Showing papers by "Bethesda Hospital published in 2007"

A study of medication reviews to identify drug‐related problems of polypharmacy patients in the Dutch nursing home setting

Abstract: Background: Little is known about the extent of drug-related problems of polypharmacy patients in Dutch nursing homes. Objectives: We investigated the feasibility of teams of hospital pharmacists and nursing home physicians carrying out medication reviews. We aimed to identify the number and nature of drug-related problems of nursing home patients receiving more than nine drugs (polypharmacy). Methods: The study was carried out in five Dutch nursing homes (n = 742 beds) between October 2005 and May 2006. Ninety-one polypharmacy patients, (average age 80 years) were included. A medication review was carried out by teams consisting of one hospital pharmacist and the patient's nursing home physician with a follow-up meeting of the same team 6 weeks later. Results: A total of 323 drug-related problems were identified (mean of 3.5 problems per patient). Sixty-two per cent of problems, in 87% of patients, were classified as 'unclear or not confirmed indication or need for review' of the prescribed drug. By the time of the follow-up, a mean of 1.7 (n = 159) problems per patient had been solved and the number of drugs per patient had decreased significantly from 13.5 to 12.7 (P <0.0001). Conclusions: The majority of patients had at least one drug prescribed for which the indication was unknown. The intervention was accompanied by a significant decrease in the number of drugs per patient, but half of the drug-related problems remained unsolved.

Risk factors and myocardial infarction in patients with obstructive sleep apnea: impact of β2-adrenergic receptor polymorphisms

Abstract: The increased sympathetic nervous activity in patients with obstructive sleep apnea (OSA) is largely responsible for the high prevalence of arterial hypertension, and it is suggested to adversely affect triglyceride and high-density lipoprotein (HDL) cholesterol levels in these patients. The functionally relevant polymorphisms of the β2-adrenergic receptor (Arg-47Cys/Arg16Gly and Gln27Glu) have been shown to exert modifying effects on these risk factors in previous studies, but results are inconsistent. We investigated a group of 429 patients (55 ± 10.7 years; 361 men, 68 women) with moderate to severe obstructive sleep apnea (apnea/hypopnea index (AHI) 29.1 ± 23.1/h) and, on average, a high cardiovascular risk profile (body mass index 31.1 ± 5.6, with hypertension in 60.1%, dyslipidemia in 49.2%, and diabetes in 17.2% of patients). We typed the β2-adrenergic receptor polymorphisms and investigated the five most frequent haplotypes for their modifying effects on OSA-induced changes in blood pressure, heart rate, and lipid levels. The prevalence of cardiovascular risk factors and coronary heart disease (n = 55, 12.8%) and survived myocardial infarction (n = 27, 6.3%) were compared between the genotypes and haplotypes. Multivariate linear/logistic regressions revealed a significant and independent (from BMI, age, sex, presence of diabetes, use of antidiabetic, lipid-lowering, and antihypertensive medication) influence of AHI on daytime systolic and diastolic blood pressure, heart rate, prevalence of hypertension, and triglyceride and HDL levels. The β2-adrenergic receptor genotypes and haplotypes showed no modifying effects on these relationships or on the prevalence of dyslipidemia, diabetes, and coronary heart disease, yet, for all three polymorphisms, heterozygous carriers had a significantly lower relative risk for myocardial infarction (Arg-47Cys: n = 195, odds ratio (OR) = 0.32, P = 0.012; Arg16Gly: n = 197, OR = 0.39, P = 0.031; Gln27Glu: OR = 0.37, P = 0.023). Carriers of the most frequent haplotype (n = 113) (haplotype 1; heterozygous for all three polymorphisms) showed a five-fold lower prevalence of survived myocardial infarction (OR = 0.21, P = 0.023). Our study showed no significant modifying effect of the functionally relevant β2-adrenergic receptor polymorphisms on OSA-induced blood pressure, heart rate, or lipid changes. Nevertheless, heterozygosity of these polymorphisms is associated with a lower prevalence of survived myocardial infarction in this group with, on average, a high cardiovascular risk profile.

