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Patient-controlled analgesia safety issues.

Patient controlled analgesia (PCA) offers meaningful advantages over traditional analgesia. However, PCA medical errors with PCA can be dangerous and even fatal. Errors associated with patient controlled analgesia (PCA) therapy are described as are ways to minimize such errors. This report is based on data from the United States Pharmacopeia (USP) and Institute for Safe Medication practices (ISMP) Medication Errors Reporting Program. PCA by proxy, appropriate patients selection for PCA, patient monitoring, patient education, medication mix ups and practice related errors are discussed. Staff training is addressed. Methods to minimize errors associated with pump purchasing, PCA prrescribing, initiation, and monitoring are described. Recommendations for pharmaceutical manufacturers elated to PCA therapy are provided.

Analgesia, Patient-Controlled↗

All slums are not equal: child health conditions among the urban poor.

Increasing urbanization has resulted in a faster growth of slum population. Various agencies, especially those in developing countries are finding it difficult to respond to this situation effectively. Disparities among slums exist owing to various factors. This has led to varying degrees of health burden on the slum children. Child health conditions in slums with inadequate services are worse in comparison to relatively better served slums. Identification, mapping and assessment of all slums is important for locating the hitherto missed out slums and focusing on the neediest slums. In view of the differential vulnerabilities across slums, an urban child health program should build context appropriate and community-need-responsive approaches to improve children's health in the slums.

Child↗

[Diabetic retinopathy: twelve-year incidence and progression].

INTRODUCTION: Diabetic retinopathy (DR) it is the main cause of preventable blindness in productive-age adults. The rate of progression to blindness from DR differs among countries and populations. MATERIAL AND METHODS: In order to report the incidence and progression of DR after 12 years of follow-up in a cohort (n = 100) of adult patients with diabetes mellitus type 2 (DM2) in Leon, Guanajuato, Mexico, we designed an open population cohort study from April 1992 to July 2004. Main variables studied longitudinally were incidence and progression of DR, fasting blood glucose, glycated hemoglobin and associated clinical parameters. RESULTS: Mean age was 54 +/- (SD) 9.2 years and the time since DM2 diagnosis was 9 +/- 6 years. Incidence rates at 3, 6 and 12 years were 23, 48 and 71%, respectively; and for progression were 56, 70 and 74%, respectively. The 12-year proliferative DR incidence and progression were 14.3 and 32%, respectively. Mean fasting blood glucose levels were 193 mg/dL and for glycated hemoglobin 11%. Mortality was 45%, half attributable to acute myocardial infarction. DISCUSSION: Diabetic retinopathy in our population has a high incidence that doubled in 3 years, and has an accelerated progression toward more severe forms. Incidence and progression are higher than that reported in white non-Hispanics. It should be high priority in our country to (a) prevent diabetes mellitus, (b) improve its metabolic control, (c) establish RD diagnostic programs and (d) give appropriate treatment.

Adult↗

[Silent myocardial ischemia in diabetic patients: to screen or not to screen?].

Cardiovascular diseases are the leading cause of death in patients with diabetes and silent myocardial ischemia occurs more frequently in diabetics than non-diabetics. Thus American Diabetes Association guidelines recommend screening for coronary artery disease in high-risk, asymptomatic diabetic patients. However these recommendations are the result of expert consensus panels instead of being evidence-based. The selection criteria for patients who should be included in screenings programs and the most appropriate treatment of silent ischemia in diabetics have to be clarified. In particular further studies are necessary to assess if myocardial revascularization is more beneficial than full medication alone. Screening of silent ischemia should be more individualized rather than systematic.

Coronary Disease↗

Home-grown CDR draws high utilization and award.

Provider access to clinical data on patients significantly enhanced through comprehensive database. Database was developed over period of years, gradually adding components as needs are seen. Duplication of tests is eliminated; more patients are referred appropriately to disease management programs.

Awards and Prizes↗

Community based participatory approaches to address health disparities in Hawai'i: recent applications in cancer prevention, detection and treatment programs.

