Medicines can affect thermoregulation and accentuate the risk of dehydration and heat-related illness during hot weather.

WHAT IS KNOWN AND OBJECTIVE: Hot days are increasingly common and are often associated with increased morbidity and mortality, especially in the elderly. Most heat-related illness and heat-related deaths are preventable. COMMENT: Medicines may accentuate the risk of dehydration and heat-related illness, especially in elderly people taking multiple medicines, through the following mechanisms: diuresis and electrolyte imbalance, sedation and cognitive impairment, changed thermoregulation, reduced thirst recognition, reduced sweat production, and hypotension and reduced cardiac output. WHAT IS NEW AND CONCLUSION: Commonly used medicines that may significantly increase the risk include diuretics, especially when combined with an angiotensin converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), anticholinergics and psychotropics. Initiation of individualized preventive measures prior to the start of the hot weather season, which includes a review of the patient and their medicines to identify thermoregulatory issues, may reduce the risk of heat-related illness or death.

Analysis of drug interactions at the end of life.

BACKGROUND: As death approaches, patients are at their most frail, but an increasing symptom burden often necessitates an increase in medications, putting them at higher risk for drug-drug interactions. OBJECTIVES: To assess the potential for drug-drug interactions in routine prescribing at the end of life. METHODS: An Australian retrospective multicentre case-note review of 266 consecutive adult patients who were referred to specialist palliative care, with data available on 166. Medications used in the last 2 weeks of life were screened for potential interactions using the 'Stockley's Drug Interactions' software. RESULTS: The mean number of medications prescribed was 10.8, median 9 (IQR 6-14); all patients received at least one medication. In this study, 72% of patients were at risk of 1 or more potential drug-drug interaction. The mean number of potential interactions was 4.4, with a median of 2.5 (IQR 0-7) per patient. There were only 4/166 (2.4%) prescribed medications with an associated clinical record of an adverse drug reaction. CONCLUSIONS: Potential drug-drug interactions are common for this group of patients. Some interactions may be recognised as an acceptable risk when the prescription is written. Further research is necessary to determine the best way to improve recognition of potential drug-drug interactions and the rates of morbidity or accelerated mortality associated with this. It is likely that palliative care services will need to implement multiple strategies including greater use of computerised prescribing software, and greater closer liaison with clinical pharmacists.

Prescribing for comorbid disease in a palliative population: focus on the use of lipid-lowering medications.

BACKGROUND: The balance of benefit versus burden of ongoing treatments for comorbid disease in palliative populations as death approaches needs careful consideration given their particular susceptibility to adverse drug effects. AIM: To provide descriptive data regarding the medications being prescribed to patients who have a life-limiting illness at the time of referral to a palliative care service in regional Australia, with particular focus on lipid-lowering medications. METHODS: A prospective case note review of 203 patients reporting the number of medications prescribed and, for lipid-lowering medications, the indication and level of prevention sought (primary, secondary, tertiary). Rates were compared by performance status, disease phase and comorbidity burden. RESULTS: Mean number of regular medications prescribed was 7.2, with higher rates observed in those patients with a non-malignant primary diagnosis (rate ratio 1.28, confidence interval (CI) 1.11-1.50) or poorer performance status (rate ratio 1.37, CI 1.11-1.69) and lower rates for those in the terminal phase of disease (rate ratio 0.48, CI 0.30-0.76). Over one fifth of patients were prescribed a lipid-lowering medication, and two fifths of these prescriptions were for primary prevention of cardiovascular disease. Patients in the highest quartile of Charlson Comorbidity Index score were 4.6 (CI 2.06-10.09) times more likely to be prescribed a lipid-lowering medication than those in the lowest quartile. CONCLUSIONS: Polypharmacy is prevalent for this group of patients, placing them at high risk of drug-drug and drug-host interactions. Prescribing may be driven by risk factors and disease guidelines rather than a rational, patient-centred approach.

Health, economic, psychological and social impact of educating carers of patients with advanced pulmonary disease (protocol).

