Potential Safety Issues With Combined Use of Dietary Supplements and Medication – Focus on Interactions

The use of dietary supplements (DS) is widespread and tends to increase with age and female gender. DS use can in some situations represent a safety risk for patients. For instance, concomitant use of medication and dietary supplements, particularly herbal remedies, may cause clinically significant pharmacological interactions. The study underlying this chapter aimed to investigate the prevalence of potentially clinically significant DS-medication interactions in a general population of middle-aged women. The study is a questionnaire survey among Norwegian women born between 1943 and 1957. Data were collected from 2002 to 2006 as a part of the Norwegian Women and Cancer study (NOWAC). The participants listed all medications and all DS they had used during the previous week. The reported DS were checked for interaction potential in combination with medication, using the Natural Medicines database. The study population comprised 3,970 women, of whom 1,885 combined medication and dietary supplements. Overall, 630 (16% of the total population) used a DS-medication combination with a potential for at least one clinically significant interaction. Of these, 132 women used herb-medication combinations, 63 used combination(s) that represented more than two interactions, and three used combinations classified as a major health risk. There is considerable potential for clinically significant medication-supplement interactions in a general population such as the one described in the study. Although few of the identified interactions represent a major health risk, the findings indicate that health personnel should take supplements into account when assessing the safety of medication use among their patients

Direction- and Angle-Assisted Buttonhole Cannulation of Arteriovenous Fistula in Hemodialysis Patients: A Multicenter Randomized Controlled Trial

Rationale & objective: Arteriovenous fistula cannulation with the buttonhole technique is often preferred by patients but has been associated with an increased infection risk. Guidelines disagree on whether it should be abandoned, thus we assessed a technologically simple method to facilitate gentler arteriovenous fistula cannulation with potentially less discomfort and damage to the epithelial lining of the buttonhole tract. Study design: 8-week, prospective, open-label, randomized controlled trial. Setting & participants: Patients with buttonhole tracts receiving hemodialysis at 7 dialysis centers in Norway were randomized to the intervention group (43 patients, 658 cannulations) or control group (40 patients, 611 cannulations). Intervention: Direction and angle of the established buttonhole tract were marked on the forearm skin in the intervention group, whereas the control group had no structured cannulation information system. Outcomes: The primary outcome was successful cannulation, defined as correct placement of both blunt needles at the first attempt without needing to change needles, perform extra perforations, or reposition the needle. The secondary outcomes were patient-reported difficulty of cannulation (verbal rating scale: 1 = very easy, 6 = impossible) and intensity of pain (numeric rating scale: 0 = no pain, 10 = unbearable pain). Results: After a 2-week run-in period, successful cannulation was achieved in 73.9% and 74.8% of the patients in the intervention and control groups, respectively (relative risk [RR], 0.99; 95% CI, 0.87-1.12; P = 0.85). However, the probability of a difficult arterial cannulation (verbal rating scale, 3-6) was significantly lower in the intervention group (RR, 0.69; 95% CI, 0.55-0.85; P = 0.001). There were no improvements for venous cannulations. Furthermore, the probability of a painful cannulation (numeric rating scale, 3-10) was lower in the intervention group (RR, 0.72; 95% CI, 0.51-1.02; P = 0.06). Limitations: Unable to evaluate hard end points such as infections and thrombosis owing to the small sample size. Conclusions: Marking direction and angle of cannulation did not improve cannulation success rates; however, patients more often reported an unproblematic procedure and less pain. Funding: None. Trial registration: ClinicalTrials.gov (NCT01536548).publishedVersio

Health Alliance for prudent antibiotic prescribing in patients with respiratory tract infections (HAPPY AUDIT) -impact of a non-randomised multifaceted intervention programme

<p>Abstract</p> <p>Background</p> <p>Excessive use of antibiotics is worldwide the most important reason for development of antimicrobial resistance. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries. Initiatives have been taken to improve the quality of antibiotic prescribing in primary care, but only few studies have been designed to determine the effectiveness of multifaceted strategies across countries with different practice setting. The aim of this study was to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different health organization and different prevalence of antibiotic resistance.</p> <p>Methods</p> <p>GPs from two Nordic countries, two Baltic Countries and two Hispano-American countries registered patients with respiratory tract infections (RTIs) in 2008 and 2009. After first registration they received individual prescriber feedback and they were offered an intervention programme that included training courses, clinical guidelines, posters for waiting rooms, patient brochures and access to point of care tests (Strep A and C-Reactive Protein). Antibiotic prescribing rates were compared before and after the intervention.</p> <p>Results</p> <p>A total of 440 GPs registered 47011 consultations; 24436 before the intervention (2008) and 22575 after the intervention (2009). After the intervention, the GPs significantly reduced the percentage of consultations resulting in an antibiotic prescription. In patients with lower RTI the GPs in Lithuania reduced the prescribing rate by 42%, in Russia by 25%, in Spain by 25%, and in Argentina by 9%. In patients with upper RTIs, the corresponding reductions in the antibiotic prescribing rates were in Lithania 20%, in Russia 15%, in Spain 9%, and in Argentina 5%.</p> <p>Conclusion</p> <p>A multifaceted intervention programme targeting GPs and patients and focusing on improving diagnostic procedures in patients with RTIs may lead to a marked reduction in antibiotic prescribing. The pragmatic before-after design used may suffer from some limitations and the reduction in antibiotic prescribing could be influenced by factors not related to the intervention.</p

