Daily Prescription Research Articles

Constructing a Real-Time Prescription Drug Monitoring System.

ObjectivesThe objective of this investigation was to demonstrate the possibility of the construction of a real-time prescription drug monitoring system (PDMOS) using data from the nationwide Drug Utilization Review (DUR) system in Korea.MethodsThe DUR system collects information on drug prescriptions issued by healthcare practitioners and on drugs dispensed by pharmacies. PDMOS was constructed using this data. The screen of PDMOS is designed to exhibit the number of drug prescriptions, the number of prescriptions dispensed by pharmacies, and the dispensed prescription drug costs on a daily and weekly basis. Data was sourced from the DUR system between June 1, 2016 and July 18, 2016. The TOGA solution developed by the EYEQMC Co. Ltd. of Seoul, Korea was used to produce the screen shots.ResultsPrescription numbers by medical facilities were more numerous than the number of prescriptions dispensed by pharmacies, as expected. The number of prescriptions per day was between 2 to 3 million. The prescriptions issued by primary care clinics were most numerous, at 75% of the total number of prescriptions. Daily prescription drug costs were found to be approximately US $50 million. The prescription drug costs were highest on Mondays and were reduced towards the end of the week. Prescriptions and dispensed prescriptions numbered approximately 1,200 and 1,000 million, respectively.ConclusionsThe construction of a real-time PDMOS has been successful to provide daily and weekly information. There was a lag time of only one day at the national level in terms of information extraction, and scarcely any time was required to load the data. Therefore, this study highlights the potential of constructing a PDMOS to monitor the estimate the number of prescriptions and the resulting expenditures from prescriptions.

Knowledge, attitude and practice of therapeutic fasting among naturopathy physicians: across sectional national survey

Introduction: Fasting is a common ingredient of naturopathic prescription in India. However no studies have been conducted to establish the use, approach of naturopathy physicians towards fasting. The present study, a cross sectional survey was conducted to assess the attitude, use, belief and understanding about therapeutic fasting among the naturopathy physicians in India. Methods: A 12 item e-mail based questionnaire was sent among 334 naturopathy physicians, which were designed to obtain demographic data, practice characteristics and multiple choice and multiple response close-ended questions along with an open-response final question. Survey questionnaire data was analyzed using descriptive statistics via frequency distribution and cross tabulations. Results: A convenient sample of total 257 participants was collected. Majority of the respondents were private practitioners with an average experience of 5 years. 50% of the total population confirms the use of fasting in their daily prescription which is mostly for 1-5 days (54%) and for all diseases (38.5%). Physicians mostly prescribe short term mono fasting with fruits or juices (42.8%) along with all other modalities (61.5%) to get desired effect. The end results of fasting therapy was quoted as satisfactory (51.7%) whereas the misconceptions of the patients was a challenge for 1/3 and most of them find it easy to administer in adults (85%). Conclusion: Naturopathy physicians use fasting as a first line management in almost all chronic and acute diseases. However there is a need for strengthening the evidence based practice to bestow better care.

Surgical cure of primary hyperparathyroidism ameliorates gastroesophageal reflux symptoms.

Gastroesophageal reflux disease (GERD) symptoms are commonly reported in primary hyperparathyroidism (pHPT). Although a calcium-mediated cause-and-effect relationship has been suggested, it remains unknown if parathyroidectomy improves GERD symptoms. Over a 22-month period, 1,175 (39%) of 3,000 consecutive adult patients with pHPT and symptomatic GERD (on prescription reflux medications daily for ≥2 years) undergoing parathyroidectomy were entered into a prospective study. Standardized Frequency Scale for Symptoms of GERD (FSSG) questionnaire was used to assess symptoms before, 1 and 2 years after parathyroidectomy. Daily prescription medication was used by 81%, while 19% used daily non-prescription drugs, both for a mean of 2.9 ± 0.7 years. GERD symptoms improved (26%) or resolved completely (36%) in 62% of patients (p < 0.0001 vs. preoperative baseline) 1 year after parathyroidectomy. Prescription medications for GERD decreased from 81% of enrolled patients to 26% (p < 0.0001) 12 months postoperatively, with 39% having complete symptom relief and taking no medications (p < 0.0001). Daily use of prescription GERD medications decreased to occasional over-the-counter drug use in 35% after parathyroidectomy (p < 0.0001). Mean FSSG scores decreased significantly postoperatively (pre-op: 18.0 ± 8.0 vs. post-op: 10.0 ± 5.0; p < 0.0001), with significant improvements in all 12 FSSG categories, including motility (pre-op: 7.3 ± 3.0 vs. post-op: 4.4 ± 3.0; p < 0.0001) and acid reflux symptoms (pre-op: 10.8 ± 5.0 vs. post-op: 5.9 ± 4.0; p < 0.0001). Symptomatic improvements were durable 2 years after parathyroidectomy. Symptomatic GERD is common in pHPT. Parathyroidectomy provides significant, durable relief of both motility and acid reflux symptoms allowing discontinuation of prescription drug use for GERD in most (74%) patients providing yet another indication for parathyroidectomy in pHPT.

