Medication errors reported to U.S. Poison Control Centers, 2000-2012

CONTEXT

Previous studies of medication errors have largely focused on healthcare facilities and have not reported generalizable national trends among out-of-hospital medication errors.

OBJECTIVE

We sought to understand U.S. trends in medication errors, including the age-related risks, the involved medications, and the medical outcomes.

MATERIALS AND METHODS

We performed a retrospective analysis of National Poison Data System (NPDS) data from the American Association of Poison Control Centers for years 2000-2012. Medication error cases were analyzed by age, gender, pharmaceutical involved, substance rank, dosing error type, management site, level of healthcare received, and medical outcome. Trends in medication error rates were analyzed using Poisson regression.

RESULTS

From 2000 to 2012, the NPDS recorded 2,913,924 calls reporting unintentional pharmaceutical-related errors that met inclusion criteria. Non-healthcare facility calls comprised 99.2% calls related to unintentional therapeutic errors. Eighty-seven percent of medication errors were managed on site. The annual medication error rate for all callers per 10,000 U.S. population increased significantly (p < 0.0001) by 69.8% from 2000 (4.98 calls per 10,000 population) to 2012 (8.46 calls per 10,000 population). Among adults aged 20 years and older, age was positively correlating (r = 0.96) with the rate of medication error. Analgesics were the most frequent pharmaceutical class involved in medication errors for ages 6-49 (N = 221,061). Among ages 20-49 years, opioid-related medication errors decreased by 7.9% from 2010 to 2012. Cardiovascular drugs were the leading source of injury among all ages (N = 14,440) and also the leading pharmaceutical class involved in medication errors among adults 50 years and older (N = 187,760).

CONCLUSION

Medication errors continue to be a source of preventable injury with increasing incidence across the out-of-hospital population.

Convergent phylogenetic and functional responses to altered fire regimes in mesic savanna grasslands of North America and South Africa

The importance of fire in the creation and maintenance of mesic grassland communities is well recognized. Improved understanding of how grasses--the dominant clade in these important ecosystems--will respond to alterations in fire regimes is needed in the face of anthropogenically driven climate and land-use change. Here, we examined how grass communities shift in response to experimentally manipulated fire regimes at multiple levels of community diversity--taxonomic, phylogenetic and functional--in C4-dominanted mesic savanna grassland sites with similar structure and physiognomy, yet disparate biogeographic histories. We found that the grass communities were similar in their phylogenetic response and aspects of their functional response to high fire frequency. Both sites exhibited phylogenetic clustering of highly abundant species in annually burned plots, driven by species of the Andropogoneae, and a narrow range of functional strategies associated with rapid post-fire regeneration in a high-light, nitrogen-limited environment. By examining multiple facets of diversity in a comparative context, we identified convergent phylogenetic and functional responses to altered fire regimes in two mesic savanna grasslands. Our results highlight the importance of a common filtering process associated with fire that is consistent across grasslands of disparate biogeographic histories and taxonomic representation.

Plant community response to loss of large herbivores differs between North American and South African savanna grasslands

Herbivory and fire shape plant community structure in grass-dominated ecosystems, but these disturbance regimes are being altered around the world. To assess the consequences of such alterations, we excluded large herbivores for seven years from mesic savanna grasslands sites burned at different frequencies in North America (Konza Prairie Biological Station, Kansas, USA) and South Africa (Kruger National Park). We hypothesized that the removal of a single grass-feeding herbivore from Konza would decrease plant community richness and shift community composition due to increased dominance by grasses. Similarly, we expected grass dominance to increase at Kruger when removing large herbivores, but because large herbivores are more diverse, targeting both grasses and forbs, at this study site, the changes due to herbivore removal would be muted. After seven years of large-herbivore exclusion, richness strongly decreased and community composition changed at Konza, whereas little change was evident at Kruger. We found that this divergence in response was largely due to differences in the traits and numbers of dominant grasses between the study sites rather than the predicted differences in herbivore assemblages. Thus, the diversity of large herbivores lost may be less important in determining plant community dynamics than the functional traits of the grasses that dominate mesic, disturbance-maintained savanna grasslands.

