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Purpose: To summarize literature specific to therapeutic interchange (TI) focusing on methodological approaches in order to develop a list of steps that healthcare facilities can consult when developing pharmacotherapeutic interchange guidelines (PTIGs) in hospitals and primary care centers., Methods: A search was conducted in PreMEDLINE, Medline, EMBASE, PsycINFO, and the Cochrane Library up to and including December 2015. PRISMA guidelines were used. The inclusion criteria were articles published on TI: methodology, implementation, guidelines, and position statements of scientific societies. Two authors independently reviewed all articles for eligibility and extracted the data., Results: A total of 102 articles were selected for full-text review; we included three guidelines on how to effect TI, nine position papers of various scientific societies with regard to TI, two articles dealt exclusively about methodology, three articles consisted of recommendations and perspectives on TI, three articles dealt with legal aspects, four articles examined general implementation procedures, two articles were a post-discharge follow-up of patients who had TI, six were surveys referring to TI, and three were articles on the use of TI in ambulatory care The remaining 67 articles focused on therapeutic groups. Study quality was generally low., Conclusions: This review identified articles on TI as published guidelines, recommendations, and studies on TI carried out in hospital settings. As a result, eight fundamental steps were established for obtaining adequate results in the development of TI programs.

Portal hypertension (PH) is responsible for the most severe complications of cirrhosis and leading cause of death and liver transplantation. The standard pharmacological treatment available for PH currently consists of the use of a non-selective beta-blocker. However, a significant proportion of patients do not respond to pharmacological treatment. This has led to the development of identifiable targets for the discovery of new horizons in PH treatment. Recently, there has been significant progress in understanding the mechanism behind PH, which is a product of increased hepatic vascular resistance including structural changes and functional change due to endothelial dysfunction. Moreover, increased portal inflow is the outcome of dilation of splanchnic vessels and hyperdynamic circulation. Here, challenges in formulating potential pharmacological treatment as well as current potential targets for PH will be reviewed. During the past decades, there have been many efforts to explore new techniques to stimulate liver regeneration in addition to pharmacological treatment. The bone marrow (BM) stem cells which differentiate into mature hepatocytes are thought to contribute to liver regeneration and have been found to demonstrate great potential as regenerative medicine in different therapeutic applications. Based on these insights, we explore the current and potential novel therapeutic uses of BM stem cell therapy in PH.

This article presents a list of potentially delirogenic properties of drugs that are currently of relevance to drug therapy in Europe, which was created through a Delphi process including experts from professions relevant to diagnosis and treatment of delirium. The Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) defines delirium as a disturbance in attention, awareness and cognition that develops over a short period of time and fluctuates. Possible causes of delirium are manifold: usually delirium is considered to develop in a multifactorial way, caused by inalterable parameters, such as advanced age and pre-existing cognitive impairment and precipitated by modifiable parameters, such as the use of certain drugs or substance withdrawal. Delirium is a serious condition with a pronounced impact on morbidity, mortality and costs to the healthcare system. Circumstances and drugs that might precipitate or worsen delirium should therefore be avoided whenever possible. A list of drugs that might have a detrimental influence on the emergence and duration of delirium has been created using the terms "delirogenity" and "delirogenic" to describe the potential of a drug or withdrawal to cause or worsen delirium. The results are novel and noteworthy, as their focus is on substances relevant to European pharmacotherapy. Furthermore, they represent a methodical consensus from a group of experts of a wide variety of professions relevant to the prevention, diagnosis and treatment of delirium, such as nursing, pharmacy, pharmacology, surgical and internal medicine, neurology, psychiatry, intensive care and medicine, with working, teaching and scientific experience in several European countries practicing both in primary and secondary care.

A checklist is an effective implementation tool, but addressing barriers that might impact on the effectiveness of its use is crucial. In this paper, we explore barriers to the uptake of an antibiotic checklist that aims to improve antibiotic use in daily hospital care. We performed an online questionnaire survey among medical specialists and residents with various professional backgrounds from nine Dutch hospitals. The questionnaire consisted of 23 statements on anticipated barriers hindering the uptake of the checklist. Furthermore, it gave the possibility to add comments. We included 219 completed questionnaires (122 medical specialists and 97 residents) in our descriptive analysis. The top six anticipated barriers included: (1) lack of expectation of improvement of antibiotic use, (2) lack of expected patients' satisfaction by checklist use, (3) lack of feasibility of the checklist, (4) negative previous experiences with other checklists, (5) the complexity of the antibiotic checklist and (6) lack of nurses' expectation of checklist use. Remarkably, 553 comments were made, mostly (436) about the content of the checklist. These insights can be used to improve the specific content of the checklist and to develop an implementation strategy that addresses the identified barriers.

The purpose of this investigation was to describe the effect of antibacterial stewardship and evaluate the trends and correlation of antibacterial resistance and usage from 2009 to 2013 in a tertiary-care teaching hospital in northwest China. Antibacterial usage was expressed as defined daily doses per 100 patients per day (DDDs/100 PDs). Hospital-wide population-level data and time series analysis were used to evaluate the trends and determine associations between antibacterial exposure and acquisition of resistance. Yearly consumption of overall antibacterials significantly decreased from 66.54 to 28.08 DDDs/100 PDs (β = -10.504, p < 0.01). The resistant rates of the five most frequently isolated species (including Escherichia coli, Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, and Klebsiella pneumoniae) significantly decreased or remained stable, and none of them showed a statistically significant upward trend. The medical quality indicators got better or remained stable. Autoregressive integrated moving average (ARIMA) models demonstrated that the monthly resistance rate of P. aeruginosa to imipenem was strongly correlated with antipseudomonal carbapenems usage (β = 34.94, p < 0.001), as did the correlation of P. aeruginosa to meropenem with antipseudomonal third-generation cephalosporins usage (β = 32.76, p < 0.01) and K. pneumoniae to amikacin with aminoglycosides usage (β = 22.01, p < 0.001). The decreased antibacterial use paralleled the improved bacterial resistance without deteriorating medical quality indicators during antimicrobial stewardship. It also suggests that optimum antibiotic use is necessary to alleviate the threat posed by resistant microorganisms at the hospital level.

