Medication errors when transferring elderly patients between primary health care and hospital care

OBJECTIVE

The aims were to evaluate the frequency and nature of errors in medication when patients are transferred between primary and secondary care.

METHOD

Elderly primary health care patients (> 65 years) living in nursing homes or in their own homes with care provided by the community nursing system, had been admitted to one of two hospitals in southern Sweden, one university hospital and one local hospital. A total of 69 patient-transfers were included. Of these, 34 patients were admitted to hospital whereas 35 were discharged from hospital.

MAIN OUTCOME MEASURE

Percentage medication errors of all medications i.e. any error in the process of prescribing, dispensing, or administering a drug, and whether these had adverse consequences or not.

RESULTS

There were 142 medication errors out of 758 transfers of medications. The patients in this study used on an average more than 10 drugs before, during and after hospital stay. On an average, there were two medication errors each time a patient was transferred between primary and secondary care. When patients were discharged from the hospital, the usage of a specific medication dispensing system constituted a significant risk for medication errors. The most common error when patients were transferred to the hospital was inadvertent withdrawal of drugs. When patients left the hospital the most common error was that drugs were erroneously added.

CONCLUSION

Medication errors are common when elderly patients are transferred between primary and secondary care. Improvement in documentation and transferring data about elderly patients' medications could reduce these errors. The specific medication dispensing system that has been used in order to increase safety in medication dispensing does not seem to be a good instrument to reduce the number of errors in transferring data about medication.

Kin-biased distribution in brown trout: an effect of redd location or kin recognition?

A wide range of animals have been reported to show kin-biased behaviours, such as reduced aggressiveness and increased food sharing among relatives. However, less is known about whether wild animals also associate with relatives under natural conditions, which is a prerequisite to facilitate kin-biased behaviours and hence kin selection. We tested, by means of microsatellite polymorphism, correlations between pair-wise relatedness and pair-wise metric distance in wild brown trout (Salmo trutta L.) under natural conditions in two streams. Our data show that young-of-the-year as well as older trout found close together also had a higher genetic relatedness in one of the two streams, whereas no relationship was found in the other stream. Very few half and full siblings were found in the second stream and under these conditions it is unlikely that kin-biased behaviours will receive positive selection. We discuss the underlying mechanisms for the observed structure and we specifically address the issue of whether the grouping of related individuals could reflect dispersal from the same spawning redds, or if it reflects active association with relatives, possibly conferring kin-selected advantages.

Sports massage after eccentric exercise

BACKGROUND

The use of sports massage is very common in the athletic community. However, only a few studies have shown any therapeutic effect of massage.

HYPOTHESIS

Sports massage can improve the recovery after eccentric exercise.

STUDY DESIGN

Prospective randomized clinical trial.

METHODS

Sixteen subjects performed 300 maximal eccentric contractions of the quadriceps muscle bilaterally. Massage was given to 1 leg, whereas the other leg served as a control. Subjects were treated once daily for 3 days. Maximal strength was tested on a Kin-Com dynamometer, and functional tests were based on 1-leg long jumps. Pain was evaluated using a visual analog scale.

RESULTS

There was a marked loss of strength and function of the quadriceps directly after exercise and on the third day after exercise. The massage treatment did not affect the level or duration of pain or the loss of strength or function following exercise.

CONCLUSION

Sports massage could not improve the recovery after eccentric exercise.

Nitrogen Balance, Microbial Protein Production, and Milk Production in Dairy Cows Fed Fodder Beets and Potatoes, or Barley

