Extra Medication Research Articles

New technologies applied to the medication-dispensing process, error analysis and contributing factors

ObjectiveCalculate error prevalence occurred in different medication-dispensing systems, the stages of occurrence, and contributing factors. MethodologyProspective observational study. The staging of the dispensing process were reviewed in five dispensing systems: Stock, Unitary-Dose dispensing systems (UDDS) without Computerised Prescription Order Entry (CPOE), CPOE-UDDS, Automated Dispensing Systems (ADS) without CPOE and CPOE-ADS. Dispensing errors were identified, together with the stages of occurrence of such errors and their contributing factors. ResultsTwo thousand one hundred eighty one errors were detected among 54,169 opportunities of error. Error-rate: Stock, 10.7%; no-CPOE-UDDS, 3.7%, CPOE-UDDS, 2.2%, no-CPOE-ADS, 20.7%; CPOE-ADS, 2.9%. Most frequent stage when error occurs: Stock, preparation of order; no-CPOEUDDS and CPOE-UDDS, filling of the unit dose cart; no-CPOE-ADS and CPOE-ADS, filling of the ADS. Most frequent error: Stock, no-CPOE-ADS and CPOE-ADS, omission; CPOE-UDDS, different amount of drug and no-CPOE-UDDS, extra medication. Contributing factor: Stock, CPOE-ADS and no-CPOE-ADS, stock out/supply problems; CPOE-UDDS, inexperienced personnel and deficient communication system between professionals; no-CPOE-UDDS, deficient communication system between professionals. ConclusionsApplying new technologies to the dispensing process has increased its safety, particularly, implementation of CPOE has enabled to reduce dispensing errors.

Systematic medication review and health-related outcome in elderly patients acutely admitted to an orthopaedic ward: a randomised controlled study

Background Acute admission to hospitals, age and number of drugs are associated with an increased risk of adverse drug events due to morbidity, poly-pharmacy and inappropriate interactions. Thus, the objective of the present study was to investigate if systematic medication review and drug counseling on admission to hospitals would have a significant impact at clinically health-related outcomes in elderly patients admitted acutely to an orthopaedic ward. Methods A randomised controlled study comprising 108 patients aged 65 years or older admitted acutely to an orthopaedic ward in Denmark was conducted. Intervention: a clinical pharmacist collected information regarding the patient’s medication and medical history in the medical record, the electronic drug order system, the registry of drug purchase and interview with the patient’s. Subsequently, this was discussed with a clinical pharmacologist and an advisory note with drug recommendations were handed directly to the ward physicians. Control: the usual medication routine in the ward. The primary outcome measure was time to first unscheduled contact to a physician post-discharge limited to emergency department visit, readmission and general practitioner. Secondary outcomes were admission time, time to first re-admission, number of re-admissions, emergency department visits, ambulatory care visits, contact to general practitioner, physicians outside working hours, medical specialist and finally, quality of life at three-month follow up. Results In the intervention group time to first unscheduled contact to a physician post-discharge was 16.3 days(95%CI: 10.522.2) and in the control group 25.6 days (95%CI:17.8-33.4), which was not a statistically significant difference. No overall differences between study groups were seen in the secondary outcome measures. The physicians complied with 41 of 222 drug recommendations. Subgroup analysis indicated that physicians were more prone to accept recommendations in the very old treated with numerous of drugs. Conclusion The findings do not lead to the recommendation of an extra medication review in a general population of elderly admitted acutely to an orthopaedic ward. Considering the physicians marked hesitation to comply with drug recommendations future studies should explore the impact of a differentiated medication review in acute admitted patients based on the individual patient’s risk of adverse drug events.

