Identification and Characterization of Adverse Drug Events in Primary Care.

The purpose of this study was to identify and characterize adverse drug events (ADEs) in a primary care setting using an electronic health record (EHR). This prospective, observational study enrolled patients with any medication change who were seen at an outpatient internal medicine clinic. Patients were evaluated for ADEs by EHR review and telephone interview. ADEs were independently assessed for causality, severity, preventability, and ameliorability by a physician and a pharmacist using a grading instrument. There were 1368 unique medication changes for 701 individuals who completed the study (1.95 changes per person). Of the 226 suspected ADEs, 68 (58%) were deemed to be "definite" or "probable" following causality assessment; 21% were preventable and 40% ameliorable. Only 2 ADEs were serious or life-threatening. Compared with prior reports, ADEs in primary care have decreased in frequency and severity, yet the occurrence of preventable and ameliorable ADEs has increased.

Alcohol-related predictors of delirium after major head and neck cancer surgery.

OBJECTIVE: To identify specific alcohol-related predictors of postoperative delirium. DESIGN: Inception cohort, logistic regression with step-wise selection. SETTING: Ohio State University Comprehensive Cancer Center, Columbus. PATIENTS: A total of 774 patients undergoing major resection of head and neck squamous cell carcinoma. MAIN OUTCOME MEASURES: The correlation of 19 variables with postoperative delirium. One variable was an alcohol-related blood test: mean red blood cell volume (MCV). Eight variables were patient responses to alcohol-related questions. RESULTS: Eighty-nine of 774 surgical procedures (11.5%) were complicated by delirium. Six variables were significantly associated with delirium: age older than 69 years (odds ratio [OR], 2.43; P < .01), preexisting cognitive impairment (OR, 3.83; P < .01), surgery duration greater than 6 hours (OR, 2.40; P < .01), MCV greater than 95.0 femtoliters (OR, 2.23; P < .01), ever being advised to cut back on alcohol (OR, 2.25; P = .01), and not abstaining from alcohol for at least 1 continuous week in the preceding year (OR, 2.16; P = .02). The number of variables stratified delirium risk (0 variables: 198 patients, 2.5% incidence of delirium; 1 variable: 278 patients, 6% incidence of delirium; 2 variables: 206 patients, 18% incidence of delirium; and >2 variables: 92 patients, 34% incidence of delirium). CONCLUSIONS: Three clinical variables not related to alcohol drinking (age, preexisting cognitive impairment, and surgery duration), an alcohol-related laboratory test (MCV), and 2 alcohol-related questions ("At any time in your life, has anyone ever suggested that you should cut back on your drinking?" and "What is the greatest number of days in a row you have gone without an alcoholic drink in the past year?") may help in estimating a patient's risk for postoperative delirium.

Lean body mass gain in patients with head and neck squamous cell cancer treated perioperatively with a protein- and energy-dense nutritional supplement containing eicosapentaenoic acid.

BACKGROUND: Cancer-associated weight loss may be mediated by an inflammatory response to cancer. Eicosapentaenoic acid (EPA) may suppress this response. METHODS: Beginning no later than 2 weeks before surgery, patients with head and neck cancer and with weight loss, who were undergoing major resection with curative intent consumed a protein- and energy-dense nutritional supplement containing EPA from fish oil, in addition to usual diet or tube feed. RESULTS: Thirty-one subjects consumed an average of 1.8 containers/day before surgery and 1.5/day during hospitalization (per container: 300 kilocalories, 16 grams (g) protein, 1.08 g EPA). Seventy percent of subjects maintained or gained weight before hospital admission. Mean weight gain was 0.71 kg at admission and 0.66 kg at discharge. At discharge lean body mass increased by 3.20 kg (p < .001) and fat decreased by 3.19 kg (p < .001). CONCLUSIONS: An EPA-containing protein- and energy-dense nutritional supplement may help increase perioperative lean body mass in patients with head and neck cancer-related weight loss.

A programme of accelerated medical education in Taiwan.

BACKGROUND: Graduates of the 7-year undergraduate medical curriculum in Taiwan are often deficient in clinical skills. AIMS: To implement and assess a programme of accelerated clinical education. METHOD: The Department of Primary Care Medicine at the National Taiwan University College of Medicine implemented a programme shortening the undergraduate clinical curriculum from 3 to 2 years and giving students more clinical responsibility. Students were prepared for clinical rotations with a 1-month clinical skills course. Core clinical rotations were redesigned to be more participatory. The programme included 1 year of a postgraduate, rotating residency. Self-selected students with adequate grades, recommendations and performance on an interview participated in the programme. None of them dropped out. RESULTS: Compared with their traditionally instructed cohorts, graduates of the accelerated programme ( approximately 10% of each class) were more likely to pass national boards (100% versus 80-97%) and were rated as more proficient on 9 of the 10 different clinical performance parameters (p < 0.01 by sign test). Sixty-nine percent reported being satisfied or very satisfied with the programme. CONCLUSION: A pilot programme of accelerated medical education at National Taiwan University that included clinical skills instruction, mentor-style classes and active learning techniques resulted in satisfactory outcomes for the students selected for the programme.