Since 2002, the Belgian Antibiotic Policy Coordination Committee (BAPCOC) has supported the development of antibiotic management teams (AMTs) in Belgian hospitals with policy guidance and federal funding for antibiotic managers. We report on the analysis of the activity reports for the year 2011 and compare the results with those for 2007. A structured questionnaire survey was performed on the composition, organisation and service activities of the AMT in all acute care and larger chronic care hospitals in the country in 2011. Descriptive statistics were stratified by duration of AMT funding. Completed questionnaires were provided by 105 of 109 hospitals (response rate 96.3%). The AMTs have further formalised their working method over the previous years. Significantly higher implementation rates were achieved in 2011 for concurrent review for antibiotic therapies (92.0% in 2011 vs. 64.2% in 2007), for the de-escalation of therapy after a few days (93.0% in 2011 vs. 63.9% in 2007) and for sequential i.v.-oral therapy for antibiotics with equivalent bioavailability (86.0% in 2011 vs. 78.7% in 2007). The AMTs who first joined the project were able to maintain their activities at a high level, while those who last joined the national project in 2007 made considerable progress 4 years later. This has also resulted in significantly higher implementation rates for the totality of the acute care hospitals. The presence of AMTs in all hospitals also proves to be a great boon when setting up projects, surveys and studies on a(n) (inter)national level.

Purposes: Relative efficacy and effectiveness assessment (REA) of a pharmaceutical product is critical in reimbursement decisions. The Pharmaceutical Forum (2005-2008) asked European Union (EU) member states (MS) to strengthen the methodological quality and rigor of REA and identify any scope for common approaches. Here, we have compared REA practices and results within three EU MS with similar reimbursement procedures for the period 2007-2010 to describe the actual situation., Methods: Assessment procedures and reports from the Belgian, Dutch and French Agency websites were retrieved and corresponding products matched. The REA-outcome was coded as added therapeutic value (ATV) yes or no. The strength of agreement between the three MS was estimated and analyzed in relation to some explanatory variables., Results: Of the 144 Belgian, 122 Dutch and 236 French assessment reports retrieved, ATV was granted in 35, 39 and 23 % of cases, respectively, with 72 matches between the three MS. In all MS the results of at least one randomized trial were available in >90 % of reports. Between two MS significant agreement was achieved in ≥ 72 % of cases; this was 54 % between the three MS. Differences in ATV existed for treatments in severe chronic diseases. Assessment procedures were poorly documented in Belgium and France., Conclusions: Our findings reveal that the three similar EU MS under study agree on the REA-outcome of only half of the new drugs. Differences in applied methodology (e.g. inferences from study results, handling of uncertainty) between MS may exist. We suggest that a joint REA approach would benefit from a common understanding and application of the scientific assessment process using shared guidelines.

Background: Whether guideline-oriented pharmacotherapy prevents the decline in pulmonary function or reduces systemic inflammation associated with chronic obstructive pulmonary disease (COPD) is uncertain., Objectives: The aim of this study was to assess the outcome of COPD in clinical practice under real-world conditions in Taiwan as measured by pulmonary function and systemic inflammation parameters (C-reactive protein (CRP) or white blood cell (WBC)) after initiation of guideline-oriented pharmacotherapy., Methods: Newly diagnosed COPD patients were enrolled and prospectively observed in real-world outpatient practice following initiation of pharmacotherapy of COPD. Pulmonary function, WBC and neutrophil counts, and CRP level of COPD patients were assessed annually. This study enrolled 566 patients and 263 returned for follow-up visits., Results: Significantly higher postbronchodilator FVC, FEV1, and FEV1/FVC but lower DLCO were found at 1 year compared to baseline values. During 4-year follow-up period, FVC and FEV1 remained stable. DLCO progressively declined compared to baseline. No significant changes were seen in CRP and neutrophil count over a 3-year period. Values of CRP, WBC, and neutrophil count correlated inversely with FEV1, FVC, FEV1/FVC, and DLCO., Conclusions: Guideline-oriented pharmacotherapy of COPD improves airflow limitation but does not prevent the alveolar destruction and systemic inflammation under real-world conditions in Taiwan.

Within the last two years the therapy of castration resistant prostate cancer (CRPC) has made major advances. Both the COU-AA-301 phase III trial and the TROPIC trial showed a survival benefit for patients after docetaxel failure treated with abiraterone or cabazitaxel, respectively. With rising interest for chemotherapeutic options and novel drugs, our goal was to review within the context of a multidisciplinary team the available evidence and explore the standards for medical treatment of prostate cancer outside of clinical trials. From this background, we are carefully evaluating the current treatment recommendations, based on the available evidence, and highlight potential future treatment options but also discuss important clinical topics like treatment until progression versus the advantage of chemo holidays and definition of particular patient subgroups. Additionally, we focus on novel molecular entities, which will most likely be available in the near future, such as MDV3100 and Sipuleucel T. The role and importance of palliation with radiotherapy and proactive medical management of pain is also discussed, as well as new options for bone directed therapy. The multitude of treatment options for patients with advanced prostate cancer clearly asks for a close collaboration between urologists, medical oncologists and radiation therapists.

Hospital antibiotic management teams (AMTs) have been recommended, but, in France, their concrete implementation remains scarce and their effectiveness largely unevaluated. The objective of this investigation was to evaluate the appropriateness of antibiotic therapy (AT) for bloodstream infections (BSIs) at a 950-bed university teaching hospital, and assess the role of an AMT in improving it. A prospective analysis of all significant BSIs occurring outside of the intensive care unit (ICU) during an 18-month period was carried out. AT was deemed effective if at least one prescribed antibiotic was effective in vitro, and appropriate if it was consistent with local recommendations. Out of 574 BSIs, 512 were evaluated: 231 community-acquired, 206 nosocomial, and 75 healthcare-associated. For 219 (42.8%) BSIs, the AT initiated prior to AMT intervention proved to be effective and appropriate, inappropriate but effective in 136 (26.5%), and ineffective or absent in 157 (30.7%). In the multivariate analysis, hospital-acquired and other healthcare-associated BSIs, as well as catheter-borne (CB) infections, were associated with inappropriate or absent AT. A recommendation from the AMT was given and followed in 233 (94%) out of 249 BSIs requiring intervention. Initially, two-thirds of BSIs outside the ICU did not receive appropriate AT. Healthcare-associated BSIs should, therefore, be the priority target of AMTs.

