Medication appropriateness index: putting a number on an old problem in older patients.
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Aged↗
Biomedical subjects
M D Murray
Publications and source records attributed to M D Murray.
Influences of vector biology on transmission of arboviruses and outbreaks of disease: the Culicoides brevitarsis model.
The use of a model to appraise arboviral epizootics is described, and examples are given which demonstrated long-distance wind-dispersal of the biting-midge vector Culicoides brevitarsis from the same endemic source. Vector abundance is characterised by peaks and troughs of abundance, the patterns of which vary between localities and annually. Short term climatic effects can change rapidly the age structure of a population, thus increasing the number of midges that can transmit a virus and profoundly influencing the probabilities of viral transmission. The population dynamics of vector and viral foci are complex, if not chaotic.
Animals↗
Acute and chronic effects of nonsteroidal antiinflammatory drugs on glomerular filtration rate in elderly patients.
To assess the effects of nonsteroidal antiinflammatory drugs (NSAIDs) on glomerular filtration rate (GFR) in elderly patients with and without renal insufficiency, we conducted an open-label, randomized, prospective three-period cross-over study. Twenty-nine patients at least 65 years old were assigned to groups with preserved GFR (> 1.16 mL/s [70 mL/min]) or with renal insufficiency (GFR 0.50-1.16 mL/s [30-70 mL/min]). Patients received 800 mg ibuprofen three times daily, 20 mg piroxicam daily, or 200 mg sulindac twice daily for 1 month. Three-hour inulin and two-day creatinine clearances were measured before and after the first and last doses of NSAIDs. Ibuprofen, piroxicam, and sulindac decreased inulin clearance after single-doses in both groups of patients. In patients with renal insufficiency, creatinine clearance did not change after administration of ibuprofen for 1 month (0 +/- 0.06 mL/s, mean +/- standard error), but was decreased similarly with administration of either piroxicam or sulindac (-0.12 +/- 0.06 mL/s [-7.2 +/- 3.6 mL/min], P < 0.02). One patient with preserved GFR, but with other risk factors for NSAID-associated renal impairment, met our criteria for withdrawal by experiencing at least a 40 mumol/L (0.5 mg/dL) increase in serum creatinine above their baseline value. Our data indicate that NSAIDs do not adversely affect GFR in patients with preserved renal function unless they have another risk factor for NSAID-associated renal impairment. In contrast, patients with renal insufficiency may have significant chronic decrements in GFR with long-acting NSAIDs such as piroxicam and sulindac, but not with short-acting ibuprofen. Such patients should have renal function monitored while being treated with long-acting NSAIDs.
Age Factors↗
Bluetongue and Douglas virus activity in New South Wales in 1989: further evidence for long-distance dispersal of the biting midge Culicoides brevitarsis.
Infection of cattle with bluetongue and Douglas viruses was detected on the central and southern coast of New South Wales from January to April 1989. Bluetongue virus infection was found well south of areas of expected occurrence. Evidence is presented to support wind-borne dispersal of infected vectors, Culicoides brevitarsis, southwards from the Hunter Valley.
Animals↗
Multidimensional work sampling in an outpatient pharmacy.
Multidimensional work sampling was performed at a hospital-based outpatient pharmacy. Data were collected from nine full-time and five part-time pharmacists over a 45-day baseline period. Pharmacists wore silent, random-signal generators that permitted continuous work sampling. We introduced the concept of quick codes to allow pharmacists to record their work using a single letter for repetitive activities. Pharmacists recorded 4,687 observations, 90 percent using quick codes. The most common activity was checking prescriptions (36.2 percent). Detection and correction of prescribing errors was the most common reason for their work (39.4 percent). Most work-related activities were performed alone (80 percent) with little time in contact with patients or physicians. These baseline measures will be compared with future measures to assess the effect of the implementation of computerized prospective drug utilization review and clinical treatment guidelines on pharmacists' work. It is expected that these technologic and process changes will increase opportunities for pharmacists to educate patients and consult with physicians.
Classification↗
The evolution of the complete denture base. Theories of complete denture retention--a review. Part 1.
The history of denture base materials and the accompanying development of impression techniques are traced from the earliest times to the present day (Part 1) as a prelude to a study (Part 2-4) of the various theories that have been advanced to explain retention of the base without mechanical support. These theories are critically reviewed and tabulated in chronological order. Some areas for further investigation are identified.
Aluminum↗
The evolution of the complete denture base. Theories of complete denture retention--a review. Part 4.
The history of denture base materials and the accompanying development of impression techniques are traced from the earliest times to the present day (Part 1) as a prelude to a study (Part 2-4) of the various theories that have been advanced to explain retention of the base without mechanical support. These theories are critically reviewed and tabulated in chronological order. Some areas for further investigation are identified.