The impact of the peritoneal glucose load index on hydration status and inflammation in peritoneal dialysis patients.

To evaluate the impact of the peritoneal glucose load (PGL) on hydration status and inflammation in peritoneal dialysis (PD) patients. This cross-sectional study evaluated stable PD patients using a novel PGL index (PGLI), which was calculated as the net glucose content (g) in the PD solutions administered in the daily PD prescription divided by the dry body weight (kg) assessed by whole-body bioimpedance spectroscopy. The relationship between PGLI and glycosylated haemoglobin (HbA1c), fluid overload (FO), and inflammatory markers was investigated. A total of 43 stable PD patients participated in the study. Significant positive correlations were found between PGLI and HbA1c, FO, plasma high sensitivity C-reactive protein (hsCRP), and plasma interleukin-6 (IL-6) levels. HbA1c, FO, plasma hsCRP and plasma IL-6 levels were significantly higher in patients with PGLI >3 g/kg/day compared with those with PGLI ≤3 g/kg/day. PGLI values >3 g/kg/day may be associated with poor glycaemic control, over hydration and augmented inflammation. PGLI might be a useful tool for the quantitative assessment of the PGL and could be applied when managing PD patients.

Influence of a Systems-Based Approach to Prescribing Errors in a Pediatric Resident Clinic

ObjectiveTo measure the difference in prescribing error rates between 2 clinics, 1 with a system in place to reduce errors and 1 with no such system; to determine variables that affect the likelihood of prescription errors. MethodsThis was a retrospective study at 2 university-based general pediatric clinics utilizing the same electronic medical record (EMR) system. Clinic 1 employed pharmacists who provided daily prescription review, provider feedback and education, and EMR customization to decrease errors. Clinic 2 had no systems in place for reducing prescribing errors. Prescriptions written by resident physicians over 2 months were identified and reviewed. ResultsA total of 1361 prescriptions were reviewed, 40.7% from clinic 1 and 59.3% from clinic 2. Errors were found in 201 prescriptions (14.8%). Clinics 1 and 2 had error rates of 11% and 17.5%, respectively (P = .0012). The odds of a prescription error at clinic 2 were 1.7 times the odds of a prescription error at clinic 1. Logistic regression identified clinic, nonpediatric resident, liquid dose forms, and younger patient age as significant predictors of prescription errors. Half of the errors could have been prevented with consistent use of a custom medication list within the EMR. ConclusionsWe found 37% fewer prescribing errors in a clinic with systems in place for prescribing error detection and prevention. Pediatric clinics should explore systematic procedures for identifying, resolving, and providing education about prescribing errors to reduce patient risk.

Frequency of dosage prescribing medication errors associated with manual prescriptions for very preterm infants.