People with advanced pulmonary disease (APD), such as those with chronic obstructive pulmonary disease, have markedly impaired quality of life. Home Oxygen Therapy (HOT) itself is burdensome, although it often improves survival duration and quality of life in these patients. The exact burdens on informal caregivers of these patients are unknown. The central purpose of the pragmatic randomized controlled study described in this protocol is to determine the effectiveness of improving the skills and knowledge of carers of patients with APD who use HOT. Specifically we aimed to estimate the incremental impact of this carer intervention above usual care on health, economic, psychological and social domains for patient and carer dyads relative to the level of current burden. Eligible patients and their carers were recruited through three major hospitals, and randomized to an intervention or control group. The carers in the intervention group received two home-delivered education sessions based on the principles of academic detailing. Participants are currently being followed over 12 months. The primary outcome will be the proportion of patients surviving without a chronic obstructive pulmonary disease-related readmission / residential (non respite) care over 12 months. Carer secondary outcomes include perceived caregiver burden, level of expected and received social support, perceived level of mastery, self esteem, health related quality of life and disability, and ability to conduct domestic chores and household maintenance, social activities and provide service to others, and fatigue. Secondary patient outcomes include health related quality of life and disability, and current respiratory health status.

Prioritising drugs for single patient (n-of-1) trials in palliative care.

Many of the drugs prescribed commonly to palliative care patients have potentially significant side-effects and are of unproven benefit. The acquisition of evidence to support the prescribing of these drugs has been very slow. Single patient trials (SPTs) (also known as n-of-1 trials) offer a potential means of obtaining the evidence necessary to support or refute the use of several of the drugs and interventions whose use is currently based on physician experience or anecdote alone. A list of SPTs considered "most urgent", for commonly employed treatments and for the most common and most troublesome symptoms in palliative care is presented. These are drugs for which the gap between evidence and practice is greatest, where the evidence of efficacy is most lacking, where significant side effects potentially lead to the greatest morbidity, or where cost is a major patient burden. Although not all the drugs used in palliative care are suitable, SPTs provide a potential alternative method of gathering evidence in palliative care.

Self-management and peer support among people with arthritis on a hospital joint replacement waiting list: a randomised controlled trial.

INTRODUCTION: To evaluate the efficacy of a self-management support program including a 6 week self-management course, individualised phone support and goal setting in osteoarthritis patients on a waiting list for arthroplasty surgery. METHOD: Randomised controlled trial of 152 public hospital outpatients awaiting hip or knee replacement surgery who were not classified as requiring urgent surgery. Participants were randomised to a self-management program or to usual care. The primary outcome was change in the Health Education Intervention Questionnaire (HeiQ) from randomisation to 6 month follow-up. Quality of life and depressive symptoms were also measured. Changes in pain and function were assessed using the Western Ontario and McMaster Universities (WOMAC) Arthritis Index. RESULTS: At 6 month follow-up, health-directed behaviour was significantly greater in the intervention [mean 4.29, 95% confidence interval (CI) 3.99-4.58] than the control (mean 3.81, 95% CI 3.52-4.09; P=0.017). There was also a significant effect on skill and technique acquisition for the intervention (mean 4.37, 95% CI 4.19-4.55) in comparison to control (mean 4.11, 95% CI 3.93-4.29; P=0.036). There was no significant effect of the intervention on the remaining HeiQ subscales, WOMAC pain or disability, quality of life or depressive symptoms. DISCUSSION: The arthritis self-management program improved health-directed behaviours, skill acquisition and stiffness in patients on a joint replacement waiting list, although the observed effects were of modest size (Cohen's d between 0.36 and 0.42). There was no significant effect on pain, function or quality of life in the short term. Self-management programs can assist in maintaining health behaviours (particularly walking) in this patient group. Further research is needed to assess their impact on quality of life and over longer periods.

Changes in utilisation of anticholinergic drugs after initiation of cholinesterase inhibitors.

