Poor awareness of preventing aspirin-induced gastrointestinal injury with combined protective medications

AIM:To investigate prescribing pattern in low-dose aspirin users and physician awareness of preventing aspirin-induced gastrointestinal(GI) injury with combined protective medications.METHODS:A retrospective drug utilization study was conducted in the 2nd Affiliated Hospital,School of Medicine,Zhejiang University.The hospital has 2300 beds and 2.5 million outpatient visits annually.Data mining was performed on all aspirin prescriptions for outpatients and emergency patients admitted in 2011.Concomitant use of proton-pump inhibitors(PPIs),histamine 2-receptor antagonists(H2RA) and mucoprotective drugs(MPs) were analyzed.A defined daily dose(DDD) methodology was applied to each MP.A further investigation was performed in aspirin users on combination use of GI injurious medicines [non-steoid anti-inflammatory drugs(NSAIDs),corticosteroids and clopidogrel and warfarin] or intestinal protective drugs(misoprostol,rebamipide,teprenone and gefarnate).Data of major bleeding episodes were derived from medical records and adverse drug reaction monitoring records.The annual incidence of major GI bleeding due to low-dose aspirin was estimated for outpatients.RESULTS:Prescriptions for aspirin users receiving PPIs,H2RA and MPs(n = 1039) accounted for only 3.46% of total aspirin prescriptions(n = 30 015).The ratios of coadministration of aspirin/PPI,aspirin/H2RA,aspirin/MP and aspirin/PPI/MP to the total aspirin prescriptions were 2.82%,0.12%,0.40% and 0.12%,respectively.No statistically significant difference was observed in age between patients not receiving any GI protective medications and patients receiving PPIs,H2RA or MPs.The combined medication of aspirin and PPI was used more frequently than that of aspirin and MPs(2.82% vs 0.40%,P < 0.05) and aspirin/H2RA(2.82% vs 0.12%,P < 0.05).The values of DDDs of MPs in descending order were as follows:gefarnate,hydrotalcite > teprenone > sucralfate oral suspension > L-glutamine and sodium gualenate granules > rebamipide > sucralfate chewable tablets.The ratio of MP plus aspirin prescriptions to the total MP prescriptions was as follows:rebamipide(0.47%),teprenone(0.91%),L-glutamine and sodium gualenate granules(0.92%),gefarnate(0.31%),hydrotalcite(1.00%) and sucralfate oral suspension(0.13%).Percentages of prescriptions containing aspirin and intestinal protective drugs among the total aspirin prescriptions were:rebamipide(0.010%),PPI/rebamipide(0.027%),teprenone(0.11%),PPI/teprenone(0.037%),gefarnate(0.017%),and PPI/gefarnate(0.013%).No prescriptions were found containing coadministration of aspirin and other NSAIDs.Among the 3196 prescriptions containing aspirin/clopidogrel,3088(96.6%) prescriptions did not contain any GI protective medicines.Of the 389 prescriptions containing aspirin/corticosteroids,236(60.7%) contained no GI protective medicines.None of the prescriptions using aspirin/warfarin(n = 22) contained GI protective medicines.Thirty-five patients were admitted to this hospital in 2011 because of acute hemorrhage of upper digestive tract induced by low-dose aspirin.The annual incidence rates of major GI bleeding were estimated at 0.25% for outpatients taking aspirin and 0.5% for outpatients taking aspirin/warfarin,respectively.CONCLUSION:The prescribing pattern of low-dose aspirin revealed a poor awareness of preventing GI injury with combined protective medications.Actions should be taken to address this issue.

Drug utilization of clarithromycin for gastrointestinal disease treatment

AIM: To evaluate the patterns of use of clarithromycin for gastrointestinal disease treatment and promote its rational use. METHODS: Using a structured pro forma,we conducted a two-month survey of the electronic prescriptions containing immediate-release (IR) or sustained-release (SR) product of clarithromycin for outpatients with gastrointestinal diseases in a 2200-bed general hospital. Suitability of the prescription was audited retrospectively. RESULTS: One hundred and sixty-four prescriptions of SR product and 110 prescriptions of IR product were prescribed for gastrointestinal disease treatment. Among prescriptions for anti-Helicobacter pylori (H pylori) therapy,triple therapy take the dominant position (91.8%),followed by quadruple therapy (4.3%) and dual therapy (3.9%). Amoxicillin was the most frequently co-prescribed antibiotic.Furazolidone and levofloxacin are used more widely than metronidazole or tinidazole. Clarithromycin SR was administered at inappropriate time points in all prescriptions. Fifty percent of all prescriptions of clarithromycin SR,and 6.4% of prescriptions of clarithromycin IR,were prescribed at inappropriate dosing intervals. Surprisingly,disconcordance between diagnoses and indications was observed in all prescriptions of clarithromycin SR which has not been approved for treating H pylori infection although off-label use for this purpose was reported in literature. On the contrary,only one prescription (0.9%) of clarithromycin IR was prescribed for unapproved indication (i.e. gastro-oesophageal reflux disease). 1.4% of prescriptions for chronic gastritis or peptic ulcer treatment were irrational in that clarithromycin was not co-prescribed with gastric acid inhibitors. Clinical significant CYP3A based drug interactions with clarithromycin were identified. CONCLUSION: There is a great scope to improve the quality of clarithromycin prescribing in patients with gastrointestinal disease,especially with regard to administration schedule,concordance between indications and diagnoses and management of drug interactions.

