Prevalence and Impact of Having Multiple Barriers to Medication Adherence in Nonadherent Patients With Poorly Controlled Cardiometabolic Disease.

Adherence to medications remains poor despite numerous efforts to identify and intervene upon nonadherence. One potential explanation is the limited focus of many interventions on one barrier. Little is known about the prevalence and impact of having multiple barriers in contemporary practice. Our objective was to quantify adherence barriers for patients with poorly controlled cardiometabolic condition, identify patient characteristics associated with having multiple barriers, and determine its impact on adherence. We used a linked electronic health records and insurer claims dataset from a large health system from a recent pragmatic trial. Barriers to medication taking before the start of the intervention were elicited by clinical pharmacists using structured interviews. We used multivariable modified Poisson regression models to examine the association between patient factors and multiple barriers and multivariable linear regression to evaluate the relation between multiple barriers and claims-based adherence. Of the 1,069 patients (mean: 61 years of age) in this study, 25.1% had multiple barriers to adherence; the most common co-occurring barriers were forgetfulness and health beliefs (31%, n = 268). Patients with multiple barriers were more likely to be non-white (relative risk [RR] 1.57, 95% confidence interval [CI] 1.21 to 1.74), be single/unpartnered (RR 1.36, 95% CI 1.06 to 1.74), use tobacco (RR 1.54, 95% CI 1.13 to 2.11), and have poor glycemic control (RR 1.77, 95% CI 1.31 to 2.39) versus those with 0 or 1 barrier. Each additional barrier worsened average adherence by 3.1% (95% CI -4.6%, -1.5%). In conclusion, >25% of nonadherent patients present with multiple barriers to optimal use, leading to meaningful differences in adherence. These findings should inform quality improvement interventions aimed at nonadherence.

A clinical TRIAD for early suspicion of autoimmune encephalitis as a possibility in patients presenting with progressive cognitive decline.

Patients with progressive cognitive decline mostly suffer from degenerative disease and carry a relatively poor prognosis. But small groups among these patients have a potentially treatable cause of illness and therefore every patient with dementia needs to be considered treatable unless proved otherwise. This group can be identified only by high degree of suspicion based on clinical clues. We have evaluated the validity of some simple clinical clues which we noticed in our patients with immune mediated dementias. The Panic score, Epsworth sleepiness score, catatonic symptoms and history of seizures were compared between 23 and 11 patients with serologically confirmed anti-NMDA antibody and anti-VGKC antibody associated encephalitis respectively. They were compared with 20 patients with probable behavioral variant of Frontotemporal dementia (bvFTD) and 20 patients with probable Alzheimer's disease (AD). Chi-square test was used to compare across the groups and there was significant difference (P < 0.05) across the 4 groups comprising anti NMDA encephalitis, anti VGKC encephalitis, FTD and AD among the four variables (Panic scores, Catatonic symptoms, Epsworth sleepiness score and seizures) studied. Our study revealed that panic and sleepiness is highly significant when tested across all groups and catatonia showed a trend towards NMDA and when compared with degenerative dementia versus immune mediated syndromes all the 4 parameters were highly significant This simple bedside TRIAD of panic, sleepiness with either of catatonia or seizures if found in patients it is appropriate to order antibody assessment before anything else is planned. This needs to be evaluated in a larger sample.

Human Cytosolic Sulfotransferase SULT1A3 Mediates the Sulfation of Dextrorphan.

Dextrorphan, an active metabolite of the antitussive dextromethorphan, has been shown to be subjected to sulfation by several zebrafish cytosolic sulfotransferases (SULTs). We were interested in finding out which of the human SULT(s) is(are) capable of catalyzing the sulfation of dextrorphan, and to verify whether sulfation of dextrorphan may occur in cultured human cells and human organ cytosols. Data from the enzymatic assays showed that, of all thirteen known human SULTs, SULT1A3 displayed the strongest dextrorphan-sulfating activity. Cell culture experiments using HepG2 human hepatoma cells and Caco-2 human colon carcinoma cells incubated with [(35)S]sulfate together with varying concentrations of dextrorphan revealed indeed the production and release of [(35)S]sulfated dextrorphan in a concentration-dependent manner. Additionally, significant dextrorphan-sulfating activity was detected in human liver, small intestine and lung cytosols. Taken together, these results provided a biochemical basis for the sulfation of dextrorphan in humans.