Purpose: To compare drug treatment changes in older hip fracture patients with and without multi-dose drug dispensing (MDD) after discharge from hospital., Methods: Hip fracture patients (aged 65 years or older) for whom the same prescribing procedure was used at discharge and at the 6-month follow-up were extracted from two patient cohorts consecutively recruited in 2008 (n = 100) and 2009 (n = 99), respectively. Of these hip fracture patients, 107 patients used MDD and 47 used ordinary prescriptions (OP) throughout the study period. Drug treatment was registered at discharge and at the 6-month follow-up. Each drug was classified as changed (withdrawn, dosage adjusted or added) or unchanged. The association between MDD and changes in drug treatment was analysed with generalised estimating equations (GEE). Age, sex, cognition, year of study and type of drug (fall-risk-increasing, fracture-preventing or other) were included in the model., Results: A total of 1,980 drugs were prescribed at discharge and at the 6-month follow-up to the 154 patients. Of the 1,413 drugs prescribed via MDD, 597 (43%) drugs were unchanged. The corresponding figure for drugs prescribed via OP was 166 out of 567 (29%) prescribed drugs. Analysis with GEE revealed an odds ratio (95% confidence interval) of 1.66 (1.20-2.31) to 1.77 (1.38-2.27) for a drug to be classified as unchanged when prescribed via the MDD system., Conclusions: MDD is associated with fewer changes in drug treatment compared with OP. Further studies of risks and benefits from this prescribing procedure are urged.

Acute respiratory tract infections (ARTIs) are the main reason for antibiotic prescription in children. In 2005, the French Drug Agency published guidelines to minimise inappropriate use of antibiotics for ARTI. The purpose of this study was to assess the impact of implementing these guidelines in a paediatric emergency department. We retrospectively analysed data collected prospectively in a French paediatric emergency department from November 2005 (date of guideline implementation) to October 2009. For each child diagnosed with ARTI, we collected age, diagnosis, and prescribed antibiotics. We computed antibiotic prescription rates in the study population. During the study period, 53,055 children were diagnosed with ARTI and 59% of the 22,198 antibiotic prescriptions given at discharge were related to ARTI. The proportion of ARTI patients given antibiotic prescriptions fell from 32.1% during the first year to 21% in year 4 (p<10(-4), Cochran-Armitage test). Amoxicillin-clavulanic acid and amoxicillin accounted for 50% and 34% of antibiotic prescriptions for ARTI, respectively. French antibiotic guidelines led to significant decreases in antibiotic prescription for ARTI in our paediatric emergency department.

Inappropriate antibiotic use contributes to antimicrobial resistance. Multi-faceted antimicrobial stewardship programmes (ASPs) are recommended for sustainable changes in prescribing practices. A multi-disciplinary ASP was established in October 2008 and piloted in the Departments of General Surgery, Renal Medicine and Endocrinology sequentially. To improve the quality of patient care via optimising the (1) choice, (2) dose, (3) route and (4) duration of antibiotics, a "whole-system" approach incorporating prospective review with immediate concurrent feedback (ICF), prescriber education (public or individualised), de-escalation of therapy, dose optimisation and parenteral-to-oral conversion, while recognising the autonomy of primary prescribers, was adopted. The audited department received a quarterly outcomes report and any common unaccepted practices would be addressed. Outcomes were analysed for 12 months post-ASP implementation. A total of 1,535 antibiotic prescriptions were reviewed. Antimicrobial use in 376 (24.5%) prescriptions was inappropriate. Of 596 interventions made, 70.2% were accepted. A reduction in audited antibiotics consumption resulted in acquisition cost savings of S$198,575 for the hospital. Patients' cost-savings attributable to ASP-initiated interventions were $91,194. The overall all-cause mortality rate and median monthly inpatient-days pre- and post-intervention remained stable. A "whole-system" ASP was effective in optimising antibiotic use in our hospital, without compromising clinical outcomes.

Aim of the Review: This review of the international literature aims to assess the evidence and its methodological quality relating to the cost-effectiveness of interventions to improve seamless care focusing on medication., Method: Studies were identified by searching Medline, EMBASE, Centre for Reviews and Dissemination databases, Cochrane Database of Systematic Reviews, and EconLit up to March 2011 using search terms related to health economics and to seamless care. To be included, economic evaluations had to explore the costs and consequences of an intervention to improve seamless care focusing on medication as compared with usual care. Methodological quality of studies was assessed by considering perspective; design; source of clinical and economic data; cost and consequence measures; allowance for uncertainty; and incremental analysis. Costs were actualized to 2007 values., Results: Eight studies on medication interventions for hospitalized patients in the transition between ambulatory and hospital care were included in the review. A variety of types of medication interventions and target populations have been assessed, but the evidence is limited to one economic evaluation for each particular intervention type and each specific target population. Most studies demonstrated an impact of interventions on compliance and (re)hospitalization rates and costs. The studies did not find an impact on quality of life or symptoms. Economic evaluations suffered from methodological limitations related to the narrow perspective; restriction to health care costs only; exclusion of costs of the intervention; use of intermediate consequence measures; no allowance for uncertainty; and absence of incremental analysis., Conclusion: In light of the small number of economic evaluations and their methodological limitations, it is not possible to recommend a specific intervention to improve seamless care focusing on medication on health economic grounds.

Clinicians have used procalcitonin (PCT) (biomarker to differentiate bacterial from non-bacterial sepsis) to guide use of antibiotics in patients. As the data for utility of PCT to discontinue antibiotics in an antimicrobial stewardship program (ASP) are lacking, we aim to describe the outcomes of patients in whom PCT was used to discontinue antibiotics under our ASP. An antimicrobial stewardship (AS) team intervened to discontinue antibiotics in patients with persistent fever or leucocytosis, source of sepsis unknown or negative bacteriological cultures, who had completed an adequate course of antibiotic therapy and had a PCT of <0.5 μg/L. Main outcomes evaluated were 14-day re-infection, 30-day mortality and readmission. Antibiotic therapy was discontinued in 42 patients in 1 year. Unknown source of sepsis was found in 38% of the patients (including possible malignant fever) and culture-negative pneumonia was found in 21%. Two patients died of advanced cancer. One patient decided for comfort care and died one week later. One patient died due to a second episode of pneumonia 37 days after first PCT test. Six patients were readmitted within 30 days due to non-infectious causes. Three patients were readmitted due to culture-negative pneumonia. None had a 14-day re-infection. PCT used to discontinue antibiotics under our ASP did not compromise patients' outcome.