PURPOSE: Cholinesterase inhibitors (CEIs) have been subsidised in Australia since February 2001 for cognitive decline associated with mild to moderate Alzheimer disease. The number of people with Alzheimer disease is expected to increase, with a continuing increase in the number of people receiving CEI's. Many anticholinergic drugs (ACDs) are also prescribed to people receiving CEIs and concerns about the impact of the interaction have been raised. The aim of this study was to describe co-prescribing of a group of important ACDs in patients initiating treatment with CEIs in Australia. METHODS: Pharmacy claim data for Australia (Pharmaceutical Benefits Scheme) was examined for the period 1 April to 30 June 2006. All selected prescriptions supplied for patients receiving their first supply of any CEIs (initiators) were extracted for 14 weeks prior to and post the first date of supply. The numbers of initiating people co-administering CEIs and ACDs was examined. RESULTS: 5797 persons received their first prescription for CEIs between 1 April and 30 June 2006. Thirty-two per cent of these also received prescriptions for at least one ACD. There was a statistically significant increase in the number of initiators receiving an ACD. The significant increase was in patients receiving atypical antipsychotics. There was a trend towards an increase in patients receiving oxybutynin. CONCLUSIONS: Extent of co-administration of ACDs and CEIs is similar to other international studies however the most significant increase is seen in patients receiving atypical antipsychotics. The implications of adding atypical antipsychotics are potential for worsening disease, increasing adverse effects and increased health resource utilisation in this vulnerable group.

Experience with academic detailing services for quality improvement in primary care practice.

BACKGROUND: Despite longstanding experimental evidence about effectiveness of academic detailing, transitioning this research-based concept into acceptable primary care quality improvement services has been slow in the USA. The purpose of this study was to describe primary care uptake, retention and response to an academic-detailing-led service in the USA. Exploration of accessible performance indicators of service acceptance, and feasibility of use of an Australian academic detailing service model were secondary objectives. METHODS: Over a 29-month period, an academic-detailing-led drug and therapeutics information service was offered to all primary care physicians providing ongoing patient care in Fayette County, Kentucky. Two programmes (on type 2 diabetes management and chronic pain management) incorporating up to four office visits were offered. RESULTS: 102 of 130 (78%) eligible primary care physicians participated in the service, 72% receiving visits for the type 2 diabetes management programme, and 58% the chronic non-malignant pain programme. At all successive encounters, participants expressed a willingness to continue to receive visits. Difficulties were experienced in obtaining appointments for subsequent visits, although on direct enquiry, only one participant explicitly declined further visits. No notable differences existed between physicians accepting visits and those who did not. Across successive visits, passive indicators of satisfaction with the service included: duration of visits, office waiting times, retention of printed materials from one visit to the next, whether physicians wished their extender colleagues to also receive visits, and observed levels of interest and participation within encounters. CONCLUSIONS: Ongoing primary care quality improvement services spearheaded by academic detailing can be acceptable to US primary care physicians in practice.

Promoting better use of the PSA test in general practice: randomized controlled trial of educational strategies based on outreach visits and mailout.

BACKGROUND: Prostate-specific antigen (PSA) testing for prostate cancer is controversial. Demand for PSA testing is likely to rise in the UK, Australia and other western countries. Primary care needs to develop appropriate strategies to respond to this demand. OBJECTIVES: Our aim was to compare the effectiveness of educational outreach visits (EOVs) and mailout strategies targeting PSA testing in Australian primary care. METHODS: A randomized controlled trial was conducted in general practices in southern Adelaide. The main outcome measures at baseline, 6 months and 12 months post-intervention were PSA testing rates and GP knowledge in key areas relating to prostate cancer and PSA testing. RESULTS: The interventions were able to demonstrate a change in clinical practice. In the 6 months post-intervention, median PSA testing rate in the EOV group was significantly lower than in the postal group, which in turn was significantly lower than the control group (P < 0.001). Statistically significant differences were not, however, maintained in the 6-12 month post-intervention period. The EOV group, at 6 months follow-up, had a significantly greater proportion of "correct" responses than the control group to questions about prostate cancer treatment effectiveness (P = 0.004) and endorsement of PSA screening by professional bodies (P = 0.041). CONCLUSIONS: Primary care has a central role in PSA testing for prostate cancer. Clinical practice in this area is receptive to evidence-based interventions.

Outcomes of an educational-outreach service for community medical practitioners: non-steroidal anti-inflammatory drugs.