Cost‐utility analysis of treatment strategies in patients with recent‐onset rheumatoid arthritis

To evaluate societal costs and quality-adjusted life years (QALYs) of treatment strategies for patients with recent-onset active rheumatoid arthritis (RA). Patients (n = 508) were randomly allocated to 1 of 4 treatment strategy groups: sequential monotherapy, step-up combination therapy, initial combination therapy with prednisone, or initial combination therapy with infliximab. For 2 years, patients reported cost and utility measures. Average QALYs (ideally 2.00) for groups 1-4 were 1.29, 1.31, 1.32, and 1.41, respectively, for the British EuroQol (P <or= 0.05 for group 4 versus groups 1-3); 1.41, 1.43, 1.44, and 1.52, respectively, for the Dutch EuroQol (P <or= 0.05 for group 4 versus groups 1-3); and 1.38, 1.38, 1.39, and 1.44, respectively, for the Short Form 6D (P <or= 0.05 for group 4 versus groups 1-3). The Time Trade-Off showed no significant differences. In the primary analysis, using the friction cost method to value productivity, the cost-utility ratio for group 4 against the next best alternative was estimated at euro 130,000 (95% confidence interval euro 27,000, euro 3,000,000) per QALY. Using the human capital method, the value of sustained productivity in group 4 largely compensated for the extra medication costs. Initial combination therapy with infliximab for patients with recent-onset active RA resulted in significantly better quality of life than other strategies. Using the friction cost method, costs to achieve this improvement are generally considered too high, and initial combination therapy with prednisone should be preferred. However, depending on the extent to which productivity is valued, infliximab costs could be largely compensated for by savings on productivity. Since patterns of infliximab use had not yet stabilized after 2 years, longer followup may change the economic conclusions.

Randomised controlled trials of palliative care – a survey of the views of advanced cancer patients and their relatives

Purpose To determine if patients with advanced cancer are interested in participation in palliative care research, particularly RCTs, and the importance of demographic factors in decision making. It sought relatives’ views towards supporting trial entry, and assessed if demographic factors can predict participation. Methods A questionnaire was developed through multiprofessional focus groups, patient and relative interviews and pilot studies. Consecutive patients known by the palliative care service to have advanced disease were approached. Relatives of consenting patients completed a parallel survey. K-means cluster analysis was used to differentiate between those willing and unwilling to participate. Multivariate logistic regression identified demographic factors predicting willingness. Results One hundred and one patients and 100 relatives were included. 92% of patients would participate in studies involving simple interventions, whereas only 26% would consider studies of complex interventions. A similar pattern was observed for relative support. Over 75% of participants expressed altruistic views. Concepts of ‘randomisation’, ‘placebo-control’ and ‘blinding’ deterred about one-half. Many were prepared to complete short questionnaires, accept extra medications, investigations, hospital visits or admissions within a trial context but the possibility of side-effects was a major deterrent. Patient age was the only significant predictor of willingness to participate, with older patients less likely to participate. Conclusion Despite the likely absence of individual benefit, many patients appear willing to participate in palliative care research. Trial design and the possibility of side-effects proved very influential in their decision making. Clinical trials in palliative care are more likely to be successful if developed in accordance with the views of patients and their relatives.

Electroconvulsive Therapy in Patients Taking Steroid Medication

Patients who take chronic steroid medication are often prescribed extra "stress doses" before procedures involving general anesthesia. The rationale for this practice is that the chronic steroid use has suppressed the ability of the endogenous hypothalamic-pituitary-adrenal steroid stress-reactivity system to handle the systemic stress of surgery. Whether the stress of treatments is sufficient enough to warrant this practice in electroconvulsive therapy (ECT) has not been broached in the literature. In this case series, we describe our experience treating 27 ECT patients taking prednisone. We conclude that use of "stress doses" of extra steroid medication is unnecessary in ECT practice and recommend that patients receive their usual morning dose of steroid before ECT treatments.