Fourteen multiparous midlactation dairy cows were used in a change-over experiment with 3 periods and 3 diets to evaluate the effects of fodder beets and potatoes on N metabolism, microbial protein production, and milk production. A basal ration of alfalfa/grass silage offered ad libitum, 1 kg of grass hay and 1 kg of heat-treated rapeseed cake was supplemented with 5 kg DM of either rolled barley/raw potatoes 80:20 (BAP), fodder beets/raw potatoes 80:20 (BEP) or rolled barley (BA). Urine and feces were collected quantitatively from 8 cows and ruminal samplings, and evacuations were performed on 4 cannulated cows. Intake and production did not differ between BAP and BA, but the BEP diet lowered intake of both silage and total ration by 0.9 kg DM. Daily yield of energy-corrected milk (ECM) was decreased by 1.7 and 2.3 kg compared with BAP and BA, respectively. Milk urea concentration was 1 mM lower with the BEP diet. The proportion of feed N recovered in milk was 20 to 21% for all diets. With the BEP diet, urinary N amount and proportion were reduced correspondingly to the lower total N intake. Fecal N amount remained unchanged, and hence nitrogen apparent digestibility decreased by 5 percentage units with the BEP diet. Microbial protein production, assessed by allantoin excretion, tended to be highest with the BAP diet. Acetate proportion of VFA was lowered by the BEP diet, while proportions of propionate and butyrate both tended to increase. Different fermentation patterns, probably related to differences in rumen microbiota, could explain why changes in energetic efficiency and milk composition reported in the literature did not occur in the actual experiment when roots replaced barley. Compared with barley, roots appeared to have a greater negative effect on silage intake in conjunction with a prewilted silage with high intake potential allowed ad libitum and this decreased milk production by a magnitude corresponding to the lower intake of ME.

Early response predicts thalidomide efficiency in patients with advanced multiple myeloma*

Sixty-five patients who were primary or secondary refractory to melphalan/prednisone or other type of chemotherapy, or relapsed within 6 months after high dose chemotherapy with stem cell support, were given thalidomide at a dose of 200 mg/d escalating to 800 mg. The patients were followed for a median of 2 years and 22 weeks. Response was evaluated according to M-protein reduction combined with improvement of haemoglobin (Hb) concentration, renal function and pain. Altogether, 14% of patients had a minor response, 14% partial response and 6% complete response. Median survival was 12 months and 29% were alive at last contact. Decline of M protein started early and a minimum 25% reduction of M protein was detected in 14 of 20 responders (70%) after 3 weeks, and in 20 of 22 responders (91%) after 5 weeks of treatment. Reduction of M protein continued for 3 months and further decline was observed in only four patients. The Hb concentration showed a different time course, with a significant increase after 3 months and further increases continued for up to 12 months. Blood concentration levels of thalidomide from 40 patients were used to evaluate the pharmacokinetics of the drug. Rate of absorption, rate of elimination, volume of distribution, clearance and elimination half-life were calculated to be 0.200/h, 0.140/h, 0.886 l/kg, 0.126 l/h/kg and 4.98 h respectively. We found no relationship between thalidomide concentration and effect after 12 weeks.

Thalidomide inhibits early atherogenesis in apoE-deficient mice

Inflammation is present in all stages of atherosclerosis, from fatty streaks to rupture of mature plaques. Tumour necrosis factor (TNF)-alpha is expressed in atherosclerotic lesions but its role in atherogenesis has not been defined. To clarify the role of this cytokine, we administered thalidomide, a compound known to inhibit TNF-alpha production, to homozygous apolipoprotein E-deficient (apoE-/-) mice in order to examine the effect of thalidomide on the development of early atherosclerotic lesions. Twelve apoE-/- mice were randomized to receive either sustained-release thalidomide or placebo pellets implanted subcutaneously, and the amount of atherosclerosis was quantified six weeks later. Thalidomide was well tolerated and did not result in any changes in body weight. Mice treated with thalidomide had significantly smaller mean (7986 +/- 5189 vs 19607 +/- 10353 microns 2, p = 0.05) and maximum (15800 [12777-23675] vs 37169 [28000-41351] microns 2, p = 0.03) lesion sizes than those treated with placebo. Thus, thalidomide is capable of inhibiting the early development of atherosclerosis, presumably by inhibition of TNF-alpha secretion.

