Although heparin has been used extensively to treat Deep Venous Thrombosis (DVT) and arterial ischemia (AI), controversy still exists regarding optimal dosage and the need for monitoring. Different authors have employed various test with variable results. Others, however, persist in giving heparin without laboratory control. This study was made in order to compare, in a prospective, randomized and blind manner, two coagulation tests, namely: Howel Time (HT) and Activated Partial Thromboplastin Time (APTT), in controlling the dose of heparin given by continuous intravenous infusion in DVT and AI. Our results show no significant difference in complications and failures of the therapy with either test, although significantly higher doses of heparin were needed to maintain APTT within therapeutic range than those needed to keep HT within a similar range.

Background Failure Mode and Effect Analysis (FMEA) is a tool to identify, assess and prevent possible failures that could occur in a process. Purpose To describe FMEA as a method to identify weaknesses in the process of prescription and transcription of medical orders. To isolate the key steps according to their risk priority number (RPN). To report the steps taken. Materials and MethodsA multidisciplinary study group was assembled. Possible errors in the prescription/transcription workflow were identified and classified according to their RPN score (calculated by multiplying the severity, occurrence, and detection). Strategies for improvement were established. ResultsErrors in the prescription were classified as follows: (1) Patient-and-history identification, (2) Clinical and laboratory data checkout, (3) Treatment conciliation, (4) Allergies, (5) Verbal prescription, (6) Handwritten prescription. Errors in transcription: (7) Patient identification (nurse), (8) Internally mailed prescriptions, (9) Paper transcription, (10) Check in pharmacy, (11) Patient identification (pharmacist), (12) Prescription validation, (13) Prescription printing, and (14) Acknowledgement of errors by the pharmacist. Top-ranked item (number), suggested solution, and indicator, respectively were: (5) Verbal prescription (288), storage of verbal prescriptions in pharmacy, % of verbal prescriptions; (9) Failure in paper transcription (288), computerised physician order entry (CPOE), % of electronic prescriptions; (14) Error report to the pharmacist (288), implementation of a two-way communication protocol, number of reports; (8) Paper-based prescriptions sent to pharmacy (243), CPOE, % of electronic prescriptions; (10) Check in pharmacy (216), CPOE, % of electronic prescriptions. The pharmacy, medical director, and Quality Unit were responsible for the changes undertaken in all cases. Conclusions Verbal prescription, failure in paper transcription, error report and mailed prescriptions to pharmacy were the steps with the highest risk of error. For most cases, CPOE was implemented, whereas the percentage of electronic prescriptions was the key indicator to measure the overall improvement in these processes. In conclusion, further efforts and pharmacy policies should focus on the implementation of CPOE in all inpatient areas, thus preventing failure of prescription/transcription and validation loops. No conflict of interest.

The precise management of Deep Venous Thrombosis (DVT), and its complications, is of considerable clinical importance as well as being a controversial topic. However, the standard treatment or complementary of others, as well as the one accepted as being of less risk and more effectiveness is adequate anticoagulation 1,2,3 with continuous intravenous infusion of heparin followed by long term oral anticoagulants.To control this therapy, various authors 1,4,5,6 have employed different laboratory tests without acheiving completely satisfactory results. Recently, Samama7 has reported the value of Howell Time (HT) in his experience.Thus, we decided to carry out a prospective controlled study with the aim of comparing the efficacy of two laboratory tests namely: the Lee-White Clotting Time (CT), and the HT, as dose controls for heparin therapy in DVT patients. Patients and MethodsFifty patients suffering from DVT with or without prior minor Pulmonary Embolism (PE) were studied. They were divided cronologically in two groups according to the laboratory test employed. There were twenty patients controlled by CT (Group A), and thirty subsequent patients controlled by HT (Group B). Both groups are comparable in age, sex, and clinical characteristics (Table I) . ' DiagnosisThe diagnosis of DVT was considered positive when Directional Doppler Ultrasound (Parks Electronics), and Impedance Plethysmography (IPG) (BR-100, Beckman Rheograph) examinations were also positive, 8 regardless of clinical signs. Phlebography was only performed in cases of serious incongruence between Doppler and IPG, or cardiac insufficiency.

