Should All Nurses Be Required to Complete Implicit Bias Training?

Bias mitigation requires a systematic approach.

Should Nursing Schools Boycott Traditional College Ranking Systems?

New measures would focus on advancing health equity.

Promoting health equity with HBCUs: Breaking away from structural racism

BACKGROUND

The United States continues to be plagued with pervasive health disparities. Leading health and professional organizations acknowledge structural racism as a contributing factor for the lack of a racially diverse nursing workforce particularly those serving in leadership roles which could help to mitigate health disparities among historically stigmatized populations.

PURPOSE

Purpose Lack of funding for Historically Black Colleges and Universities (HBCUs) and lack of meaningful partnerships, stymie efforts that can be made by nursing programs at HBCUs.

DISCUSSION

Discussion This position paper examines collaborative actions that can address upstream factors that perpetuate healthcare disparities through deep engagement between the policymakers, professional associations, industry, and educational institutions.

METHODS

Faculty representing HBCU's and predominately White institutions, professional organizations, and staff met via videoconference to refine the focus of the paper, determine topic areas for writing teams, and refine details which occurred during weekly meetings.

CONCLUSION

To disengage from structural racism, three critical recommendations are amplified with associated examples.

Transforming nursing education in response to the Future of Nursing 2020-2030 report

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity report (NASEM, 2021) provides a comprehensive plan to improve the quality of health care and candidly acknowledges historical and contemporary issues that have stalled previous efforts to dismantle health care disparities. This article spotlights the role that nursing education, nurse leaders, and faculty play in enabling all people to achieve their highest level of health. Through the framework of the four pillars of (1) reconciling the shortage of nurses with expertise in public health and health equity, (2) creating policies that include and promote the tenets of diversity, antiracism, and well-being, (3) designing curricular resources and activities that address contemporary issues, and (4) creating and supporting an ethos that invites, retains, and graduates diverse students and facilitates a sense of belonging, our future nursing graduates will be prepared to advance health equity for all.

medna-metadata: an open-source data management system for tracking environmental DNA samples and metadata

MOTIVATION

Environmental DNA (eDNA), as a rapidly expanding research field, stands to benefit from shared resources including sampling protocols, study designs, discovered sequences, and taxonomic assignments to sequences. High-quality community shareable eDNA resources rely heavily on comprehensive metadata documentation that captures the complex workflows covering field sampling, molecular biology lab work, and bioinformatic analyses. There are limited sources that provide documentation of database development on comprehensive metadata for eDNA and these workflows and no open-source software.

RESULTS

We present medna-metadata, an open-source, modular system that aligns with Findable, Accessible, Interoperable, and Reusable guiding principles that support scholarly data reuse and the database and application development of a standardized metadata collection structure that encapsulates critical aspects of field data collection, wet lab processing, and bioinformatic analysis. Medna-metadata is showcased with metabarcoding data from the Gulf of Maine (Polinski et al., 2019).

AVAILABILITY AND IMPLEMENTATION

The source code of the medna-metadata web application is hosted on GitHub (https://github.com/Maine-eDNA/medna-metadata). Medna-metadata is a docker-compose installable package. Documentation can be found at https://medna-metadata.readthedocs.io/en/latest/?badge=latest. The application is implemented in Python, PostgreSQL and PostGIS, RabbitMQ, and NGINX, with all major browsers supported. A demo can be found at https://demo.metadata.maine-edna.org/.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Reducing the rate of cervical cancer: ethical challenges in public health

Human papilloma virus (HPV) is the most common sexually transmitted infection in the United States and HPV is the single most significant risk factor for acquiring cervical cancer. There are two vaccines that prevent some strains of HPV and are believed to help reduce the rate of cervical cancer: Whether or not the HPV vaccine should be mandated has resulted in monumental debates and given rise to several ethical concerns. For instance, how will mandating this vaccine affect the patient's right to self determination ? Will parents accept a vaccine that prevents a disease that is primarily sexually transmitted and targeted for adolescents girls? Have studies proven the vaccine to be effective against the types of HPV associated with cervical cancer? This paper critically analyzes several studies that address these questions and utilizes the nursing code of ethics as a framework to reveal inherent ethical issues confronting nurses.

