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Am Fam Physician. 2000;62(7):1702-1708

Call for Use of Handheld Prescribing Technology

In a new discussion paper, the Institute for Safe Medication Practices (ISMP) calls for the widespread use of handheld prescribing technology as a way to prevent dangerous medication errors that result from illegible handwritten prescriptions. The recently published discussion paper, titled “A Call to Action: Eliminate Handwritten Prescriptions Within 3 Years,” urges the health care community and everyone in public policy circles to help implement widespread use of the handheld prescribing technology by 2003.

The ISMP discussion paper provides an overview of the benefits, drawbacks and cost and technology considerations of using handheld technology to address prescribing errors. The paper also includes references, a resource list and suggested additional reading.

This 12-page discussion paper is the first in a series of educational “White Papers” that are being issued by the ISMP to address various topics on medication error prevention.

The ISMP is a nonprofit organization that provides independent review of medication errors reported through the United States Pharmacopoeia Medication Errors Reporting Program. Through this program, health care professionals can confidentially report actual and potential medication errors by calling 800-23-ERROR (800–233–7767).

For more information on the prevention of medication errors, write to the ISMP, P.O. Box 328, Fulton, MD 20759-0328, or call 301–497–2375. The document will also be available on the ISMP Web site at

New Patient-Administered Hemoglobin A1c Test

A new test kit for monitoring levels of glycosylated hemoglobin (HbA1c) may make testing easier for patients with diabetes. The BioSafe HbA1c test kit allows patients to collect their own blood sample for laboratory analysis and physician interpretation. The test uses a proprietary method of re-hydrating dried blood samples to produce readings as accurate as tests conducted with liquid samples, according to the manufacturer.

Patients use the kit's finger lancet to collect blood while routinely checking their blood glucose levels. After three drops of blood are put on a collection card, the patient drops the card into a specially sealed packet and mails it in the postage-paid envelope to the BioSafe laboratory for analysis. The results of the test are forwarded to the patient's physician, who interprets the results and adjusts treatment protocols accordingly.

The manufacturer of the test kit cites recommendations of the American Diabetes Association that anyone with diabetes have an HbA1c test at least twice a year. According to the manufacturer, the majority of persons with diabetes are not using HbA1c testing, which is one of the best ways to determine overall blood glucose control. The manufacturer believes that the BioSafe HbA1c test kit will make testing more convenient and patients more compliant. The cost of the kit is covered by most insurance plans.

For more information on the BioSafe HbA1c test kit, visit the BioSafe Web site at

Rates of Physical Activity Among Employed Adults

A report in the May 19, 2000 issue of Morbidity and Mortality Weekly Report examined the prevalence of regular physical activity among working adults. The report is a summary of the results from the 1990 National Health Interview Survey (NHIS).

To determine the prevalence of leisure-time and occupational physical activity, researchers collected data on 20,766 employed civilian adults 18 years and older. Survey respondents were asked to identify the frequency and duration of their participation in 24 sports and conditioning activities during the two weeks before the survey. They were also asked to record the number of hours per day they spent doing hard physical labor on the job. Leisure-time physical activities were scored on intensity, frequency and duration of effort.

According to the report, during leisure-time about 63.9 percent of employed adults in the United States do not meet current recommendations for participation in moderate or vigorous physical activity. Researchers also found that women, older adults, persons with fewer than 12 years of education and ethnic/racial minorities are most likely to be inactive during leisure time. However, many persons from groups that are sedentary during leisure time may be getting sufficient occupational physical activity.

According to the researchers, the findings are subject to at least four limitations: (1) estimates are based on self-reported activity and may be overestimates; (2) recall of the 24 types of leisure-time physical activity may have resulted in under-reporting if seasonal or irregular activities were not performed during the two-week period; (3) this study does not provide information on other sources of physical activity, such as transportation or housework, which may be disproportionately higher in certain groups such as women and minorities; and (4) questions about occupational physical activity have not been asked since the 1990 NHIS, and the level of physical activity during work may have changed during the past decade.