Patients’ transport in the hospital: An underestimated cause of pain and discomfort for cancer patients

20515 Background: During their stay in the hospital, cancer patients are submitted to a lot of transports from their room to different destinations: consultations, radiotherapy sessions, or various radiological examinations. In a previous small survey many patients complained with transport conditions. In order to better evaluate this problem we decided to conduct a prospective study. Methods: Patients were asked to fill a self questionnaire before and after the transport process, reporting pain level (visual analogical scale from 0 to 10) before and during the transport, pain treatments, way of transport (own bed, stretcher trolley, wheel chair), and conditions of this transport. Results: 223 patients were included, with a median age of 59 years, 53% were female, 64% were going to radiology. 65% of patients reported some pain before transport, 71% of them receiving chronic pain treatment. Only 1/3 of painful patients get some pain treatment to specifically prevent pain related to transport. We found no relation between the mode of transport and the level of pain before transport. More than 50% of patients complained from significant pain during the transport, in most of the cases these patients were painful before transport. The same proportion of patients reported pain due to transport itself and to manipulations (ie to bring the patient from the stretcher trolley to the radiotherapy table for example). This study is the first to address the problem of patients’ transport in a cancer center. It demonstrates that this is painful for many of them. Ways to improve this situation include the following: give patients extra pain medications before transport, according to basal pain level and expected pain during transport; adapt transport modalities to each patient: painful patients should be transported in their own beds; improve quality and comfort of stretcher trolleys and wheel chairs; give stretcher bearers a specific teaching about pain evaluation. We are implementing specific measures to improve each one of these points. Conclusions: Patients transport is a significant cause of pain for many of them. Identification and prevention of this problem is a way to improve quality of care of cancer patients during their hospital stay. No significant financial relationships to disclose.

Long-term Inhaled Corticosteroids in Preschool Children at High Risk for Asthma

Guilbert TW, Morgan WJ, Zeiger RS, et al. N Engl J Med. 2006;354:1985–1997 PURPOSE OF THE STUDY. To determine the role of inhaled corticosteroid (ICS) in preventing the development of asthma in a group of high-risk children before the development of symptomatic disease or abnormal lung function. STUDY POPULATION. Subjects were 285 children aged 2 to 3 years at high risk for developing asthma. METHODS. Subjects were assigned to fluticasone propionate (FP) 88 μg twice per day with a pressurized metered-dose inhaler with spacer or placebo for a 2-year treatment period. The patients were observed without treatment for 1 year. RESULTS. During the 2-year treatment period, there was significant improvement in symptom-free days for those in the FP group (86.8%–85.9%). Children in the FP group had more episode-free days, decreased exacerbations, and decreased need for extra controller medication. Those in the ICS group had a 1.1-cm decrement in growth after the first 2 years of the study, but this difference decreased to 0.7 cm after the 1-year observation period. CONCLUSIONS. Although ICS had a significant effect on the burden of asthma during the treatment period, there was no evidence that a long-term effect was carried over to the 1-year observation period. REVIEWER COMMENTS. The burden of childhood asthma is benefited with administration of ICS, but there is no evidence that long-term disease modification occurs.

Nursing home scenario was unrealistic

In the article ‘Terminal sedation: promoting ethical nursing practice’ the scenario in which a nurse manager of a nursing home refuses a patient extra medication is unrealistic (art&science May 2).

Impact of Splitting Risperidone Tablets on Medication Adherence and on Clinical Outcomes for Patients With Schizophrenia

Impact of Splitting Risperidone Tablets on Medication Adherence and on Clinical Outcomes for Patients With Schizophrenia

Ladybug hypersensitivity among residents of homes infested with ladybugs in Kentucky

