Peter Vanbrabant

Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department

Background Recent literature revealed that medication histories obtained by physicians and nurses are often incomplete. However, the number of patients included was often low. Study objective In this study, the authors compare medication histories obtained in the Emergency Department (ED) by pharmacists versus physicians and identify characteristics contributing to discrepancies. Methods Medication histories were acquired by the pharmacist from patients admitted to the ED, planned to be hospitalised. A structured form was used to guide the pharmacist or technician to ensure a standardised approach. Discrepancies, defined as any difference between the pharmacist-acquired medication history and that obtained by the physician, were analysed. Results 3594 medication histories were acquired by pharmacy staff. 59% (95% CI 58.2% to 59.8%) of medication histories recorded by physicians were different from those obtained by the pharmacy staff. Within these inaccurate medication histories, 5963 discrepancies were identified. The most common type of error was omission of a drug (61%; 95% CI 60.4% to 61.6%), followed by omission of dose (18%; 95% CI 17.6% to 18.4%). Drugs belonging to the class of psycholeptics, acid suppressors and beta blocking agents were related to the highest discrepancy rate. Acetylsalicylic acid, omeprazole and zolpidem were most commonly forgotten. Conclusion This large prospective study demonstrates that medication history acquisition is very often incomplete in the ED. A structured form and a standardised method is necessary. Pharmacists are especially suited to acquire and supervise accurate medication histories, as they are educated and familiar with commonly used drugs.

Impact of Temperature Exposure on Stability of Drugs in a Real-World Out-of-Hospital Setting

STUDY OBJECTIVE The aim of this study is to determine the content of 5 important emergency medical services (EMS) drugs after being stored at the recommended refrigerated temperature, room temperature, or in an emergency physician transport vehicle operating under real-world working conditions. METHODS Adrenaline hydrochloride, cisatracurium besylate, lorazepam, methylergonovine maleate, and succinylcholine chloride were stored for 1 year under the 3 conditions. For each storage condition, samples of the drugs were taken after 1, 2, 3, and 4 weeks and after 2, 4, 6, 8, 10, and 12 months. For adrenaline hydrochloride, however, the samples were taken after 1, 2, 4, 6, 8, 10, and 12 months. The samples were analyzed with a validated high-performance liquid chromatography assay. A drug was considered stable if its content was above 90%. RESULTS Adrenaline hydrochloride and methylergonovine maleate remained stable for 1 year at room temperature and in the emergency physician transport vehicle. At room temperature and in the emergency physician transport vehicle, lorazepam became unstable within 4 weeks. Succinylcholine chloride was stable for 2 months at room temperature and for 1 month in the emergency physician transport vehicle. Cisatracurium besylate became unstable within 4 months at room temperature. However, it remained stable for 4 months in the emergency physician transport vehicle. CONCLUSION When stored at room temperature or in the emergency physician transport vehicle, lorazepam became unstable within weeks, whereas succinylcholine chloride and cisatracurium besylate became unstable within months. Adrenaline hydrochloride and methylergonovine maleate remained stable for several months, even under room temperature and emergency physician transport vehicle conditions. Thus, real-world EMS working conditions pose challenges for maintaining optimal efficacy of these important EMS drugs.

Severity (and treatment) of chronic lithium poisoning: clinical signs or lab results as a criterion?

Abstract A 60-year old woman with a lithium intoxication presented initially to the emergency department with a Glasgow coma scale (GCS) of 15/15. With initial conservative treatment (hydratation) she developed coma, necessitating haemodialysis. During haemodialysis there was no clinical improvement although there was a drop in the serum lithium levels. However, neurological recovery occurred after the first haemodialysis session, while the lithium level rose again. This case illustrates initial clinical deterioration despite decreasing lithium levels as well as consequent clinical improvement without drop in lithium levels. This case also illustrates the pharmacokinetic profile of lithium and supports the use of primarily clinical signs completed with serum levels of lithium to determine the severity of a lithium poisoning and the adequate therapy including dialysis.

