Mucositis management practices for hospitalized patients: national survey results.

The optimal management strategies for cancer chemotherapy and radiotherapy-induced mucositis have not been identified. In 1989, the National Institutes of Health (NIH) published a consensus statement outlining a standardized approach for the prevention and treatment of oral complications. The purpose of this survey was to identify the national treatment practices for oral mucositis, mucocutaneous Herpes simplex virus infections, and oral candidiasis, and to compare them to the NIH guidelines. Surveys were mailed to clinical pharmacists at 200 hospitals throughout the United States. Sixty-two of the 200 questionnaires were completed and returned. Institutions used a diversity of agents, generating substantial variability in mucositis prophylaxis and treatment protocols. Many of these therapies included products or combinations of ingredients that lack proven clinical efficacy. Mucositis management strategies for hospitalized patients vary widely at US hospitals. Coordinated, controlled studies are needed to identify optimal therapies for these patients.

Measuring medical residents' chart-documentation practices.

To determine the adequacy of medical history documentation, investigators videotaped 26 clinical interviews performed by medical residents in ambulatory practice, and the contents of each videotape were compared with the corresponding entries in the medical record. The residents recorded a little over half of all medical history information observed on the videotapes. Medical issues were more often documented than psychosocial or health behaviors. The residents in their second postgraduate year had the best documentation practices regardless of their residency track (primary-care or traditional track). Also, no difference was noted between the performances of primary-care internal medicine residents and traditional internal medicine residents. For one-quarter of the patients, less than 40 percent of the information that was present on the videotapes was documented in their charts. The residents documented more-severe illnesses better than less-severe ones and documented the medical histories of older patients better than the histories of younger ones. The residents' records of health behavior and psychosocial concerns were less complete for women patients. To improve chart documentation, members of both the attending and the house staffs should review videotapes and corresponding medical records of clinical encounters to help them investigate factors causing inadequate chart-documentation.

Audit of digoxin prescribing in ambulatory patients.

Digoxin prescribing for ambulatory patients with uncomplicated congestive heart failure in normal sinus rhythm (UCHF) was evaluated. The audit was conducted at a hospital primary care clinic and was performed retrospectively over a recent 2-year period. The audit focused on the discontinuance of digoxin prescribing and the attendant monitoring necessary. There was 34 patients prescribed digoxin during the study period who were classified as UCHF. Of these, 23 (68%) met our a priori criteria for digoxin discontinuance. However, only three of the 23 were discontinued and none met the criteria for proper follow-up. With regard to monitoring, the average patient was seen once every 2 months, but in fewer than half of the visits the patient was assessed on basic subjective and objective parameters of CHF status and digoxin toxicity. These results are being used in an educational program for the clinic physicians who before the audit had perceived their care of digoxin patients to be optimal.

Drug prescribing for ambulatory patients 85 years of age and older.

Drug prescribing for ambulatory patients greater than or equal to 85 years of age was studied using data from the 1980 National Ambulatory Medical Care Survey (NAMCS) on office visits to physicians. NAMCS is a survey by the US National Center for Health Statistics, which collected information on office visits and extrapolated the results to the US population. Of the 575.7 million office visits by all ages, 6.8 million (1 per cent) were by persons greater than or equal to 85 years of age, and 64 per cent involved females. Ninety per cent of the total office visits of those greater than or equal to 85 years were with a physician who had seen them before; 94 per cent were with MDs as compared with DOs; 56 per cent were with general practitioners or internists; and 95 per cent had some type of follow-up planned. The most frequent duration of the office visit was 11-15 minutes (36 per cent). The most frequent diagnostic class was diseases of the circulatory system. The survey physicians were asked to list all drugs, new or already in use by the patient, that were ordered, administered, or prescribed during the visit. The authors converted the drug brand names to their nonproprietary or generic name component(s); each active ingredient of combination products was treated as a separate drug entity. All drug analyses used generic names. Thirty-two per cent of visits did not involve the use of any drug, 21 per cent involved one drug; 12 per cent, two drugs; and 16 per cent, three drugs. Cardiovascular-renal drugs were the most frequently mentioned. One-third of the visits involved the use of one or more drugs that have psychologic effects, either intended or as side effects. Three per cent of the office visits involved the use of two or more drugs that had the potential for clinically important interactions.

Insulin resistance: definition and treatment.

Two cases of insulin resistance are described, and recent developments in the pathogenesis and treatment of insulin resistance are reviewed. Both immune and nonimmune types of insulin resistance have been described. Immune resistance is related to the presence of circulating antibodies directed against exogenous insulin or the insulin receptor sites. Nonimmune resistance is associated with obesity, ketoacidosis, infection, or endocrinopathies. Treatment of insulin-resistant diabetics can include proper diet and weight control; use of insulin in large quantities; selection of less antigenic forms of insulin, such as pork, fish, or sulfated insulin; oral hypoglycemics such as tolbutamide; and immunosuppressive therapy with corticosteroids. The production of human insulin by recombinant DNA technology promises benefits to patients with high levels of antibodies directed against insulin from animal sources. True insulin resistance is a rare phenomenon, which must be documented adequately before vigorous treatment is considered.