Precise measurement of the neutron magnetic form factor G(M)n in the few-GeV2 region

The neutron elastic magnetic form factor was extracted from quasielastic electron scattering on deuterium over the range Q;{2}=1.0-4.8 GeV2 with the CLAS detector at Jefferson Lab. High precision was achieved with a ratio technique and a simultaneous in situ calibration of the neutron detection efficiency. Neutrons were detected with electromagnetic calorimeters and time-of-flight scintillators at two beam energies. The dipole parametrization gives a good description of the data.

Point prevalence survey of antibiotic use in Scottish hospitals utilising the Glasgow Antimicrobial Audit Tool (GAAT)

A point prevalence survey of antimicrobial prescribing was performed in 10 Scottish hospitals using the Glasgow Antimicrobial Audit Tool (GAAT). Appropriateness of the intravenous (IV) route was determined by an infectious diseases physician (IDP) and by a computerised algorithm. The IDP also estimated IV agent appropriateness. Each hospital was surveyed on a single day. Of 3826 patients surveyed, 1079 (28.3%) received an antibiotic, 381 (35.3%) intravenously; 197 (28.2%) orally treated had prior IV therapy. Median duration of IV was 4 days (IQR 2-7 days) and oral switch was 3.5 days (2-6). IV route was appropriate in 84% (IDP) and 84.8% (algorithm). Choice of agent was appropriate in 80% (IDP). Third-generation cephalosporins (3GC) (28.3%) were most frequent, followed by co-amoxiclav (20.2%), metronidazole (19.2%) and glycopeptides (18.6%). Regional differences were seen. The study shows it is possible to coordinate, collect and compare data from UK hospitals using the GAAT. Data may usefully inform local and national audit and support prescribing initiatives.

Measurement of deeply virtual compton scattering with a polarized-proton target

The longitudinal target-spin asymmetry AUL for the exclusive electroproduction of high-energy photons was measured for the first time in ep-->e;'pgamma. The data have been accumulated at JLab with the CLAS spectrometer using 5.7 GeV electrons and a longitudinally polarized NH3 target. A significant azimuthal angular dependence was observed, resulting from the interference of the deeply virtual Compton scattering and Bethe-Heitler processes. The amplitude of the sinvarphi moment is 0.252+/-0.042stat+/-0.020sys. Theoretical calculations are in good agreement with the magnitude and the kinematic dependence of the target-spin asymmetry, which is sensitive to the generalized parton distributions H and H.

Eta' photoproduction on the proton for photon energies from 1.527 to 2.227 GeV

Differential cross sections for the reaction gamma p --> eta' p have been measured with the CLAS spectrometer and a tagged photon beam with energies from 1.527 to 2.227 GeV. The results reported here possess much greater accuracy than previous measurements. Analyses of these data suggest for the first time the coupling of the eta'N channel to both the S11(1535) and P11(1710) resonances, known to couple strongly to the etaN channel in photoproduction on the proton, and the importance of J = 3/2 resonances in the process.

Beam-helicity asymmetries in double-charged-pion photoproduction on the proton

Beam-helicity asymmetries for the two-pion-photoproduction reaction gammap-->ppi(+)pi(-) have been studied for the first time in the resonance region for center-of-mass energies between 1.35 and 2.30 GeV. The experiment was performed at Jefferson Lab with the CEBAF Large Acceptance Spectrometer using circularly polarized tagged photons incident on an unpolarized hydrogen target. Beam-helicity-dependent angular distributions of the final-state particles were measured. The large cross-section asymmetries exhibit strong sensitivity to the kinematics and dynamics of the reaction. The data are compared with the results of various phenomenological model calculations, and show that these models currently do not provide an adequate description for the behavior of this new observable.

Onset of asymptotic scaling in deuteron photodisintegration

We investigate the transition from the nucleon-meson to the quark-gluon description of the strong interaction using the photon energy dependence of the d(gamma,p)n differential cross section for photon energies above 0.5 GeV and center-of-mass proton angles between 30 degrees and 150 degrees. A possible signature for this transition is the onset of cross-section s(-11) scaling with the total energy squared, s, at some proton transverse momentum P(T). The results show that the scaling has been reached for proton transverse momentum above about 1.1 GeV/c. This may indicate that the quark-gluon regime is reached above this momentum.