The risk of dosage Prescription Medication Error (PME) among manually written prescriptions within 'mixed' prescribing system (computerized physician order entry (CPOE)+manual prescriptions) has not been previously assessed in neonatology. This study aimed to evaluate the rate of dosage PME related to manual prescriptions in the high-risk population of very preterm infants (GA<33weeks) in a mixed prescription system. The study was based on a retrospective review of a random sample of manual daily prescriptions in two neonatal intensive care units (NICU) A and B, located in different French University hospitals (Dijon and La Reunion island). Daily prescription was defined as the set of all drugs manually prescribed on a single day for one patient. Dosage error was defined as a deviation of at least ±10% from the weight-appropriate recommended dose. The analyses were based on the assessment of 676 manually prescribed drugs from NICU A (58 different drugs from 93 newborns and 240 daily prescriptions) and 354 manually prescribed drugs from NICU B (73 different drugs from 131 newborns and 241 daily prescriptions). The dosage error rate per 100 manually prescribed drugs was similar in both NICU: 3·8% (95% CI: 2·5-5·6%) in NICU A and 3·1% (95% CI: 1·6-5·5%) in NICU B (P=0·54). Among all the 37 identified dosage errors, the over-dosing was almost as frequent as the under-dosing (17 and 20 errors, respectively). Potentially severe dosage errors occurred in a total of seven drug prescriptions. None of the dosage PME was recorded in the corresponding medical files and information on clinical outcome was not sufficient to identify clinical conditions related to dosage PME. Overall, 46·8% of manually prescribed drugs were off label or unlicensed, with no significant differences between prescriptions with or without dosage error. The risk of a dosage PME increased significantly if the drug was included in the CPOE system but was manually prescribed (OR=3·3; 95% CI: 1·6-7·0, P<0·001). The presence of dosage PME in the manual prescriptions written within mixed prescription systems suggests that manual prescriptions should be totally avoided in neonatal units.

Will the health care home help to reduce the health cost for drug users in Medicaid?

Aims: U.S. prescription drug use is common, second only to marijuana use. Kentucky continues with high rates of non-medical prescription use, particularly prescription opioids in Appalachian Kentucky. Prescription opioid abuse is associated with increasing arrests. However, there is little systematic examination of prescriptionopioiduse in criminal justice settings. The aimof this study is to examine prescription opioid use levels among Kentucky prisoners to understand other drug use and related behavior. Methods: The ASSIST and TCU Drug Screeners were administered to 337 prisoners. After consent, subjects entered protocols as part of the NIDA CJDATS 2 cooperative agreement. Analysis examined past 3 month drug use and problem behaviors for 3 levels of prescription opioid use: daily (n=86), some (n=91) and none (n=160). ANCOVA and logistic regressions were performed controlling for group differences in age, gender, race, and rural residence. Results: Daily prescription opioid users were younger (34.2), more female (39.5%), more white (90.7%) and more rural (58.5%). Daily users significantly reported more use of prescription sedatives (71.3% vs. 56% and 15%, p=< .000) than those in the no use or some use categories. There were no differences in other drug use patterns except for those who reported some use of prescription stimulants (p=< .003) and hallucinogens (p=< .035). Daily users weremore likely to inject drugs, rate their druguse asmore serious, rate themselves asmore dependent on drugs, and report that treatment is important. However, there was no difference in previous treatment history. Conclusions: Findings suggest that daily users of prescription opioids in the criminal justice system are at greater risk for additional substanceuseand relatedproblems. Theyarealsomore likely to report the importance of treatment. Implications for treatment planning, community re-entry and treatment will be discussed. Financial support: CJDATS 2 is funded by NIDA in collaboration with SAMSHA and DOJ.