There have been isolated case reports of hypersensitivity to the ladybug species Harmonia axyridis. Entomologists now report a rapid increase in ladybug numbers, giving rise to increasing complaints of residential infestations. To determine whether ladybug infestation of homes causes hypersensitivity among residents and to estimate the prevalence of self-reported ladybug allergy in this population. This pilot observational study was conducted using an anonymous survey. The participation rate was 59% (99/167). The incidence of self-reported allergy symptoms in this population was 77% (95% confidence interval [CI], 67%-85%). The prevalence of self-reported ladybug allergy was 50% (95% CI, 39%-60%). Of all the respondents, 19% (95% CI, 12%-28%) reported allergy symptoms on direct contact with ladybugs and 31% (95% CI, 22%-41%) reported the use of extra allergy medications during times of infestation. The correlation between worsening of allergy symptoms and time of infestation was significant for spring, fall, and winter infestations (P = .02, P = .001, and P < .001, respectively). To our knowledge, this is the first study to estimate the prevalence of ladybug hypersensitivity, which was found to be 50% by self-report among people with home infestations. These results suggest that the ladybug could be a significant cause of respiratory allergy in heavily infested homes. Further studies using diagnostic testing to confirm allergy are now indicated. We recommend that patients with spring, fall, and winter allergies be asked about ladybug infestation and that ladybug reagents be made available for diagnostic testing.

Intensified, intermittent, low-dose intravenous cyclophosphamide together with oral alternate-day steroid therapy in lupus nephritis (long-term outcome)

The objective of this study is to evaluate the efficacy, toxicity, and long-term outcome of low-dose IV cyclophosphamid therapy with repeated frequent intervals in combination with oral and IV methylprednisolone in patients with SLE nephritis. In this study, 113 patients diagnosed as having SLE and glomerulonephritis were assessed in between 1993 and 2002, with a median follow-up of 44.1+/-41.2 months. The patients were treated with 500 mg IV cyclophosphamide and 1 g IV methylprednisolone together with 60 mg/alternate-day oral methylprednisolone in a given schedule. The clinical and laboratory data were evaluated. There were significant improvements in the clinical and the laboratory parameters. Six patients died shortly after being hospitalized due to the disease activity itself. Eight patients were excluded from the study because of low compliance. The renal functions of the patients remained stable throughout the therapy; only 16/99 patients needed one or two additional pulses. Temporary leukopenia developed in 18/99 patients and diminished with the suspension or prolongation of the IV cyclophosphamide administration. Gastrointestinal side effects, which needed extra medication, developed in 20 patients. Hematuria was observed in 6/99 patients. Menstrual abnormalities were seen in 7/99 patients. No serious infections due to immunosuppression were observed with the given regimen. Hypertension was observed in 13 patients (minimum of 140/90 mmHg, maximum of 190/110 mmHg) and controlled with angiotensine-converting enzyme inhibitors. Mild central obesity was observed in 15 of the patients. Leimyosarcoma was observed in one patient who died during the follow-up period. Therapy starting with the weekly low-dose IV cyclophosphamide to induce remission together with IV and oral steroids, followed by prolonged intervals with the same doses for 2 years, appears to be useful in preserving renal function without major side effects in patients with lupus nephritis, in comparison to other studies.

Ladybug Hypersensitivity Among Residents of Homes Infested with Ladybugs in Kentucky

RATIONALE: There have been isolated case reports of insect hypersensitivity involving the ladybug species, Harmonia axyridis. The purpose of this study is to determine if ladybug infestation of homes is a cause of hypersensitivity among residents and to estimate the prevalence of self reported ladybug allergy among this population. METHODS: This pilot observational study was conducted using an anonymous survey questionnaire. RESULTS: The participation rate was 59% (99/167). The incidence of self reported allergy symptoms in this population was 77% (95% CI, 67%-85%). The prevalence of self reported ladybug allergy was 50% (95% CI, 39%-60%). Of the respondents, 19% (95% CI, 12%-28%) reported allergy symptoms on direct contact with ladybugs and 31% (95% CI, 22%-41%) reported use of extra allergy medications during times of infestations. The correlation between worsening of allergy symptoms and time of infestation was statistically significant for spring, fall and winter infestations (p value= 0.021, 0.001, <0.0001 respectively). CONCLUSIONS: To our knowledge, this is the first study to estimate the prevalence of ladybug hypersensitivity which was found to be 50% by self report in this population. Further studies using diagnostic testing to confirm allergy are now indicated. We recommend that patients with spring, fall and winter allergies be asked about ladybug infestation and reagents be made available for in vitro and in vivo testing. Harmonia axyridis infestation poses a potential health hazard as it continues to spread throughout the United States.

