Matthew O. Wiens

Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study

Background: Medication-related visits to the emergency department are an important but poorly understood phenomenon. We sought to evaluate the frequency, severity and preventability of drug-related visits to the emergency department. Methods: We performed a prospective observational study of randomly selected adults presenting to the emergency department over a 12-week period. Emergency department visits were identified as drug-related on the basis of assessment by a pharmacist research assistant and an emergency physician; discrepancies were adjudicated by 2 independent reviewers. Results: Among the 1017 patients included in the study, the emergency department visit was identified as drug-related for 122 patients (12.0%, 95% confidence interval [CI] 10.1%–14.2%); of these, 83 visits (68.0%, 95% CI 59.0%–76.2%) were deemed preventable. Severity was classified as mild in 15.6% of the 122 cases, moderate in 74.6% and severe in 9.8%. The most common reasons for drug-related visits were adverse drug reactions (39.3%), nonadherence (27.9%) and use of the wrong or suboptimal drug (11.5%). The probability of admission was significantly higher among patients who had a drug-related visit than among those whose visit was not drug-related (OR 2.18, 95% CI 1.46–3.27, p < 0.001), and among those admitted, the median length of stay was longer (8.0 [interquartile range 23.5] v. 5.5 [interquartile range 10.0] days, p = 0.06). Interpretation: More than 1 in 9 emergency department visits are due to drug-related adverse events, a potentially preventable problem in our health care system.

NSAID use and the risk of Parkinson's disease: systematic review and meta-analysis of observational studies.

BackgroundSeveral studies have suggested that NSAID use may modify the risk of developing Parkinson’s disease (PD).ObjectiveOur aim was to conduct a meta-analysis of observational studies evaluating NSAID use and the risk of PD.MethodsWe systematically searched MEDLINE (1966–November 2008), EMBASE (1980–November 2008) and other databases. Data from 11 studies were included in the meta-analysis. We used the random effects model to calculate risk ratios (relative risks) and their corresponding 95% confidence intervals (CIs).ResultsThe pooled risk ratio of PD with NSAID use was 0.95 (95% CI 0.80, 1.12). The pooled risk ratio of PD with high-dose or long-duration NSAID use was 0.91 (95% CI 0.78, 1.05). The pooled risk ratio of PD for aspirin (acetylsalicylic acid) users was 1.08 (95% CI 0.93, 1.26). The pooled risk ratio of PD among ibuprofen users was 0.76 (95% CI 0.65, 0.89). The pooled risk ratio of PD in men using NSAIDs was 0.79 (95% CI 0.69, 0.92), and in women using NSAIDs, it was 0.72 (95% CI 0.45, 1.15).ConclusionsNSAIDs as a class do not seem to modify the risk of PD. However, ibuprofen may have a slight protective effect in lowering the risk of PD. Although the risk ratios of PD in male and female NSAID users were similar, the 95% CI for men was suggestive of a slight risk reduction.

NSAID Use and the Risk of Parkinson’s Disease

BackgroundSeveral studies have suggested that NSAID use may modify the risk of developing Parkinson’s disease (PD).ObjectiveOur aim was to conduct a meta-analysis of observational studies evaluating NSAID use and the risk of PD.MethodsWe systematically searched MEDLINE (1966–November 2008), EMBASE (1980–November 2008) and other databases. Data from 11 studies were included in the meta-analysis. We used the random effects model to calculate risk ratios (relative risks) and their corresponding 95% confidence intervals (CIs).ResultsThe pooled risk ratio of PD with NSAID use was 0.95 (95% CI 0.80, 1.12). The pooled risk ratio of PD with high-dose or long-duration NSAID use was 0.91 (95% CI 0.78, 1.05). The pooled risk ratio of PD for aspirin (acetylsalicylic acid) users was 1.08 (95% CI 0.93, 1.26). The pooled risk ratio of PD among ibuprofen users was 0.76 (95% CI 0.65, 0.89). The pooled risk ratio of PD in men using NSAIDs was 0.79 (95% CI 0.69, 0.92), and in women using NSAIDs, it was 0.72 (95% CI 0.45, 1.15).ConclusionsNSAIDs as a class do not seem to modify the risk of PD. However, ibuprofen may have a slight protective effect in lowering the risk of PD. Although the risk ratios of PD in male and female NSAID users were similar, the 95% CI for men was suggestive of a slight risk reduction.