Prescription opioid abuse and related behavior among prisoners

Aims: U.S. prescription drug use is common, second only to marijuana use. Kentucky continues with high rates of non-medical prescription use, particularly prescription opioids in Appalachian Kentucky. Prescription opioid abuse is associated with increasing arrests. However, there is little systematic examination of prescriptionopioiduse in criminal justice settings. The aimof this study is to examine prescription opioid use levels among Kentucky prisoners to understand other drug use and related behavior. Methods: The ASSIST and TCU Drug Screeners were administered to 337 prisoners. After consent, subjects entered protocols as part of the NIDA CJDATS 2 cooperative agreement. Analysis examined past 3 month drug use and problem behaviors for 3 levels of prescription opioid use: daily (n=86), some (n=91) and none (n=160). ANCOVA and logistic regressions were performed controlling for group differences in age, gender, race, and rural residence. Results: Daily prescription opioid users were younger (34.2), more female (39.5%), more white (90.7%) and more rural (58.5%). Daily users significantly reported more use of prescription sedatives (71.3% vs. 56% and 15%, p=< .000) than those in the no use or some use categories. There were no differences in other drug use patterns except for those who reported some use of prescription stimulants (p=< .003) and hallucinogens (p=< .035). Daily users weremore likely to inject drugs, rate their druguse asmore serious, rate themselves asmore dependent on drugs, and report that treatment is important. However, there was no difference in previous treatment history. Conclusions: Findings suggest that daily users of prescription opioids in the criminal justice system are at greater risk for additional substanceuseand relatedproblems. Theyarealsomore likely to report the importance of treatment. Implications for treatment planning, community re-entry and treatment will be discussed. Financial support: CJDATS 2 is funded by NIDA in collaboration with SAMSHA and DOJ.

The impact of glucose load on left ventricular mass in peritoneal dialysis patients

Cardiovascular (CV) complications are the main cause of morbidity and mortality in peritoneal dialysis (PD) patients. Left ventricular hypertrophy (LVH) is a well-known major CV risk factor. To evaluate the impact of peritoneal glucose load on left ventricular mass (LVM) in PD patients. In this cross sectional study the glucose load and LVM were evaluated in 43 stable patients on maintenance PD for 24 - 78 months. Glucose load was calculated using a unique peritoneal glucose load index (PGLI) referred to g/kg/day glucose given in the daily PD prescription. LVM index (LVMI) was calculated using the Devereux et al. formula. The PGLI was positively correlated with HbA1c and LVMI (p < 0.001). Patients with PGLI > 3 g/kg/day had higher HbA1c and LVMI compared to those with PGLI ≤ 3 g/kg/day (p < 0.001). Higher PGLI values were associated with worse glycemic control and increased LVMI. Efforts should be made to minimize the PGL. All other risk factors that may contribute to the development of LVH in PD patients should be identified and treated. Additional multicenter, randomized control trials are needed to determine the target objectives of PGLI.

Elephantiasis Legs

A30-year-old man presented with significant enlargement and disfigurement of lower extremities. He had a history of Graves' disease with ophthalmopathy for 6 years. Initially, he responded poorly to antithyroid drug treatment. Two years ago, a total of 28 mCi iodine 131 was given on 2 separate occasions. After treatment, euthyroidism was maintained with daily prescription of 5 mg of methimazole and 25 mg of levothyroxine. However, he complained that the skin on both legs, which first changed 3 years before, deteriorated progressively during the past year. On physical examination, non-pitting plaques with peau d'orange appearance on both pretibial surfaces were found (Figures 1A and 1B). A 6-month trial therapy of topical gluco- corticoid showed no noticeable improvement. Elephantiasis is a rare and advanced form of Graves' dermopathy, which can create functional disability. With a history of thyrotoxicosis, the diagnosis is usually obvious, yet its management difficult. 1. Cohen J.B. Balzer B. Wapnir I. et al. Elephantiasic pretibial myxedema. Thyroid. 2004; 14: 237-238 Crossref PubMed Scopus (6) Google Scholar , 2. Fatourechi V. Pretibial myxedema: pathophysiology and treatment options. Am J Clin Dermatol. 2005; 6: 295-309 Crossref PubMed Scopus (141) Google Scholar

Outcome Study of Cobalt Based Stereotactic Body Radiation Therapy for Patients with Inoperable Stage III Non-small Cell Lung Cancer.

