International Journal of Risk & Safety in Medicine - Volume 18, issue 3
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The International Journal of Risk and Safety in Medicine is concerned with rendering the practice of medicine as safe as it can be; that involves promoting the highest possible quality of care, but also examining how those risks which are inevitable can be contained and managed.
This is not exclusively a drugs journal. Recently it was decided to include in the subtitle of the journal three items to better indicate the scope of the journal, i.e. patient safety, pharmacovigilance and liability and the Editorial Board was adjusted accordingly. For each of these sections an Associate Editor was invited. We especially want to emphasize patient safety. Our journal wants to publish high quality interdisciplinary papers related to patient safety, not the ones for domain specialists. For quite some time we have also been devoting some pages in every issue to what we simply call WHO news. This affinity with WHO underlines both the International character of the journal and the subject matter we want to cover. Basic research, reports of clinical experience and overviews will all be considered for publication, but since major reviews of the literature are often written at the invitation of the Editorial Board it is generally advisable to consult with the Editor in advance. Submission of news items will be appreciated, as will be the contribution of letters on topics which have been dealt with in the journal.
Abstract: The most important diagnostic tools available to the internist are the patient history and physical examination, after which a plan must be made for further diagnostic evaluation and treatment. For this the internist uses clinical reasoning based on his or her knowledge of evidence-based medicine and pathobiology. Pathobiology is primarily concerned with the question of how something works; evidence-based medicine is concerned with whether something works, and if so, how often or how much on average. Diseases do not exist in their own right and diagnostic criteria are based on consensus. A diagnosis of a ‘disease’ is based on observations…of patients as well as our opinions, be they right or wrong, regarding its causes. It is important to distinguish between ‘partial causes’ and a ‘causative complement’. Because of these concepts, the biological relevance of a partial cause in the development of a disease cannot be derived from the strength of the link between it and the disease. Our opinions regarding the cause of disease appear to be based on induction. However, induction is not a good foundation from which to determine causation. Hypotheses on the causes of disease cannot be proved. They can, however, be refuted. Education, training, research and patient care all depend on effective communication. Communication is enhanced if the thesis is provided first followed by the arguments to support it. Hence, transfer of patient information such as during a morning report should begin with a working diagnosis (the ‘thesis’) and thereafter the findings of patient history and other relevant data (the ‘arguments’). At the present time, too little attention is devoted in education and continuing education in internal medicine to these aspects of clinical reasoning and communication.
Abstract: It has to be realized that rational drug use has become one of the most difficult, complicated and challenging medical responsibilities, for governments but certainly for practicing doctors and it therefore deserves considerable time and intellectual interest of all prescribers. Drug education, i.e. clinical pharmacology, has to be the cornerstone here. Probably because of the fact that the WHO approach has to be a public health approach, much of the material on drug subjects produced by WHO and intended for emerging countries makes the false impression of simplicity. However, it seems that the WHO strategies are not very effective. As…an example, the 5th edition of the essential drug list of China shows a dramatic increase in the number of drugs in comparison with the WHO model list. It is certain that with public health advice alone you cannot amend the disturbing fact that at the moment drugs are among the 6 main causes of death. Approaching rational drug use from a public health perspective and then presenting it as an objective that can be achieved by rather simple means is very attractive for authorities who then can focus on the costs of drugs alone. It is also attractive for Medical Schools in order to reduce pharmacotherapy teaching in the medical curriculum. Therefore, in an era where we are experiencing an epidemic of drug induced morbidity and mortality and as long as pharmacotherapy teaching is so abominable in all medical curricula, WHO should have an active policy to stimulate the discipline of clinical pharmacology to help doctors in making responsible decisions for their patients.