OBJECTIVE: Exploration of longer-term outcomes of an ongoing educational-outreach service for community doctors. DESIGN: Quasi-experimental, with parallel and historical comparisons. SETTING: Since 1992, a teaching-hospital-based service has been providing advice and information on drugs and therapeutic strategies to community medical practitioners. PARTICIPANTS: 210 doctors practising in a particular area of metropolitan Adelaide (79% general practitioners; 21% specialists). INTERVENTIONS: Two surgery visits during 1992 focused on better use of prescribed non-steroidal anti-inflammatory drugs (NSAIDs). Subsequent visits on other topical therapeutic issues have occurred regularly. MAIN OUTCOME MEASURES: Doctor participation in the service; supply of prescription NSAIDs; hospital admissions for gastrointestinal (GI) effects of NSAID use. RESULTS: 89% of doctors practising within the service area received the first visit on NSAIDs and 86% received the second visit. More than 85% continue to receive the service. Relative to a comparison area, aggregate reductions of 9% and 28%, respectively, were observed in two different measures of NSAID use. During an 11-year observation period, a single change point in the number of hospital admissions for GI disorders occurred in the service area, coinciding with delivery of the NSAID program. In the five years since the visits commenced, a 70% reduction in admissions was observed. No notable changes in hospital admission rates occurred in the comparison area. CONCLUSIONS: A continuing education and support service for community medical practitioners which uses principally academic detailing methods in its contact with doctors has contributed to sustained changes in prescribed NSAID use over a five-year period. A focus on risk-minimisation in prescribing of NSAIDs appears to have contributed to reductions in hospitalisations for GI adverse events.

Towards the safer use of non-steroidal anti-inflammatory drugs.

Musculoskeletal conditions afflict most of us at some time in our lives, and we all have relatives and friends who suffer the pain and disability sometimes associated with conditions such as back or neck pain, fibrositis and osteoarthritis. The goal of those of us who try to help individuals with these conditions is to achieve effective, but also safe, management of their musculoskeletal disorders, the commonest symptom of which is pain. This goal can be achieved by better diagnosis and problem formulation (allowing better selection of treatment options); informed selection of non-drug and drug therapeutic options, based on relative cost-benefit considerations; and the judicious, appropriate and safe use of drugs, particularly non-steroidal anti-inflammatory drugs (NSAID). Setting realistic goals and maintaining regular surveillance of patients are also important considerations. Finally, the active involvement of the patient in their own management is associated with better and safer outcomes.

The effect of hypoxaemia on drug disposition in chronic respiratory failure.

OBJECTIVE: The influence of hypoxaemia on the disposition of two common drugs has been examined in ten adults with stable chronic respiratory failure. METHODS: There were two experimental periods in this cross-over study: during these periods supplemental oxygen was either withheld or administered to impose clinical hypoxaemia or maintain normoxaemia, respectively. Each participant received either oral (40 mg) or intravenous (20 mg) frusemide combined with oral paracetamol (500 mg) on consecutive days of the two experimental periods. RESULTS: The total (bound plus unbound) plasma clearance of frusemide during hypoxaemia (arterial oxygen tension, PaO2 < or = 50 Torr) was not significantly different from the value during normoxaemia (PaO2 > or = 60 Torr) [76.9 and 62.4 ml.min-1]. The volume of distribution was not affected by acute hypoxaemia (121 ml.kg-1 without and 109 ml.kg-1 with oxygen; P > 0.05). Renal and non-renal clearances of frusemide were similar during the period of hypoxaemia (31 and 38 ml.min-1, respectively) compared to respective values during supplemental oxygen delivery (29 and 32 ml.min-1). The absolute bioavailability of frusemide during hypoxaemia (0.62) was not different to that obtained during normoxaemia (0.56). The combined sodium and potassium excretion rate (expressed as a function of the frusemide excretion rate) was not altered by changing the oxygen tension. The pharmacokinetics of paracetamol were unaffected by hypoxaemia.

Myoglobinuria in carnitine palmityltransferase deficiency.

An 18-year-old male developed recurrent myoglobinuria after prolonged physical exertion. Histochemical analysis of biopsied muscle revealed complete absence of carnitine palmityltransferase. Significant ultrastructural abnormalities of muscle were present, but these could be the result of the recent episode of rhabdomyolysis. Recurrent myoglobinuria can occur in several disorders of glycogen and lipid metabolism in muscle, and such disorders should be suspected in cases of unexplained recurrent myoglobinuria.

Incidence of thyroid disorders in Connecticut.

A prospective study involving 1,544 patients who had annual physical examinations during a one-year period was conducted to determine the incidence of htyroid abnormalities in a practice of general internal medicine. A total of 5.8% abnormalities were found including nodular disease, thyroiditis, Graves' disease, hypothyroidism, simple goiter, and iatrogenic hyperthyroidism. No thyroid cancer was detected.