Implementation of a clinical decision support system for the optimization of antidiabetic drug orders by pharmacists.

AIMS: The objective of the study was to describe the impact of a clinical decision support system (CDSS) on antidiabetic drug management by clinical pharmacists for hospitalized patients with T2DM. METHODS: We performed a retrospective, single-centre study in a teaching hospital, where clinical pharmacists analysed prescriptions and issued pharmacist interventions (PIs) through a computerized physician order entry (CPOE) system. A CDSS was integrated into the pharmacists' workflow in July 2019. We analysed PIs during 2 periods of interest: one before the introduction of the CDSS (from November 2018 to April 2019, PIs issued through the CPOE alone) and one afterwards (from November 2020 to April 2021, PIs issued through the CPOE and/or the CDSS). The study covered nondiabetology wards as endocrinology, diabetes and metabolism departments were not computerized at the time of the study. RESULTS: There were 203 PIs related to antidiabetic drugs in period 1 and 319 in period 2 (a 57.5% increase). Sixty-four of the 319 PIs were generated by the CDSS. Noncompliance/contraindication was the main problem identified by the CDSS (41 PIs, 68.4%), and 57.8% led to discontinuation of the drug. Most of the PIs issued through the CDSS corresponded to orders that had not been flagged up by clinical pharmacists using the CPOE. Conversely, most alerts about indications that were not being treated were detected by the clinical pharmacists using the CPOE and not by the CDSS. CONCLUSION: Use of CDSS by clinical pharmacists improved antidiabetic drug management for hospitalized patients with T2DM. The CDSS might add value to diabetes care in nondiabetology wards by decreasing the frequency of potentially inappropriate prescriptions and adverse drug reactions.

For a better understanding of the profile of nurses working in France who hold or are working toward a Ph.D: A quantitative descriptive study / Mieux connaître le profil des infirmières titulaires d'un doctorat en sciences ou doctorantes exerçant en France : une étude descriptive quantitative

Introduction: In 2009, the French Association de recherche en soins infirmiers (Nursing Research Association) counted fifty-four nurses holding a doctorate or working toward one. Recent developments in this area include the creation of section 92, for nursing sciences, in the National Council of Universities, making it possible for nurses in France to become professors with teaching and research responsibilities. Objectives: To update and complete the 2009 data by identifying the grades, fields of activity, and disciplines of nurses holding a doctorate or studying for one. Method: A quantitative descriptive study was carried out using an online questionnaire between December 1, 2021 and March 22, 2022. Results: the study involved 147 nurses working in France: seventy-five with a doctorate and 72 doctoral students. The majority of the respondents were women, held a supervisory position, and were working in the field of education. Among the doctorates obtained, education sciences accounted for the largest share. However, this disciple was less well represented among the doctoral candidates. Discussion: This study shows a change in the characteristics of nurses who are also doctoral candidates and in the disciplines in which they have obtained or are currently obtaining a doctorate, and an increase in the value of the degree, particularly in research, but little access to academic posts.

Introduction: En 2009, l'Association de recherche en soins infirmiers avait recensé 54 infirmières titulaires d'un doctorat et doctorantes. Parmi les intérêts récents de s'engager dans des cursus académiques figure la création, en 2019, de la section 92 « sciences infirmières ¼ au Conseil national des universités, rendant possible en France l'accès au corps d'enseignants-chercheurs à des infirmières. Objectifs: Actualiser et compléter les données de 2009 en identifiant les grades, les domaines d'activité, les disciplines des infirmières titulaires d'un doctorat ou doctorantes. Méthode: Une étude quantitative descriptive a été réalisée par un questionnaire en ligne, entre le 01/12/2021 et le 22/03/2022. Résultats: 147 participants, exerçant en France, ont été inclus, dont 75 infirmières titulaires d'un doctorat et 72 doctorantes. La majorité des répondants étaient des femmes, avaient un grade d'encadrement et exerçaient une activité professionnelle dans le domaine de la formation. Le plus grand nombre de doctorats a été obtenu en sciences de l'éducation ; cette discipline est moins représentée chez les doctorantes. Discussion: Cette étude montre une évolution des caractéristiques des infirmières doctorantes et des disciplines des doctorats obtenus ou en cours, une valorisation du diplôme notamment en recherche mais un faible accès aux fonctions académiques.