Objective of the Study: Body size based dosing is often used for prescribing anticancer drugs. However the scientific and the clinical rationales of this historical method have recently been criticized. As a result, alternative dosing strategies have been suggested, as flat-fixed dosing regimens, but not implemented in routine practice. Dose standardisation is a first step in order to rationalise chemotherapy dose calculation. A new method, derived from dose-banding, was developed, taking into account prescription and economic criteria., Setting: Feasibility and interest of this concept were studied in two French cancer centres Institut Curie and Hôpital Saint-Louis., Main Outcome Measures: The aim of our study was to assess dose standardisation of expensive anticancer drugs in objectives of quality and economy., Method: Nine candidate drugs were selected and standardized rounded doses (SRD) were proposed. To determine the specific standard doses of these two centres, two theoretical and practical methods were applied, and then, their results were compared. For each anticancer drug the objective was to fix SRD in order to cover all the doses most frequently prescribed., Results: It has been possible to propose SRD for six of the nine drugs. These SRD have been implemented with the agreement of the medical staff. These doses are, whenever possible, rounded to the nearest vial size, or correspond to a combination of the different strength of the commercial drug., Conclusion: Our study shows that dose standardisation is a help to optimise the productivity and improve the organisation of the preparation unit.

All published evidence on procalcitonin (PCT)-guided antibiotic therapy was obtained in trials where physicians knew that they were being monitored, possibly resulting in higher adherence to the PCT algorithm. This study investigates the effectiveness of PCT guidance in an observational quality control survey. We monitored antibiotic therapy and algorithm adherence in consecutive patients with respiratory tract infections admitted to the Kantonsspital Aarau, Switzerland, between May 2008 and February 2009. The results were compared to the site-specific results of the former ProHOSP study. Overall and more pronounced for patients with community-acquired pneumonia, the median duration of antibiotic treatment in this survey was shorter than the ProHOSP control patients (6 vs. 7 days, P = 0.048 and 7 vs. 9 days, P < 0.001). In 72.5% of patients, antibiotics were administered according to the prespecified PCT algorithm. No significant differences concerning adverse medical outcome could be detected. This study mirrors the use of PCT-guided antibiotic therapy in clinical practice, outside of trial conditions. If algorithm adherence is reinforced, antibiotic exposure can be markedly reduced with subsequent reduction of antibiotic-associated side effects and antibiotic resistance. The integration of the PCT algorithm into daily practice requires ongoing reinforcement and involves a learning process of the prescribing physicians.

Target Population: This recommendation applies to adults with newly diagnosed brain metastases; however, the recommendation below does not apply to the exquisitely chemosensitive tumors, such as germinomas metastatic to the brain., Recommendation: Should patients with brain metastases receive chemotherapy in addition to whole brain radiotherapy (WBRT)? Level 1 Routine use of chemotherapy following WBRT for brain metastases has not been shown to increase survival and is not recommended. Four class I studies examined the role of carboplatin, chloroethylnitrosoureas, tegafur and temozolomide, and all resulted in no survival benefit. Two caveats are provided in order to allow the treating physician to individualize decision-making: First, the majority of the data are limited to non small cell lung (NSCLC) and breast cancer; therefore, in other tumor histologies, the possibility of clinical benefit cannot be absolutely ruled out. Second, the addition of chemotherapy to WBRT improved response rates in some, but not all trials; response rate was not the primary endpoint in most of these trials and end-point assessment was non-centralized, non-blinded, and post-hoc. Enrollment in chemotherapy-related clinical trials is encouraged.

Purpose: To evaluate if nurses after receiving training in clinical pharmacology can improve the quality of the drug therapy in elderly hospitalized patients., Methods: Nurses were given a 1-day training in clinical pharmacology to identify drug-related problems (DRPs).All patients admitted to the ward aged 65 or more were studied. Patients at the same ward before the intervention were considered as control group. Outcome variables were re-hospitalized 3 months from discharge, drug-related readmissions, the proportion of inappropriate drug use (IDU), and DRPs found by the nurses., Results: Of 460 patients (250 intervention group and 210 in the control group) 38 and 36%, respectively, had at least one re-admission to hospital (p=0.86) and 24% of the patients died. Eighteen and 17% (43/37), respectively, used one or more inappropriate drug (p 0.90). The nurses found 86 clinically significant DRPs not detected by the usual care. A substantial part of the DRPs detected by the nurses were revealed with assistance of Symptoms Assessment Form (SYM). There were no statistical difference in the number of drug-related re-admissions between the groups, 14/16, respectively, (p=0.40)., Conclusions: Nurses are able to detect a high proportion of clinically relevant DRPs not detected by the usual care and thereby increase the quality of the drug treatment in elderly hospitalized patients. Our study showed no effect on re-hospitalization or IDU. By using a SYM nurses can find DRPs that computer-based decision support systems miss.

Objective: To assess the effects and cost effects of introducing clinical pharmacists on hospital wards., Methods: Comparative prospective study on four orthopaedic surgical wards in two hospitals. The primary effect variables were 10 target areas widely considered to be indicators of good prescription practice. Prescriptions not following good practice in these intervention areas were defined as "sub-optimal prescriptions," and then discussed between a physician and a clinical pharmacist. The primary parameter was the difference in the number of days with a sub-optimal prescription (Mann-Whitney test)., Results: On an average 20% of all the patients had a sub-optimal prescription. Of these, 70% were changed by the physician after intervention by the clinical pharmacist. There was a statistically significant difference in the duration of days in treatment with a sub-optimal prescription. Where sub-optimal prescriptions were changed, 43% resulted in cost reductions. The reductions achieved could cover 47% of the costs of clinical pharmacy service., Conclusion: Clinical pharmacy services offered to four orthopaedic surgical wards resulted in reduction of sub-optimal prescriptions. Every time the pharmacist screened seven patients one sub-optimal prescription was found and adjusted. The reduction in medicine costs due to adjusted sub-optimal prescriptions could not cover the whole cost of clinical pharmacy service.

Background: We present outcome data of a cohort of 164 immunocompetent PCNSL patients uniformly diagnosed at a single center for stereotactic neurosurgery, and evaluate the acceptance and impact of combination radiotherapy (RT) and chemotherapy (CHT) with high-dose methotrexate (HD-MTX) over time., Method: We assessed choice of treatment and patient survival in a series of 164 PCNSL cases diagnosed from 1989 to 2001, and performed a re-evaluation of histopathology and pre-operative clinical data., Findings: From 1989 to 1993, RT was the predominant therapy, and additional CHT did not improve survival. After 1994, the use of combination CHT/RT increased continuously, consistently contained MTX, and was associated with longer survival than RT only: median survival was 14 months after CHT/RT (2-year survival 35.7%) and 10 months (2-year survival 26.2%) after RT only (not significant). Overall median survival remained poor, increasing from six (1989-1993) to nine months (1994-2001) (p = 0.008). Survival was variable, with a few patients surviving >4 years after diagnosis in the CHT/RT as well as in the RT only group., Conclusions: Despite considerable improvement of PCNSL therapy, the overall benefit of combined CHT/RT versus RT only was lower than that expected from previous phase II clinical trials. The striking variability of survival in either treatment group may suggest a yet undefined biological heterogeneity of PCNSL, which may also include a more aggressive PCNSL subtype in the group of patients with rapidly progressive disease and not eligible for standard therapy.