Pharmacotherapeutic interventions by a multi-specialty team: opinions of the general practitioners and nurses

OBJECTIVES

The objective of this study was to assess the opinions of the general practitioners (GPs) and nurses towards a previous pharmacotherapeutic intervention and their opinions towards future alternative or complementary methods to improve nursing-home patients' drug treatments.

METHODS

Sixty-six GPs and forty-five nursing-home nurses, working at nursing homes in southern Sweden, were sent a questionnaire to assess their opinions towards a pharmacotherapeutic intervention conducted by a multi-specialty team and their opinions on alternative or complementary future methods potentially improving patient treatment.

RESULTS

The response rate was 62% for the GPs and 69% for the nurses. Both GPs and nurses were positive towards further co-operation regarding pharmacotherapeutic interventions. All nurses that were positive to further co-operation wished to do it in a multidisciplinary team, whereas some GPs wished to do this in a multi-specialty team.

CONCLUSION

The opinions of GPs and nurses towards the pharmacotherapeutic intervention indicate that this or similar methods may successfully be used in clinical practice for improving drug therapy.

Descriptive study and pharmacotherapeutic intervention in patients with epilepsy or Parkinson's disease at nursing homes in southern Sweden

OBJECTIVES

To describe the drug use in epilepsy and Parkinson's patients living in nursing homes and to evaluate the impact of multi-speciality team intervention on health-related quality of life, activities of daily living (ADL) and confusion state.

METHODS

Nursing home residents with epilepsy or Parkinson's disease in the county of Skåne in Sweden were identified. From 119 nursing homes, 262 patients were identified. After obtaining informed consent, 157 patients from 48 nursing homes were included. Of these patients 74 were diagnosed with epilepsy and 84 with Parkinson's disease (one patient had both diagnoses). The average age of the epilepsy patients was 79 years and of the Parkinson's patients 81 years. Pharmacists documented the patients' drug use and any drug-related problems after communication with nursing-home residents, their contact persons at the nursing home and the residents' physicians. A multi-speciality group consisting of pharmacists, a primary care physician, a neurologist, a neuro-psychiatrist and a clinical pharmacologist evaluated the patients' medication and, when appropriate, suggested changes. Lists of each resident's medications were collected together with information about drug-related problems. The use of drugs deemed inappropriate for geriatric nursing-home residents according to Beer's criteria was documented. Health-related quality of life was evaluated using a generic health-related quality of life instrument, SF-36. Confusion state was measured using the Behaviour Pathology in Alzheimer's Disease Rating Scale (Behave-AD), and ability to perform ADL was assessed using the Schwab and England capacity for daily living scale. All measurements were repeated after approximately 6 months. During that period, for the group randomised to active intervention, the physicians involved in the care of the patients had received the recommendations for changes in drug treatment from the multi-speciality group.

RESULTS

Epilepsy patients at nursing homes used on average 8.0 drugs for continuous use whereas Parkinson's patients used 8.6 drugs. According to Beer's criteria about 40% of both patient groups used drugs that are classified as inappropriate to geriatric nursing-home patients. Dopamine receptor-blocking psychotropic drugs were used by 29% of the Parkinson's patients. Indication for a patient's total drug treatment was not documented for 50% of epilepsy and 40% of Parkinson's patients. There were no significant differences between the active and control groups in changes in SF-36, Behave-AD or ADL for epilepsy patients. For Parkinson's patients there was a significant decrease in ADL for the active group, whereas there were no differences in SF-36 or Behave-AD.

CONCLUSION

Nursing-home residents with epilepsy or Parkinson's disease use many drugs and often drugs that are classified as inappropriate. A simple problem-oriented questionnaire may be helpful in identifying specific drug-related problems in geriatric patients with common neurological diseases. Methods on how to improve the pharmacotherapy of these patients still have to be developed.