Denture Bases↗
The evolution of the complete denture base. Theories of complete denture retention--a review. Part 2.
The history of denture base materials and the accompanying development of impression techniques are traced from the earliest times to the present day (Part 1) as a prelude to a study (Part 2-4) of the various theories that have been advanced to explain retention of the base without mechanical support. These theories are critically reviewed and tabulated in chronological order. Some areas for further investigation are identified.
Adhesiveness↗
The evolution of the complete denture base. Theories of complete denture retention--a review. Part 3.
The history of denture base materials and the accompanying development of impression techniques are traced from the earliest times to the present day (Part 1) as a prelude to a study (Part 2-4) of the various theories that have been advanced to explain retention of the base without mechanical support. These theories are critically reviewed and tabulated in chronological order. Some areas for further investigation are identified.
Adhesiveness↗
Renal toxicity of the nonsteroidal anti-inflammatory drugs.
NSAIDs pose little threat of renal insult in normal, healthy persons at therapeutic dosages. However, NSAID administration to susceptible persons may cause decrements in renal plasma flow and glomerular filtration rate within hours. Such acute noxious renal effects are mediated by products of arachidonic acid metabolism. Precipitous decrements in glomerular filtration and renal ischemia, manifested by increased serum creatinine and urea nitrogen, are possible. However, these effects are usually fully reversible with prompt discontinuation of the offending NSAID. Risk factors for the development of these acute renal effects are known. Acute interstitial nephritis with or without nephrotic syndrome is a rare form of renal toxicity that typically occurs between 2-18 months of use. Renal impairment may be so severe as to require temporary hemodialysis; however, renal function usually returns to normal upon discontinuation of the NSAID. The mechanism of acute interstitial nephritis is presumed to be of allergic origin but could also be caused by a reactive metabolite. Fenoprofen use appears to be associated with a much higher risk for its development. In contrast to the acute effects of NSAIDs, irreversible, analgesic-associated nephropathy manifested by papillary necrosis and chronic interstitial nephritis may occur following months to years of high doses of analgesic mixtures. The mechanism by which combination analgesics produce this form of renal injury is unknown and could be either a result of medullary ischemia or a direct effect of a reactive metabolite. An important issue to be resolved is the relationship between the acute, reversible, prostaglandin-mediated renal effects of the NSAIDs and chronic, irreversible destruction, if such a relationship exists. Theoretically, continual or repeated decrements in renal function in patients with predisposing risk factors could cause or contribute to progressive deterioration in renal function. Elevations in blood pressure or interference with the effects of antihypertensive medications could theoretically also contribute to long-term renal deterioration. In addition to renal syndromes caused by NSAIDs that result in renal impairment, other transient effects on electrolyte and water metabolism may also occur. Reduced secretion of sodium may result in formation of edema, exacerbation of heart failure, or increased blood pressure. Hyporeninemic-hypoaldosteronism may produce hyperkalemia. Finally, reduced excretion of water has rarely caused hyponatremia. It has been suggested that NSAIDs may be renoprotective in patients with nephrotic syndrome. Others have suggested that sulindac is "renal-sparing" because of a unique metabolic pathway that supposedly limits the exposure of the kidney to the active sulfide metabolite.(ABSTRACT TRUNCATED AT 400 WORDS)
Animals↗
Medication compliance in elderly outpatients using twice-daily dosing and unit-of-use packaging.
OBJECTIVE: To determine the effect of unit-of-use drug packaging of medications on compliance among elderly outpatients treated with complex medication regimens. DESIGN: Nonblind, randomized, clinical trial. SETTING: Geriatric outreach health centers in urban public housing units for independent-living elderly people. PATIENTS: Thirty-one patients (aged > or = 60 y), each taking three or more prescribed medications. Patients were randomly assigned to one of three study groups: group 1 (n = 12), no change in dosing or packaging; group 2 (n = 10), conventional packaging with twice-daily dosing; group 3 (n = 9), unit-of-use packaging with twice-daily dosing. INTERVENTION: A unit-of-use package consisting of a two-ounce plastic cup with a snap-on lid containing all medications to be taken at the time of dosing. MAIN OUTCOME MEASURES: Medication compliance was assessed monthly for six months using tablet counts. RESULTS: Medication compliance was significantly better in group 3 (92.6 percent) using unit-of-use packaging compared with either group 1 (79 percent) or group 2 (82.6 percent) (p = 0.017). Compliance did not differ between groups 1 and 2. CONCLUSIONS: In this small study of elderly outpatients taking three or more medications, unit-of-use packaging and twice-daily dosing improved medication compliance compared with conventional packaging.