Adjuvant local anaesthetics in the epipharyngeal space in day-case adenoidectomy: A prospective, randomized, double-blind, placebo-controlled trial

Conclusion. Mepivacaine applied in the epipharyngeal space as an adjuvant local anaesthetic does not reduce postoperative pain after adenoidectomy in children given high-dose paracetamol preoperatively. Objective. To evaluate the pain-reducing effect of an adjuvant local anaesthetic (mepivacaine) applied in the epipharyngeal space after outpatient adenoidectomy. Material and methods. This was a prospective, randomized, double-blind, placebo-controlled trial. Postoperative pain was assessed in 98 children aged 3–10 years using a visual analogue scale (VAS) and the Wong–Baker FACES pain rating scale. The time between the end of surgery and discharge from hospital was recorded, as well as the need for extra pain medication in addition to the high-dose paracetamol (acetaminophen) that had been given preoperatively. Serum levels of mepivacaine were analysed in 10 consecutive patients. Results. No difference was seen between the mepivacaine and control groups regarding postoperative pain as estimated using either the VAS or the Wong–Baker FACES pain rating scale. There were also no differences between the groups concerning the time to discharge from hospital and the need for extra pain medication before discharge. No mepivacaine could be detected in the patients’ sera.

A Policy for Nurse-Administered Analgesic Dosing Through a Patient-Controlled Analgesic Device

Patient-controlled analgesia (PCA) has improved pain management in the hospital setting by decreasing the time it takes for patients to obtain intravenous analgesics and to allow for titration based on activity and level of pain. However, when patients are inappropriate for PCA because of cognitive impairment or physical inabilities, they are unable to obtain analgesics in such a timely manner and must wait longer periods of time for analgesics. In our institution, all of our continuous narcotic infusions are administered using a PCA machine for security purposes. But when the patients needed extra medication, the nurses would have to obtain these medications elsewhere. We developed a policy so that the PCA machine could be used to deliver the extra medication by the nurses when needed. This allows the nurse to perform a pain assessment, determine a need for analgesia, administer the prescribed dose, and document this information without leaving the bedside. When the nurse returns to evaluate the effectiveness of this dose, an additional dose of medication may be administered if indicated. We have found this to be invaluable for unplanned dressing changes, line placements, transfers, and other causes of active pain. It has also been useful for giving small doses of fentanyl to cognitively challenged elderly patients who would otherwise be ineligible for this medication. The outcome is diminished time needed to administer analgesia to the physically and cognitively impaired patients as well as decreasing nursing workload. PCA has replaced intermittent injections of narcotics for most patients. However, for those who are cognitively impaired or physically unable to press a PCA button, they must wait longer for their pain relief. In our institution, we developed a policy that allows nurses to administer narcotics using a PCA machine (Nurse Administered Analgesic Dosing), which decreases the time for medication delivery and improves patient comfort. The purpose of this clinical project is to educate nurses about how to safely use PCA devices to improve the delivery of PRN analgesics.

Slowing the progression of chronic renal failure: Economic benefits and patients' perspectives