Methylation changes in the human IGF2 p3 promoter parallel IGF2 expression in the primary tumor, established cell line, and xenograft of a human hepatoblastoma

Hepatoblastoma (HB) is a rare malignant embryonal liver tumor. Its pathogenesis has been associated with altered regulation of the IGF2 and H19 genes, and previous studies have suggested a correlation between abnormal methylation and altered expression of these genes in hepatoblastoma. Upregulation of the activity of the IGF2 promoter P3 has previously been shown to be tightly correlated with demethylation in hepatoblastoma. Here, we have used bisulfite genomic sequencing to characterize the methylation pattern of the IGF2 promoter P3 in the hepatoblastoma-derived cell line Hep T1, in the original tumor from which Hep T1 is derived, and in nude mouse xenografts of the Hep T1 cell line. The results show a clear difference in methylation pattern of the most proximal region of the IGF2 P3 promoter between the primary tumor, the cell line, and the xenografts. RNase protection and mRNA in situ hybridization revealed that variations in methylation patterns was paralleled by the levels of IGF2 P3 mRNA, which was detectable in the primary tumor and xenografts, but not in the cell line. Furthermore, it was demonstrated that H19 was reactivated and demethylated in the HepT1 cell line by 5-azaCytidine, in contrast to IGF2 P3, which was not demethylated or reactivated. We suggest that methylation of the proximal IGF2 P3 is important for its regulation.

A retrospective analysis of factors associated with multiple implant failures in maxillae

This retrospective study was designed to verify the factors that influence implant failures. Six prosthodontic clinics in Sweden participated in the study, and together they included a total of 54 patients treated between January 1988 and December 1996. All patients were completely edentulous in the maxilla, and received either a fixed prosthesis or an overdenture supported by at least 4 implants (Brånemark System). Half of the patients belonged to the study group, and an inclusion criterion for this group was that they had lost at least half of their implants. To reduce bias, the patients in the control group were matched to the study group, i.e. they were selected so that both groups were as identical as possible. The results of the study indicate that the control group had a better initial bone support than the study group. Furthermore, the patients in the study group suffered from circumstances that could induce implant failure, such as bruxism, personal grief, depression, as well as addictions to cigarettes, alcohol and/or narcotics. On the study form the clinicians were asked to give their own opinion of the reason for implant failure. The answers given could easily be grouped into 5 different topics, and this experience can be useful to improve patient selection. This study suggests that there are certain factors of importance to consider to prevent a cluster phenomenon of implant failures i.e. lack of bone support, heavy smoking habits and bruxism.

A furnace forin situX-ray diffraction studies of insertion processes in electrode materials at elevated temperatures

A furnace is described forin situX-ray diffraction studies, in transmission mode, of structural changes in electrode materials for Li-ion (polymer) batteries in the ambient to 300°C temperature range. The method exploits the thin flat-cell geometry of the lithium-polymer battery concept. The flat sample is able to oscillate about a horizontal axis in its own plane in the X-ray beam, to provide better averaging during the diffraction experiment. The use of the device is demonstrated in a study of lithium intercalation in graphite (a commonly used anode material in lithium-ion batteries) during electrochemical cycling and storage at 70°C.

Clinical pharmacology of thalidomide

BACKGROUND

Thalidomide has a chiral centre, and the racemate of (R)- and (S)-thalidomide was introduced as a sedative drug in the late 1950s. In 1961, it was withdrawn due to teratogenicity and neuropathy. There is now a growing clinical interest in thalidomide due to its unique anti-inflammatory and immunomodulatory effects.

OBJECTIVE

To critically review pharmacokinetic studies and briefly review pharmacodynamic effects and studies of thalidomide in consideration of its chemical and stereochemical properties and metabolism.

METHODS

Literature search and computer simulations of pharmacokinetics.