Health Alliance for Prudent Prescribing, Yield and Use of Antimicrobial Drugs in the Treatment of Respiratory Tract Infections (HAPPY AUDIT)

<p>Abstract</p> <p>Background</p> <p>Excessive and inappropriate use of antibiotics is considered to be the most important reason for development of bacterial resistance to antibiotics. As antibiotic resistance may spread across borders, high prevalence countries may serve as a source of bacterial resistance for countries with a low prevalence. Therefore, bacterial resistance is an important issue with a potential serious impact on all countries.</p> <p>The majority of respiratory tract infections (RTIs) are treated in general practice. Most infections are caused by virus and antibiotics are therefore unlikely to have any clinical benefit. Several intervention initiatives have been taken to reduce the inappropriate use of antibiotics in primary health care, but the effectiveness of these interventions is only modest. Only few studies have been designed to determine the effectiveness of multifaceted strategies in countries with different practice setting. The aim of this study is to evaluate the impact of a multifaceted intervention targeting general practitioners (GPs) and patients in six countries with different prevalence of antibiotic resistance: Two Nordic countries (Denmark and Sweden), two Baltic Countries (Lithuania and Kaliningrad-Russia) and two Hispano-American countries (Spain and Argentina).</p> <p>Methods/Design</p> <p>HAPPY AUDIT was initiated in 2008 and the project is still ongoing. The project includes 15 partners from 9 countries. GPs participating in HAPPY AUDIT will be audited by the Audit Project Odense (APO) method. The APO method will be used at a multinational level involving GPs from six countries with different cultural background and different organisation of primary health care. Research on the effect of the intervention will be performed by analysing audit registrations carried out before and after the intervention. The intervention includes training courses on management of RTIs, dissemination of clinical guidelines with recommendations for diagnosis and treatment, posters for the waiting room, brochures to patients and implementation of point of care tests (Strep A and CRP) to be used in the GPs'surgeries.</p> <p>To ensure public awareness of the risk of resistant bacteria, media campaigns targeting both professionals and the public will be developed and the results will be published and widely disseminated at a Working Conference hosted by the World Association of Family Doctors (WONCA-Europe) at the end of the project period.</p> <p>Discussion</p> <p>HAPPY AUDIT is an EU-financed project with the aim of contributing to the battle against antibiotic resistance through quality improvement of GPs' diagnosis and treatment of RTIs through development of intervention programmes targeting GPs, parents of young children and healthy adults. It is hypothesized that the use of multifaceted strategies combining active intervention by GPs will be effective in reducing prescribing of unnecessary antibiotics for RTIs and improving the use of appropriate antibiotics in suspected bacterial infections.</p

Spatiotemporal Changes in Vegetation following Range Expansion in Svalbard reindeer (Rangifer tarandus platyrhynchus)