DIAGNOSTIC YIELD OF SYNCOPE INVESTIGATION (INITIATED) IN THE EMERGENCY DEPARTMENT: A PILOT STUDY

Abstract Objective: To determine the diagnostic yield of investigations in patients presenting to the emergency department (ED) with syncope. To determine the cause of the syncope. Patients and methods: We retrospectively identified consecutive patients presenting to the ED who underwent investigations for syncope at a 1900 bed university teaching hospital during 4 months. From the medical records we abstracted clinical information, results of testing and the cause of syncope. Results: A total of 117 patients participated in the study. The mean age was 57 year (range 6-93 year), and 45% were male. Diagnostic procedures most often performed were blood analysis, ECG, chest X-ray and Holter monitoring (respectively in 94,1%, 88,8%, 74,4% and 36,8% of the patients). The corresponding diagnostic yield for these test was 4,5%, 6,7%, 0% en 16,3%. Other procedures were (% of patients; diagnostic yield): Ct scan of the head (35,1%; 0%), transthoracic echocardiogram (24,8%; 6,9%), ECG monitoring (24,8%; 27,6%), EEG (19,7%; 0%), neurovascular imaging (19.7%; 0%), abdominal ultrasound (11,1%; 0%), Ct scan of the chest (11,1%; 23,1%), head up tilt test (7,7%; 11,1%), carotid sinus massage (3,4%; 0%), pulmonary ventilation perfusion scintigraphy (2,6%; 33%) and exercise test (1,7%; 0%). The most common cause of syncope was neurocardiogenic (58,5% of patients), followed by orthostatic (11,1%), cardiac (11,1%), unknown (9,3%), hyperventilation (3,4%), pulmonary embolism (2,5%), drug related (2,5%) and others (1.7%). Conclusion: Patients admitted in the ED for syncope undergo various investigations. However, the diagnostic yield is poor. The most common cause of syncope is neurocardiogenic, followed by orthostatic and cardiac.

Incidence and outcome of first syncope in primary care: A retrospective cohort study

BackgroundAssessment of risk for serious cardiovascular outcome after syncope is difficult.ObjectivesTo determine the incidence of first syncope in primary care. To investigate the relation between syncope and serious cardiovascular (CV) outcome and serious injury.MethodsRetrospective cohort study using data from the Intego general practice-based registration network, collecting data from 55 general practices (90 GPs). All patients with a first syncope from 1994 to 2008 were included; five participants without syncope were matched for age and gender for every patient with syncope. The main outcome measures were incidence of first syncope by age and gender and one year risk of serious CV outcome or injury after syncope.Results2785 patients with syncope and 13909 matched patients without syncope were included. The overall incidence of a first syncope was 1.91 per 1000 person-years (95% CI 1.83-1.98). The incidence was higher in females (2.42 (95% CI 2.32-2.55) per 1000 person-years) compared to males (1.4 (95% CI 1.32-1.49) per 1000 person-years) and follows a biphasic pattern according to age: a first peak at the age of 15-24 years is followed by a sharp rise above the age of 45. One year serious outcome after syncope was recorded in 12.3% of patients. Increasing age (HR 1.04 (1.03-1.04)), CV comorbidity (HR 3.48 (95% CI 2.48-4.90) and CV risk factors (HR 1.65 (95% CI 1.24-2.18) are associated with serious outcome. Cox regression, adjusting for age, gender, CV comorbidity and risk factors, showed that syncope was an independent risk factor for serious CV outcome or injury (HR 3.99 (95% CI 3.44-4.63)). The other independent risk factors were CV comorbidity (HR 1.81 (95% CI 1.51-2.17)) and age (HR 1.03 (95% CI 1.03-1.04)).ConclusionsIncidence rate of first syncope in primary care was 1.91 per 1000 person-years. One year risk of serious outcome after syncope was 12.3%. Increasing age, CV comorbidity and risk factors are associated with serious outcome. Compared to a control group, syncope on itself is an independent risk factor for serious outcome (adjusted for age, gender, CV comorbidity and risk factors).