Assessment of recent trends in the prevalence and incidence of cancer, and its associated risk and protective factors in the State of Hawai'i illustrate that there are definite ethnic, socio-economic, and geographic health disparities. Disparities in access to health care are reflected in decreased and under utilization of all types of preventive cancer screening tests and decreased proportions of people with health insurance coverage. Increases in obesity mirror U.S. national trends and disproportionately affect certain ethnic groups and those with low income. Tobacco use has increased among at-risk populations including: certain ethnic groups, those with low-income and/or low education and those in rural areas. Data that reveal continuing or worsening health disparities imply that either the old methods have not been effective and/or resources are not available or are not being applied to address such disparities. Promising methodologies and programmatic focuses to reduce health disparities are needed as mechanisms for improving the circumstances of at-risk populations. Community based participatory approaches are described here for cancer prevention, detection, and treatment programs that utilize culturally appropriate methods.

Community Health Planning↗

[Chronic fatigue syndrome in cardiology neurohumoral changes].

Chronic fatigue markedly worsens quality of life of cardiological patients. Chronic fatigue and chronic fatigue syndrome are neuro-immuno-endocrine disorders which manifest as moderate and severe even invalidizing fatigue with psychosomatic symptoms. External and internal stress such as psychological stress, stress after major surgery and trauma, depressive states, inadequate physical exercise, chronic heart failure, chronic viral infection, oncologic diseases, -- can promote development of chronic fatigue. Immune and hypothalamic-pituitary-adrenal (HPA) axis abnormalities were found to be associated with this condition. Measurement of plasma cortisol concentration is used as basic characteristic of HPA axis function. Measures aimed at detection of chronic fatigue in cardiological patients and its appropriate management should supplement programs of integrated rehabilitation in order to improve quality of life and facilitate return to work.

Fatigue Syndrome, Chronic↗

[Results of the socioeconomic study of the population of patients with schizophrenia].

The authors provide the results of an analysis of direct and indirect expenses for schizophrenic patients (n-386) depending on certain social factors. The analysis has shown a wide variability of expenses for patients depending on the level of education and skills, the character of work organization, familial status, and living conditions. The social parameters exerting the most essential influence on the magnitude and character of expenses for schizophrenic patients, incurred by the state have also been defined. Adequate financing of the appropriate social and rehabilitation programs may produce an appreciable effect on the patients social status, lead to a decrease of expenses for them, which later will warrant the primary expenses for the programs.

Costs and Cost Analysis↗

Perception of blindness and blinding eye conditions in rural communities.

PURPOSE: The purpose of this qualitative study was to explore the causes and management of blindness and blinding eye conditions as perceived by rural dwellers of two Yoruba communities in Oyo State, Nigeria. METHODS: Four focus group discussions were conducted among residents of Iddo and Isale Oyo, two rural Yoruba communities in Oyo State, Nigeria. Participants consisted of sighted, those who were partially or totally blind and community leaders. Ten patent medicine sellers and 12 traditional healers were also interviewed on their perception of the causes and management of blindness in their communities. FINDINGS: Blindness was perceived as an increasing problem among the communities. Multiple factors were perceived to cause blindness, including germs, onchocerciasis and supernatural forces. Traditional healers believed that blindness could be cured, with many claiming that they had previously cured blindness in the past. However, all agreed that patience was an important requirement for the cure of blindness. The patent medicine sellers' reports were similar to those of the traditional healers. The barriers to use of orthodox medicine were mainly fear, misconception and perceived high costs of care. There was a consensus of opinion among group discussants and informants that there are severe social and economic consequences of blindness, including not been able to see and assess the quality of what the sufferer eats, perpetual sadness, loss of sleep and dependence on other persons for daily activities. CONCLUSION: Local beliefs associated with causation, symptoms and management of blindness and blinding eye conditions among rural Yoruba communities identified have provided a bridge for understanding local perspectives and basis for implementing appropriate primary eye care programs.

Aged↗

Developmental screening by the Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) in HIV- infected children.

Bayley Scales of Infant Development (BSID) is considered to be a standard test for child development. The test requires experienced evaluator and is time consuming; therefore, it is not easy to apply in busy clinic. The Cognitive Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) is an easy assessment method that has been demonstrated to correlate with BSID in many studies among normal and developmental delayed children, including in HIV-infected infants. We created a pilot system of CAT/CLAMS assessment applied to 16 HIV-infected infants ages 12-34 months. They were all in the normal range score of developmental quotient (DQ). However, longitudinal follow-up by CAT/CLAMS assessment is needed in these HIV-infected children. When DQ score is below 70 (assuming to be delayed development), the child should be evaluated by BSID. In this way delayed development can be screened easily and early developmental stimulation program can be implemented appropriately.