RESULTS

Rational use of thalidomide is problematic due to lack of basic knowledge of its mechanism of action, effects of the separate enantiomers and metabolites and dose- and concentration-effect relationships. Due to its inhibition of tumour necrosis factor-alpha and angiogenesis, racemic thalidomide has been tested with good effect in a variety of skin and mucous membrane disorders, Crohn's disease, graft-versus-host disease, complications to human immunodeficiency virus and, recently, in multiple myeloma. Adverse reactions are often related to the sedative effects. Irreversible toxic peripheral neuropathy and foetal malformations are serious complications that can be prevented. The results of several published pharmacokinetic studies can be questioned due to poor methodology and the use of non-stereospecific assays. The enantiomers of thalidomide undergo spontaneous hydrolysis and fast chiral interconversion at physiological pH. The oral bioavailability of thalidomide has not been unequivocally determined, but available data suggest that it is high. Absorption is slow, with a time to maximum plasma concentration of at least 2 h, and may also be dose-dependent; however, that of the separate enantiomers may be faster due to higher aqueous solubility. Estimation of the volume of distribution is complicated by probable hydrolysis and chiral inversion also in peripheral compartments. A value of around 11/kg is however plausible. Plasma protein binding is low with little difference between the enantiomers. Elimination of thalidomide is mainly by pH-dependent spontaneous hydrolysis in all body fluids with an apparent mean clearance of 10 l/h for the (R)- and 21 l/h for the (S)-enantiomer in adult subjects. Blood concentrations of the (R)-enantiomer are consequently higher than those of the (S)-enantiomer at pseudoequilibrium. The mean elimination half-life of both enantiomers is 5 h. One hydroxylated metabolite has been found in low concentrations in the blood. Since both enzymatic metabolism and renal excretion play minor roles in the elimination of thalidomide, the risk of drug interactions seems to be low.

CONCLUSIONS

The interest in and use of thalidomide is increasing due to its potential as an immunomodulating and antiangiogenic agent. The inter-individual variability in distribution and elimination is low. Apart from this, its use is complicated by the lack of knowledge of dose- or concentration-effect relationships, possible dose-dependent oral absorption and of course by its well-known serious adverse effects.

Expression levels of insulin-like growth factor binding proteins and insulin receptor isoforms in hepatoblastomas

Hepatoblastoma, a rare pediatric liver tumour, is a poorly understood disease. While expression studies for some members of the Insulin-like growth factor axis have been studied in hepatoblastoma, a systematic analysis of the IGF-axis has not been carried out. We have examined a series of hepatoblastomas with matched normal liver tissue for gene expression differences with emphasis on members of the insulin-like growth factor binding proteins. The expression profiles obtained reveal that the expression of these genes are altered in these tumors. The results indicate that the IGF-axis is seriously disturbed in the tumors.

Gender differences in risk factors for suicide in Denmark

BACKGROUND

Gender is one of the most frequently replicated predictors for suicide.

AIMS

To identify risk factors for suicide among males and females and to investigate whether risk factors for suicide differ by gender.

METHOD

A time-matched nested case-control design was performed using Danish longitudinal register databases to obtain 811 suicide cases and 79 871 controls. Data were analysed using conditional logistic regression.

RESULTS

A history of hospitalised mental illness was the most marked risk factor for suicide for both genders. Unemployment, retirement, being single and sickness absence were significant risk factors for men, whereas having a child <2 years old was significantly protective for women. The relative risks for suicide differed significantly between genders according to psychiatric admission status and being the parent of a child <2 years. However, adjustment for these factors did not eliminate the gender difference in suicide risk.

CONCLUSIONS

Risk factors for suicide differed by gender and gender differences could not be explained by differential exposure to known risk factors.

Expression of genes involved with cell cycle control, cell growth and chromatin modification are altered in hepatoblastomas

Hepatoblastoma is a rare pediatric liver tumor. While much progress has been made in the treatment of the disease, very little is known about the moleculer events underlying the pathogenesis of this disease. We sought to investigate a series of hepatoblastomas for alterations in gene expression patterns with emphasis on important cell regulatory genes, including chromatin modifying enzymes, cyclin dependent kinase inhibitors, growth factors, oncogenes and cell cycle regulators. Total RNA was extracted from a series of sporadic hepatoblastomas with matched normal liver, some unmatched tumors and fetal livers, and gene expression was measured for various genes using RNase Protection Analysis (RPA). The results of this analysis show that the expression of many important regulatory genes are distinctly altered in these tumors, and a subset of tumors can be distinguished on the basis of these gene expression differences and histopathological features. Because the molecular events underlying the pathogenesis of this rare tumor are so poorly understood, this study represents a first step in determining some of the possible mechanisms involved which may provide future avenues of research.