Effect of Feeding Management on Aspiration Pneumonia in Elderly Patients with Dysphagia

Objective： To investigate the effects of feeding safety instructions and dietary intervention on aspiration pneumonia in elderly patients with dysphagia. Methods： The study included 40 long-term hospitalized elderly patients with dysphagia who needed oral intake, According to the voluntary and matching principle, participants were divided into the intervention group （n =20） and control group （n = 20）. We formed a multi-disciplinary team including clinical nurses, rehabilitation therapists and nutritionists. Clinical nurses collaborated with nutritionists and rehabilitation therapists to carry out feeding management. The patients in the control group were fed with semi-solid food, thick liquid, a partial mushy diet and so on according to their swallowing situations and tastes or preferences. The patients in the intervention group were fed with an all mushy diet. Patients in both groups were able to eat foods on their own or with assistance. Results： After a three-month intervention, the incidence of aspiration pneumonia in both groups was decreased, and the difference was statistically significant （P〈0.05）. In the control group, seven patients had aspiration pneumonia, including two cases who died after nasogastric feeding due to aggravated dysphagia. In the control group, seven patients had aspiration pneumonia, including two cases was given nasogastric feeding due to aggravated dysphagia and then one case died. In the intervention group, four patients had aspiration pneumonia. There was no dropouts in either group. Conclusions： Elderly patients with dysphagia require a multidisciplinary team to work closely with them to carry out feeding management. Nurses should conduct safety guidance for care catering and encouraging patients to actively eat a mushy diet. The diet can reduce the incidence of aspiration pneumonia, maintain oral intake and improve the quality of life.

Evaluation and analysis of the effect of continuing education on nurses’physical restraint knowledge,attitude,and behavior

Objective:The objective of the study is to construct a training course for physical restraint(PR)evidence‑based practice project and apply it to verify its effect.Methods:A total of 162 nurses from five departments of a general hospital in Beijing were trained to compare the PR knowledge,attitudes,and behaviors of nurses before and after training.Results:The nurses were satisfied with the overall curriculum;the total scores of PR’knowledge,attitude and behavior of nurses after training were higher than before,and the difference was statistically significant(P<0.05);the total scores of nurses who received evidence‑related training before this training were higher than those of nurses who did not receive relevant training,and the difference was statistically significant(P<0.05).Conclusion:Continuing education can effectively improve nurses’knowledge,attitude,and behavior level of PR,ensure patient safety,and promote physical and psychological rehabilitation of patients.

Synthesis,Characterization and Phase Transformation of 3D Open-framework Zinc Phosphate [Zn_6(H_2O)P_5O_(20)][C_5N_2H_(14)][C_6H_(16)N_2]_(0.5)·3H_2O

With N,N′-dimethylpiperazine（DMPIP） as the structure-directing agent, a zinc phosphate [Zn6（H2O）P5O20] [C5N2H14] [C6H16N2]0.5·3H2O（1） with a novel three-dimensional（3D） open-framework architecture was hydrothermally synthesized. Its structure was determined by single-crystal X-ray diffraction analysis and further characterized by ICP, NMR, and TG analyses. Compound 1 crystallized in the triclinic space group P1（No.2） with a=0.9984（2） nm, b=1.2354（3） nm, c=1.2384（3） nm, α=88.32（3）°, β=74.57（3）°, γ=75.81（3）° and Z=2. The alternation arrrangement of tetrahedral Zn units[ZnO4 and ZnO3（H2O）] and PO4 units forms an anionic 3D open framework containing intersecting 16-, 10- and 8-ring channels. Water molecules, diprotonated DMPIP, and diprotonated N-methyl-piperazine（MPIP） decomposed from DMPIP, are located in the channels and interact with the host framework via H-bonds. Compound 1 transforms to another new phase（compound 2） upon calcination at 200―350℃ with the removal of the water coordinated to Zn atoms in the lattice. The phase transformation of compound 2 was further studied.