortality in the Intensive Care Unit (ICU) and mortality QOL (with modified EuroQOL Instrument) one year after discharge were studied in 239 admitted patients who developed MOF. Cost was estimated from administrative dats of cost patients-day. To determine mortality independent predicting factors, a logistic regression model was used. RESULTS: Of the 239 patients studied, 144 (60%) died in ICU and 29 (12%) died after discharge. The independent predicting factors of mortality one year after discharge from ICU were: age (p < 0.1, odds ratio [OR] = 1.02), cardiac surgery (p < 0.0000, OR = 0.1899) and trauma (p < 0.05, OR = 0.2287). Of the 66 surviving patients, 18% were severely discapacitated. Forty one percent recovered their previous QOL, 18% improved it and 39% got worse. Patients with MOF consumed 64% of ICU total resources and of these, 77% was consumed by patients who died and by severely discapacitated. CONCLUSION: A high proportion of resources were used by MOF patients, but patients who died and who remained with worst QOL consumed the highest part. Although the mortality after one year was high (72%), 80% of the survivors achieved an acceptable QOL and for this reason, treatment of these patients should not be limited if survival and QOL predictions are not 100% correct.

Specific IgE levels to Cicer arietinum (Chick pea) in tolerant and nontolerant children: evaluation of boiled and raw extracts.

The chick pea, Cicer arietinum, is a legume commonly consumed in Spain and other Mediterranean countries. The sera of 29 children (mean age: 8.4 years) with a current or past history of allergic reactions after ingestion of chick pea, and positive skin tests to this legume, were used to study the allergenic composition of raw and boiled chick pea extracts. The patient population was divided into 2 groups: group 1 consisted of 19 patients with clinical sensitivity confirmed by either positive oral challenges or a convincing recent history of anaphylaxis after eating chick peas, and group 2 consisted of 10 patients with clinical sensitivity in the past, but tolerant at the time of blood extraction. Six atopic children, not allergic to legumes, were included as controls. Specific IgE to the raw and boiled extracts was measured by ELISA. The allergenic composition of both extracts was analyzed by SDS-PAGE and immunoblots. There were no significant differences between specific IgE levels to the raw and boiled extracts (p = 0.23). The mean levels in group 1 were significantly higher than in group 2 and controls (p = 0.0001). Multiple IgE binding proteins/peptides were detected in both extracts in the molecular weight range of 10-106 kD. Only nontolerant patients recognized a similar number of bands in both extracts. Chick pea extracts contain a majority of heat-stable allergens, which could be responsible for the clinical sensitivity to chick pea. Patients with a current clinical allergy to chick pea have statistically higher specific IgE levels than tolerant patients and controls.

Specific IgE determinations to crude and boiled lentil (Lens culinaris) extracts in lentil-sensitive children and controls.

BACKGROUND: The aims of this study were to evaluate the allergenicity of boiled and crude lentil extracts and to compare specific IgE binding in tolerant and nontolerant lentil-allergic children. METHODS: Thirty-eight children were studied and divided into three groups. Group I comprised 24 children with a positive open oral challenge, or a convincing history of anaphylaxis after the ingestion of lentils; group II comprised nine children with a history of allergic reactions in the past, but currently tolerant of lentils; and group III comprised five children allergic to other legumes, but always tolerant of the ingestion of lentils. Specific IgE determinations and ELISA inhibitions were performed with the crude and boiled lentil extracts. The allergenic profile of both extracts was evaluated by SDS-PAGE and immunoblot. RESULTS: Mean specific IgE levels in group I were significantly higher than in groups II and III. The heating process caused a significant decrease in specific IgE binding. However, IgE-inhibition studies showed that the boiled lentil extract had a greater inhibitory capacity than the crude extract. Immunoblots revealed no important differences in IgE-binding patterns between the two extracts. Multiple allergens were detected in a wide range of molecular masses. CONCLUSIONS: Boiled lentil extracts maintain strong allergenicity. Patients who have developed tolerance of lentil ingestion have lower specific IgE levels than symptomatic patients.