For a better understanding of the profile of nurses working in France who hold or are working toward a Ph.D: A quantitative descriptive study / Mieux connaître le profil des infirmières titulaires d'un doctorat en sciences ou doctorantes exerçant en France : une étude descriptive quantitative

INTRODUCTION: In 2009, the French Association de recherche en soins infirmiers (Nursing Research Association) counted fifty-four nurses holding a doctorate or working toward one. Recent developments in this area include the creation of section 92, for nursing sciences, in the National Council of Universities, making it possible for nurses in France to become professors with teaching and research responsibilities. OBJECTIVES: To update and complete the 2009 data by identifying the grades, fields of activity, and disciplines of nurses holding a doctorate or studying for one. METHOD: A quantitative descriptive study was carried out using an online questionnaire between December 1, 2021 and March 22, 2022. RESULTS: the study involved 147 nurses working in France: seventy-five with a doctorate and 72 doctoral students. The majority of the respondents were women, held a supervisory position, and were working in the field of education. Among the doctorates obtained, education sciences accounted for the largest share. However, this disciple was less well represented among the doctoral candidates. DISCUSSION: This study shows a change in the characteristics of nurses who are also doctoral candidates and in the disciplines in which they have obtained or are currently obtaining a doctorate, and an increase in the value of the degree, particularly in research, but little access to academic posts.

Introduction: En 2009, l'Association de recherche en soins infirmiers avait recensé 54 infirmières titulaires d'un doctorat et doctorantes. Parmi les intérêts récents de s'engager dans des cursus académiques figure la création, en 2019, de la section 92 « sciences infirmières ¼ au Conseil national des universités, rendant possible en France l'accès au corps d'enseignants-chercheurs à des infirmières. Objectifs: Actualiser et compléter les données de 2009 en identifiant les grades, les domaines d'activité, les disciplines des infirmières titulaires d'un doctorat ou doctorantes. Méthode: Une étude quantitative descriptive a été réalisée par un questionnaire en ligne, entre le 01/12/2021 et le 22/03/2022. Résultats: 147 participants, exerçant en France, ont été inclus, dont 75 infirmières titulaires d'un doctorat et 72 doctorantes. La majorité des répondants étaient des femmes, avaient un grade d'encadrement et exerçaient une activité professionnelle dans le domaine de la formation. Le plus grand nombre de doctorats a été obtenu en sciences de l'éducation ; cette discipline est moins représentée chez les doctorantes. Discussion: Cette étude montre une évolution des caractéristiques des infirmières doctorantes et des disciplines des doctorats obtenus ou en cours, une valorisation du diplôme notamment en recherche mais un faible accès aux fonctions académiques.

Estimating human exposure to pyrethroids' mixtures from biomonitoring data using physiologically based pharmacokinetic modeling.

Human biomonitoring data provide evidence to exposure of environmental chemicals. Physiologically based pharmacokinetic (PBPK) modelling together with an adequate exposure scenario allows to transpose measured concentrations of chemicals or their metabolites into exposure levels, as daily intakes. In France, high levels of urinary pyrethroids metabolites have been measured in populations. Our work aims at estimating the exposure of the French ENNS cohort to mixtures of four pyrethroids (deltamethrin, permethrin, cypermethrin, and cyfluthrin) from the urinary concentrations of five pyrethroids' metabolites commonly measured in biomonitoring studies. We developed a modelling approach based on a global toxicokinetic model that accounts for the cumulative exposure to pyrethroids as some of the metabolites can be shared by several parent compounds and for human inter-individual variability in metabolism. The median of the individual daily intakes was estimated to 8.1 ng/kg bw/day for permethrin, 17.7 ng/kg bw/day for cypermethrin, 20.4 ng/kg bw/day for cyfluthrin and 34.3 ng/kg bw/day for deltamethrin leading to similar weights for the pair permethrin and cypermethrin (36%), cyfluthrin (31%) and deltamethrin (33%) to the cumulative exposure. Accounting for human variability enabled to explain some of the variations in the metabolites' levels within the cohort. The cumulative exposure was then weighted by their toxicities towards three neurotoxic effects to calculate margins of exposure (MOE). Low MOE values were always associated with high measured concentrations of metabolites in urine and the lowest MOEs were observed for the autonomic division. No risks associated with reconstructed mixtures of pyrethroids were expected for the ENNS cohort. Our approach is an asset to analyse the biomarkers of exposure to pyrethroids simultaneously and could be easily adapted to any local or national specificities in pyrethroids' exposure or populations.