Background Gastroprotective agents are widely used in both hospital and community settings, and they are generally perceived as safe drugs. Purpose To find out whether the prescription of anti-ulcer drugs in the Emergency Room (ER) accords with their approved indications, and the financial impact of their inappropriate use. Materials and Methods Indications for use of proton pump inhibitors (PPIs) and H2 antagonists (via the Spanish Medicines Agency): gastro-duodenal ulcers (including NSAIDs and steroid-related ulcers), reflux oesophagitis, Zollinger-Ellison’s syndrome, and Helicobacter pylori eradication. Inclusion criteria: patients >65 years old on at least four home medicines and an anti-ulcer prescription in the ER. Pharmaceutical interventions were recorded and their degree of acceptance calculated. The cost resulting from drug misuse was calculated considering a mean stay in the unit of one day. Results 111 patients, 70.2% male, median age 78.9 years-old [65–94]. 94.6% of patients (92.9% PPI, 1.7% H2 antagonists) received one of these agents upon presentation (95.5% of them were prescribed de novo), with intravenous pantoprazole the agent mainly involved (82% of cases). 29.7% of prescriptions did not meet the indications, while this percentage decreased to 12.5% upon ward admission. The pharmaceutical interventions were accepted in 16.2% of cases. Monthly, the estimated cost of the off-label use was €1850. Conclusions Gastro-protection in the ER did not meet the criteria in nearly 1/3 of patients. This contrasted with the poor acceptance of the pharmaceutical recommendations of discontinuation. The rationale might be the so-perceived harmless profile of these drugs with the short-term use. The rate of off-label prescriptions dropped to half upon ward admission, likely due to thorough revision by the prescriber. Since only patients at a higher risk of suffering from a medicines-related problem were included, the cost resulting from the misuse of anti-ulcer drugs was probably underestimated. In conclusion, forthcoming pharmacy policies should focus on improving the adherence to the indications of both widely-used and expensive drugs, given their financial and health-care impact. No conflict of interest.

Background Some authors have reported reductions in health-related quality of life (HRQOL) of hepatitis C (HCV)-infected patients, but studies fail to discriminate between the effect of factors such as the antiviral regimen, the viral load (VL) or the degree of fibrosis. Purpose To evaluate HRQOL in chronically-ill HCV patients prior to, and after, treatment initiation Materials and Methods Inclusion criteria: patients >18-years old, HCV antibodies+ and HCV-RNA+, no other relevant co-morbidities. Recruitment period: 9 months. Patients were stratified according to the previous VL and their degree of fibrosis, and started on antiviral treatment based on ribavirin + peginterferon. On their follow-up visits (weeks 0, 4 and 12), subjects were given a validated questionnaire (SF36) to be completed at home and delivered on their next visit to the outpatient pharmacy. SPSS v17 was used for the statistical analysis. Results18 subjects recruited (n = 18), percentage of males 67%, mean age 47.3. 10 patients had genotype 2 or 3, and 8 patients had genotype 1 or 4. Low-grade (stage 1–2) and high-grade (3–4) fibrosis was found in 11 and 7 patients respectively. 9 patients had >800,000 RNA copies/mL at presentation. With regard to the antiviral therapy, statistically significant differences in the following items were found between week 0 and week 4: physical functioning (P = 0.046), physical role (P = 0.001), pain (P = 0.001), health (0.046), energy/fatigue (P = 0.001), and emotional wellbeing (P = 0.001). Additionally, we found statistically significant differences in the emotional component with regard to the VL (P = 0.005) and the degree of fibrosis (P = 0.03). Conclusions Antiviral therapy was associated with deterioration in HRQOL. Items involving physical health exhibited the greatest differences. Conversely, those subjects with higher VL and an advanced degree of fibrosis had worse scores in the items involving emotional wellbeing. Long-term studies are currently being conducted to determine whether the existing differences are emphasised over time, as well as the implications of these findings. No conflict of interest.