Because of the predicted increase in end-stage renal disease (ESRD) incidence (projected increase from 1998 to 2010; 86,825 to 172,667), prevalence (projected increase from 1998 to 2010; 326,217 to 661,330), and cost (total cost based on 1998 ratio of Medicare versus non-Medicare cost; $16.74 billion in 1998 to $39.35 billion in 2010), a cohesive national effort is needed to develop strategies to slow the progression of chronic renal failure (CRF). The question arises to how much reduction in the progression of CRF would lead to a meaningful decrease in the prevalence and cost of ESRD. There are no objective data that show the economic impact of slowing the progression of CRF. We developed a mathematical model to assess the economic impact of decreasing the progression of CRF by 10%, 20%, and 30%. US Renal Data System (USRDS) projections were used to model the rate of increase in ESRD incidence and prevalence. Glomerular filtration rate (GFR) at the initiation of ESRD therapy and cost per patient-year were based on USRDS data. The average decline in GFR in subjects with CRF was estimated to be 7.56 mL/min/y. All dollar savings reflect 1998 costs, discounted for the future at 3% per annum. We also determined how much slowing of the progression of CRF is important from patients' perspectives by means of a written questionnaire (which inquired about willingness to go on a restricted diet, take six extra medications per day, and make six extra office visits per year) and calculation of the pre-ESRD time gained for different degrees of reduction in the progression of CRF. If the rate of decline in GFR decreased by 10%, 20%, and 30% after December 31, 1999, in all patients with GFRs of 60 mL/min or less, cumulative direct healthcare savings through 2010 would equal approximately $18.56, $39.02, and $60.61 billion, respectively. For a 10%, 20%, and 30% decrease in the rate of decline in GFR in all patients with a GFR of 30 mL/min or less, estimated cumulative savings through 2010 equal $9.06, $19.98, and $33.37 billion, respectively. Responses to the questionnaire showed that approximately 79% of subjects with CRF (n = 113) perceived a few weeks' dialysis-free period significant (P ≤ 0.0001), a period corresponding to a 10% reduction in the rate of decline in GFR. Our data suggest that the cumulative economic impact of slowing the progression of CRF, even by as little as 10%, would be staggering. They provide strong support for the development and implementation of intensive reno-protective efforts beginning at the early stages of chronic renal disease and continued throughout its course. © 2002 by the National Kidney Foundation, Inc.

Making the business case for infection control: Pitfalls and opportunities

Any discussion of the business case for infection control (IC) must start by acknowledging that the single most important reason for IC is to prevent morbidity and mortality associated with nosocomial infections. Each year, hundreds of thousands of Americans suffer the consequences of nosocomial infections, ranging from the inconvenience of taking extra medications to death. Beyond the human cost is the important economic burden that these infections place on society, including not only the obvious increase in health care resource use but also indirect costs associated with the loss of productivity of patients and their caregivers.

The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care.

To determine the additional direct costs of hospitalization attributable to catheter-associated urinary tract infection (CAUTI) in 1,497 newly catheterized patients. Prospective observational and laboratory study. University hospital. Data were collected on risk factors for CAUTI (defined as > 10(3) colony-forming units [CFU]/mL), severity of illness, and diagnostic and therapeutic interventions in consenting newly catheterized patients. Daily urine cultures were obtained from each newly catheterized patient, but the results of these cultures were not revealed to his or her physician. During the study, one of the investigators (DGM) reviewed each patient's record and made a judgment as to which of the diagnostic tests and treatments ordered and what incremental length of stay could reasonably be ascribed to his or her CAUTI. The total hospital costs for each patient were also obtained. Overall, 235 patients acquired CAUTIs during the study; most of the CAUTIs were completely asymptomatic, and only 52% were diagnosed by the patients' physicians using the hospital laboratory. Only 1 patient with a CAUTI had a secondary bloodstream infection. Thirty-three (13%) of the CAUTIs were caused by Escherichia coli; 63 (25%) by Klebsiella, Enterobacter, Citrobacter, Pseudomonas aeruginosa, or other antibiotic-resistant, gram-negative bacilli; 87 (35%) by enterococci or staphylococci; and 67 (27%) by Candida species. The 123 CAUTIs diagnosed by the hospital laboratory were judged to have been responsible for an additional $20,662 in extra costs of diagnostic tests and $35,872 in extra medication costs, a mean of $589 (median, $356) per CAUTI. CAUTIs caused by E. coli cost considerably less than infections caused by other gram-negative bacilli ($363.3 +/- $228.2 vs $690.4 +/- $783.7; P = .02) or yeasts ($821.2 +/- $2,169.9). There were less striking differences in the costs per CAUTI caused by staphylococci or enterococci ($387.1 +/- $434.8). The extra direct costs associated with nosocomial CAUTI found in this prospective study, which was done in the era of managed care during the late 1990s, are substantially lower than those reported in the largest comparable studies done more than 15 years ago, most of which were retrospective, reflecting the powerful impact of cost-containment measures that are now implemented in managed care.