Objective: Pure pineal germinomas have been rarely reported in girls. Gender incidence and differences of pure pineal germinomas are not well known. The authors report a series of pure pineal germinoma and its gender characteristic is reviewed., Methods and Results: Of a total of 50 germ cell tumors operated on between 1988 and 2004 we found 26 cases (median age at diagnosis, 12 years) of pineal germ cell tumors. Of these, 14 cases (male/female ratio: 13/1) were pure pineal germinomas, and 12 cases (male/female ratio: 12/0) were non-germinoma germ cell tumors. In pure pineal germinomas, the main clinical presentations were intracranial hypertension and cranial nerve dysfunction. Imaging studies disclosed a homogeneous type of tumor (n = 10) and associated hydrocephalus (n = 6). Cases were managed with biopsy and subsequent radiation therapy and chemotherapy. After a follow up of 10 years, pure germinoma cases have no neurological deficits and tumor recurrence. The literature on gender incidence of pure pineal germinomas is analyzed and possible causes are discussed., Conclusions: Although rare, pure pineal germinoma can be found in female subjects. On the basis of the literature review, the male/female ratio in cases of pure pineal germinoma is between 5:1 and 22:1 (mean 14:1). In our series, the male/female ratio was 13:1.

Background and Objectives: Product labeling and published guidelines reflect the importance of monitoring laboratory parameters for drugs with a risk of organ system toxicity or electrolyte imbalance. Limited information exists about adherence to laboratory monitoring recommendations. The objective of this study was to describe laboratory monitoring among ambulatory patients dispensed medications for which laboratory testing is recommended at therapy initiation., Design and Subjects: We conducted a retrospective cross-sectional analysis of patients in 10 geographically distributed health maintenance organizations who were newly prescribed medications with recommended laboratory test monitoring. The main outcome measure was the proportion of initial drug dispensing without recommended baseline laboratory monitoring for 35 newly initiated drugs or drug classes., Results: One hundred seven thousand, seven hundred sixty-three of 279,354 (39%) initial drug dispensings occurred without recommended laboratory monitoring. Patients without monitoring were younger than patients who had monitoring (median 57 vs 61 years, P<.001). Thirty-two percent of dispensings where a serum creatinine was indicated did not have it evaluated (range across drugs, 12% to 61%); 39% did not have liver function testing (range 10% to 75%); 32% did not have hematologic monitoring (range 9% to 51%); and 34% did not have electrolyte monitoring (range 20% to 62%) (P<.001)., Conclusions: Substantial opportunity exists to improve laboratory monitoring of drugs for which such monitoring is recommended. This study emphasizes the need for research to identify the clinical implications of not conducting recommended laboratory monitoring, existing barriers to monitoring, and methods to improve practice.

Objective: To evaluate the inter-group and intra-group reliability of a modified Medication Appropriateness Index (MAI) for use in primary care., Methods: Elderly (>65 years) polypharmacy (> or =5 drugs) patients in Copenhagen County participated in the study. Information concerning their medical history and information regarding each drug taken by them was provided by their own general practitioners. A MAI was scored by two groups of evaluators for every drug. To evaluate inter-group agreement, 211 drugs taken by 30 patients were rated according to the ten criteria making up the MAI. Both evaluator groups provided summaries of comments on the medication of each patient. Intra-group agreement was determined from MAI ratings performed twice at two different times on 86 drugs taken by ten patients. Agreement and chance-adjusted agreement were determined, the latter through kappa statistics. The proportion of positive (ppos) and negative (pneg) agreement was also determined., Results: The overall chance-adjusted inter-group agreement (kappa) was moderate. The agreement was good on the criteria practical directions and drug-disease interaction, moderate on the criteria dosage and duration, fair on the criteria indication, effectiveness, duplication and expense, and poor on the criterion drug-drug interaction. The overall chance-adjusted intra-group agreement was good for all criteria and very good for the criteria indication and practical directions., Conclusion: The MAI is used to quantify appropriate and inappropriate prescribing and changes in prescribing quality in intervention studies. However, caution should be used when comparing results across different settings and evaluators. Our study suggests that the index should only be used in intervention studies if the same group rates the appropriateness pre- and post-intervention.

Expenditures for prescription drugs continue to increase, prompting insurers and health systems to adopt formulary or coverage policies restricting the use of more expensive drugs. Those establishing formulary policies face a complex array of claims regarding differences in efficacy, safety, treatment cost, or cost-effectiveness. We describe and illustrate 5 specific principles for applying research evidence to formulary decisions: (1) Experimental data should take precedence over models or simulations, and assumptions of such models should be carefully examined. (2) Morbidity or mortality outcomes should take precedence over surrogate or intermediate outcomes. (3) Claims for advantages of new treatments should consider the full range of alternatives rather than those selected by industry. (4) Variation in effects across individuals or subgroups argue against restrictions on first-line treatment, but only if those differences are predictable. (5) Variation in effects argues against requiring changes in ongoing treatment. We also discuss how economic incentives are likely to influence selection of research questions, especially research related to drug-gene interactions and to identifying new indications for existing drugs.

Objective: Criteria for inappropriate drug use developed by Beers have been widely used in drug utilization reviews as the basis for educational materials and to assess the quality of prescribing. However, there is inconclusive evidence that these criteria can impact on patient outcomes. The objective of this study was to evaluate the impact of inappropriate drug use on all-cause mortality, adverse drug reactions (ADRs) and length of stay among in-hospital patients., Methods: We performed a retrospective, cohort study on 5,152 patients aged 65 years or older admitted to 81 hospitals in Italy between 1997 and 1998. Inappropriate drug use was defined by 2003 Beers criteria. Outcomes of the study were: (a) in-hospital mortality; (b) incidence of ADR occurring during hospital stay; (c) length of hospital stay 13 days or more., Results: The mean age of 5,152 participants was 78.8 years (standard deviation = 8.4 years), and 2,463 (47.8%) were men. During hospital stay, 1,475 (28.6% of the study sample) patients received one or more inappropriate drugs. After adjusting for potential confounders, use of inappropriate drugs was not associated significantly with either mortality [odds ratio (OR) 1.05; 95% confidence intervals (CI): 0.75-1.48], ADR (OR 1.20; 95% CI: 0.89-1.61) or length of stay 13 days or more (OR 1.09; 95% CI: 0.95-1.25)., Conclusions: This study did not show any significant effect of inappropriate drug use defined by Beers 2003 criteria on health outcomes among hospitalized older adults. Further studies conducted in different settings, using additional health outcomes and alternate measures of inappropriate drug use, are needed.