Proton source size measurements in the eA-->e'ppX reaction

Two-proton correlations at small relative momentum q were studied in the eA(3He,4He,C,Fe)-->e(')ppX reaction at E(0)=4.46 GeV using the CLAS detector at Jefferson Lab. The enhancement of the correlation function at small q was found to be in accordance with theoretical expectations. Sizes of the emission region were extracted, and proved to be dependent on A and on the proton momentum. The size of the two-proton emission region for He was measured in eA reactions for the first time.

Two-nucleon momentum distributions measured in 3He(e,e'pp)n

We have measured the 3He(e,e'pp)n reaction at 2.2 GeV over a wide kinematic range. The kinetic energy distribution for "fast" nucleons (p>250 MeV/c) peaks where two nucleons each have 20% or less, and the third nucleon has most of the transferred energy. These fast pp and pn pairs are back to back with little momentum along the three-momentum transfer, indicating that they are spectators. Calculations by Sargsian and by Laget also indicate that we have measured distorted two-nucleon momentum distributions by striking one nucleon and detecting the spectator correlated pair.

Observation of an exotic baryon with S=+1 in photoproduction from the proton

The reaction gamma p-->pi(+)K(-)K(+)n was studied at Jefferson Laboratory using a tagged photon beam with an energy range of 3-5.47 GeV. A narrow baryon state with strangeness S=+1 and mass M=1555+/-10 MeV/c(2) was observed in the nK(+) invariant mass spectrum. The peak's width is consistent with the CLAS resolution (FWHM=26 MeV/c(2)), and its statistical significance is (7.8+/-1.0)sigma. A baryon with positive strangeness has exotic structure and cannot be described in the framework of the naive constituent quark model. The mass of the observed state is consistent with the mass predicted by the chiral soliton model for the Theta(+) baryon. In addition, the pK(+) invariant mass distribution was analyzed in the reaction gamma p-->K(-)K(+)p with high statistics in search of doubly charged exotic baryon states. No resonance structures were found in this spectrum.

Observation of an exotic S = +1 baryon in exclusive photoproduction from the deuteron

In an exclusive measurement of the reaction gammad-->K(+)K(-)pn, a narrow peak that can be attributed to an exotic baryon with strangeness S=+1 is seen in the K(+)n invariant mass spectrum. The peak is at 1.542+/-0.005 GeV/c(2) with a measured width of 0.021 GeV/c(2) FWHM, which is largely determined by experimental mass resolution. The statistical significance of the peak is (5.2+/-0.6)sigma. The mass and width of the observed peak are consistent with recent reports of a narrow S=+1 baryon by other experimental groups.

Measurement of the proton spin structure function g1(x,Q2) for Q2 from 0.15 to 1.6 GeV2 with CLAS

Double-polarization asymmetries for inclusive ep scattering were measured at Jefferson Lab using 2.6 and 4.3 GeV longitudinally polarized electrons incident on a longitudinally polarized NH3 target in the CLAS detector. The polarized structure function g(1)(x,Q2) was extracted throughout the nucleon resonance region and into the deep inelastic regime, for Q(2)=0.15-1.64 GeV2. The contributions to the first moment Gamma(1)(Q2)= integral g(1)(x,Q2) dx were determined up to Q(2)=1.2 GeV2. Using a parametrization for g(1) in the unmeasured low x regions, the complete first moment was estimated over this Q2 region. A rapid change in Gamma(1) is observed for Q2<1 GeV2, with a sign change near Q(2)=0.3 GeV2, indicating dominant contributions from the resonance region. At Q(2)=1.2 GeV2 our data are below the perturbative QCD evolved scaling value.

Measurement of ep-->e' ppi+ pi- and baryon resonance analysis

The cross section for the reaction ep-->e(')ppi(+)pi(-) was measured in the resonance region for 1.4<W<2.1 GeV and 0.5<Q2<1.5 GeV(2)/c(2) using the CLAS detector at Jefferson Laboratory. The data show resonant structures not visible in previous experiments. The comparison of our data to a phenomenological prediction using available information on N(*) and Delta states shows an evident discrepancy. A better description of the data is obtained either by a sizable change of the properties of the P13(1720) resonance or by introducing a new baryon state, not reported in published analyses.