Public Availability of Data Management and Analysis Scripts of Studies Conducted on Open-Access Intensive Care Databases.

Intensive care units (ICUs) provide care for critical patients at high risk of morbidity and mortality, and require continuous monitoring of clinical, biological and, imaging parameters. Collaborative ventures have enabled the emergence of large open access databases for the secondary use of Electronic Health Records (EHRs). The objective of this work was to evaluate the availability of scripts and datasets in publications based on ICU open-access databases. We included 910 original articles based on four ICU open-access databases (Amsterdam University Medical Centers Database, eICU Collaborative Research Database, High time resolution ICU dataset, and Medical Information Mart for Intensive Care). The majority of the studies did not provide their data management scripts (n=839, 92.9%), neither the analysis script (n=843, 93.4%) in the article. Attempts to contact the 845 corresponding authors in question resulted in 89.11% (n=753) of our e-mail requests going unanswered over a two-month period. We received 51 automated messages (55.43%) indicating that emails have not been delivered, while 6 messages (6.52%) redirected to alternative email addresses. Only 20 corresponding authors (18.18%) answered, finally providing the requested materials. Despite scientific journals recommendations to share materials, our study unveils the absence of crucial components for the replication of studies by other research teams.

Usability Checklists for Health Technology: Case Study and Experts' Opinions.

Application of usability evaluations throughout the health technology lifecycle is necessary to improve the efficiency, safety, and effectiveness of health service delivery. Unfortunately, technology vendors and healthcare organizations may not have funding, time or expertise to conduct usability studies. In this paper, we describe how usability checklists can potentially fill this gap. First, we introduce a case study using a checklist to identify usability issues with a primary care dashboard. Then we provide an expert summary of the strengths and limitations of usability checklists. Findings suggest that checklists are efficient to identify important usability issues. They can be used effectively by project team members - including clinicians - without formal usability training. However, checklists should complement rather than replace usability evaluations with representative users.

Clinical Decision Support Systems for Operating Room Nurses: A Rapid Review.

This rapid review delves into Clinical Decision Support Systems (CDSS) for Operating Room Nurses (ORN). Analyzing three studies over 20 years, it highlights limited impact on ORN decision-making. The findings suggest that CDSS positively influence some aspects of care, ORN perceive them as supplementary rather than pivotal to their decision-making processes. Our review highlights the importance of understanding ORN' decision-making for customizing CDSS effectively.

Transforming Primary Care Data Into the Observational Medical Outcomes Partnership Common Data Model: Development and Usability Study.

Background: Patient-monitoring software generates a large amount of data that can be reused for clinical audits and scientific research. The Observational Health Data Sciences and Informatics (OHDSI) consortium developed the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM) to standardize electronic health record data and promote large-scale observational and longitudinal research. Objective: This study aimed to transform primary care data into the OMOP CDM format. Methods: We extracted primary care data from electronic health records at a multidisciplinary health center in Wattrelos, France. We performed structural mapping between the design of our local primary care database and the OMOP CDM tables and fields. Local French vocabularies concepts were mapped to OHDSI standard vocabularies. To validate the implementation of primary care data into the OMOP CDM format, we applied a set of queries. A practical application was achieved through the development of a dashboard. Results: Data from 18,395 patients were implemented into the OMOP CDM, corresponding to 592,226 consultations over a period of 20 years. A total of 18 OMOP CDM tables were implemented. A total of 17 local vocabularies were identified as being related to primary care and corresponded to patient characteristics (sex, location, year of birth, and race), units of measurement, biometric measures, laboratory test results, medical histories, and drug prescriptions. During semantic mapping, 10,221 primary care concepts were mapped to standard OHDSI concepts. Five queries were used to validate the OMOP CDM by comparing the results obtained after the completion of the transformations with the results obtained in the source software. Lastly, a prototype dashboard was developed to visualize the activity of the health center, the laboratory test results, and the drug prescription data. Conclusions: Primary care data from a French health care facility have been implemented into the OMOP CDM format. Data concerning demographics, units, measurements, and primary care consultation steps were already available in OHDSI vocabularies. Laboratory test results and drug prescription data were mapped to available vocabularies and structured in the final model. A dashboard application provided health care professionals with feedback on their practice.