Infection control dogma among nurses in Iran.

Using 33 dogmatic statements about infection control, we assessed the knowledge of infection control nurses at a conference in Iran and compared their responses with those of infection control nurses at a conference in the United States. A majority of those at the Iran conference responded correctly to 11 (33%) of 33 statements, whereas a majority at the US conference responded correctly to 20 (61%) of the statements. The differences in responses were significant (P<.001). Nurses at the Iran conference were more likely to agree with dogma not supported by the literature and to put more faith in general cleanliness to prevent infection than is supported by the literature. A similar questionnaire survey might be useful in countries like Iran that are developing their infection control personnel and infrastructure.

Antimicrobial prophylaxis in the surgical patient.

The primary prophylactic measure against postoperative infection is antiseptic technique in patient preparation, during surgery, and in postoperative patient care. Antimicrobial prophylaxis against postoperative infection is not indicated for procedures with a low infection rate because the expected benefit of antimicrobial treatment is less than the risk of an adverse medication reaction. Antimicrobial prophylaxis has been demonstrated to be of greater benefit than risk in some procedures with higher infection rates; however, because the problem is complex and the data are limited, extra-polating these findings to the practitioner's setting and the individual patient remains a challenge (Table 1). Although antimicrobial prophylaxis for bacterial endocarditis is not effective for most patients, the seriousness of the potential infection has driven the creation of guidelines recommending prophylaxis for at-risk patients undergoing at-risk procedures. Applying these guidelines appropriately could help to reduce unwarranted use of antimicrobials. In the prophylactic use of antimicrobials, as in many medical interventions, the difficulty is balancing the risks of the intervention with the potential benefits. Although we do not have either the randomized, controlled trials or the detailed, patient-specific information to estimate this balance precisely, there are general guidelines to help the clinician choose treatment for most patients.

Perioperative issues in patients with cancer.

The perioperative care of patients with cancer can be an exciting challenge. The physician must consider many factors, including the cancer diagnosis, the extent of disease, treatment received, the presence of comorbid conditions, and the patient's prognosis and must understand the impact of these factors on the planned surgical procedure. In this setting, the physician has the opportunity to perform an essential role in the perioperative management of patients with cancer.

Simple predictors of survival in head and neck squamous cell carcinoma.

OBJECTIVE: To develop a simple prognostic survival rule from easily obtained characteristics of patients undergoing potentially curative resection of head and neck squamous cell carcinoma using classification and regression trees. DESIGN: Inception cohort. SETTING: Tertiary care center. PATIENTS: Consecutive patients undergoing resection lasting at least 2 hours, from July 1993 through June 1997. MAIN OUTCOME MEASURE: Survival, age, TNM tumor stage, functional class, systolic and diastolic blood pressure, body mass index, and serum albumin concentration were evaluated as predictors. RESULTS: Four hundred six patients were followed up for 5 to 1446 days (median, 391 days), during which time 172 deaths occurred. Median survival was 687 days. Patients with TNM stage I, II, or III squamous cell carcinoma had a mean survival of 1068 days. Patients with TNM stage IV or recurrent disease were further stratified. Those with a serum albumin concentration less than 3.85 g/dL had a median survival of 404 days (95% confidence interval, 286-532 days), and those with an serum albumin concentration of 3.85 g/dL or above had a median survival of 625 days (95% confidence interval, 536-1032 days). A similar survival was found using age younger than 66.5 years as a predictor instead of serum albumin concentration less than 3.85 g/dL. CONCLUSIONS: At our institution, patients with stage I, II, or III squamous cell carcinoma had a mean survival of approximately 3 years. Those with stage IV or recurrent squamous cell carcinoma could be stratified by either serum albumin concentration or by age into 2 groups with a median survival of 1 or 2 years.

Factors influencing cotinine half-life during smoking abstinence in African American and Caucasian women.

Cotinine, the proximate metabolite of nicotine, has been identified as an indicator of smoke constituent exposure. Higher cotinine levels in African American cigarette smokers have been identified. Because African Americans experience disproportionate smoking-related morbidity and mortality, it is important to examine potential factors influencing these higher levels of cotinine. The current study examined selected factors of ethnicity, menthol cigarette preference, body composition and alcohol-use history on cotinine half-life in 6 days of smoking abstinence in African American and Caucasian women. A 7-day inpatient protocol was conducted in the General Clinical Research Center, in which day 1 was ad lib smoking and days 2-7 were smoking abstinence (n = 32). Plasma cotinine was measured every 8 h throughout. Average cotinine half-life was 21.3 h, similar to previously reported 18-20 h. Three women exhibited >14 ng/ml cotinine after 136 h of smoking abstinence. Host factors explaining 52.0% of variance in cotinine half-life and associated with longer half-life were being an African American menthol smoker, fewer years of alcohol use and greater lean body mass. Among menthol smokers, baseline cotinine level and cotinine half-life were not significantly different in Caucasian and African American women. Intra-individual cotinine half-life variation and CYP2A6 genotype were examined in substudies. To improve accuracy in correctly classifying non-smokers with cotinine levels, a period of at least 7 days of smoking abstinence may be warranted.