Analysis of parameters influencing the release of antibiotics mixed with bone grafting material using a reliable mixing procedure

Local infections arising from fracture fixation, defect reconstruction or joint replacement can cause extreme pain and impaired healing, lead to revision operations, prolong hospital stay and increase costs. Treatment options including prophylaxis are afforded by the use of grafts and biomaterials loaded with antibiotics. These can produce local therapeutic concentrations with a reduced systemic concentration and reduced systemic side-effects. Patient-specific loading of osteogenic graft materials with antibiotic could be an important option for orthopaedic surgeons. A local therapeutic concentration must be available for the desired duration and cytotoxic effects must be kept within an acceptable range. The present study investigates a simple and reliable mixing procedure that could be used for the perioperative combination of antibiotic powders and solutions with bone grafting materials. The potential influence of concentration and sampling regime on the release kinetics of gentamicin, tobramycin and vancomycin was studied over a period of 56days and potency and cytotoxicity were evaluated. In all treatment groups, gentamicin and tobramycin were completely released within 3days whilst vancomycin was released over a period of 14days. The results clearly show that the main parameter influencing release is the molecular weight of the drug. Growth of Staphylococcus aureus was inhibited in all 3 treatment groups for at least 3days. Cell viability and alkaline phosphatase activity of primary osteoblast-like cells were not significantly affected by the antibiotic concentrations obtained from the elution experiments. Bone grafting is an established component of surgery for bone defect filling and for biological stimulation of healing. Patient-specific enhancement of such procedures by incorporation of antibiotics for infection prevention or by addition of cytokines for promotion of impaired healing or for treatment of critical size defects will be a relevant issue in the future.

Characteristics of foot structure and footwear associated with hallux valgus: a systematic review

OBJECTIVE

Factors associated with the development of hallux valgus (HV) are multifactorial and remain unclear. The objective of this systematic review and meta-analysis was to investigate characteristics of foot structure and footwear associated with HV.

DESIGN

Electronic databases (Medline, Embase, and CINAHL) were searched to December 2010. Cross-sectional studies with a valid definition of HV and a non-HV comparison group were included. Two independent investigators quality rated all included papers. Effect sizes and 95% confidence intervals (CIs) were calculated (standardized mean differences (SMDs) for continuous data and risk ratios (RRs) for dichotomous data). Where studies were homogeneous, pooling of SMDs was conducted using random effects models.

RESULTS

A total of 37 papers (34 unique studies) were quality rated. After exclusion of studies without reported measurement reliability for associated factors, data were extracted and analysed from 16 studies reporting results for 45 different factors. Significant factors included: greater first intermetatarsal angle (pooled SMD = 1.5, CI: 0.88-2.1), longer first metatarsal (pooled SMD = 1.0, CI: 0.48-1.6), round first metatarsal head (RR: 3.1-5.4), and lateral sesamoid displacement (RR: 5.1-5.5). Results for clinical factors (e.g., first ray mobility, pes planus, footwear) were less conclusive regarding their association with HV.

CONCLUSIONS

Although conclusions regarding causality cannot be made from cross-sectional studies, this systematic review highlights important factors to monitor in HV assessment and management. Further studies with rigorous methodology are warranted to investigate clinical factors associated with HV.

Genetic diversity of a dominant C4 grass is altered with increased precipitation variability

Climate change has the potential to alter the genetic diversity of plant populations with consequences for community dynamics and ecosystem processes. Recent research focused on changes in climatic means has found evidence of decreased precipitation amounts reducing genetic diversity. However, increased variability in climatic regimes is also predicted with climate change, but the effects of this aspect of climate change on genetic diversity have yet to be investigated. After 10 years of experimentally increased intra-annual variability in growing season precipitation regimes, we report that the number of genotypes of the dominant C(4) grass, Andropogon gerardii Vitman, has been significantly reduced in native tallgrass prairie compared with unmanipulated prairie. However, individuals showed a different pattern of genomic similarity with increased precipitation variability resulting in greater genome dissimilarity among individuals when compared to unmanipulated prairie. Further, we found that genomic dissimilarity was positively correlated with aboveground productivity in this system. The increased genomic dissimilarity among individuals in the altered treatment alongside evidence for a positive correlation of genomic dissimilarity with phenotypic variation suggests ecological sorting of genotypes may be occurring via niche differentiation. Overall, we found effects of more variable precipitation regimes on population-level genetic diversity were complex, emphasizing the need to look beyond genotype numbers for understanding the impacts of climate change on genetic diversity. Recognition that future climate change may alter aspects of genetic diversity in different ways suggests possible mechanisms by which plant populations may be able to retain a diversity of traits in the face of declining biodiversity.