Aim of this paper is to retrospectively evaluate the efficacy and toxicity of specialized Body Cobalt based system (BCBS) treatment in the senior patients group (.65 years) with Stage III non-small cell lung carcinoma (NSCLC). A total of 49 patients (41 males and 8 females) with Stage III NSCLC according to UICC TNM classification (6(th) edition) were treated using OUR-QGD™ BCBS which was designed and manufactured in China. Post treatment evaluation with follow-up information was collected from April 2001 to December 2006 in our department. Median age of enrolled patients was 71 years old (65-85). Among those patients, 36 patients were pathologically identified with squamous cell carcinoma, and the other 13 patients were confirmed as adenocarcinoma. All patients were immobilized by vacuum based immobilization mold and then performed slow CT scan without any respiration gating devices. The daily radiation prescription dose was defined at 50% isodose line covering primary lesions and metastatic lymph nodes with doses from 2.5 to 6 Gy in 5 fractions per week according to the tumor stage and internally approved treatment protocols by the Institutional Review Board (IRB). Median daily dose and total delivery dose of 50% isodose line were 4 Gy and 41 Gy, respectively. In this study group, total of 3 patients received neoadjuvant cisplatin-based chemotherapy. Tumor response evaluated 12 weeks after radiation has demonstrated 13 complete responses (26.5%), 21 partial responses (42.9%). The overall survival (OS) rate of 1-year, 2-year and 3-year was 63.3%, 40.8% and 20.4%, respectively. The median and mean survival time was 22 and 24 months. All 49 patients tolerated the treatment well and have completed the planned therapy regiment. Body Cobalt based system treatment of those over 65 years old patients with Stage III NSCLC had reasonable and superior curative effect as well as local control, and at the same time without severe radiation side effects.

Ultrasound guided selective cervical nerve root block and superficial cervical plexus block for surgeries on the clavicle.

We report the anaesthetic management of two cases involving surgeries on the clavicle, performed under superficial cervical plexus block and selective C5 nerve root block under ultrasound (US) guidance, along with general anaesthesia. Regional analgesia for clavicular surgeries is challenging. Our patients also had significant comorbidities necessitating individualised approach. The first patient had a history of emphysema, obesity, and was allergic to morphine and hydromorphone. The second patient had clavicular arthritis and pain due to previous surgeries. He had a history of smoking, Stevens-Johnson syndrome, along with daily marijuana and prescription opioid use. Both patients had an effective regional block and required minimal supplementation of analgesia, both being discharged on the same day. Interscalene block with its associated risks and complications may not be suitable for every patient. This report highlights the importance of selective regional blockade and also the use of US guidance for an effective and safe block.

Evaluation the Role of Clinical Pharmacist on Prevents or Reduced the Medication Error in Emergency Department

Objective: To identify the role and importance of the clinical pharmacist in the Emergency Department on preventor reduced the medication error.Methodology: We collected the medical file of 3400 patients, 1400 patient's file in (A) hospital, and 1000 patient'sfile in each of (B and C) hospital, who admitted to the ED, at primary weekdays between 8 am to 2 pm, andrecorded all the intervention made by clinical pharmacist through an active search in clinical charts, with analysisof the daily medical prescription. The potential severity of harm of the medication error judged by two reviewers,a permanent emergency physician, and clinical pharmacist based on the National Coordinating Council (NCC) ofMedication Error Reporting and Prevention error classification system.Results: Four of intervention that have the greatest incidence which represent the majority of the cases, and theywere related to: dosage 500 (38.7%), route of administration 300 (23.2%), frequency 100 (7.7%), andincompatibility 120 (9.3%). The severity of medication errors that was judged as potentially life threatening (67;5.1%), serious (135; 10.4%), significant (634; 49.1%), and insignificant (454; 35.1%). The acceptance to thepresence and intervention of pharmacist was as follow: senior physicians 75%, permanent physicians 20%, residentphysicians 77%, and nurses 30%.Recommendation: Hospitals should contemplate assigning well-trained knowledgeable, efficient and skilled EDclinical pharmacists to prospectively review medication orders whenever clinically possible. It is also recommendedthat each hospital performs acquainted analysis of medication errors occurring in its ED, in order to determinetheir origin and then establish the necessary ED-based clinical pharmacy services. The sets of actions needed toprovide such services, as well as the skills, which their ED pharmacists must possess or acquire in order to becapable of producing desired outcomes

Planning, treatment and in vivo thermo-luminescent dosimetry in patients with breast cancer treated with a VMAT technique: Geneva experience

