admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Preamble and Transition to ACC/AHA Guidelines to

The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases (CVDs); improve the management …

/pdf/2013-aha-acc-guideline-on-lifestyle-management-to-reduce-4cwv0mif24.pdf

2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk

Practice Guideline2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines☆

The purpose of this review was to estimate the extent of under-reporting of adverse drug reactions (ADRs) to spontaneous reporting systems and to investigate whether there are differences between different types of ADRs. A systematic literature search was carried out to identify studies providing a numerical estimate of under-reporting. Studies were included regardless of the methodology used or the setting, e.g. hospital versus general practice. Estimates of under-reporting were either extracted directly from the published study or calculated from the study data. These were expressed as the percentage of ADRs detected from intensive data collection that were not reported to the relevant local, regional or national spontaneous reporting systems. The median under-reporting rate was calculated across all studies and within subcategories of studies using different methods or settings. In total, 37 studies using a wide variety of surveillance methods were identified from 12 countries. These generated 43 numerical estimates of under-reporting. The median under-reporting rate across the 37 studies was 94% (interquartile range 82-98%). There was no significant difference in the median under-reporting rates calculated for general practice and hospital-based studies. Five of the ten general practice studies provided evidence of a higher median under-reporting rate for all ADRs compared with more serious or severe ADRs (95% and 80%, respectively). In comparison, for five of the eight hospital-based studies the median under-reporting rate for more serious or severe ADRs remained high (95%). The median under-reporting rate was lower for 19 studies investigating specific serious/severe ADR-drug combinations but was still high at 85%. This systematic review provides evidence of significant and widespread under-reporting of ADRs to spontaneous reporting systems including serious or severe ADRs. Further work is required to assess the impact of under-reporting on public health decisions and the effects of initiatives to improve reporting such as internet reporting, pharmacist/nurse reporting and direct patient reporting as well as improved education and training of healthcare professionals.

Under-reporting of adverse drug reactions : a systematic review.

Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease

[Juvenile temporal arteritis: a benign disease].

Successful treatment of Actinobacillus actinomycetemcomitans endocarditis with ofloxacin.

Abcès des parties molles à Mycobacterium fortuitum par inoculation iatrogène chez une patiente immunocompétente

To the Editor: Second-line therapy of primary immune thrombocytopenia (ITP) is based on splenectomy or rituximab (1–3). French guidelines recommend pneumococcal vaccination for both treatments (3). Indeed, the risk of overwhelming infection in unselected asplenic patients is well documented. Streptococcus pneumoniae is the main cause with a high mortality rate (4). By contrast, the risk of S. pneumoniae infection in patients treated with rituximab is not well described although it seems to be quite low during the first year of follow-up (5). Pneumococcal vaccination prevalence has not been assessed in ITP patients treated with rituximab. The objective of this retrospective study was to assess the prevalence of this vaccination in a cohort of ITP patients exposed to rituximab or splenectomy. We selected all the patients splenectomized in our University hospital from 1997 to 2010 thanks to the request in the Programme de M edicalisation des Syst emes d’Information (PMSI). The PMSI records administrative data and the International Classification of Diseases (ICD) codes related to every hospital stay. All hospital stays encoded as ITP and with splenectomy performed in our hospital were selected. The ITP patients exposed to rituximab were selected using the computerized register of drug dispensing by the Pharmacy Department of our hospital from 2002 to mid-2011. The medical files of all these patients were then reviewed to confirm the diagnosis according to the international definition (1) and to search for antipneumococcal vaccine prescription. The patients and their general practitioners were also contacted by phone in August 2012 to assess whether they had been exposed to this vaccine before or after splenectomy or first rituximab infusion. Hospital stays for pneumonia were also colligated. We build a cohort of 105 patients, including 62 splenectomized patients and 43 patients treated with rituximab. These were older (mean, 66.5 18.5 vs. 38.5 14.1 years) and had more comorbidities (data not shown). Antipneumococcal vaccination was unknown or doubtful in 13 splenectomized and in six rituximab-treated patients. Among the remaining patients, the prevalence of vaccination was 77.5%, 95% CI (65.8–89.2) in the splenectomized group and 32.4%, 95% CI (17.3–47.5) in the rituximab-treated group (P < 0.001). Five patients experienced bacterial pneumonia leading to hospitalization after rituximab (median follow-up: 3 years), which occurred on average 14.8 months after the first rituximab infusion. Three of them had not been vaccinated against S. pneumoniae (this information was not available for the two others). The prevalence of vaccination was good among splenectomized patients group. It was comparable to that observed in previous studies (6, 7). By contrast, it was low in rituximab-treated patients. This indicates that clinicians may not be conscious or convinced of an increased risk of pneumococcal infection after rituximab. The relatively high frequency of pneumococcal infections in old or comorbid patients exposed to rituximab deserves confirmation. Although these pneumonia were not microbiologically documented and immunoglobulins were not measured at the time of the adverse events, this should encourage to pay more attention to the guidelines for the prevention of infections after rituximab.

Prevalence of pneumococcal vaccination in adult immune thrombocytopenia patients exposed to rituximab or to splenectomy.

Validation of hemolytic anemia discharge diagnosis codes in the French hospital database.

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