First measurement of transferred polarization in the exclusive ep-->e'K+Lambda--> reaction

The first measurements of the transferred polarization for the exclusive e-->p-->e(')K+Lambda--> reaction have been performed at Jefferson Laboratory using the CLAS spectrometer. A 2.567 GeV beam was used to measure the hyperon polarization over Q2 from 0.3 to 1.5 (GeV/c)(2), W from 1.6 to 2.15 GeV, and over the full K+ center-of-mass angular range. Comparison with predictions of hadrodynamic models indicates strong sensitivity to the underlying resonance contributions. A nonrelativistic quark-model interpretation of our data suggests that the ssmacr; quark pair is produced with spins predominantly antialigned. Implications for the validity of the most widely used quark-pair creation operator are discussed.

Photoproduction of the omega meson on the proton at large momentum transfer

The differential cross section, dsigma/dt, for omega meson exclusive photoproduction on the proton above the resonance region (2.6<W<2.9 GeV) was measured up to a momentum transfer -t=5 GeV2 using the CLAS detector at Jefferson Laboratory. The omega channel was identified by detecting a proton and pi(+) in the final state and using the missing mass technique. While the low momentum transfer region shows the typical diffractive pattern expected from Pomeron and Reggeon exchange, at large -t the differential cross section has a flat behavior. This feature can be explained by introducing quark interchange processes in addition to the QCD-inspired two-gluon exchange.

Eta photoproduction on the proton for photon energies from 0.75 to 1.95 GeV

Differential cross sections for gammap-->etap have been measured with tagged real photons for incident photon energies from 0.75 to 1.95 GeV. Mesons were identified by missing mass reconstruction using kinematical information for protons scattered in the production process. The data provide the first extensive angular distribution measurements for the process above W=1.75 GeV. Comparison with preliminary results from a constituent quark model support the suggestion that a third S11 resonance with mass approximately 1.8 GeV couples to the etaN channel.

Hydrogen peroxide supports hepatocyte P450 catalysed xenobiotic/drug metabolic activation to form cytotoxic reactive intermediates

1. A H2O2 generating system markedly increased the cytotoxicity of catechols, hydroquinone, in isolated hepatocytes, but not in P450 inhibited hepatocytes. 2. H2O2 or NADPH supported microsomal catalysed GSH conjugate formation with catechols or hydroquinone. Cytochrome P450 inhibitors inhibited conjugate formation. However, superoxide dismutase inhibited NADPH, but did not affect H2O2 supported GSH conjugate formation. The conjugate formed with dihydrocaffeic acid was identified as a mono-GSH conjugate indicating that the o-quinone was the major metabolite formed. 3. Dopamine (a catecholamine) induced cytotoxicity was prevented by inhibitors of monoamine oxidase (MAO) or P450, but was markedly increased by hepatocyte catalase inhibition or NAD(P)H:quinone oxidoreductase inhibition. This suggests that H2O2 formed by the mitochondrial metabolism of monoamine oxidase then oxidised dopamine to cytotoxic o-quinone catalysed by P450. Dihydrocaffeic acid cytotoxicity was also increased by the monoamine oxidase substrate tyramine. 4. It is concluded that polyphenolics are oxidised by H2O2/P450 in hepatocytes to form quinone metabolites.

Q2 Dependence of quadrupole strength in the gamma*p --> Delta(+)(1232) --> p pi(0) transition

Models of baryon structure predict a small quadrupole deformation of the nucleon due to residual tensor forces between quarks or distortions from the pion cloud. Sensitivity to quark versus pion degrees of freedom occurs through the Q2 dependence of the magnetic (M1+), electric (E1+), and scalar (S1+) multipoles in the gamma*p-->Delta(+)-->p pi(0) transition. We report new experimental values for the ratios E(1+)/M(1+) and S(1+)/M(1+) over the range Q2 = 0.4-1.8 GeV2, extracted from precision p(e,e(')p)pi(0) data using a truncated multipole expansion. Results are best described by recent unitary models in which the pion cloud plays a dominant role.