Store planteetere som introduseres til nye omr&#229;der er i stand til &#229; modifisere abundansen og sammensetting av vegetasjonen, spesielt i omr&#229;der uten predatorer. I dette studiet unders&#248;kte jeg endringer i vegetasjonen i tre n&#230;rliggende omr&#229;der som representerer en gradient i akkumulert beitetrykk. Gradienten er en f&#248;lge av forskjellige &#229;r med re-etableringer (1978, 1994, 1996) av den ville svalbardreinen (Rangifer tarundus platyrhynchus), som ikke har noen naturlige predatorer. For &#229; unders&#248;ke forandringer i viktige artsgrupper og arter repeterte jeg vegetasjonsanalyser fra 2000 og 2005 sommeren 2013. I omr&#229;det med lengst beitehistorie og irrupsjonsdynamikk var lav generelt helt nedbeitet gjennom 2000 - 2013, mens det var en sterkt nedgang i plantegruppen i de to andre omr&#229;dene. Dette viser en overgang fra lav-rik til lav-fattig vegetasjon som en f&#248;lge av re-etableringer av reinsdyr og en &#248;kning i akkumulert beitetrykk. Mosedekket viste ogs&#229; en minking og det var ingen tydelig overgang fra lav-dominerende til mose-dominerende vegetasjon. Det var imidlertid en &#248;kning i graminoider i de mer senere etablerte omr&#229;dene i l&#248;pet av 2000 &#150; 2013, som tyder p&#229; en overgang fra vegetasjon dominerende av lav til en mer graminoid-dominerende vegetasjon. Dette stemmer med &#148;alternative stable states&#148; &#150;hypotesen som tilsier at forandringer i tettheten av planteetere kan medf&#248;re vegetasjonsoverganger i &#248;kosystem p&#229; tundraen. Studiet st&#248;tter dermed antakelsen om at reinsdyr kan ha en betydelig innvirkning p&#229; vegetasjonen gjennom beiting og nedtr&#229;kking. Dette er i samsvar med &#148;exploitation ecosystem &#150; hypotesen&#148; som antar at planteetere styrer vegetasjon gjennom en &#148;top &#150; down&#148;- kontroll

Poretrykssrespons ved kalk-/sementstabilisering

I Norge finnes bløt og sensitiv leire som det kan være behov for å stabilisere. Da kan det benyttes kalk-/sementstabilisering. Det er en vanlig stabiliseringsmetode hvor bindemiddel blåses inn i leira ved hjelp av lufttrykk. Lufttrykket, blant flere ting, kan føre til at poretrykket øker, og dette kan være negativt for stabiliteten. I områder med lav initiell sikkerhet kan dette bli et problem. Det er nyttig å kjenne størrelsen og influensområde på poreovertrykk på forhånd, og derfor er poretrykksrespons ved installasjon av kalk-/sementpeler analysert i denne rapporten. Målet har vært å vurdere størrelsen på poreovertrykk, influensområde og konsolideringstid. Med hovedfokus på feltdata fra et prosjekt på Sluppen i Trondheim, er poretrykksresponsen analysert. I tillegg er det brukt andre metoder for å vurdere poretrykksrespons ved kalk-/sementstabilisering. Dette gjelder endelig elementmetode (FEM), i form av programvaren Plaxis 2D, hvor installasjon av én KS-pel er modellert. I tillegg er det benyttet ulike analytiske og empiriske metoder for å vurdere poreovertrykk. Utførte analyser av feltdata viser at poreovertrykk kan komme opp mot 95kPa i avstand 0,2m fra kanten av kalk-/sementpelene. Analysene viser også at poreovertrykket reduseres med avstand fra installerte peler, og at poreovertrykk av betydning ikke oppstår lengre unna KS-pelene enn ca. 10m. I tillegg viser det seg at poreovertrykket når 10kPa (ca. 80% reduksjon av overtrykket) etter omtrent 1,5 døgn med opphold av KS-stabilisering, og at poreovertrykket går under 0 grunnet økt permeabilitet. Det er også en sammenheng mellom antall kalk-/sementpeler som er installert og størrelsen på poreovertrykket, noe som betyr at det er en kumulativ effekt på poreovertrykk ved installasjon av flere KS-peler. Plaxis 2D fungerer for å simulere poretrykk ved KS-stabilisering med bruk av volumtøyning for å modellere installasjonen av KS-peler. Jordmodellen Hardening Soil er bedre til å simulere poreovertrykk enn Mohr-Coulomb. En analytisk løsning for poreovertrykk ved KS-stabilisering fungerer om parameterne er godt tilpasset. En empirisk løsning ikke ga like god overensstemmelse. Det er mange forhold som påvirker poretrykksrespons ved kalk-/sementstabilisering. Det påpekes at det er viktig å vurdere poretrykk i hvert tilfelle, på grunn av at det varierer mye ut fra grunnforhold, og at andre faktorer som varierer i de ulike prosjektene spiller inn

Retning- og vinkelassistert kanylering av AV-fistel hos hemodialysepasienter - en randomisert, kontrollert klinisk studie