Child Development↗

Ensuring management of vascular risk factors after stroke.

Ischemic stroke patients are at high risk for subsequent cardiovascular events. Despite this, an unacceptably high proportion of these patients do not receive treatment with evidence-based, guideline-recommended, vascular risk-reduction therapies when exposed to conventional care. The golden opportunity to most favorably influence the vascular future of stroke patients is at the initial encounter in the hospital or in the postdischarge setting. As such, there has been profound interest in identifying effective strategies and systems that increase the use of evidence-based therapies in the hospital and outpatient settings, to reduce the substantial morbidity and mortality that can result from recurrent vascular events after stroke. One strategy is the implementation of a stroke hospitalization quality-improvement program geared at optimizing appropriate drug therapy before discharge, intensifying patient education, and ensuring vigilant follow-up with early recognition and management of problems. Available evidence suggests that hospital-based systems can markedly improve medical care and education of hospitalized ischemic stroke patients, and increase longer-term patient adherence in the community.

Cerebrovascular Disorders↗

Racial/ethnic differences among youths in cigarette smoking and susceptibility to start smoking--United States, 2002-2004.

Limited information on cigarette smoking in racial/ethnic subpopulations hinders development and implementation of targeted interventions for smoking prevention and cessation. Because of small sample sizes or inadequate study formats, cigarette smoking among youths has been studied mostly in major racial/ethnic populations (e.g., Asian or Hispanic) instead of subsets of these populations (e.g., Vietnamese or Cuban). Data on major population categories might mask differences in tobacco-use prevalence among subpopulations. To assess the prevalence of cigarette smoking among youths aged 12-17 years in six major racial/ethnic populations and nine Asian or Hispanic subpopulations in the United States, the Substance Abuse and Mental Health Services Administration and CDC analyzed self-reported data collected during 2002-2004 from the National Survey on Drug Use and Health (NSDUH). This report summarizes the results of that analysis, which indicated that the estimated prevalence of cigarette smoking in this age group ranged from 23.1% for American Indians/Alaska Natives (AI/ANs) to 2.2% for Vietnamese. Implementing tobacco-control programs that include culturally appropriate interventions might help reduce cigarette smoking in racial/ethnic subpopulations.

Adolescent↗

Exercise and fitness.

Exercise testing and prescription appear to play an important role in promoting health maintenance strategies for women. Multistage exercise tolerance testing provides invaluable information in assessing the patient's functional capacity. The diagnostic significance of exercise-induced ST-segment depression is tenuous, however, in women with a low likelihood of heart disease. Research suggests that numerous physiologic mechanisms act to increase fetal tolerance to the circulatory and respiratory challenges of moderate maternal exercise. Moreover, appropriately prescribed endurance exercise programs for women are associated with the same salutary effects as men. Even more encouraging is the fact that these benefits can be attained at moderate levels of exercise--if long-term compliance is maintained.

Exercise↗

Patterns of antibiotic use and expenditures during 7 years at a university hospital.

Before 1982, annual retrospective drug-use audits clearly established the pattern of increased antibiotic use and expenditures at the University of Minnesota Hospital. At that point, a concurrent trend analysis system was developed to track this use by individual drug and therapeutic class, to identify trends in use for qualitative evaluation, and to provide an assessment of any intervention intended to alter use. Monthly use of all injectable antibiotics and antifungal agents, and selected oral antifungals has been tracked since 1982 as both defined daily doses and dollars. Use patterns in 1981 served as baseline. The defined daily dose index, which captures changes associated with intensity of antibiotic use per patient, increased 62% from baseline through 1988. This increase, however, resulted in a disproportionate 228% rise from baseline in antibiotic expenditures to nearly $3 million/year for 1988. The defined daily dose index peaked in 1985, declined in 1986, and remained stable for 1987 and 1988. Qualitative drug-use review programs were associated with this positive change. These results demonstrate the utility of concurrent trend analysis as a resource-management tool and as a measure of effectiveness for collaborative physician-pharmacist programs to foster safe, appropriate, and economical use of antiinfective agents.