Objective To assess the dose delivered to the skin during a volumetric modulated arc therapy (VMAT) irradiation in patients with breast cancer. Material and method Ten patients with breast cancer were treated using RAPIDARC ® (6 with supraclavicular and/or axillary regions). Decision to perform VMAT treatments was made when the dose received to the contra-lateral breast, lungs or heart exceeds protocol limits with usual 3D conformal techniques. Ten plans were created on Eclipse ® with a daily dose prescription of 2.25 Gy to the mean target volume. Dose planning technique used 1 cm expansion of the target in air (Nicolini et al., Med. Phys. 2011) to take into account patient's breathing movements. Boluses were added in 7 plans for proper target coverage. Patients were treated supine on a 2100C/D Varian linac equipped with on-board imaging. Daily patient positioning was performed by orthogonal images alone or with cone-beam computed tomography scans (CBCT). Thermoluminescent dosimeters (TLD) were located at specific distances on the skin respect to the isocenter, and expected doses were estimated. Measurements reproducibility using bolus was tested on 28 points by repeating several times TLD in vivo dosimetry. Results A total of 116 measurements (100 with bolus, 16 without) were analyzed. Mean standard deviations representing TLD reproducibility was 4.8 cGy. For 52 points measured with bolus the mean measured/expected dose ratio was 1.018 (SD 0.037), while for 16 points without bolus 1.044 (SD 0.065). Conclusion Results indicate that the overall treatment process is adequate and that 1 cm target expansion is sufficient to take into account breast motion during treatment. This technique is well-indicated for patients with convex thoracic wall to avoid important lungs volume irradiated at high dose and also for patients with left breast tumor to reduce heart doses.

Kiwifruit: our daily prescription for health

Kiwifruit are unequalled, compared with other commonly consumed fruit, for their nutrient density, health benefits, and consumer appeal. Research into their health benefits has focussed on the cultivars Actinidia deliciosa 'Hayward' (green kiwifruit) and Actinidia chinensis 'Hort 16A', ZESPRI(®) (gold kiwifruit). Compared with other commonly consumed fruit, both green and gold kiwifruit are exceptionally high in vitamins C, E, K, folate, carotenoids, potassium, fibre, and phytochemicals acting in synergy to achieve multiple health benefits. Kiwifruit, as part of a healthy diet, may increase high-density lipoprotein cholesterol, and decrease triglycerides, platelet aggregation, and elevated blood pressure. Consuming gold kiwifruit with iron-rich meals improves poor iron status, and green kiwifruit aids digestion and laxation. As a rich source of antioxidants, they may protect the body from endogenous oxidative damage. Kiwifruit may support immune function and reduce the incidence and severity of cold or flu-like illness in at-risk groups such as older adults and children. However, kiwifruit are allergenic, and although symptoms in most susceptible individuals are mild, severe reactions have been reported. While many research gaps remain, kiwifruit with their multiple health benefits have the potential to become part of our "daily prescription for health."

Falls Are Associated with Stroke, Arthritis and Multiple Medications among Community-Dwelling Elderly Persons in Japan

Falls are a major public health problem and the second leading cause of death due to unintentional accidental injury after road traffic accidents. Inactive, older individuals with several chronic illnesses fall more frequently than older individuals who are active and healthy. No population-based study has addressed the association of stroke, arthritis, hypnotic and other prescription medications with falls among the elderly simultaneously in a single population in Japan. We examined the prevalence of falls among community-dwelling elderly Japanese individuals, whom we randomly selected from a list of inhabitants aged ≥ 65 years compiled from the resident registration, and the associations between falls and each of stroke, arthritis, and hypnotic and other prescription medications. We interviewed 295 men and 307 women, and collected information about the number of falls during the latest one year, hemiplegia due to stroke, arthritis in the legs, and the number of hypnotic and other medications. We found that 46 men (16%) and 67 women (22%) had fallen at least once during the latest one year. Logistic regression analysis adjusted for age showed that hemiplegia due to stroke (p < 0.001), arthritis in the legs (p < 0.001), and taking at least four daily prescription medications (p < 0.05) were significantly associated with falls in men. Arthritis in the legs (p = 0.05) and taking at least four daily prescription medications (p < 0.05) were associated with falls in women. Treatment of fall-related diseases and medication management are important strategies for reducing falls among elderly persons.