Intravenous formulations of the enantiomers of thalidomide: pharmacokinetic and initial pharmacodynamic characterization in man

Thalidomide, a racemate, is coming into clinical use as an immunomodulating and antiinflammatory drug. These effects may chiefly be exerted by S-thalidomide, but the enantiomers are interconverted in-vivo. Thalidomide is given orally, although parenteral administration would be desirable in some clinical situations. The aim of this study was to prepare solutions of the enantiomers of thalidomide for intravenous administration and to investigate their pharmacokinetics and sedative effects following infusion in man. Solubility and stability of the enantiomers in 5% glucose solution was investigated. After a dose-determination experiment in one subject, six healthy male volunteers received R- and S-thalidomide separately by 1-h infusions in a randomized double-blind cross-over study. Blood was sampled over 22h and sedative effects were recorded. Blood concentrations of the enantiomers were determined by stereospecific HPLC. A four-compartment model consisting of a two-compartment model for each enantiomer, with elimination from both compartments, connected by rate constants for chiral inversion was fitted to the concentration data, while the sedative effects were correlated with the blood concentrations of R- and S-thalidomide by means of logistic regression. The enantiomers of thalidomide were chemically stable in solution for at least a week at room temperature. The infusions were well tolerated. Sedation, which was the only observed effect, was related to the blood concentration of R-thalidomide. Inter-individual variation in the disposition of the enantiomers was modest (e.g. terminal half-lives ranged between 3.9 and 5.3h). Pharmacokinetic modelling predicted that varying the infusion time of a fixed dose of S-thalidomide between 10 min and 6h would have little influence on the maximal blood concentration of formed R-thalidomide. To our knowledge this is the first time that thalidomide has been administered intravenously.

Altered expression of members of the IGF-axis in hepatoblastomas

Previous reports have demonstrated that expression of insulin-like growth factor 2 (IGF2) is altered in hepatoblastoma. Using RNAase protection analysis (RPA), we examined the gene expression for IGF1, IGF2, IGF1R, M6P/IGF2R, IGFBP-1 and IGFBP-2 in a series of hepatoblastomas with corresponding normal liver from the same individuals. The results show that the expression of the IGF-axis members included in the present study are altered between tumour and normal, and indicate that the IGF-axis may be involved in hepatoblastoma development.

Species names in phylogenetic nomenclature

Linnaean binomial nomenclature is logically incompatible with the phylogenetic nomenclature of de Queiroz and Gauthier (1992, Annu. Rev. Ecol. Syst. 23:449-480): The former is based on the concept of genus, thus making this rank mandatory, while the latter is based on phylogenetic definitions and requires the abandonment of mandatory ranks. Thus, if species are to receive names under phylogenetic nomenclature, a different method must be devised to name them. Here, 13 methods for naming species in the context of phylogenetic nomenclature are contrasted with each other and with Linnaean binomials. A fundamental dichotomy among the proposed methods distinguishes those that retain the entire binomial of a preexisting species name from those that retain only the specific epithet. Other relevant issues include the stability, uniqueness, and ease of pronunciation of species names; their capacity to convey phylogenetic information; and the distinguishability of species names that are governed by a code of phylogenetic nomenclature both from clade names and from species names governed by the current codes. No method is ideal. Each has advantages and drawbacks, and preference for one option over another will be influenced by one's evaluation of the relative importance of the pros and cons for each. Moreover, sometimes the same feature is viewed as an advantage by some and a drawback by others. Nevertheless, all of the proposed methods for naming species in the context of phylogenetic nomenclature provide names that are more stable than Linnaean binomials.