Use of Lipid-Lowering Agents for the Prevention of Age-Related Macular Degeneration: A Meta-Analysis of Observational Studies

Purpose : To examine the effect of lipid-lowering agents in the development of age-related macular degeneration (AMD) through the techniques of meta-analysis. Methods : Case-control and cohort studies presenting relative risks and 95% confidence intervals were identified through a literature review. Inclusion was limited to studies where both the exposure of interest (lipid-lowering agents) and outcome (AMD) were explicitly defined. Pooled estimates were computed using the random effects model. To quantify heterogeneity we calculated the proportion of total variance of between study variance using the Ri statistic. The Q statistic for heterogeneity was also calculated. Results : Eight studies were identified. The pooled relative risk (RR) for all studies was 0.74 (95% CI, 0.55–1.00). When only those studies examining the use of statins were pooled (n = 7), the RR was 0.70 (95% CI, 0.48–1.03). Using the Ri statistic, the heterogeneity between studies was found to be 0.85 for all studies and 0.89 for studies examining statins. Conclusion : Lipid-lowering agents, including statins, do not appear to lower the risk of developing AMD, although clinically significant effects cannot be excluded. The use of these agents in the prevention of AMD cannot be recommended until well designed prospective studies with long follow up have demonstrated a benefit.

Pediatric sepsis in the developing world: challenges in defining sepsis and issues in post-discharge mortality.

Sepsis represents the progressive underlying inflammatory pathway secondary to any infectious illness, and ultimately is responsible for most infectious disease-related deaths. Addressing issues related to sepsis has been recognized as an important step towards reducing morbidity and mortality in developing countries, where the majority of the 7.5 million annual deaths in children under 5 years of age are considered to be secondary to sepsis. However, despite its prevalence, sepsis is largely neglected. Application of sepsis definitions created for use in resource-rich countries are neither practical nor feasible in most developing country settings, and alternative definitions designed for use in these settings need to be established. It has also been recognized that the inflammatory state created by sepsis increases the risk of post-discharge morbidity and mortality in developed countries, but exploration of this issue in developing countries is lacking. Research is urgently required to characterize better this potentially important issue.

Pediatric Post-Discharge Mortality in Resource Poor Countries: A Systematic Review

Objectives Mortality following hospital discharge is an important and under-recognized contributor to overall child mortality in developing countries. The primary objective of this systematic review was to identify all studies reporting post-discharge mortality in children, estimate likelihood of death, and determine the most important risk factors for death. Search Strategy MEDLINE and EMBASE were systematically searched using MeSH terms and keywords from the inception date to October, 2012. Key word searches using Google Scholar™ and hand searching of references of retrieved articles was also performed. Studies from developing countries reporting mortality following hospital discharge among a pediatric population were considered for inclusion. Results Thirteen studies that reported mortality rates following discharge were identified. Studies varied significantly according to design, underlying characteristics of study population and duration of follow-up. Mortality rates following discharge varied significantly between studies (1%–18%). When reported, post-discharge mortality rates often exceeded in-hospital mortality rates. The most important baseline variables associated with post-discharge mortality were young age, malnutrition, multiple previous hospitalizations, HIV infection and pneumonia. Most post-discharge deaths occurred early during the post-discharge period. Follow-up care was examined in only one study examining malaria prophylaxis in children discharged following an admission secondary to malaria, which showed no significant benefit on post-discharge mortality. Conclusions The months following hospital discharge carry significant risk for morbidity and mortality. While several characteristics are strongly associated with post-discharge mortality, no validated tools are available to aid health workers or policy makers in the systematic identification of children at high risk of post-discharge mortality. Future research must focus on both the creation of tools to aid in defining groups of children most likely to benefit from post-discharge interventions, and formal assessment of the effectiveness of such interventions in reducing morbidity and mortality in the first few months following hospital discharge.

Clinical decision rules to improve the detection of adverse drug events in emergency department patients.