Abstract: A retrospective analysis of the 110 prescriptions was carried out to investigate the prescribing pattern of drugs among the hospitalized elderly patients at a public tertiary care teaching hospital. The patients received an average (±SEM) of 8±0.21 medications per encounter. Nearly three quarters (73%) of the patients received more than five, about a quarter (23%) of the patients received more than nine medications and only 4% of patients received less than five medications concurrently on a particular day. During the hospital stay, 88.2% of patients received antibiotics and 86.4% of patients were prescribed injections. Of all the admitted patients, 41%…received 1–2 antibiotics and 47% of patients received more than two antibiotics. The percentage of drugs prescribed by generic name was only 18%, while 68.8% of these drugs were listed on the National Essential Medicine List. The three most commonly prescribed drug categories were antibiotics followed by the drugs acting on the cardiovascular system and oral hypoglycemic agents. The five most frequent disorders among elderly were Circulatory system disorders, Endocrine disorders, Digestive system disorder and Genitourinary system disorders. The results indicate that the prescribing of drugs to the elderly requires rationalization, particularly prescribing of antibiotics, injections and the prescribing by generic names. These are achievable and can be achieved through orienting the prescribers to the principles of pharmacotherapy in geriatric patients.
Keywords: Elderly, prescribing pattern, drug utilization review, polypharmacy
Abstract: Xantinol nicotinate, a nicotinic acid derivative is used in the management of peripheral and cerebral vascular disorders and in hyperlipidaemias for over 40 years. Nicotinic acid derivatives have been associated with dermatological adverse effects. Flushing is claimed to be less frequent than with nicotinic acid, but has nevertheless been repeatedly observed. We present here a case of bullous eruptions due to xanthinol nicotinate, a probable reaction according to the Naranjo Adverse Drug Reaction Probability Scale.
Abstract: The high mortality, morbidity and cost associated with adverse drug reactions (ADRs) represent an important public health concern. Cutaneous ADRs, the most common ADRs constitute of 15 to 30% of the total ADRs. The economic impact of cutaneous ADRs is not known. The present study analyzed the cutaneous ADRs reported to the Regional Pharmacovigilance Center, Manipal Teaching Hospital, Western Nepal and established their causality, severity, preventability and calculated the cost of drug therapy in managing them. The filled ADR reporting forms received by the center from September 2004 till August 2005 were analyzed. Additional patient details were obtained from the…medical records department. Altogether, fifty seven ADRs were reported (men 22 and women 35). Mean ± SD age distribution was 30.21±17.89 years. Department of Dermatology reported 22 (38.59%) ADRs followed by Medicine department 14 (24.56%). Antibiotics were responsible for 18 (31.57%) cases of ADRs. Maculopapular rashes were reported in 18 (31.57%) of the cases followed by contact dermatitis in 9 cases (15.78%). The causality assessment (Naranjo algorithm) revealed that 47 (82.45%) ADRs could be probably attributed to the suspected drugs, 50 (87.71%) ADRs were Moderate (Level 3) [Modified Hartwig and Siegel scale] 2 (3.5%) of the ADRs could be definitely preventable (Schumock and Thornton scale). Fifty four (94.73%) patients were prescribed 181 drugs (average 3.17) for managing the ADRs. Antihistamines were most commonly used [56 (30.93%)] followed by corticosteroids [53 (29.28%)]. The average treatment duration was 13±7 days with an average cost burden of US$ 1.58±1.41 for drug therapy. Early detection and prevention may be beneficial in minimizing the economic implications of the cutaneous ADRs.
Keywords: Adverse drug reaction reporting systems, causality assessment, economic impact
Abstract: Multiple pregnancy rates in the Maltese Islands have increased significantly in the last forty years from 1.04% during the period 1960–1969 to 1.30% during 1990–1999. This increase has in part been influenced by changes which have occurred in maternal age distribution which alone would have increased the twin pregnancy rate to only 1.07%. The difference must be attributable to other factors, the most likely being the increasing use of pharmacological and technological reproductive aids. The occurrence of a multiple pregnancy remains fraught with adverse outcomes and in spite of the advances in obstetric antenatal surveillance and easier recourse to early…delivery, the stillbirth rates in multiple maternities has remained markedly elevated contrasting with the fall in the singleton stillbirth rate. The early neonatal mortality also remains markedly greater than that registered for singleton births, but has shown a proportional decrease.
Keywords: Demography, Malta, multiple pregnancy, twins, higher order births