AAP Statement on Safety in Youth Ice Hockey

According to the Committee on Sports Medicine and Fitness of the American Academy of Pediatrics (AAP), approximately 200,000 children in the United States play ice hockey. The AAP has classified ice hockey as a collision sport because of the intentional body contact, called checking, that occurs. Because body checking can occur at high speeds, the AAP warns that participants are at risk for serious injury. In response, the AAP committee has issued a statement on safety and the effects of body checking in youth ice hockey. The AAP policy statement appears in the March 2000 issue of Pediatrics.

The AAP committee cites recent studies of youth hockey that show high-speed collisions, size disparities within age groups and a false sense of security from the use of protective equipment have all contributed to an increase in checking-related injuries.

In the statement, the AAP committee discusses a concept called fair-play that was created for improved sportsmanship and reduction of injuries in youth hockey. The concept is used in scoring ice hockey games to reward teams and individual players with few penalties and punish teams and players with larger numbers of penalties. The potential benefits of the fair-play concept were compared with use of regular rules in a recent study of a youth hockey tournament. The participants were all younger than 20 years. The researchers found that the injury rate was four times higher during the portion of the tournament when regular rules were used, compared with the injury rate during the portion of the tournament when the fair-play concept was in place.

To enhance safety among participants in youth ice hockey, the AAP committee makes the following recommendations:

  • Body checking in youth hockey should not be allowed for children 15 years or younger.

  • Programs that promote good sportsmanship, such as the fair-play concept, have been shown to reduce injury and penalty rates and should be adopted for all levels of youth hockey.

  • Youth hockey players, parents and coaches should be educated about the importance of knowing and following the rules, as well as the dangers of body checking another player from behind.

Updated Guide for Older Adults on Medication Use

The Council on Family Health (CFH) reports that the use of multiple medications, a greater prevalence of chronic health conditions and normal body changes caused by aging can increase the likelihood of potential medication problems for the elderly. In response, the CFH has updated its 1991 educational guide for older adults on safe and responsible use of medication.

“Medicines and You: A Guide for Older Americans” is a 15-page booklet that provides practical information for older adults about the use of prescription and nonprescription medications. The booklet includes facts about drug interactions, tips for talking with health care professionals and ideas on how to lower drug costs. The guide also features “My Medicine Record,” a chart on which older adults can record the medications they use and other relevant health information.

The CFH has also collaborated with the National Council on Aging to launch a program on the safe use of medication for older adults. The program includes a kit titled “Don't Mix and Match Your Medicines” that is used in workshops on safe and responsible medicine use. The kit provides educational materials for older patients and tools for conducting senior center workshops, such as a poster and bags in which older adults can carry their medications when seeing a physician. The “Medicines and You” guide is also included in the kit.

To obtain a copy of “Medicines and You: A Guide for Older Americans,” send a self-addressed, 6 x 9 stamped envelope to Council on Family Health, “Medicines and You,” 1155 Connecticut Ave., N.W., Ste. 400, Washington, DC 20036, or call 202-429-6600. “My Medicine Record” and a tip sheet on the safe use of medication for older adults are available on the CFH Web site at For more information about the workshop kit, call 877-390-7828.

ACC/AHA Pocket Guidelines on Acute MI and Chronic Stable Angina

The American College of Cardiology (ACC) and the American Heart Association (AHA) have collaborated recently on a new series of pocket guidelines to provide physicians with a quick reference to the diagnostic and therapeutic recommendations contained in the ACC/AHA practice guidelines.

The latest ACC/AHA pocket guidelines, “The Management of Patients with Acute Myocardial Infarction” and “The Management of Patients with Chronic Stable Angina,” are the third and fourth set of publications in the ACC/AHA series. The ACC and AHA are also releasing pocket guidelines on valvular heart disease, coronary artery bypass graft surgery and unstable angina.

“The Management of Patients with Acute Myocardial Infarction” includes an introduction and sections on initial assessment and evaluation, initial management, hospital management, summary of myocardial infarction management and preparation for discharge from the hospital. Algorithms and a sample patient education form are also included.

“The Management of Patients with Chronic Stable Angina” is divided into an introduction and sections on clinical assessment, stress testing and angiography, treatment and patient follow-up. The pocket guideline also features algorithms, tables and a treatment mnemonic.

Copies of the pocket guidelines are available by calling the ACC Resource Center at 800-253-4636, ext. 694, or 301-897-5400, ext. 694.