Objective: Facility in psychopharmacology is a major goal of psychiatric residency. This study assesses the adequacy of pharmacotherapy provided to depressed patients in a resident clinic., Methods: Charts of all 285 patients seen in an outpatient triage clinic during 2000 were reviewed. One hundred twelve patients had diagnoses of major depression, dysthymia, depressive disorder not otherwise specified, adjustment disorder with depressed mood, or bipolar disorder with a documented depressed episode during the studied period. Pharmacotherapy prescribed to these 112 patients was rated using the Antidepressant Treatment History Form (ATHF). Also analyzed were weeks in treatment and Clinical Global Impression (CGI) Severity score assigned retrospectively., Results: Of the 112 charts subjected to detailed review, 49.1% documented adequate treatment. Antidepressant Treatment History Form ratings increased with treatment duration. No correlation was found between ATHF ratings and CGI ratings., Conclusions: Results suggest that time retained in treatment is a major factor in treatment adequacy.

The 12th AMG amendment and the EU Directive 2001/20/EC set down clear legal guidelines on clinical studies of drug products in children. As a consequence there are new prospects for an increasing involvement of the pharmaceutical industry in developing drugs for use in children. BfArM has acted on this development by setting up a committee of experts on drug approval for use in children-similar to committees at the EMEA and FDA working on the same issue. Another useful step consists in the strengthening of pharmaco-vigilance measures. Treatment standards have been developed on the basis of the research instrument "clinical therapy optimization studies", frequently conducted as co-operative national or international studies joining many trial sites, and may definitely benefit from the new requirements. Clearly defined terms and regulations, such as "sponsor responsibility", "trial approval", "investigational medical product", "insurance", and "monitoring" describe problems that can or at times cannot be solved by such research groups. The sponsor's responsibilities in an international trial e. g. cannot usually be shouldered by a single scientist or treatment center. When in the future practically every single research question on drug treatment is governed by those regulations, costs will soar and fewer questions will be asked in clinical studies. So far, the AMG amendment has not given an assessment of benefit and risk regarding treatment quality and drug safety in children. Such an assessment depends on the willingness of all concerned to explore the scope of the legal regulations in order to let children participate in scientific progress where it is needed and where it makes sense.

Aim: To measure the outcomes of a harmonized, structured pharmaceutical care programme provided to elderly patients by community pharmacists., Method: A randomised, controlled, longitudinal, clinical trial with repeated measures was performed over an 18-month period, involving community pharmacies (5 intervention and 5 control) in Northern Ireland. Elderly, ambulatory patients (> or = 65 years), taking 4 or more prescribed medications were eligible for participation. Patients attending an intervention pharmacy received education on medical conditions, implementation of compliance strategies, rationalizing of drug regimens and appropriate monitoring; patients attending control sites received normal services. A battery of clinical, humanistic and economic outcomes were assessed., Results: A significantly higher proportion of intervention patients were compliant at the end of the 18-month study and experienced fewer problems with medication compared to control patients (P < 0.05). There was little impact on quality of life and health care utilisation., Conclusions: Pharmaceutical care provision to community-dwelling patients resulted in an improvement in medication compliance and evidence of cost-savings. Future pharmaceutical care studies may benefit from a more focussed selective approach to data collection and outcomes measurement.

Background: This article presents the results of a study on quality of pharmacy services and perceived risk of pharmaceuticals. The results presented here are part of a multi-study evaluation of major changes in drug distribution in Iceland., Objectives: This sub-study addressed the question: what is the lay user perspective on pharmaceuticals and pharmacy services, including their perception of risk?, Methods: To answer this question, seven focus group discussions were conducted with pharmacy customers in different locations in Iceland following new drug distribution legislation in 1996., Results: The lay perspective emphasizes a definite split between lay and expert views on the value and quality of pharmaceuticals, drug therapy and pharmacy services, as well as in their assessment of risk. Participants voiced spontaneous criticism of the roles of both physicians and pharmacists in drug therapy; and expressed concern about the quality and safety of pharmaceuticals. Some scope for shared values was noted between the legislative goals and the lay user perspective, despite the fact that the public was in no way involved in the drafting of the new legislation., Conclusion: The results of this study raise questions about the nature and extent of the perceived gap between the medical and pharmacy professions on the one side and the lay public and health policy decision-makers on the other side in their views on the quality and safety of pharmaceuticals and pharmacy services.

Objective: To explore the domains encompassed within the assessment of the appropriateness of prescribing for an individual patient., Method: The Nominal Group Technique was used to address the question "How can we assess inappropriate drug therapy of individual patients that is responsive to pharmaceutical care?" The group participants were a self-selected group of nine pharmacists and one pharmacologist attending an international working conference on the Outcomes of Pharmaceutical Care. Item generation was followed by discussion for clarification and operationalization. Voting achieved a consensus, defined as > or = 70%, agreement on the importance of items for inclusion in an instrument to assess appropriateness., Results: Sixty-seven items were initially generated. During discussion, similar items were combined and items were grouped into domains. Items that considered the patient's perspective were commonly suggested, but many were discarded after discussing their operationalization. Consensus was obtained that eighteen items, in seven domains, should be included in the instrument. The domains were indication and drug choice (5 items), effectiveness (2), risks and safety (2), dosage (3), interactions (1), practical use (4), and monitoring (1)., Conclusion: It is hoped that, with adequate testing, these indicators of appropriateness of prescribing can be used by pharmacists to begin to routinely assess the impact of pharmaceutical care on the quality of prescribing for patients under their care.

Aim: To establish what is known about the clinical and economic impact of drug information (DI) services on patient outcome., Method: A systematic review and critical appraisal of world literature on work conducted by Drug Information Centres and UK Schools of Pharmacy., Results: Six relevant published articles were recovered--three from the UK; two from the US and one from Canada; just one was prospective in design. Four were single-centre and two were multi-centre studies. Four studies relied heavily on questionnaire surveys of the enquirer to establish an effect; only one monitored patient outcome independently and used peer review to assess impact., Conclusion: The clinical and economic impact of drug information consultation and provision on patient care has not been investigated rigorously. A research methodology for such an investigation is suggested.