Germline mutation of Brca1 alters the fate of mammary luminal cells and causes luminal-to-basal mammary tumor transformation

Breast cancer developed in familial BRCA1 mutation carriers bears striking similarities to sporadic basal-like breast tumors. The mechanism underlying the function of BRCA1 in suppressing basal-like breast cancer remains unclear. We previously reported that the deletion of p18(Ink4c) (p18), an inhibitor of G1 cyclin Ds-dependent CDK4 and CDK6, stimulates mammary luminal progenitor cell proliferation and leads to spontaneous luminal tumor development. We report here that germline mutation of Brca1 in p18-deficient mice blocks the increase of luminal progenitor cells, impairs luminal gene expression and promotes malignant transformation of mammary tumors. Instead of the luminal mammary tumors developed in p18 single-mutant mice, mammary tumors developed in the p18;Brca1 mice, similar to breast cancer developed in familial BRCA1 carriers, exhibited extensive basal-like features and lost the remaining wild-type allele of Brca1. These results reveal distinct functions of the RB and BRCA1 pathways in suppressing luminal and basal-like mammary tumors, respectively. These results also suggest a novel mechanism--causing luminal-to-basal transformation--for the development of basal-like breast cancer in familial BRCA1 carriers and establish a unique mouse model for developing therapeutic strategies to target both luminal and basal-like breast cancers.

Assessment of axial bone rigidity in rats with metabolic diseases using CT-based structural rigidity analysis

Objectives

This study aims to assess the correlation of CT-based structural rigidity analysis with mechanically determined axial rigidity in normal and metabolically diseased rat bone.

Methods

A total of 30 rats were divided equally into normal, ovariectomized, and partially nephrectomized groups. Cortical and trabecular bone segments from each animal underwent micro-CT to assess their average and minimum axial rigidities using structural rigidity analysis. Following imaging, all specimens were subjected to uniaxial compression and assessment of mechanically-derived axial rigidity.

Results

The average structural rigidity-based axial rigidity was well correlated with the average mechanically-derived axial rigidity results (R² = 0.74). This correlation improved significantly (p < 0.0001) when the CT-based Structural Rigidity Analysis (CTRA) minimum axial rigidity was correlated to the mechanically-derived minimum axial rigidity results (R² = 0.84). Tests of slopes in the mixed model regression analysis indicated a significantly steeper slope for the average axial rigidity compared with the minimum axial rigidity (p = 0.028) and a significant difference in the intercepts (p = 0.022). The CTRA average and minimum axial rigidities were correlated with the mechanically-derived average and minimum axial rigidities using paired t-test analysis (p = 0.37 and p = 0.18, respectively).

Conclusions

In summary, the results of this study suggest that structural rigidity analysis of micro-CT data can be used to accurately and quantitatively measure the axial rigidity of bones with metabolic pathologies in an experimental rat model. It appears that minimum axial rigidity is a better model for measuring bone rigidity than average axial rigidity.

Invasion of an intact plant community: the role of population versus community level diversity

To improve the understanding of how native plant diversity influences invasion, we examined how population and community diversity may directly and indirectly be related to invasion in a natural field setting. Due to the large impact of the dominant C(4) grass species (Andropogon gerardii) on invasion resistance of tallgrass prairie, we hypothesized that genetic diversity and associated traits within a population of this species would be more strongly related to invasion than diversity or traits of the rest of the community. We added seeds of the exotic invasive C(4) grass, A. bladhii, to 1-m(2) plots in intact tallgrass prairie that varied in genetic diversity of A. gerardii and plant community diversity, but not species richness. We assessed relationships among genetic diversity and traits of A. gerardii, community diversity, community aggregated traits, resource availability, and early season establishment and late-season persistence of the invader using structural equation modeling (SEM). SEM models suggested that community diversity likely enhanced invasion indirectly through increasing community aggregated specific leaf area as a consequence of more favorable microclimatic conditions for seedling establishment. In contrast, neither population nor community diversity was directly or indirectly related to late season survival of invasive seedlings. Our research suggests that while much of diversity-invasion research has separately focused on the direct effects of genetic and species diversity, when taken together, we find that the role of both levels of diversity on invasion resistance may be more complex, whereby effects of diversity may be primarily indirect via traits and vary depending on the stage of invasion.