First measurement of the double spin asymmetry in (-->)e(-->)p-->e(prime)pi(+)n in the resonance region

The double spin asymmetry in the (-->)e(-->)p --> e(prime)pi(+)n reaction has been measured for the first time in the resonance region for four-momentum transfer Q2 = 0.35-1.5 GeV(2). Data were taken at Jefferson Lab with the CLAS detector using a 2.6 GeV polarized electron beam incident on a polarized solid NH3 target. Comparison with predictions of phenomenological models shows strong sensitivity to resonance contributions. Helicity-1/2 transitions are found to be dominant in the second and third resonance regions. The measured asymmetry is consistent with a faster rise with Q(2) of the helicity asymmetry A1 for the F(15)(1680) resonance than expected from the analysis of the unpolarized data.

Photoproduction of the rho(0) meson on the proton at large momentum transfer

The differential cross section, d sigma/dt, for rho(0) meson photoproduction on the proton above the resonance region was measured up to a momentum transfer -t = 5 GeV2 using the CLAS detector at the Thomas Jefferson National Accelerator Facility. The rho(0) channel was extracted from the measured two charged-pion cross sections by fitting the pi(+)pi(-) and p pi(+) invariant masses. The low momentum transfer region shows the typical diffractive pattern expected from Reggeon exchange. The flatter behavior at large -t cannot be explained solely in terms of QCD-inspired two-gluon exchange models. The data indicate that other processes, like quark interchange, are important to fully describe rho photoproduction.

Systems for evaluation of new drugs in the United Kingdom

The cost of drugs represents 10% of the National Health Service (NHS) budget in the UK and this fraction is increasing. Because the NHS is centrally funded and because there is a budgetary limit, prioritization in health care is required. The National Institute for Clinical Excellence in England and Wales and the Health Technology Board for Scotland have been established with the aim (among others) of ensuring that the NHS secures maximum health gain from available resources by focusing on treatments with clear evidence of cost effectiveness. Reconciling the interests of those responsible for financing the service with the interests of patients and other concerned parties might prove difficult.

Fanconi anemia group C protein prevents apoptosis in hematopoietic cells through redox regulation of GSTP1

The Fanconi anemia group C protein (FANCC) plays an important role in hematopoiesis by ensuring the survival of hematopoietic progenitor cells through an unknown mechanism. We investigated the function of FANCC by identifying FANCC-binding proteins in hematopoietic cells. Here we show that glutathione S-transferase P1-1 (GSTP1) interacts with FANCC, and that overexpression of both proteins in a myeloid progenitor cell line prevents apoptosis following factor deprivation. FANCC increases GSTP1 activity after the induction of apoptosis. GSTP1 is an enzyme that catalyzes the detoxification of xenobiotics and by-products of oxidative stress, and it is frequently upregulated in neoplastic cells. Although FANCC lacks homology with conventional disulfide reductases, it functions by preventing the formation of inactivating disulfide bonds within GSTP1 during apoptosis. The prevention of protein oxidation by FANCC reveals a novel mechanism of enzyme regulation during apoptosis and has implications for the treatment of degenerative diseases with thiol reducing agents.

The ep -->e'p eta reaction at and above the S11(1535) baryon resonance

New cross sections for the reaction e p-->e p eta are reported for total center of mass energy W = 1.5--1.86 GeV and invariant momentum transfer Q2 = 0.25--1.5 (GeV/c)(2). This large kinematic range allows extraction of important new information about response functions, photocouplings, and eta N coupling strengths of baryon resonances. Newly observed structure at W approximately 1.65 GeV is shown to come from interference between S and P waves and can be interpreted with known resonances. Improved values are derived for the photon coupling amplitude for the S11(1535) resonance.