Maternal mortality in the main referral hospital in The Gambia, West Africa

Abstract: A retrospective analysis of 78 maternal deaths was performed during 1991-1992 to estimate maternal mortality at the maternity unit of the main tertiary level hospital in The Gambia. The non-abortion maternal mortality ratio (MMR) was 736 per 100 000 live births. Among the direct causes, haemorrhage caused most deaths (24%), followed by hypertensive disorders in pregnancy (HDP) (21%). Sepsis was the main cause of death in 15%. Anaemia led among the indirect causes of death (8%) and was a co-factor in 41% of all deaths. Substandard care factors other than medical causes were determined involving health care facilities, staff, drugs and equipment, and patient-related factors. Well known risk factors of low age (< or = 19 years) and nulliparity were highly represented in the maternal death group, and delivery by Caesarean section occurred more than threefold compared to the overall Caesarean section rate. Taking haemorrhage as an example, it is demonstrated that the way diagnoses are grouped significantly affects the statistical elaboration of maternal deaths.

Patch testing in children – recommendations of the German Contact Dermatitis Research Group (DKG)

Abstract: Summary Allergic contact dermatitis occurs frequently in children. Patch testing is needed to identify the responsible allergens and should be performed in children. We recommend a panel of 12 contact allergens as a standard series in children from 6–12 years. Four additional contact allergens should be tested in case of a positive history or suggestive clinical picture. For patch testing in children, the allergens should be applied for 24 hours and the readings should be performed at 48 and 72 hours. Standardized patch testing makes it possible to systematically investigate allergic contact dermatitis and identify relevant allergens in children.

Comparison of Accuracy Measures of Two Screening Tests for Gestational Diabetes Mellitus

Abstract: OBJECTIVE — To compare the accuracy measures of the random glucose test and the 50-g glucose challenge test as screening tests for gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS — In this prospective cohort study, pregnant women without preexisting diabetes in two perinatal centers in the Netherlands underwent a random glucose test and a 50-g glucose challenge test between 24 and 28 weeks of gestation. If one of the screening tests exceeded predefined threshold values, the 75-g oral glucose tolerance test (OGTT) was performed within 1 week. Furthermore, the OGTT was performed in a random sample of women in whom both screening tests were normal. GDM was considered present when the OGTT (reference test) exceeded predefined threshold values. Receiver operating characteristic (ROC) analysis was used to evaluate the performance of the two screening tests. The results were corrected for verification bias. RESULTS — We included 1,301 women. The OGTT was performed in 322 women. After correction for verification bias, the random glucose test showed an area under the ROC curve of 0.69 (95% CI 0.61–0.78), whereas the glucose challenge test had an area under the curve of 0.88 (0.83–0.93). There was a significant difference in area under the curve of the two tests of 0.19 (0.11–0.27) in favor of the 50-g glucose challenge test. CONCLUSIONS — In screening for GDM, the 50-g glucose challenge test is more useful than the random glucose test.

Human embryo: a biological definition

Abstract: This paper defines a human embryo from a biological standpoint that takes into account emerging technologies in reproductive science. The paper does not consider legal, moral, religious or social views. As the definition of a human embryo must reflect the multifactorial processes of development, an approach has been adopted which combines recognition of observed events with potential for further development. This acknowledges that fertilization and development are not static processes, and as such embryo status can only be defined by observation of specific markers. The following biological definition of ‘human embryo’ is proposed. A human embryo is a discrete entity that has arisen from either: 1. the first mitotic division when fertilization of a human oocyte by a human sperm is complete or 2. any other process that initiates organized development of a biological entity with a human nuclear genome or altered human nuclear genome that has the potential to develop up to, or beyond, the stage at which the primitive streak appears,and has not yet reached 8 weeks of development since the first mitotic division.