OBJECTIVES Adverse drug events (ADEs) are unintended and harmful consequences of medication use. They are associated with high health resource use and cost. Yet, high levels of inaccuracy exist in their identification in clinical practice, with over one-third remaining unidentified in the emergency department (ED). The study objective was to derive clinical decision rules (CDRs) that are sensitive for the detection of ADEs, allowing their systematic identification early in a patients hospital course. METHODS This was a prospective observational cohort study carried out in two Canadian tertiary care hospitals. Participants were adults presenting to the ED having ingested at least one prescription or over-the-counter medication within 2 weeks. Nurses and physicians evaluated patients for standardized clinical findings. A second evaluator performed interobserver assessments of predictor variables in a subset of patients. Pharmacists, who were blinded to the predictor variables, evaluated all patients for ADEs. An independent committee reviewed and adjudicated cases where the ADE assessment was uncertain or the pharmacists diagnosis differed from the physicians working diagnosis. The primary outcome was an ADE that required a change in medical therapy, diagnostic testing, consultation, or hospital admission. CDRs were derived using kappa coefficients, chi-square statistics, and recursive partitioning. RESULTS Among 1,591 patients, 131 (8.2%, 95% confidence interval [CI] = 7.0% to 9.7%) were diagnosed with the primary outcome. The following variables were associated with ADEs and were used to derive two CDRs: 1) presence of comorbid conditions, 2) antibiotic use within 7 days, 3) medication changes within 28 days, 4) age ≥ 80 years, 5) arrival by ambulance, 6) triage acuity, 7) recent hospital admission, 8) renal failure, and 9) use of three or more prescription medications. The more sensitive rule had a sensitivity of 96.7% (95% CI = 91.8% to 98.6%) and required 40.8% (95% CI = 37.7% to 42.9%) of patients to have medication review. The more specific rule had a sensitivity 90.8% (95% CI = 81.4% to 95.7%) and required 28.3% of patients to proceed to medication review. CONCLUSIONS The authors derived CDRs that identified patients with ADEs with high sensitivity. These rules may improve the identification of ADEs early in a patients hospital course while limiting the number of patients requiring a detailed medication review.

Cocaine adulterant linked to neutropenia

A 28-year-old Aboriginal woman was admitted to hospital after presenting to the emergency department with a three-day history of fever, chills, difficulty swallowing because of a sore throat, and cough with production of sputum. The patient’s history included juvenile rheumatoid arthritis that was

Adequacy of antidote stocking in British Columbia hospitals: the 2005 Antidote Stocking Study

BACKGROUND Inadequate hospital stocking and the unavailability of essential antidotes is a worldwide problem with potentially disastrous repercussions for poisoned patients. Research indicates minimal progress has been made in the resolution of this issue in both urban and rural hospitals. In response to this issue the British Columbia Drug and Poison Information Centre developed provincial antidote stocking guidelines in 2003. We sought to determine the compliance with antidote stocking in BC hospitals and any factors associated with inadequate supply. METHODS A 2-part survey, consisting of hospital demographics and antidote stocking information, was distributed in 2005 to all acute care hospital pharmacy directors in BC. The 32 antidotes examined (21 deemed essential) and the definitions of adequacy were based on the 2003 BC guidelines. Availability was reported as number of antidotes stocked per hospital and proportion of hospitals stocking each antidote. For secondary purposes, we assessed factors potentially associated with inadequate stocking. RESULTS Surveys were completed for all 79 (100%) hospitals. A mean of 15.6+/-4.9 antidotes were adequately stocked per hospital. Over 90% of hospitals had adequate stocks of N-acetylcysteine, activated charcoal, naloxone, calcium salts, flumazenil and vitamin K; 71%-90% had adequate dextrose 50% in water (D50W), ethyl alcohol or fomepizole, polyethylene glycol electrolyte solution, protamine sulfate, and cyanide antidotes; 51%-70% had adequate folic acid, glucagon, methylene blue, atropine, pralidoxime, leucovorin, pyridoxine, and deferoxamine; and <50% had adequate isoproterenol and digoxin immune Fab. Only 7 (8.9%) hospitals sufficiently stocked all 21 essential antidotes. Factors predicting poor stocking included small hospital size (p < 0.0001), isolation (p = 0.01) and rural location (p < 0.0001). CONCLUSION Although antidote stocking has improved since the implementation of the 2003 guidelines, essential antidotes are absent in many BC hospitals. Future research should focus on determining the reasons for this situation and the effects of corrective interventions.

Mobile health applications for HIV prevention and care in Africa.

Purpose of reviewMore people have mobile phones in Africa than at any point in history. Mobile health (m-health), the use of mobile phones to support the delivery of health services, has expanded in recent years. Several models have been proposed for conceptualizing m-health in the fields of maternal–child health and chronic diseases. We conducted a literature review of m-health interventions for HIV prevention and care in African countries and present the findings in the context of a simplified framework. Recent findingsOur review identified applications of m-health for HIV prevention and care categorized by the following three themes: patient-care focused applications, such as health behavior change, health system-focused applications, such as reporting and data collection, and population health-focused applications, including HIV awareness and testing campaigns. SummaryThe potential for m-health in Africa is numerous and should not be limited only to direct patient-care focused applications. Although the use of smart phone technology is on the rise in Africa, text messaging remains the primary mode of delivering m-health interventions. The rate at which mobile phone technologies are being adopted may outpace the rate of evaluation. Other methods of evaluation should be considered beyond only randomized-controlled trials.