Cytochrome P450 2E1 metabolically activates propargyl alcohol: propiolaldehyde-induced hepatocyte cytotoxicity

Pargyline, an antihypertensive agent and monoamine oxidase inhibitor, induces hepatic GSH depletion and hepatotoxicity in vivo in rats [E.G. De Master, H.W. Sumner, E. Kaplan, F. N. Shirota, H.T. Nagasawa, Toxicol. Appl. Pharmacol. 65 (1982) 390-401]. Propargyl alcohol (2-propyn-1-ol), because of its structural similarity to allyl alcohol, was thought to be activated by alcohol dehydrogenase. However, it is a poor substrate compared to allyl alcohol and it was therefore proposed that propargyl alcohol-induced liver injury involved metabolic activation by catalase/H(2)O(2) [E.G. De Master, T. Dahlseid, B. Redfern, Chem. Res. Toxicol. 7 (1994) 414-419]. In the following we showed that; (1) propargyl alcohol-induced cytotoxicity was markedly enhanced in CYP 2E1-induced hepatocytes and prevented by various CYP 2E1 inhibitors but was only slightly affected when alcohol dehydrogenase was inhibited with methylpyrazole/DMSO or when catalase was inactivated with azide or aminotriazole, (2) hepatocyte GSH depletion preceded cytotoxicity and was inhibited by cytochrome P450 inhibitors but not by catalase/alcohol dehydrogenase inhibitors. GSH conjugate formation during propargyl alcohol metabolism by microsomal mixed function oxidase in the presence of GSH was also prevented by anti-rat CYP 2E1 or CYP 2E1 inhibitors, (3) cytotoxicity was prevented when lipid peroxidation was inhibited with antioxidants, desferoxamine (ferric chelator) or dithiothreitol. Propargyl alcohol-induced cytotoxicity and reactive oxygen species formation were markedly increased in GSH-depleted hepatocytes. All of this evidence suggests that propargyl alcohol-induced cytotoxicity involves metabolic activation by CYP 2E1 to form propiolaldehyde that causes hepatocyte lysis as a result of GSH depletion and lipid peroxidation.

The formaldehyde metabolic detoxification enzyme systems and molecular cytotoxic mechanism in isolated rat hepatocytes

The toxicity and carcinogenicity of formaldehyde (HCHO) has been attributed to its ability to form adducts with DNA and proteins. A marked decrease in mitochondrial membrane potential and inhibition of mitochondrial respiration that was accompanied by reactive oxygen species formation occurred when isolated rat hepatocytes were incubated with low concentrations of HCHO in a dose-dependent manner. Hepatocyte GSH was also depleted by HCHO in a dose-dependent manner. At higher HCHO concentrations, lipid peroxidation ensued followed by cell death. Cytotoxicity studies were conducted in which isolated hepatocytes exposed to HCHO were treated with inhibitors of HCHO metabolising enzymes. There was a marked increase in HCHO cytotoxicity when either alcohol dehydrogenase or aldehyde dehydrogenase was inhibited. Inhibition of GSH-dependent HCHO dehydrogenase activity by prior depletion of GSH markedly increased hepatocyte susceptibility to HCHO. In each case, cytotoxicity was dose-dependent and corresponded with a decrease in hepatocyte HCHO metabolism and increased lipid peroxidation. Antioxidants and iron chelators protected against HCHO cytotoxicity. Cytotoxicity was also prevented, when cyclosporine or carnitine was added to prevent the opening of the mitochondrial permeability transition pore which further suggests that HCHO targets the mitochondria. Thus, HCHO-metabolising gene polymorphisms would be expected to have toxicological consequences on an individual's susceptibility to HCHO toxicity and carcinogenesis.

Play position is influenced by knowledge of SIDS sleep position recommendations

OBJECTIVE

This study determined whether knowledge of sleeping in the prone position as a risk factor for sudden infant death syndrome (SIDS) influences caregivers' positioning of their infants for play and sleep.

METHODOLOGY

One hundred caregivers attending Adelaide metropolitan Child Adolescent and Family Health Services (CAFHS) were surveyed by self-administered questionnaire.

RESULTS

Ninety-three per cent of parents reported that their knowledge of SIDS influenced infant positioning for sleep and 84% reported they never put their infant in the prone position for sleep. Thirty-seven per cent reported that SIDS knowledge did influence play positioning and 26% reported never placing their infant prone for play. There was a significant association (P = 0.002) between the influence of SIDS knowledge on play positioning and avoidance of the prone position for play.

CONCLUSIONS

Community educators may need to clarify that prone positioning for play is not a risk factor for SIDS and that it is desirable for infants to spend supervised wakeful time in the prone position.