Predictors for unintentional medication reconciliation discrepancies in preadmission medication: a systematic review

PurposeDiscrepancies in preadmission medication (PAM) are common and potentially harmful. Medication reconciliation is able to reduce the discrepancy rate, yet implementation is challenging. In order for reconciliation efforts to be more cost-effective, patients at high risk for reconciliation errors should be identified. The purpose of this systematic review is to identify predictors for unintentional discrepancies in PAM.MethodsMedline and Embase were searched systematically until June 2017. Only studies concerning adult subjects were retained. Quantitative studies were included if predictors for unintentional discrepancies in the PAM had been determined on hospital admission. Variables were divided into patient-, medication-, and setting-related predictors based on a thematic analysis. Studies on identification of predictors for discrepancies and potentially harmful discrepancies were handled separately.ResultsThirty-five studies were eligible, of which 5 studies focused on potentially harmful discrepancies. The following 16 significant variables were identified using multivariable prediction models: number of preadmission drugs, patient’s age, availability of a drug list, patients’ understanding of medication, usage of different outpatient pharmacies, number of high-risk drugs, discipline for which the patient is admitted, admitting physician’s experience, number and type of consulted sources, patient’s gender, type of care before admission, number of outpatient visits during the past year, class of medication, number of reimbursements, use of an electronic prescription system, and type of admission (elective vs emergency). The number of preadmission drugs was identified as a predictor in 20 studies. Potentially harmful discrepancies were ascertained in 5 studies with age found to have a predictive value in all 5 studies.ConclusionMultiple suitable predictors for PAM-related discrepancies were identified of which higher age and polypharmacy were reported most frequently.

18-fluoro-deoxyglucose positron emission tomography may contribute to the diagnosis and follow-up of malakoplakia

Abstract Malakoplakia is a rare inflammatory disease involving most frequently the urinary tract. We present a case of bilateral renal malakoplakia, in which FDG-PET contributed to diagnosis. We made this diagnosis on the basis of clinical presentation, renal biopsy showing a mixed cellular infiltrate with granuloma formation and possible Michaelis-Gutmann bodies, resolution of the lesions after prolonged antibiotic therapy and evidence of leukocyte dysfunction. We briefly discuss the pathofysiology and therapy of this rare and difficult to prove disease and the role of FDG-PET in the diagnosis of inflammatory and infectious diseases.

SHORT-TERM RETURN VISITS OF 'GENERAL INTERNAL MEDICINE' PATIENTS TO THE EMERGENCY DEPARTMENT: EXTENT AND RISK FACTORS

Abstract Objectives: Although emergency department (ED) return visits are a significant problem universally, it has not been previously studied in our ED. The aim of this study was to determine the extent of the problem in our ED, to identify the relevant clinical predictor variables and to detect diagnostic errors. Methods: A retrospective observational study of ED return visits by patients managed by the General Internal Medicine (GIM) service was performed. The study was performed over a one year period at a tertiary hospital ED. Data are reported as relative risk (RR) and 95% confidence interval (CI). Results: There were a total of 51.210 ED visits during the study period. The total number of ED return visits within 72 hours was 1.124 (2,19%; 95% CI 2,07 to 2,32). The total number of ED patients managed by the GIM service was 9.511. The percentage of patients treated by the GIM service who returned to the ED within 72 hours was 1,48% (95% CI 1,25 to 1,74) when calculated for the whole group and 2,9 % (95% CI 2,46-3,41) for those discharged home from the ED (n=4.860). The majority (82,98%) of ED return visits by patients discharged from the GIM service were unscheduled and related to their index presenting complaint. Abdominal pain was the commonest initial presenting symptom in the patients who returned to the ED after discharge. Patients with diarrhoea as the initial initial presenting symptom had the highest relative risk of an ED return visit (RR=4.07). Conclusion: The percentage ED return visits by patients discharged from the ED by the GIM service is 1,48%. Patients presenting with diarrhoea as the initial presenting symptom have the highest relative risk of an early ED return visit. Our main practical conclusion is that patients with abdominal pain need to be re-examined carefully and instructed about potential evolution before discharge.