Anti-Bacterial Agents↗

Tests of thyroid function: update in the diagnosis and management of thyroid disease.

Current thyroid function tests give the clinician powerful tools for the accurate assessment of thyroid status in the majority of patients encountered. There are, however, a small number of clinical situations in which there appear to be inconsistencies in the interrelationship of the thyroid function tests and/or in which they are apparently inappropriate to the clinical status of the patient. In most instances, there is a rational explanation for these observed alterations. The application of this information should allow clinicians to further refine their diagnostic accuracy and thereby enable them to proceed with an appropriate therapeutic or management program.

Adult↗

Compliance in the elderly.

Noncompliance is not a unique phenomenon associated with aging. Many of the same problems concerning taking medications most appropriately apply to 40 year olds as well as to 80 year olds. What is unique about the elderly is their greater sensitivity to medications, their greater propensity for the development of adverse effects, and the greater complexity of their regimens as they develop chronic illnesses through the course of their lives. In addition, decreasing acuity of special senses, problems with memory, and the interposition of other caregivers are all unique phenomena that have to be dealt with through expansion of the standard methods but only rarely through specific methods. Utilization of modern technology such as video cassette recorders, large print reproductions, and improved communication modalities for people with hearing and sight disabilities may overcome some of the problems leading to decreased comprehension and communication ability in elderly patients. Similarly, for those with financial barriers to appropriate utilization of medications, programs such as the Elderly Pharmaceutical Insurance Coverage (EPIC) in New York State may be helpful. Medicaid and AARP programs for obtaining medications at lower prices can help financially strapped patients. The necessity for physicians to learn about cultural attitudes toward family and governmentally supplied caregivers may also facilitate optimal medication utilization in our polycultural society. Medications can serve the elderly to great benefit. Misapplication and misuse of medications may result in undesirable outcomes, ranging from lack of maximum efficacy, annoying nuisance side effects, diminishing quality-of-life, and even life-threatening adverse outcomes.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

Adolescent idiopathic scoliosis.

The effective treatment of adolescent idiopathic scoliosis (AIS) is predicted on timely detection and appropriate intervention. School screening programs have resulted in a reduced incidence of advanced curvature upon referral. Studies of the natural history of AIS demonstrate that a number of factors are of predictive value in assigning risk for progressive curvature and subsequent deformity and/or morbidity. These are age at time of diagnosis, stage of skeletal maturity, and magnitude and pattern of curvature. The options in treating AIS are observation, orthosis, and operation. Spinal orthoses are designed to arrest the progression of curvature during skeletal maturation. Newer brace designs and protocols facilitate compliance with long-term bracing and may reduce the incidence of curves requiring operative intervention. The goal in scoliosis surgery is to reduce curvature and to create a stable framework on which vertebral fusion can occur. Technical advances have yielded a number of instrumentation options for achieving this goal. Basic technical comparisons are made among of prototypes of posterior spinal instrumentation. The newest of these, Cotrel-Dubousset, may supplant Harrington rod instrumentation as the preferred standard in the operative treatment of AIS.

Adolescent↗

Trends in oral health in the aging population.

Increased survival of the natural dentition, persistence of periodontal disease, deterioration of prior dental restorations, root surface caries, and continued incidence of oral cancer represent a complex of emerging oral health problems of the aged in the United States. Additional data on the epidemiology of oral mucous membrane syndromes will help to characterize the prevalence of these diseases in the aging population as well. Improvement in the utilization and accessibility of dental services by the aging cohorts will contribute to the prevention of oral disease in the future. Combined with the substantial growth in the size of this cohort of the population and alterations in the prevalence of these oral health status indicators, changes in the need for and projected utilization of professional oral health services can continue to be anticipated. Clinical research directed toward assessment of efficacy of treatment modalities for prevention of dental disease and maintenance of dental health are essential for the projection of dental health manpower needs for the future. This should also lead to the development of appropriate academic and training programs to meet the changing needs of the elderly.

Aged↗