Starch safety in resuscitation – when will we ever learn?

Recent trials have failed to demonstrate a survival benefit from the use of hydroxyethyl starches (HES) as a colloid in fluid resuscitation and have raised concerns of renal harm. In severe sepsis, there is a concerning signal of increased mortality. New high-quality systematic reviews consistently demonstrate a statistically non-significant relative risk of death of 1.08 - 1.10 and a significant 25% increased chance of requiring renal replacement therapy. The HES literature contains many industry-affiliated reviews of indifferent quality. Traditional efficacy confidence limits may warrant re-evaluation when considering these harms. Newer formulations of HES and more focused indications for use show benefit on surrogate endpoints, but these trials are currently underpowered to ensure safety

The knowledge and attitudes of South African-based runners regarding the use of analgesics during training and competition

Background: The use of analgesics is prevalent in runners, with the associated potential for serious harm. However, there is limited information regarding runners’ knowledge and attitudes towards the use of analgesics in relation to running. Objectives: To describe South African-based runners’ knowledge and attitudes regarding running-related analgesic use. Methods: This study has a descriptive, cross-sectional design. South African-based runners, over the age of 18 who ran at least one race in the year preceding the study were included in this study. Participants completed an online questionnaire, including sections on demographic information, training and competition history, pain medication use, and knowledge and attitudes regarding running-related analgesic use. Results: Data from 332 participants were analysed. Attitudes regarding the use of analgesics in relation to running were generally positive; however, knowledge was poor, with only 20% of participants achieving adequate knowledge scores (75% or above). Very few (n=49; 15%) had both adequate knowledge and positive attitudes, with most respondents (n=188; 58%) having inadequate knowledge and negative attitudes. Negative attitudes towards the use of analgesics were found to increase the odds of running-related analgesic use (OR 2.32; 95% CI:1.31-4.11). Conclusion: Knowledge regarding running-related use of analgesics was inadequate. Despite a lack of knowledge, attitudes were positive. Participants displayed positive attitudes towards safe practice regarding running-related analgesic use, but these did not translate into good practice. Targeted interventions are required to educate runners and improve their knowledge of all the effects associated with running-related analgesic use.

Dosage adjustment in medical patients with renal impairment at Groote Schuur Hospital

BACKGROUND: Many drugs are eliminated by the kidneys and therefore may require dose adjustment in patients with renal impairment. The need for dose adjustment is frequently neglected by prescribers. METHODS: We reviewed folders of patients admitted to the Groote Schuur Hospital general medical wards between January and March 2008. Patients with renal impairment, defined as an estimated glomerular filtration rate (eGFR) or = 1 day after renal function tests were performed. We determined what proportion of these prescriptions required dose adjustment and whether drug doses were appropriately adjusted. RESULTS: We found renal impairment in 32% (97/301) of medical admissions. There were 615 prescription entries for the 97 patients with renal impairment. Dose adjustment was required in 19% (117/615) of prescription entries, and only 32% (37/117) of these prescription entries were correctly dose adjusted. Of 97 patients, 69 received one or more drugs that required dose adjustment (median 1, range 1 - 5). All drug doses were correctly adjusted in 12% (8/69) of patients. Importantly, in the majority of patients (59% (41/69)) no doses had been correctly adjusted. CONCLUSION: Consistent with international studies, drug dose adjustment in patients with renal impairment in a South African hospital was frequently neglected. Strategies to alert clinicians of the need for dose adjustment in renal impairment should be considered, including automated eGFR reporting and computerised aids to guide drug dosing, that account for renal impairment

A survey of hypertensive practices at two community health centres in Cape Town

Background: Control of hypertension remains an elusive goal, but doctors' non-compliance with guidelines, patient attitudes and adherence to treatment, and poor delivery of care at clinics are important contributing factors. Objectives: To determine the overall quality of hypertensive care, and compliance with current hypertension guidelines at community health centres (CHCs) in the Western Cape. Methods. Consecutive patients attending hypertension clinics at two CHCs were selected to participate. A questionnaire was designed to determine patient demographics, doctors' compliance with hypertension guidelines, factors leading to treatment non-adherence, and delivery of care. Accuracy of blood pressure (BP) recording was evaluated by comparing the clinic BP with that measured using an approved manometer. Results: One hundred and sixty-one patients were evaluated, 100 from CHC 1 and 61 from CHC 2. There was no difference in both control systolic and diastolic BP measured by the hypertension nurse (147.9 v. 144.8 mmHg, p = 0.45, and 89.3 v. 85.6 mmHg, p = 0.14) respectively. All clinic BP readings were recorded to the nearest 10 mmHg mercury. The difference in both systolic and diastolic BP > 10 mmHg between the clinic and control BP was significantly greater at CHC 2 than CHC 1 (28% v. 56%, p = 0.005, and 43% v. 64%, p = 0.007) respectively. Overall, 39.8% of patients had a systolic and diastolic BP < 140 and < 90 mmHg. The mean number of antihypertensive drugs was 2.4 per patient. The use of non-steroidal antiinflammatory drugs (NSAIDs) and tricyclic antidepressants was high at both centres, and few patients underwent basic investigations, lifestyle interventions, risk stratification or global cardiovascular risk reduction. Conclusions: 39.8% of patients achieved a BP < 140/90 mmHg. There is significant scope for improvement in prescription of medication, application of uniform lifestyle changes, and avoidance of NSAIDs and tricyclic antidepressants. Major deficiencies were identified in BP measurement, assessment of target organ damage, risk stratification and the reduction of overall cardiovascular risk

Dosage adjustment in medical patients with renal impairment at Groote Schuur Hospital

Background. Many drugs are eliminated by the kidneys and therefore may require dose adjustment in patients with renal impairment. The need for dose adjustment is frequently neglected by prescribers. Methods. We reviewed folders of patients admitted to the Groote Schuur Hospital general medical wards between January and March 2008. Patients with renal impairment, defined as an estimated glomerular filtration rate (eGFR) ≤50 ml per minute per 1.73 m2, were identified. In-patient prescriptions were captured if they were written after clinical notes indicated impaired renal function, or ≥1 day after renal function tests were performed. We determined what proportion of these prescriptions required dose adjustment and whether drug doses were appropriately adjusted. Results. We found renal impairment in 32% (97/301) of medical admissions. There were 615 prescription entries for the 97 patients with renal impairment. Dose adjustment was required in 19% (117/615) of prescription entries, and only 32% (37/117) of these prescription entries were correctly dose adjusted. Of 97 patients, 69 received one or more drugs that required dose adjustment (median 1, range 1 - 5). All drug doses were correctly adjusted in 12% (8/69) of patients. Importantly, in the majority of patients (59% (41/69)) no doses had been correctly adjusted. Conclusion. Consistent with international studies, drug dose adjustment in patients with renal impairment in a South African hospital was frequently neglected. Strategies to alert clinicians of the need for dose adjustment in renal impairment should be considered, including automated eGFR reporting and computerised aids to guide drug dosing, that account for renal impairment