Barriers encountered with clinical data warehouses: Recommendations from a focus group.

BACKGROUND AND OBJECTIVE: The increasing implementation and use of electronic health records over the last few decades has made a significant volume of clinical data being available. Over the past 20 years, hospitals have also adopted and implemented data warehouse technology to facilitate the reuse of administrative and clinical data for research. However, the implementation of clinical data warehouses encounters a set of barriers: ethical, legislative, technical, human and organizational. This paper proposes an overview of difficulties and barriers encountered during a clinical data warehouse (CDW) development and implementation project. METHODS: We conducted a focus group at the 2023 Medical Informatics Europe Conference and invited professionals involved in the implementation of CDW. These experts described their CDW and the difficulties and barriers they encountered at each phase: (i) launching of the data warehouse project, (ii) implementing the data warehouse and (iii) using a data warehouse in routine operations. They were also asked to propose solutions they were able to implement to address the barriers previously reported. RESULTS: After synthesis and consensus, a total of 26 barriers were identified, 10 pertained to tasks, 5 to tools and technologies, 4 to persons, 4 to organization, and 3 to the external environment. To address these challenges, a set of 15 practical recommendations was offered, covering essential aspects such as governance, stakeholder engagement, interdisciplinary collaboration, and external expertise utilization. CONCLUSIONS: These recommendations serve as a valuable resource for healthcare institutions seeking to establish and optimize CDWs, offering a roadmap for leveraging clinical data for research, quality enhancement, and improved patient care.

A systematic review of the value of clinical decision support systems in the prescription of antidiabetic drugs.

INTRODUCTION: The management of chronic diabetes mellitus and its complications demands customized glycaemia control strategies. Polypharmacy is prevalent among people with diabetes and comorbidities, which increases the risk of adverse drug reactions. Clinical decision support systems (CDSSs) may constitute an innovative solution to these problems. The aim of our study was to conduct a systematic review assessing the value of CDSSs for the management of antidiabetic drugs (AD). MATERIALS AND METHODS: We systematically searched the scientific literature published between January 2010 and October 2023. The retrieved studies were categorized as non-specific or AD-specific. The studies' quality was assessed using the Mixed Methods Appraisal Tool. The review's results were reported in accordance with the PRISMA guidelines. RESULTS: Twenty studies met our inclusion criteria. The majority of AD-specific studies were conducted more recently (2020-2023) compared to non-specific studies (2010-2015). This trend hints at growing interest in more specialized CDSSs tailored for prescriptions of ADs. The nine AD-specific studies focused on metformin and insulin and demonstrated positive impacts of the CDSSs on different outcomes, including the reduction in the proportion of inappropriate prescriptions of ADs and in hypoglycaemia events. The 11 nonspecific studies showed similar trends for metformin and insulin prescriptions, although the CDSSs' impacts were not significant. There was a predominance of metformin and insulin in the studied CDSSs and a lack of studies on ADs such as sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists. CONCLUSION: The limited number of studies, especially randomized clinical trials, interested in evaluating the application of CDSS in the management of ADs underscores the need for further investigations. Our findings suggest the potential benefit of applying CDSSs to the prescription of ADs particularly in primary care settings and when targeting clinical pharmacists. Finally, establishing core outcome sets is crucial for ensuring consistent and standardized evaluation of these CDSSs.

Home Care Nursing on Long-Term Illness Management in the French Healthcare System.

This study explores the role of home care nurses in managing long-term illnesses (L-TI) within the French healthcare system, utilizing data from the SNDS. Focused on data from 2022, it categorizes nursing actions into medical procedures, care procedures, and nursing processes, revealing significant involvement in patient care. The findings highlight the crucial, evolving role of home care nurses in addressing the complex needs of millions suffering from chronic conditions like diabetes and cardiovascular diseases in France.

OpenDataPsy: An Open-Data Repository with Standardized Storage and Description for Research in Psychiatry.