Productivity is a poor predictor of plant species richness

For more than 30 years, the relationship between net primary productivity and species richness has generated intense debate in ecology about the processes regulating local diversity. The original view, which is still widely accepted, holds that the relationship is hump-shaped, with richness first rising and then declining with increasing productivity. Although recent meta-analyses questioned the generality of hump-shaped patterns, these syntheses have been criticized for failing to account for methodological differences among studies. We addressed such concerns by conducting standardized sampling in 48 herbaceous-dominated plant communities on five continents. We found no clear relationship between productivity and fine-scale (meters(-2)) richness within sites, within regions, or across the globe. Ecologists should focus on fresh, mechanistic approaches to understanding the multivariate links between productivity and richness.

Long-term open-label study of tanezumab for moderate to severe osteoarthritic knee pain

OBJECTIVE

This study was designed to evaluate the long-term safety and effectiveness of repeated doses of the humanized anti-nerve growth factor antibody, tanezumab, during open-label treatment of patients with OA knee pain.

DESIGN

The current study (clinicaltrials.gov identifier: NCT00399490) was a multicenter, phase II, open-label, multiple-dose extension of an earlier randomized clinical trial. All patients (N=281) received infusions of tanezumab 50μg/kg on Days 1 and 56 with subsequent doses administered at 8-week intervals (up to a total of eight infusions). The primary endpoint of this study was safety. Effectiveness evaluations included overall knee pain, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index subscales, and subject global assessment (SGA) of response to therapy on 0-100 point visual analog scales.

RESULTS

Repeated administration of tanezumab resulted in a low incidence of treatment-related adverse events (AEs; 7.5%). The rate of serious AEs was also low (2.8%) with none considered treatment-related. Few AEs of abnormal peripheral sensation were reported; hypoesthesia was reported by nine patients (3.2%), paresthesia by seven patients (2.5%), and hyperesthesia, peripheral neuropathy, and sensory disturbance were each reported by one patient (0.4% for each). Most AEs of abnormal peripheral sensation were rated as mild (95%) and the majority (65%) resolved before study completion. At Week 8, overall knee pain and SGA improved from baseline by a mean (± standard error) of -12.8 (±1.78) and 8.0 (±1.66), respectively. Similar improvements occurred for WOMAC subscales.

CONCLUSIONS

Repeated injections of tanezumab in patients with moderate to severe knee OA provide continued pain relief and improved function with a low incidence of side effects. Additional studies to define the efficacy and duration of pain reduction and to provide a more complete assessment of long-term safety are warranted.

Different stages of rheumatoid arthritis: features of the synovium in the preclinical phase

BACKGROUND

The aetiology of rheumatoid arthritis (RA), a prototype immune-mediated inflammatory disorder, is poorly understood. It is currently unknown whether the disease process starts in the synovium, the primary target of RA, or at other sites in the body.

OBJECTIVE

To examine, in a prospective study, the presence of synovitis in people with an increased risk of developing RA.

METHODS

Thirteen people without evidence of arthritis, who were positive for IgM rheumatoid factor and/or anticitrullinated protein antibodies, were included in the study. To evaluate synovial inflammatory changes, all participants underwent dynamic contrast-enhanced MRI and arthroscopic synovial biopsy sampling of a knee joint at inclusion. Results were compared with knee MRI data and synovial biopsy data of 6 and 10 healthy controls, respectively.