Background: Arteriovenous fistula (AVF) is the preferred access for hemodialysis and choosing a good cannulation technique is a very important factor in preservation of the AVF. There are three different techniques for cannulation of the AVF, the buttonhole technique (BH technique) is considered to be the best choice. Purpose: This study tested if a simple marking on the skin of the direction and angle of cannulation could improve the probability of a successful and pain free cannulation. Material and methods: 83 hemodialysis patients from seven Norwegian hospitals were included from February to March 2012, the study lasted for 8 weeks. All had established AVF and were cannulated with BH technique using blunt needles. Primary outcome was successful cannulation with blunt needles, secondary outcome was level of success seen from nurse’s and patient’s opinion. Patients were also once a week assessed for fear – and painintensity. Results: We found no significant difference in cannulating blunt needles between the groups in the study. We found improvements in cannulating blunt needles within both groups, comparing study week 1 and 2 with week 7 and 8, highest improvements in intervention group (Chi- square t-test, p=0,05). The level of fear1 was lower in controlgroup (t- test between groups, p=0,05), level of pain (VAS) was significant lower in intervention group comparing first/ last period (t- test within group, p= 0,05). Levels of fear/ pain dropped in both groups comparing first - with last weeks, no significance. Infectionrate was at a low level. Conclusions: We did not achieve significant "overall" difference between the intervention - and control group. We did not see an immediate effect of the intervention, but observed the effect coming gradually through the study. The study indicated that the intervention may have a positive effect on the chance of successful canulations, fear and pain, but it is too early to make a clear recommendation

Direction and angle-assisted cannulation of AV-fistula in hemodialysis patients – a randomized controlled study

Background: Arteriovenous fistula (AVF) is the preferred access for hemodialysis and choosing a good cannulation technique is a very important factor in preservation of the AVF. There are three different techniques for cannulation of the AVF, the buttonhole technique (BH technique) is considered to be the best choice. Purpose: This study tested if a simple marking on the skin of the direction and angle of cannulation could improve the probability of a successful and pain free cannulation. Material and methods: 83 hemodialysis patients from seven Norwegian hospitals were included from February to March 2012, the study lasted for 8 weeks. All had established AVF and were cannulated with BH technique using blunt needles. Primary outcome was successful cannulation with blunt needles, secondary outcome was level of success seen from nurse’s and patient’s opinion. Patients were also once a week assessed for fear – and painintensity. Results: We found no significant difference in cannulating blunt needles between the groups in the study. We found improvements in cannulating blunt needles within both groups, comparing study week 1 and 2 with week 7 and 8, highest improvements in intervention group (Chi- square t-test, p=0,05). The level of fear1 was lower in controlgroup (t- test between groups, p=0,05), level of pain (VAS) was significant lower in intervention group comparing first/ last period (t- test within group, p= 0,05). Levels of fear/ pain dropped in both groups comparing first - with last weeks, no significance. Infectionrate was at a low level. Conclusions: We did not achieve significant "overall" difference between the intervention - and control group. We did not see an immediate effect of the intervention, but observed the effect coming gradually through the study. The study indicated that the intervention may have a positive effect on the chance of successful canulations, fear and pain, but it is too early to make a clear recommendation

Spatiotemporal Changes in Vegetation following Range Expansion in Svalbard reindeer <i>(Rangifer tarandus platyrhynchus)<i>

Store planteetere som introduseres til nye områder er i stand til å modifisere abundansen og sammensetting av vegetasjonen, spesielt i områder uten predatorer. I dette studiet undersøkte jeg endringer i vegetasjonen i tre nærliggende områder som representerer en gradient i akkumulert beitetrykk. Gradienten er en følge av forskjellige år med re-etableringer (1978, 1994, 1996) av den ville svalbardreinen (Rangifer tarundus platyrhynchus), som ikke har noen naturlige predatorer. For å undersøke forandringer i viktige artsgrupper og arter repeterte jeg vegetasjonsanalyser fra 2000 og 2005 sommeren 2013. I området med lengst beitehistorie og irrupsjonsdynamikk var lav generelt helt nedbeitet gjennom 2000 - 2013, mens det var en sterkt nedgang i plantegruppen i de to andre områdene. Dette viser en overgang fra lav-rik til lav-fattig vegetasjon som en følge av re-etableringer av reinsdyr og en økning i akkumulert beitetrykk. Mosedekket viste også en minking og det var ingen tydelig overgang fra lav-dominerende til mose-dominerende vegetasjon. Det var imidlertid en økning i graminoider i de mer senere etablerte områdene i løpet av 2000 2013, som tyder på en overgang fra vegetasjon dominerende av lav til en mer graminoid-dominerende vegetasjon. Dette stemmer med alternative stable states hypotesen som tilsier at forandringer i tettheten av planteetere kan medføre vegetasjonsoverganger i økosystem på tundraen. Studiet støtter dermed antakelsen om at reinsdyr kan ha en betydelig innvirkning på vegetasjonen gjennom beiting og nedtråkking. Dette er i samsvar med exploitation ecosystem hypotesen som antar at planteetere styrer vegetasjon gjennom en top down - kontroll