Endobronchial rhinosporidiosis.

Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi. We report a rare case of rhinosporidiosis, with involvement of the skin, nasal cavity, larynx, oropharynx, and the bronchial tree. The patient underwent bronchoscopic electrocautery excision of the endobronchial lesion with good symptomatic improvement.

Factors associated with pain among ambulatory patients with cancer with advanced disease at a comprehensive cancer center.

PURPOSE: The prevalence and severity of pain have not been well described among oncology patients in ambulatory care. To better understand the burden of pain among patients with advanced cancer, we examined the prevalence of pain reported during office and treatment visits. METHODS: A retrospective study of 4,014 patients with advanced disease (stage 4 at diagnosis or metastatic progression) who completed an ambulatory visit between 2004 and 2006 was conducted at a comprehensive cancer center in Boston, Massachusetts. RESULTS: At their first visit during the study period, 74% of patients reported no pain (0 score); 12%, low pain (1 to 3 score); 9%, moderate pain (4 to 6 score); and 5%, severe pain (7 to 10 score). The prevalence of pain was highest among patients who were younger than 60 years of age, were nonwhite, did not speak English as their primary language, or were covered by Medicaid, received free care, or paid their own health care costs. Patients with thoracic, breast, and head and neck cancers had higher pain scores than those with other diseases. Pain was reported more frequently among patients whose diagnosis or metastatic progression occurred less than 3 months before the reported pain score. In multivariable regression analysis, age, race, cancer type, and time since diagnosis/progression were identified as important factors associated with severe pain. CONCLUSION: Younger age, minority race, and recent onset of advanced disease are associated with severe pain among patients with cancer. Recognizing these high-risk groups could inform targeted interventions to address pain care in ambulatory patients with advanced cancer.

Incidence of severe pain in newly diagnosed ambulatory patients with stage IV cancer.

BACKGROUND: Pain is common among cancer patients. OBJECTIVE: To characterize the incidence of severe pain among newly diagnosed patients with stage IV cancer in ambulatory care. METHODS: A retrospective cohort of 505 ambulatory oncology patients with newly diagnosed stage IV solid tumours at a comprehensive cancer centre (Dana-Farber Cancer Institute, Boston, Massachusetts, USA) was followed from January 1, 2004, to December 31, 2006. Pain intensity scores were extracted from electronic medical records. The incidence of severe pain was calculated using the maximum monthly pain scores reported at outpatient visits. RESULTS: Of the 505 patients included in the present study, 340 (67.3%) were pain-free at the initial visit, 90 (17.8%) experienced mild pain, 48 (9.5%) experienced moderate pain and 27 (5.4%) experienced severe pain. At least one episode of severe pain within one year of diagnosis was reported by 29.1% of patients. Patients with head and neck, gastrointestinal and thoracic malignancies were more likely to experience severe pain compared with patients with other types of cancer (52.6%, 33.9% and 30.5%, respectively). In the multivariable model, patients whose primary language was not English (OR 2.90 [95% CI 1.08 to 7.80]), patients who reported severe pain at the initial visit (OR 9.30 [95% CI 3.72 to 23.23]) and patients with head and neck (OR 10.17 [95% CI 2.87 to 36.00]) or gastrointestinal (OR 4.05 [95% CI 1.23 to 13.35]) cancers were more likely to report severe pain in the following year. CONCLUSIONS: The incidence of severe pain was high in ambulatory patients with newly diagnosed stage IV cancer.

Unusual mediastinal cystic lesions with air fluid level.

An air-fluid level within an enlarged mediastinal lymph node is unusual. We describe three patients who had mediastinal lymphadenopathy containing air-fluid levels. The differential diagnosis and approach are discussed.

Systematically seeking clinicians' insights to identify new safety measures for intensive care units and general surgery services.

Comprehensive measures to benchmark or track safety performance do not yet exist. The authors aimed to develop and validate a process to identify comprehensive, clinically meaningful sets of safety measures that would draw on the clinical experiences and perceptions of active practitioners. They pilot tested this process for safety measure development for 2 hospital departments (ie, intensive care units and general surgery services) by holding 7 brainstorming sessions with physicians and nurses in major academic and community teaching hospitals in Boston, Massachusetts, and Baltimore, Maryland. Participants identified lists of patient harms that they considered to be among the 20 most frequent and the 20 most severe in their respective units. The authors generated a master list of patient harms, which participants then ranked by both frequency and severity via E-mail voting. This process produced safety measures with inherent credibility with clinicians on the front lines of care.