Satisfied patients, pharmacists patients, pharmacists at Phoenix VA

Satisfied patients, pharmacists patients, pharmacists at Phoenix VA

Neuroleptic Prescription Pattern for Delirium in Patients with Advanced Cancer

Neuroleptics are frequently used by palliative care specialists to treat delirium. In this study, we determined the median daily neuroleptic dose and prescription pattern in a cohort of unselected advanced cancer in-patients with delirium. We retrospectively reviewed the charts of 100 consecutive patients admitted to our acute palliative care unit with delirium for demographics, delirium characteristics, and neuroleptic use during the first five days of delirium. The dose of neuroleptics was expressed using the concept of haloperidol equivalent daily dose (HEDD). The median delirium duration was six days, and the median Memorial Delirium Assessment Scale on day 1 was 13/30. Subtypes of delirium included hypoactive (31 percent), mixed (59 percent), and hyperactive (10 percent). Haloperidol, olanzapine, and chlorpromazine were given to 94 (94 percent), 8 (8 percent), and 5 (5 percent) of patients, respectively. The median five-day average HEDD was 3.2 mg (interquartile range 1.5-6.0 mg). HEDD was not associated with any clinical characteristics except delirium subtype. Among the 31 occasions in which > or =3 breakthrough doses were given in a day, only 9 (29 percent) resulted in an increase in the scheduled neuroleptic dose, and 1 (3 percent) resulted in the addition of a new neuroleptic the next day. Among the 73 patients with 24 days of delirium, only 49 (67 percent) had an increase in the neuroleptic dose, and 2 (3 percent) had a new neuroleptic added. HEDD was lower than doses reported in previous studies involving cancer patients and was adjusted sparingly. Prospective clinical trials are necessary to identify the optimal neuroleptic dose for delirium.

Medication administration hassles for Mexican American family caregivers of older adults

In order to take their medications at home, elders rely increasingly on their family, but little is known about the factors influencing this task. This study explored the effects of acculturation and social exchange on the hassles that Mexican American (MA) family caregivers face in administering medication to their elders. A descriptive, correlational design, with a convenience sample of 239 MA adult caregivers of elders who were on a daily prescription that was recruited in Dallas, Texas and San Diego, California, USA, was used. The caregivers' scores on the medication administration hassles scale were significantly affected by acculturation and social exchange factors that explained 36% of the variance in the scores; the social exchange block had a larger influence than did the acculturation block. Caregiving might be an outcome of dynamic family exchange relationships between the caregiving dyad. The results can help healthcare professionals to detect potentially at-risk MA families and provide them with culturally appropriate nursing interventions.

A qualitative investigation of adherence to nutritional therapy in malnourished adult AIDS patients in Kenya

To understand factors affecting the compliance of malnourished, HIV-positive adults with a nutritional protocol using ready-to-use therapeutic food (RUTF; Plumpy'nut®). Qualitative study using key informant interviews, focus group discussions and direct observations. Ministry of Health HIV/programme supported by Médecins Sans Frontièrs (MSF) in Nyanza Province, Kenya. Adult patients (n 46) currently or previously affected by HIV-associated wasting and receiving anti-retroviral therapy, their caregivers (n 2) and MoH/MSF medical employees (n 8). Thirty-four out of forty-six patients were receiving RUTF (8360 kJ/d) at the time of the study and nineteen of them were wasted (BMI < 17 kg/m2). Six of the thirteen wasted out-patients came to the clinic without a caregiver and were unable to carry their monthly provision (12 kg) of RUTF home because of physical frailty. Despite the patients' enthusiasm about their weight gain and rapid resumption of labour activities, the taste of the product, diet monotony and clinical conditions associated with HIV made it impossible for half of them to consume the daily prescription. Sharing the RUTF with other household members and mixing with other foods were common. Staff training did not include therapeutic dietetic counselling. The level of reported compliance with the prescribed dose of RUTF was low. An improved approach to treating malnourished HIV-positive adults in limited resource contexts is needed and must consider strategies to support patients without a caregiver, development of therapeutic foods more suited to adult taste, specific dietetic training for health staff and the provision of liquid therapeutic foods for severely ill patients.