Purpose of the Study: This pilot study examined the prevalence and types of questions elderly patients have about their current drug therapy. It also evaluated the effectiveness of a brief intervention to prepare patients to ask questions about drug therapy during medical visits., Design and Methods: The research used a posttest-only experimental design. Forty-five elderly patients seen at a primary care clinic during a one-month period consented to participate and completed the study. After consent, subjects were randomly assigned to intervention and control conditions. A brief interview with intervention group subjects conducted by a medical student assigned to the clinic as part of a summer research experience helped subjects formulate questions they had about current therapy before they went into medical visits. Patient-physician visits were audiotaped and patient questions about medications and health care were tallied., Results: Subjects in the intervention group were significantly more likely to ask questions of providers than were subjects in the control group. Intervention group subjects were found to ask a wider variety of medication-related questions than were control group subjects, including questions related to proper use, problems perceived with medications, and effectiveness of treatment., Implications: Assisting patients to formulate questions before medical visits results in an increased likelihood that patients will ask questions and will ask a wider variety of questions during the medical visit.

Objective: There is at present no comprehensive directory of medicines available in European countries. Such a directory would be valuable to policy analysts, clinicians, regulatory agencies, pharmaceutical companies and consumer groups. The aim of this project was to compile such a directory of all medicines marketed in each of the European Union member countries., Methods: Lists of medicines for each country, compiled from several national sources, classified by Anatomical-Chemical-Therapeutic (ATC) code. Census date was late 1998., Results: A comprehensive directory was created using data from 14 of the 15 European Union countries. Numbers of trade names and of active ingredients varied widely, from Germany with 18,554 and 1,973, respectively, to Denmark with 1,915 and 1,016, respectively. In individual therapeutic areas, there were variations in the numbers of active ingredients available: the least variation between countries was in antineoplastic medicines (ATC code L, maximum number available in any country 101, minimum 60) and wider variation in alimentary (ATC code A, maximum 256. minimum 103) or cardiovascular (ATC code C, maximum 269, minimum 112). Only 7% of all the active ingredients were available in all the countries studied. The Scandinavian countries had the greatest proportion of active ingredients (60%) available in all other countries. Each country had a number of active ingredients available only in that country Italy had the largest number of these., Conclusions: The directory illustrates the wide variations in the availability of medicines across the European Union. The range of drugs available in each country represents differences in regulatory and market policies, as well as cultural and historic differences. This directory lends itself to many further analyses.

Aim of Study: This study sought to determine whether multidisciplinary case conference reviews improved outcomes for nursing home residents, and the effects of this team approach to resident care on carers, including the hands-on carers employed by the nursing home, and health professionals., Method: 245 residents of three Canberra nursing homes were enrolled in this non-randomised controlled trial. The intervention consisted of sessions of three case conference reviews held between 10/4/96 and 4/12/96. These sessions were attended by the General Practitioners (GPs) of the residents discussed, the GP project officer from the ACT Division of General Practice, a clinical pharmacist, senior nursing staff, other health professionals e.g. physiotherapist, and occasionally the resident concerned or their representative. At each review, a case presentation by the resident's GP was followed by a multidisciplinary discussion of all aspects, medical and non-medical, of the resident's care. The review concluded with a management plan for the resident. In total 75 residents were reviewed., Main Outcome Measures: Medication use and cost, and mortality., Results: One month after the reviews were completed comparisons between those who were reviewed and those who were not showed non-significant reductions in medication orders, medication cost, and mortality in the reviewed group. Many of the 92 recommendations in the management plans that were carried out benefited the residents (n = 37) and/or carers (n = 24). The responses of the GPs and the Directors of Nursing to the reviews were overwhelmingly positive., Conclusion: Recommendations arising from multidisciplinary case conferences were carried out to the benefit of patients and carers. Given the support shown by key stakeholders, multidisciplinary conferences should be used more.

Objective: This study aims to reveal whether a short training course of problem-based pharmacotherapy teaching, based on the World Health Organization's (WHO's) Guide to Good Prescribing and the Yemen Essential Drug List and Standard Treatment Guidelines, will improve the competence of rational prescribing among medical and health assistant students in Yemen., Design: In a controlled pre/post-test study, 111 students from universities and health institutes participated on a voluntary basis. They were randomly separated into a study and a control group. Students of the study group were taught to generate standard first-choice drugs for asthma or diarrhoea. The students were then taught how to apply this set of first-choice drugs to specific patient problems, using the WHO six-step problem-solving approach., Results: Students from the study group performed significantly better than those from control in all problems presented and also when compared with the results of the pre-test. The results of the pre-test also show that teaching students all basic knowledge about drugs does not guarantee rational prescribing in Yemen., Conclusion: It can be concluded from this study that proper training, i.e. 'immunising' future doctors using problem-based pharmacotherapy teaching, is an efficient way of teaching rational prescribing in Yemen.

Objectives: Thirty years ago, a drug therapy consultation service centre was established simultaneously with the Institute of Clinical Pharmacology based at the university hospital in Magdeburg. The combination of therapeutic drug monitoring and a drug information service including individual patient-oriented drug dosage and bedside consultation permits an effective support of the treatment of drug related therapeutic problems. Currently, the service offers drug monitoring for 161 drugs and additional 46 metabolites., Methods and Discussion: In a representative 2-year period (1997-1998), drug monitoring was performed for 6293 patients, and 569 drug-related inquiries were answered. The main categories of required drug information were: pharmacokinetics/metabolism/analytical problems (38%), adverse drug reactions/drug safety (24%), therapeutic drug use/drug indication (21%) and pharmaceuticals (9%). Further activities of the institute refer to teaching of undergraduates, continuing education of local physicians in recent aspects of drug therapy, providing therapeutic bulletins and conducting supporting clinical studies.