Sharing health data could avoid duplication of effort in data collection, reduce unnecessary costs in future studies, and encourage collaboration and data flow within the scientific community. Several repositories from national institutions or research teams have making their datasets available. These data are mainly aggregated at spatial or temporal level, or dedicated to a specific field. The objective of this work is to propose a standardized storage and description of open datasets for research purposes. For this, we selected 8 publicly accessible datasets, covering the fields of demographics, employment, education and psychiatry. Then, we studied the format, nomenclature (i.e., files and variables names, modalities of recurrent qualitative variables) and descriptions of these datasets and we proposed on common and standardized format and description. We made available these datasets in an open gitlab repository. For each dataset, we proposed the raw data file in its original format, the cleaned data file in csv format, the variables description, the data management script and the descriptive statistics. Statistics are generated according to the type of variables previously documented. After one year of use, we will evaluate with the users if the standardization of the data sets is relevant and how they use the dataset in real life.

Description of a French Population of Diabetics Treated Followed up by General Practitioners.

In France, the prevalence of treated diabetes has been estimated at 4.6%, or more than 3 million people and 5.2% in Northern France. The reuse of primary care data allows to study outpatient clinical data such as laboratory results and drug prescriptions, which are not documented in claims and hospital databases. In this study, we selected the population of treated diabetics from the Wattrelos primary care data warehouse, in North of France. Firstly, we studied the laboratory results of diabetics by identifying whether the recommendations of the French National Authority for Health (HAS) were respected. In a second step, we studied the prescriptions of diabetics by identifying the oral hypoglycemic agents treatments and insulins treatments. The diabetic population represents 690 patients of the health care center. The recommendations on labortatory are respected for 84% of diabetics. The majority of diabetics are treated with oral hypoglycemic agents 68.6%. As recommended by the HAS, metformin is the first-line treatment in the diabetic population.

Inter-Professional Communications During Follow-Up of Type 2 Diabetes Patients: An Exploratory Study.

Follow-up of patients with type 2 diabetes mellitus (T2DM) involves several healthcare professionals. The quality of their communication is crucial for optimizing care. This exploratory work aims to characterize those communications and their problems. Interviews were performed with general practitioners (GP), patients and other professionals. Data were analyzed deductively, and results were structured through a people map. We performed 25 interviews. GP, patients, nurses, community pharmacists, medical specialists and diabetologists are the main actors of the T2DM patients' follow-up. Three communication issues were identified: difficulties in reaching the hospital diabetologist, delays in receiving reports, and difficulties for patient to transmit information. Results were discussed in terms of tools, care pathways and new roles to support communications during T2DM patients' follow-up.

Definition of a Practical Taxonomy for Referencing Data Quality Problems in Health Care Databases.

INTRODUCTION: Health care information systems can generate and/or record huge volumes of data, some of which may be reused for research, clinical trials, or teaching. However, these databases can be affected by data quality problems; hence, an important step in the data reuse process consists in detecting and rectifying these issues. With a view to facilitating the assessment of data quality, we developed a taxonomy of data quality problems in operational databases. MATERIAL: We searched the literature for publications that mentioned "data quality problems," "data quality taxonomy," "data quality assessment," or "dirty data." The publications were then reviewed, compared, summarized, and structured using a bottom-up approach, to provide an operational taxonomy of data quality problems. The latter were illustrated with fictional examples (though based on reality) from clinical databases. RESULTS: Twelve publications were selected, and 286 instances of data quality problems were identified and were classified according to six distinct levels of granularity. We used the classification defined by Oliveira et al to structure our taxonomy. The extracted items were grouped into 53 data quality problems. DISCUSSION: This taxonomy facilitated the systematic assessment of data quality in databases by presenting the data's quality according to their granularity. The definition of this taxonomy is the first step in the data cleaning process. The subsequent steps include the definition of associated quality assessment methods and data cleaning methods. CONCLUSION: Our new taxonomy enabled the classification and illustration of 53 data quality problems found in hospital databases.

Comparison of the validity, perceived usefulness, and usability of I-MeDeSA and TEMAS, two tools to evaluate alert system usability.