A patient with recurrent hypothermia associated with thrombocytopenia

A 69 year old woman had 13 hospital admissions because of hypothermia attributed to self-neglect. On each occasion she was found to be thrombocytopenic, and the platelet count always returned to normal with rewarming. The case records of all patients admitted to the Victoria Infirmary between 1986 and 1990 with a primary diagnosis of hypothermia were reviewed. Two other patients of the 75 assessed were found to have had thrombocytopenia linked to hypothermia, but neither showed a recurrent relationship.

Adverse reactions as a cause of hospital admission in the aged

Truly elderly people comprise an increasingly large fraction of the population and consume a disproportionate amount of drugs. Over the last 25 years a number of different studies have illustrated that advancing age is associated with adverse drug reactions (ADRs). Advancing age is also associated with polypharmacy and multiple pathology, and this complex inter-relationship makes it difficult to conclude that age itself is a causative factor for ADRs. ADRs resulting in hospital admission have been the subject of study for many years, but it has not been consistently demonstrated that advancing age is a predisposing factor. Early studies used the method of intensive inpatient monitoring and identified digoxin, diuretics, aspirin, psychotropics and cytotoxics as drugs of concern. Smaller more recent studies have used more sophisticated statistical techniques to identify predisposing factors. Nonsteroidal anti-inflammatory drugs have been added to the list of drugs that may cause ADR-related hospital admission. Polypharmacy, and altered pharmacokinetics and pharmacodynamics are possible causative factors; however, variable compliance and multiple pathology may cause difficulties with attributing causality. Some basic guidelines for sensible prescribing would almost certainly result in fewer ADRs in the elderly, including those ADRs severe enough to result in hospital admission.

The roles of general and geriatric medicine in the provision of acute medical care for elderly patients

To determine whether there are differences between elderly patients admitted acutely to general medicine and those admitted to geriatric medical wards, and whether the patients are appropriately referred, a prospective survey of 426 consecutive patients aged 65 years or over admitted acutely to general medical and geriatric wards over a three month period was performed. A total of 286 patients were admitted to general medicine (GM) and 140 to the geriatric unit (GER). GER patients were older (81.0 v. 75.8 years) and had greater pre-morbid functional impairment and incontinence. Fewer GER patients presented with readily apparent organ specific diagnoses (56% v. 94%). Median length of stay was longer in GER patients (23 days v. 9 days). Variables independently predictive of GER admission were increasing age, increasing duration of illness, poor pre-morbid functional status and prior reliance on a carer. Length of stay was not associated with unit of admission allowing for the variables described above. GER patients are a different population. They have more chronic illness and functional impairment, and are more likely to require multidisciplinary assessment and rehabilitation in addition to treatment of presenting illness. Elderly patients are appropriately referred by General Practitioners (GPs) without a formal admissions policy.

Management of elderly patients with sustained hypertension

OBJECTIVE

To assess the clinical benefits of treating hypertension in elderly patients and to derive practical guidelines regarding indications, goals, and forms of treatment.

DESIGN

Review of six published randomised trials.

RESULTS

Active treatment of hypertension in elderly patients was associated with significant improvements in several indices of cardiovascular morbidity and mortality, particularly the incidence of fatal and non-fatal strokes. On the basis of the trial data, combined systolic and diastolic hypertension was defined as a sustained systolic pressure greater than 160 mmHg and diastolic pressure greater than 90 mmHg. There is convincing evidence that efforts should be made to reduce both systolic and diastolic pressures to below these levels in patients up to the age of 80 years. Isolated systolic hypertension was defined as a systolic pressure greater than 160 mmHg in the presence of a diastolic pressure less than 90 mmHg. Two trials reported benefit from the treatment of isolated systolic hypertension in patients up to the age of 80, and further trials are underway to support or refute this recommendation. Diuretics have an established role in the management of hypertension in elderly patients; beta adrenoceptor antagonists have given variable results, and the benefits are less impressive than with diuretic based regimens. Newer agents show promise in the treatment of elderly patients, particularly in the presence of coexisting disease, but their effects on morbidity and mortality have not been evaluated in large randomised trials.

CONCLUSIONS

Diuretics rather than beta blockers are the treatment of choice for patients with uncomplicated hypertension, but combinations of drugs may be required in as many as 50% of patients.