Metformin-associated lactic acidosis (mala): case report

Abstract Metformin is the first-line therapy for the treatment of diabetes mellitus. In certain conditions lactic acidosis (MALA) can occur. Starting with a case report of a 62-year-old woman presenting with abdominal pain, we bring this complication to attention, describing its pathogenesis and its management. This underlines the need for thoughtful use of metformin.

Human Computation as a New Method for Evidence-Based Knowledge Transfer in Web-Based Guideline Development Groups: Proof of Concept Randomized Controlled Trial

Background Guideline developers use different consensus methods to develop evidence-based clinical practice guidelines. Previous research suggests that existing guideline development techniques are subject to methodological problems and are logistically demanding. Guideline developers welcome new methods that facilitate a methodologically sound decision-making process. Systems that aggregate knowledge while participants play a game are one class of human computation applications. Researchers have already proven that these games with a purpose are effective in building common sense knowledge databases. Objective We aimed to evaluate the feasibility of a new consensus method based on human computation techniques compared to an informal face-to-face consensus method. Methods We set up a randomized design to study 2 different methods for guideline development within a group of advanced students completing a master of nursing and obstetrics. Students who participated in the trial were enrolled in an evidence-based health care course. We compared the Web-based method of human-based computation (HC) with an informal face-to-face consensus method (IC). We used 4 clinical scenarios of lower back pain as the subject of the consensus process. These scenarios concerned the following topics: (1) medical imaging, (2) therapeutic options, (3) drugs use, and (4) sick leave. Outcomes were expressed as the amount of group (dis)agreement and the concordance of answers with clinical evidence. We estimated within-group and between-group effect sizes by calculating Cohen’s d. We calculated within-group effect sizes as the absolute difference between the outcome value at round 3 and the baseline outcome value, divided by the pooled standard deviation. We calculated between-group effect sizes as the absolute difference between the mean change in outcome value across rounds in HC and the mean change in outcome value across rounds in IC, divided by the pooled standard deviation. We analyzed statistical significance of within-group changes between round 1 and round 3 using the Wilcoxon signed rank test. We assessed the differences between the HC and IC groups using Mann-Whitney U tests. We used a Bonferroni adjusted alpha level of .025 in all statistical tests. We performed a thematic analysis to explore participants’ arguments during group discussion. Participants completed a satisfaction survey at the end of the consensus process. Results Of the 135 students completing a master of nursing and obstetrics, 120 participated in the experiment. We formed 8 HC groups (n=64) and 7 IC groups (n=56). The between-group comparison demonstrated that the human computation groups obtained a greater improvement in evidence scores compared to the IC groups, although the difference was not statistically significant. The between-group effect size was 0.56 (P=.30) for the medical imaging scenario, 0.07 (P=.97) for the therapeutic options scenario, and 0.89 (P=.11) for the drug use scenario. We found no significant differences in improvement in the degree of agreement between HC and IC groups. Between-group comparisons revealed that the HC groups showed greater improvement in degree of agreement for the medical imaging scenario (d=0.46, P=.37) and the drug use scenario (d=0.31, P=.59). Very few evidence arguments (6%) were quoted during informal group discussions. Conclusions Overall, the use of the IC method was appropriate as long as the evidence supported participants’ beliefs or usual practice, or when the availability of the evidence was sparse. However, when some controversy about the evidence existed, the HC method outperformed the IC method. The findings of our study illustrate the importance of the choice of the consensus method in guideline development. Human computation could be an acceptable methodology for guideline development specifically for scenarios in which the evidence shows no resonance with participants’ beliefs. Future research is needed to confirm the results of this study and to establish practical significance in a controlled setting of multidisciplinary guideline panels during real-life guideline development.