OBJECTIVE: Two tools are currently available in the literature to evaluate the usability of medication alert systems, the instrument for evaluating human factors principles in medication-related decision support alerts (I-MeDeSA) and the tool for evaluating medication alerting systems (TEMAS). This study aimed to compare their convergent validity, perceived usability, usefulness, strengths, and weaknesses, as well as users' preferences. METHOD: To evaluate convergent validity, two experts mapped TEMAS' items against I-MeDeSA's items with respect to the usability dimensions they target. To assess perceived usability, usefulness, strengths, and weaknesses of both tools, staff with expertise in their medication alerting system were asked to use French versions of the TEMAS and I-MeDeSA. After the use of each tool, participants were asked to complete the System Usability Scale (SUS) and answer questions about the understandability and usefulness of each tool. Finally, participants were asked to name their preferred tool. Numeric scores were statistically compared. Free-text responses were analyzed using an inductive approach. RESULTS: Forty-five participants from 10 hospitals took part in the study. In terms of convergent validity, I-MeDeSA focuses more on the usability of the graphical user interface while TEMAS considers a wider range of usability principles. Both tools have a fair level of perceived usability (I-MeDeSA' SUS score = 61.85 and TEMAS' SUS score = 62.87), but results highlight that revisions are necessary to both tools to improve their usability. Participants found TEMAS more useful than I-MeDeSA (t = -3.63, p =.005) and had a clear preference for TEMAS to identify problems in formative evaluation (39 of 45; 0.867, p <.001) and to compare the usability of alert systems during the procurement process (36 of 45; 0.8, p <.001). CONCLUSIONS: The TEMAS is perceived as more useful and is preferred by participants. The I-MeDeSA seems more relevant for quick evaluations that focus on the graphical user interface. The TEMAS seems to be more suitable for in-depth usability evaluations of alert systems. Even if both tools are perceived to be equally usable, they suffer from wording, instructional, and organizational problems that hinder their use. The results of this study will be used to improve the design of I-MeDeSA and TEMAS.

Implementation of a Data Warehouse in Primary Care: First Analyses with Elderly Patients.

The implementation of clinical data warehouses has advanced in recent years. The standardization of clinical data in these warehouses has made it possible to carry out multicenter studies and to formalize the clinical vocabulary. However, there is limited insight into a patient's overall care pathway in the clinical domain. Regarding primary care data, the implementation of this type of warehouse in a routine way is hindered in particular by the analysis of textual data provided by general practitioners during patient consultations. In our study we collected primary care data for standardization in a data warehouse. The purpose of this analysis was to assess the feasibility of analyzing primary care data, and particularly to study the consultations and prescriptions of the elderly patient contained in our primary care data warehouse.

Defining explicit definitions of potentially inappropriate prescriptions for antidiabetic drugs in patients with type 2 diabetes: A systematic review.

INTRODUCTION: Potentially inappropriate prescriptions (PIPs) of antidiabetic drugs (ADs) (PIPADs) to patients with type 2 diabetes mellitus (T2DM) have been reported in some studies. The detection of PIPs in electronic databases requires the development of explicit definitions. This approach is widely used in geriatrics but has not been extended to PIPADs in diabetes mellitus. The objective of the present literature review was to identify all explicit definitions of PIPADs in patients with T2DM. MATERIALS AND METHODS: We performed a systematic review of the literature listed on Medline (via PubMed), Scopus, Web of Science, and, Embase between 2010 and 2021. The query included a combination of three concepts ("T2DM" AND "PIPs" AND "ADs") and featured a total of 86 keywords. Two independent reviewers selected publications, extracted explicit definitions of PIPADs, and then classified the definitions by therapeutic class and organ class. RESULTS: Of the 4,093 screened publications, 39 were included. In all, 171 mentions of PIPADs (corresponding to 56 unique explicit definitions) were identified. More than 50% of the definitions were related to either metformin (34%) or sulfonylureas (29%). More than 75% of the definitions were related to either abnormal renal function (56%) or age (22%). In addition, 20% (n = 35) mentions stated that biguanides were inappropriate in patients with renal dysfunction and 17.5% (n = 30) stated that sulfonylureas were inappropriate above a certain age. The definitions of PIPADs were heterogeneous and had various degrees of precision. CONCLUSION: Our results showed that researchers focused primarily on the at-risk situations related to biguanide prescriptions in patients with renal dysfunction and the prescription of sulfonylureas to older people. Our systematic review of the literature revealed a lack of consensus on explicit definitions of PIPADs, which were heterogeneous and limited (in most cases) to a small number of drugs and clinical situations.