Activities of Daily Living↗
Effects of flurbiprofen on renal function in patients with moderate renal insufficiency.
1. Renal function was assessed in eight patients with chronic renal insufficiency following the administration of flurbiprofen 50 mg as a single dose and after chronic administration of 50 mg four times daily for 8 and 27 days. Diet and fluid intake were controlled. 2. Inulin and creatinine clearances and urinary excretion of sodium were measured at baseline and every 20 min for at least 3 h after dosing. The time of the mean peak concentration of (S)-flurbiprofen was used to guide the analysis of the clearances. Creatinine clearance, urinary excretion of sodium, and serum sodium and potassium were also assessed for 24 h after the dose and on a daily basis. Body weight and blood pressure were measured on a daily basis. 3. Decrements in inulin and creatinine clearances were small and reversible within 3 h of an oral dose of flurbiprofen. Comparison of baseline clearances for the three study periods (first dose and at 8 and 27 days of chronic dosing) revealed a lack of chronic effect on glomerular filtration rate. 4. In contrast, flurbiprofen caused a substantial (73 to 86%) and progressive decrease in the urinary excretion of sodium that reached a nadir within 4-5 h after drug administration. However, comparison of baseline values did not differ, indicating that balance conditions had been re-established. 5. Results of 24 h assessments were in agreement with the clearance study results. Reduced urinary excretion of sodium appeared to be limited to the first few days of flurbiprofen administration.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Parallel bonded cast attachments for removable partial dentures.
The original design of a semi-precision extra-coronal attachment for partial dentures is illustrated, and its fabrication in a cast non-precious bondable alloy is described. A step-by-step method is also described of bonding multiple attachments in parallel for the retention and support of removable partial dentures. Clinical cases are illustrated. The results of trials indicate that the method is clinically viable and, in selected cases, appears to offer distinct advantages over existing retention systems.
Chromium Alloys↗
Adverse effects of nonsteroidal anti-inflammatory drugs on renal function.
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Anti-Inflammatory Agents, Non-Steroidal↗
Complete denture retention. Part I: Physical analysis of the mechanism. Hysteresis of the solid-liquid contact angle.
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Chemical Phenomena↗
Ibuprofen-associated renal impairment in a large general internal medicine practice.
The authors determined the incidence of ibuprofen-associated renal impairment and risk factors for its development in 1908 patients treated with ibuprofen using data from a computerized medical records system. Renal impairment occurred in 343 patients (18%). Multivariable analysis revealed six independent predictors of renal impairment: age, prior renal insufficiency, coronary artery disease, male gender, elevated systolic blood pressure, and diuretic use. They then tested the degree to which ibuprofen contributed to the development of renal impairment by evaluating a control group of 3933 acetaminophen recipients. Neither ibuprofen nor acetaminophen was among the independent predictors of risk when all patients were considered (adjusted odds ratio, 1.05; 95% Cl, 0.88-1.26). However, two subsets of at risk patients had an ibuprofen effect: patients greater than or equal to 65 years of age who received ibuprofen were at greater risk of renal impairment as compared to acetaminophen recipients (adjusted odds ratio, 1.34; 95% Cl, 1.05 to 1.72) as were patients with coronary artery disease (adjusted odds ratio, 2.54; 95% Cl, 1.38 to 4.68). Their results suggest that elderly patients and patients with coronary artery disease are at risk for ibuprofen-associated renal impairment and therefore should have their renal function monitored when ibuprofen and possibly other nonsteroidal anti-inflammatory drugs are prescribed.
Acetaminophen↗
Nonsteroidal anti-inflammatory drugs.
Although the increased need for studies assessing the influence of age on the pharmacokinetics and pharmacodynamics of all drugs has been emphasized, relatively little is known about NSAIDs in the elderly. The pharmacokinetics of some NSAIDs have been examined in elderly subjects; unfortunately, recent data indicate that much of the earlier information may be incomplete or even misleading. Many studies report the disposition of only total NSAIDs. Since all of the NSAIDs are highly protein bound, it is the unbound, pharmacologically active, fraction that is most important. Few studies have quantified the pharmacokinetics of unbound NSAID in any age group, much less in elderly patients. Also, it is now apparent that studies of the propionic acid derivatives and other drugs with chiral centers must assess the disposition of the active S-enantiomer. Finally, studies of NSAIDs that form acylglucuronides are confounded by the reversion of these metabolites to active drug. Reduced renal elimination of these metabolites may be greater in elderly persons. Studies that account for these features of NSAIDs will provide necessary data for safe and effective use of NSAIDs in the elderly.
Age Factors↗
Investigation into the effectiveness of surface treatment on poly(methyl methacrylate) when exposed in the mouth.
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Adhesiveness↗