RESULTS

MRI findings evaluated by measurement of maximal enhancement, rate of enhancement, synovial volume and enhancement shape curve distribution were similar between the autoantibody-positive subjects and the healthy controls. Consistent with these findings, all but one autoantibody-positive subject showed very low scores for phenotypic markers, adhesion molecules and vascularity, all in the same range as those in normal controls. The one person with higher scores had patellofemoral joint space narrowing.

CONCLUSION

Subclinical inflammation of the synovium does not coincide with the appearance of serum autoantibodies during the pre-RA stage. Thus, systemic autoimmunity precedes the development of synovitis, suggesting that a 'second hit' is involved. This study supports the rationale for exploring preventive strategies aimed at interfering with the humoral immune response before synovial inflammation develops.

Epiflex(®) a new decellularised human skin tissue transplant: manufacture and properties

The manufacture and initial testing of a new human tissue transplant is described. Epiflex(®) is a human acellular dermis transplant that is manufactured from skin recovered from screened consenting donors according to validated and approved methods. The transplant is approved as a drug in Germany. The safety, stability and usability of the transplant are discussed with respect to the results of sterility, residual moisture content and rehydration tests. Histological and confocal laser scanning microscopy experiments and analysis of oxygen and water vapour permeability demonstrate that the native extracellular matrix structure and transport properties of human connective tissue are retained in the transplant. Results from initial clinical investigations suggest that Epiflex(®) can be used successfully in the treatment of burns, hypertrophic scars and as a transplant seeded with autologous dermal fibroblasts for soft-tissue regeneration in settings with wound healing problems following multi-modal treatments for sarcomas of the extremities.

A framework for assessing ecosystem dynamics in response to chronic resource alterations induced by global change

In contrast to pulses in resource availability following disturbance events, many of the most pressing global changes, such as elevated atmospheric carbon dioxide concentrations and nitrogen deposition, lead to chronic and often cumulative alterations in available resources. Therefore, predicting ecological responses to these chronic resource alterations will require the modification of existing disturbance-based frameworks. Here, we present a conceptual framework for assessing the nature and pace of ecological change under chronic resource alterations. The "hierarchical-response framework" (HRF) links well-documented, ecological mechanisms of change to provide a theoretical basis for testing hypotheses to explain the dynamics and differential sensitivity of ecosystems to chronic resource alterations. The HRF is based on a temporal hierarchy of mechanisms and responses beginning with individual (physiological/metabolic) responses, followed by species reordering within communities, and finally species loss and immigration. Each mechanism is hypothesized to differ in the magnitude and rate of its effects on ecosystem structure and function, with this variation depending on ecosystem attributes, such as longevity of dominant species, rates of biogeochemical cycling, levels of biodiversity, and trophic complexity. Overall, the HRF predicts nonlinear changes in ecosystem dynamics, with the expectation that interactions with natural disturbances and other global-change drivers will further alter the nature and pace of change. The HRF is explicitly comparative to better understand differential sensitivities of ecosystems, and it can be used to guide the design of coordinated, cross-site experiments to enable more robust forecasts of contemporary and future ecosystem dynamics.

Systematic review of tumour number and outcome after radical treatment of colorectal liver metastases

Background

Resection of colorectal liver metastases (CLMs) is potentially curative but the effect of tumour number on prognosis is uncertain. This study compared the prognosis after resection and/or ablation of between one and three, or four or more CLMs.

Methods

A systematic literature review from January 2000 to June 2008 was performed. Study selection and data extraction were standardized, and analysis included assessment of methodological quality, heterogeneity and bias. Main outcomes were 3- and 5-year survival. A meta-analysis comparing radical treatment in the two groups was performed using the hazard ratio for overall survival.

Results

Of 1307 studies screened, 46 (9934 patients) were included in the analysis. Methodological quality was variable, and there was significant heterogeneity and reporting bias. The overall 5-year survival rate after radical treatment ranged from 7 to 58 per cent. Pooled hazard ratio for overall survival was 1·67 (95 per cent confidence interval 1·43 to 1·95; P &lt; 0·001). Median reported 5-year survival for patients with four or more CLMs was 17·1 per cent.

Conclusion

Radical treatment of more than three CLMs results in poorer overall survival. Nevertheless, 5-year survival is achievable and the number of lesions should not, of itself, be used to exclude patients from surgery.