Clinicians' assessments of electronic medication safety alerts in ambulatory care.

BACKGROUND: While electronic prescribing (e-prescribing) systems with drug interaction and allergy alerts promise to improve medication safety in ambulatory care, clinicians often override these safety features. We undertook a study of respondents' satisfaction with e-prescribing systems, their perceptions of alerts, and their perceptions of behavior changes resulting from alerts. METHODS: Random sample survey of 300 Massachusetts ambulatory care clinicians who used a commercial e-prescribing system. RESULTS: A total of 184 respondents completed the survey (61%). Respondents indicated that e-prescribing improved the quality of care delivered (78%), prevented medical errors (83%), and enhanced patient satisfaction (71%) and clinician efficiency (75%). In addition, 35% of prescribers said that electronic alerts caused them to modify a potentially dangerous prescription in the last 30 days. They suggested that alerts also led to other changes in clinical care: counseling patients about potential reactions (49% of respondents), looking up information in medical references (44%), and changing the way a patient was monitored (33%). Altogether, 63% of clinicians reported taking action other than discontinuing or modifying an alerted prescription in the previous month in response to alerts. Despite these benefits, fewer than half of respondents were satisfied with drug interaction and allergy alerts (47%). Problems included alerts triggered by discontinued medications (58%), alerts that failed to account for appropriate drug combinations (46%), and excessive volume of alerts (37%). CONCLUSION: Although clinicians were critical of the quality of e-prescribing alerts, alerts may lead to clinically significant modifications in patient management not readily apparent based on "acceptance" rates.

Are patient safety indicators related to widely used measures of hospital quality?

CONTEXT: Patient safety indicators (PSIs) are screening tools that use administrative data to identify potential complications of care and are being increasingly used as measures of hospital safety. It is unknown whether PSIs are related to standard quality metrics. OBJECTIVE: To examine the relationship between select PSIs and measures of hospital quality. DESIGN, SETTING, AND PARTICIPANTS: We used the 2003 MedPAR dataset to examine the performance of 4,504 acute-care hospitals on four medical PSIs among Medicare enrollees. MAIN OUTCOME MEASURES: We used bivariate and multivariate techniques to examine the relationship between PSI performance and quality scores from the Hospital Quality Alliance program, risk-adjusted mortality rates, and selection as a top hospital by US News & World Report. RESULTS: We found inconsistent and usually poor associations among the PSIs and other hospital quality measures with the exception of "failure to rescue," which was consistently associated with better performance on all quality measures tested. For example, hospitals in the top quartile of failure to rescue performance had a 0.9% better summary performance score in acute myocardial infarction (AMI) processes and a 22% lower mortality rate in AMI compared to hospitals in the bottom quartile of failure to rescue (p < 0.01 for both comparisons). Death in low mortality DRG, decubitus ulcer, and infection due to medical care generally had poor or often inverse relationships with the other quality measures. CONCLUSIONS: With the exception of failure to rescue, we found poor or inverse relationships between PSIs and other measures of healthcare quality. Whether the lack of relationship is due to the limitations of the PSIs is unknown, but suggests that PSIs need further validation before they are employed broadly.

Profile of GERD in the adult population of a northeast urban community.

STUDY: An observational, cross-sectional, epidemiology study of the characteristics of GERD in a large northeast urban population was performed using a self-responding 84-question survey. Four-hundred and ten surveys were completed from a population sample with demographics comparable to those of the 1990 US Census data. RESULTS: No differences in heartburn frequency (monthly) were found between white or black, male or female respondents. Heartburn was significantly (P = 0.01) less common in those over age 60 (36.9%) than in young (47.7%) or middle-age (57.3%) respondents. Impact of heartburn on social activities was less (P = 0.002) in the over 60 group (4.9%) compared with the young (19.3%) or middle-age (20.0%) groups. Although 49.8% of respondents were familiar to the term GERD, few were aware that swallowing difficulty (17.3%), asthma (9.3%) or hoarseness (11.5%) were possible symptoms and similar numbers considered stroke (33.2%) and cancer (31.7%) to be complications of GERD. CONCLUSIONS: Frequency of GERD symptoms in the United States is unaffected by gender or race but is lower in the elderly.