Pemirolast for Allergic Conjunctivitis

The U.S. Food and Drug Administration (FDA) has approved pemirolast potassium (Alamast) ophthalmic solution 0.1 percent, a new ocular allergy medication indicated for the prevention of itching associated with allergic conjunctivitis. Approximately 20 percent of persons in the United States have allergies, about 50 percent of whom require ocular medication for the relief of allergic symptoms.

Pemirolast is a mast cell stabilizer that inhibits the antigen-induced release of inflammatory mediators that are involved in the allergic process.

In clinical studies, side effects of pemirolast included foreign body sensation (2 percent), burning/stinging (1 percent), dry eye (1 percent) and ocular discomfort (1 percent). The manufacturer suggests that patients who wear soft contact lenses and whose eyes are not red should wait at least 10 minutes after using pemirolast before inserting contact lenses.

ATS Statement on Health Effects of Air Pollution

The Assembly on Environmental and Occupational Health of the American Thoracic Society (ATS) has updated its 1985 official statement on what constitutes an adverse health effect of air pollution. ATS has revised the statement because new scientific findings have raised questions as to the boundary between adverse and nonadverse health effects of air pollution. The revised statement appears in the February 2000 issue of the American Journal of Respiratory and Critical Care Medicine.

The new statement is intended to provide guidance to policy makers and others who interpret the scientific evidence on the health effects of air pollution for the purpose of risk management. The statement proposes principles to be used when weighing evidence and setting boundaries between adverse and nonadverse health effects.

In preparing the statement, the ATS committee identified the following general considerations for interpreting evidence on the health effects of air pollution: population health versus individual risk, ethics and equity, economic costs, susceptibility and heterogeneity of perspectives.

Based on the dimensions of adverse effects, the ATS committee makes the following recommendations:

Biomarkers. Biomarkers were examined as indicators of exposure, effect or susceptibility. Few of the many biomarkers have been sufficiently validated to allow them to be used to determine adverse effects that warrant preventive measures.

Quality of Life. Decreased health-related quality of life caused by pollution should be accepted as an adverse health effect.

Physiologic Impact. Reversible loss of lung function in combination with the presence of symptoms should be considered adverse; any detectable level of permanent lung function loss attributable to air pollution exposure should be considered adverse.

Symptoms. Air pollution-related symptoms associated with diminished quality of life or with a change in clinical status should be considered adverse.

Clinical Outcomes. Detectable effects of air pollution on clinical measures should be considered adverse.

Mortality. Any effect on mortality should be considered adverse. Consideration should be given to the extent of life-shortening that underlies the association.

Population Health Versus Individual Risk. Assuming that the relationship between the risk factor and the disease is causal, a shift in the risk factor distribution, and hence the risk profile of the exposed population, should be considered adverse, even in the absence of the immediate occurrence of frank illness.

AAP Policy on Pediatric Emergency Care

The Committee on Pediatric Emergency Medicine of the American Academy of Pediatrics (AAP) has issued a policy statement on access to pediatric emergency medical care. The policy statement appears in the March 2000 issue of Pediatrics.

Every day in the United States, thousands of children and adolescents seek emergency care. However, many of these young persons must face significant barriers that limit access to emergency care, at times resulting in significant morbidity. According to the AAP committee, long standing issues related to these barriers include the following: lack of universal understanding and application of a definition of “emergency”; lack of third-party payment for medical care; lack of reasonable access to alternative sources of health care until the emergency department is left as the only place that will see everyone; the misconception that freestanding urgent care centers provide comprehensive emergency services; variability in pediatric training and experience among physicians in the emergency department; and lack of access to pediatric emergency medical care in rural areas.

The first AAP policy on access to emergency medical care was published in 1992. Since that time, the following substantial advances have occurred:

  • Significant increase in emergency medicine residency programs that include pediatric emergency training.

  • Improvements in pediatric training and experience for emergency department residents.

  • Increasing dissemination of pediatric emergency education courses, including requirements by some hospitals that certain of these courses be studied to practice in the emergency department.

  • Improvements in pediatric education for emergency medical technicians.

  • Increased availability of physicians with specific training and certification in pediatric emergency care.

The AAP committee states that all children should have access to emergency care and recommends that local, state and federal agencies guarantee prompt and appropriate access to pediatric emergency care for all children and increase public awareness about the magnitude of the barriers to such access.

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