Background: Two sets of drug sales data, published by the Icelandic Ministry of Health, did not match for antibacterials in 1989. The search for causes turned out to be a project in itself., Objective: To analyze quality problems in the sales data on antibacterials and describe a method for systematic quality assessment of drug sales data., Methods: Documentary analysis based on the following sources: 1) Nordic Statistics on Medicines, 1975-95; 2) Drug Use (Notkun Iyfja), 1975-93; 3) Icelandic Drug Market, 1975-94; 4) Unpublished data from the Icelandic Ministry of Health. The following framework was developed to evaluate the quality of drug sales data: 1. Completeness of registration; 2. Accuracy and degree of completeness of data; 3. Size and coverage of the data source; 4. Data format; 5. Data accessibility, availability and cost., Results: Four discrepancies were found, two due to changes in DDD, and two larger ones stemming from errors in calculating DDD, resulting in an overestimation of the contribution of the respective products to the total DDD/1000 inhabitants/day. Errors were detected in available sales data at least back to 1980, resulting in sales being overestimated by up to 13%. The reasons for the discrepancies were found mostly under point 2 in the framework., Conclusion: The errors uncovered by this study indicate a possible low quality of drug statistics which might lead to wrong conclusions about the level and development of sales of drugs. As a tool, the framework might be used for quality assessment of drug sales data.

As a first step toward obtaining quality assurance regarding use and handling of drugs at Malmö University Hospital, a problem detection study (PDS) was performed, drug related problems being collected from nurses, physicians and pharmacists. Problem questionnaires relevant for physicians (67 items) and nurses (82 items) were prepared and sent to chief physicians and head nurses for distribution to colleagues. The problems identified covered all aspects of drug use and handling such as availability, prescription, dispensing, information and monitoring. Fifty-six per cent (79/141) of the physicians and 68 per cent (88/130) of the nurses responded. The main problems were related to information, chart order sheets and follow up. The item 'Uncertain whether patients take their medicine correctly after discharge' scored highest among physicians. The two main problems for the nurses were that 'newly licensed drugs and drugs used on a named-patient basis are not included in FASS' (the Swedish national formulary). The problem detection technique proved useful for the identification of drug-related problems, and the results will provide a basis for further improvement in quality assurance in pharmacotherapy at the hospital.

In many countries, prescription data are used as an instrument to provide feedback on prescribing. This article describes the development and implementation of a computer program as a tool for pharmacotherapy audit meetings and it illustrates the possibilities of such a program. The program was developed to support the optimisation of prescribing in the various stages of behavioural change. It enables pharmacists to make sophisticated overviews of prescribing by physicians in their audit group and furthermore, pharmacists can conduct drug utilisation studies or pharmaco-epidemiological studies in their own patient population. Forty percent of Dutch pharmacies have purchased the computer program since its introduction; it was distributed together with a technical handbook and a course book, which elaborated on the types of graphs available and their interpretation. An educational course was developed regarding the optimal selection and interpretation of graphs. Examples of prescription data as a tool to support various aims of audit meetings are given. The program is acknowledged as a welcome contribution to pharmacotherapy audit and to the pharmacists' advisory role in pharmacotherapy.

This article discusses how prescription data that are available from pharmacies can be used as a tool to support the improvement of prescribing behaviour. For the optimal use of prescription data in pharmacotherapeutic audit, the specific aim of the audit meeting must be clear. Next, appropriate measures (quality of drug choice, volume, cost) have to be selected for the presentation and discussion of prescribing. For several aims of audit meetings, suggestions for adequate measures are given. For each stage of behavioural change the article describes why and how prescription data can provide a useful contribution. Finally, recommendations are given regarding prerequisites for the optimal use of prescription data. Important factors are that the prescription data should sufficiently cover the physicians' patient population, information regarding the extent of repeat prescribing is needed, and the prescribing of drugs with multiple indications can cause difficulties with the interpretation of the graphs. With this information in mind, feedback on prescribing can be tailored to the audit groups' needs and targeted to the intervention that is pursued.

A survey regarding the management of rational pharmacotherapy was conducted among all Dutch general hospitals in 1998. The response was 99% (n = 120). The presence of a drugs and therapeutics committee and antibiotic policies in Dutch general hospitals appears independent of hospital characteristics. However, formulary agreements and treatment guidelines are less likely to be present in hospitals that employ only 1 pharmacist or those served by community pharmacies. More than half of the hospitals claim to have restrictive formulary agreements. Large hospitals, hospitals in the eastern and southern provinces and those served by hospital pharmacies more often tend to have restrictive agreements compared to small hospitals, hospitals in the northern, central, and western provinces, and those served by community pharmacies. Various methods to impose restriction and ensure formulary compliance are mentioned. It must be noted that hospitals tend to operate rather solely regarding the large number of different formularies. Surprisingly just a small majority of pharmacists evaluates formulary agreements positively as a management tool. Many drawbacks appear to be present. The results of this survey indicate that in the future Dutch hospitals will favour disease management (treatment guidelines) over drug management (formulary agreements) in the management of rational pharmacotherapy and that information technology will be used to influence clinicians' prescribing behaviour.

Drug-treatment failures can be prevented by applying a Pharmaceutical Care system. Therapeutic outcome monitoring is such a system, which can be applied to the (drug) treatment of several diseases like asthma, diabetes and cardiovascular diseases. Pharmaceutical Care is an outcome oriented, cooperative, systematic approach to providing drug therapy directed at the improvement of all dimensions of health related quality of life.

This study presents estimates of the prevalence of perceived needs and unmet needs among people with HIV disease in the United States for six areas of community services: mental health, drug treatment, home care, housing, transportation, and entitlements. The prevalence of service needs and unmet needs within racial, gender, drug use history, and other subgroups was also examined. The study is based on a nonrandom cross-sectional sample of 907 people with HIV disease interviewed between November 1988 and May 1989 in nine major urban areas of the United States. Respondents reported high levels of need and unmet need across a variety of service areas. One third or more of all respondents reported a need for mental health services (57%), housing (39%), entitlements (34%), and transportation (32%). Within each of the six service areas, 40% or more reported unmet need. Women, people of color, and injected drug users were more likely to report unmet service need in a number of areas. Given the limitations of the sampling and the focus on current needs, these estimates may represent a lower bound on the magnitude of service need and unmet need within this population.

A group of senior European clinical pharmacologists presents a position paper on the possible role of clinical pharmacology (CP) in bridging the gap between academic drug evaluation and drug prescribing in primary health care (PHC). As a teaching, research and service discipline CP has developed in academic or other major hospitals while 80% of all drugs are prescribed in PHC. CP therefore has to extend its functions to PHC. Examples are given of how joint ventures between clinical pharmacologists and PHC physicians may improve the quality of drug research and increase the clinical relevance of drug information in PHC, thereby contributing towards rational drug utilization in PHC. Colleagues in PHC are invited to respond to this call for collaboration.