Think Globally Act Locally: The Case for Symphysiotomy

Abstract: When expatriate doctors from developed countries working in sub-Saharan Africa suggest to the local doctors and midwives that symphysiotomies should sometimes be done, they are silenced neither with quotations from the medical literature nor with tales of patients seen, but with: “If symphysiotomies are such good operations why don't you perform them at home?” Here is why.

Short report: clarithromycin, an alternative to metronidazole in the triple therapy of Helicobacter pylori infection

Abstract: SUMMARY Background: Triple therapy for Helicobacter pylori using metronidazole is less effective in patients with a metronidazole resistant strain. Moreover, metronidazole is responsible for many side-effects. This open study examined the efficacy and side-effects of a triple treatment regimen substituting clarithromycin for metronidazole. Methods: 36 patients with a H. pylori infection, proven by culture, were treated with tripotassium dicitrato bismuthate 120 mg q.d.s., tetracycline 250 mg q.d.s. and clarithromycin 250 mg q.d.s. for 10 days. Eradication was defined as a negative culture and histological examination of antral biopsy specimens, taken at least 6 weeks after completion of the treatment. Results: Eradication was achieved in 26 patients (72%). The treatment was well tolerated with only 4 (11 %) of the patients having significant side-effects. Conclusion: Triple therapy with clarithromycin seems to be less effective than standard triple treatment when the prevalence of metronidazole resistance is low. It is suggested, however, that this combination could be a valuable alternative in areas with a high prevalence of metronidazole resistance.

A polypharmacy intervention study on Dutch nursing home residents

Abstract: Objectives: This study firstly aimed to identify the percentage of nursing home patients who were prescribed more than nine drugs (polypharmacy) and compared prescribing patterns of this patient group to patients who were prescribed fewer drugs. Secondly, teams of hospital pharmacists and nursing home physicians aimed to identify the drug related problems of the polypharmacy patients and the extent to which it was feasible to optimise their medication profiles. Methods: Characteristics of the polypharmacy population were illustrated by retrospective point measurements in five Dutch nursing homes (total of 742 beds) over the years 2004, 2005 and 2006. Additionally, 91 polypharmacy patients in those nursing homes were included for a medication review by a hospital pharmacist and a nursing home physician. The appropiateness of each drug was discussed adressing indication, effectiveness and safety, as well as possible undertreatment. Drug related problems were accordingly (sub)categorised. The pharmacist and physician prioritised the problems and jointly preparared a plan who to optimise the medication profile. Six weeks later, the same pharmacist and physician met again and discussed for each patient the list of problems and the alterations in the medication profile. Results: We found an increase in the percentage polypharmacy patients over the years (14.6%, 2004; 17.5%, 2005; 19.8%, 2006). Drugs from the ATC-groups ‘alimentary tract and metabolism’, ‘cardiovascular system’ and ‘nervous system’ were prescribed most frequently in the polypharmacy population. The 91 reviewed polypharmacy patients used 1226 drugs. We registered 323 drug related problems (mean of 3.5 problems per patient). A decreased renal function (creatinin clearance < 40 ml/min) was observed in a high number of polypharmacy patients (at least 40%). The majority of drug related problems were in the category ‘indication’. In total, 62% of all drug related problems were subcategorised as ‘unclear or not confirmed indication’. These problems were observed in 87% of the polypharmacy patients. A mean of 1.7 (n=159) problems per patient were solved during the subsequent intervention period and the number of drugs per patients decreased statistically significantly from 13.5 to 12.7 (p < 0.0001). Conclusion: The percentage of nursing home patients meeting the polypharmacy definition ranged from 14,6% to 19,8% over 2004–2006. The majority of polypharmacy patients had at least one drug prescribed for which the indication was unknown. The intervention was accompanied with a significant decrease in the number of drugs per patient, but half of the drug related problems remained unsolved.