PEE8: FOUR YEAR COST-EFFECTIVENESS OF INITIAL TRABECULECTOMY VERSUS CONVENTIONAL THERAPY IN PRIMARY OPEN-ANGLE GLAUCOMA (POAG)

OBJECTIVES: To determine the cost-effectiveness of the primary treatment of primary open-angle glaucoma (POAG) with trabeculectomy versus conventional therapy. METHODS: A four-year incremental cost/quality-adjusted life year (QALY) model (year 2000 US dollars) of POAG using a societal perspective; including direct and indirect costs with a 3% annual discount rate for the base case. In the Glasgow trial, patients newly diagnosed with POAG with an intraocular pressure of 26mmHg and/or with glaucomatous field defects were randomized to trabeculectomy or conventional therapy (up to three medications). In the trabeculectomy branch, patients would either be 1) controlled without extra medication, 2) controlled with extra medication or 3) die from natural causes. Annual chance nodes for the conventional were 1) controlled by medication, 2) surgery or 3) death from natural causes. QALYs were calculated assuming a decline in utility would accompany loss in visual field. A 65-year old patient with a 5% rate of decline in utility was used as the base case. Sensitivity analyses were performed on the rate of utility decline, cost of medications, trabeculectomy cost, and discount rate. RESULTS: For the base case, the cost of initial trabeculectomy was $8316 versus $6339 for conventional therapy. The incremental cost was $1977 and the incremental QALY was 0.08, with ICE ratio of $24,830/QALY. CONCLUSIONS: Initial trabeculectomy is cost-effective for POAG. The model was most sensitive to the rate of decline in utility (<2%) and robust to changes in the costs of medications and trabeculectomy. Limitations include the lack of long-term clinical and QALY data on glaucoma patients with different treatments. Currently the standard of practice in the US is to start with conventional therapy for patients with moderate or severe glaucoma. Our results indicate that trabeculectomy may be a cost-effective option for these patients.

Postoperative atrial fibrillation: An old problem crying for new solutions

J Thorac Cardiovasc Surg 2001;121:638-41

Air pollution and exacerbation of asthma in African-American children in Los Angeles.

Significant increases in asthma morbidity and mortality in the United States have occurred since the 1970s, particularly among African-Americans. Exposure to various environmental factors, including air pollutants and allergens, has been suggested as a partial explanation of these trends. To examine relations between several air pollutants and asthma exacerbation in African-Americans, we recruited a panel of 138 children in central Los Angeles. We recorded daily data on respiratory symptoms and medication use for 13 weeks and examined these data in conjunction with data on ozone (O3) nitrogen dioxide (NO2), particulate matter (PM10 and PM2.5), meteorological variables, pollens, and molds. Using generalized estimating equations, we found associations between respiratory symptom occurrence and several environmental factors. For example, new episodes of cough were associated with exposure to PM10 (OR = 1.25; 95% CI = 1.12-1.39; interquartile range [IQR] = 17 microg/m3, 24-hour average), PM2.5 (OR = 1.10; 95% CI = 1.03-1.18; IQR = 30 microg/m3, 12-hour average), NO2, and the molds Cladosporium and Alternaria, but not with exposure to O3 or pollen. The factors PM10 and O3 were associated with the use of extra asthma medication. For this population several bioaerosols and air pollutants had effects that may be clinically significant.