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PRECIOUS HEARTS ROMANCE
Dugtong, dugtong, dugtong...

Ang nakaraan... Si DOC ay nagsabing bibilhan nya ng t-back si AMOR at nang naglao'y napagpasyahan nilang gumawa ng iskrapbuk kung saan ilalagay sana nila ang resibo ng kanilang mga dates nang maalala ni DOC ang kanyang kakuriputan sa waiter nang di nya ito nabigyan ng TIP

CHAPTER III: KILIG-LIGO – At nagpapaalam na si DOC na maligo, nang gusto nyang halikan si AMOR… at nagkaroon nga ng matagalang “laway award” ceremony sa XAT…

…at ang mga malalambot at mala-porselanang mga kamay ni AMOR, na tila isang prinsesa sa paningin ni DOC

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Chaka Moments

LOVE BIRDS EDITION

PRECIOUS HEARTS ROMANCE

…at si doc ay sinapian ng kanyang pagka-menyek

***snapshot missing***

lafangga: buti ka pa meh alam mo ung ireregalo mo sakin

lafangga: ako hirap ako makahanap ng gift sau

amorgatory: kasi nagkukwento ka deh

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CHAKA MOMENTS REVIVED AFTER A DECADE OF MILLENNIA

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August 25 Lecture 1 Part 1 Intravenous Therapy

August 25 Lecture 1 Part 2 Intravenous Therapy

August 25 Lecture 1 Part 3 Intravenous Therapy

September 1 Lecture 2 Part 1 Central Venous Therapy

September 1 Lecture 2 Part 2 Central Venous Therapy

September 8 Lecture 3 Part 1 Perioperative Nursing Skills

September 8 Lecture 3 Part 2 Perioperative Nursing Skills

September 15 Lecture 4 Oxygen Therapy

September 22 Lecture 5 Tracheostomy Care

September 29 Lecture 6 Chest Tubes

October 6 Lecture 7 Part 1 Cardiac Dysrhythmias 1

October 6 Lecture 7 Part 2 Cardiac Dysrhythmias 1

October 13 Lecture 8 Part 1 Cardiac Dysrhythmias 2 & Pacemakers

October 13 Lecture 8 Part 2 Cardiac Dysrhythmias 2 & Pacemakers

October 20 Lecture 9 Part 1 Enteral Nutrition & Diagnostic Tests

October 20 Lecture 9 Part 2 Enteral Nutrition & Diagnostic Tests

October 27 Lecture 10 Care of the Orthopedic Client

November 3 Lecture 11 Part 1 Blood Transfusion Therapy

November 3 Lecture 11 Part 2 Blood Transfusion Therapy Monday Lectures

September 12 Lecture 2 Part 1 Central Venous Therapy

September 12 Lecture 2 Part 2 Central Venous Therapy

September 12 Lecture 2 Part 3 Central Venous Therapy

September 19 Lecture 3 Part 1 Perioperative Nursing Skills

September 19 Lecture 3 Part 2 Perioperative Nursing Skills

September 26 Lecture 4 Oxygen Therapy

October 3 Lecture 5 Tracheostomy Care

October 10 Lecture 6 Part 1 Chest Tubes

October 10 Lecture 6 Part 2 Chest Tubes

October 24 Lecture 8 Cardiac Dysrhythmias 2 and Pacemakers

October 31 Lecture 9 Enteral Nutrition and Diagnostic Tests

November 7 Lecture 10 Care of the Orthopedic Client

November 14 Lecture 11 Part 1 Blood Transfusion Therapy

November 14 Lecture 11 Part 2 Blood Transfusion Therapy

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When it comes to eating healthy most people think of dull, boring food that's green in color. In reality, most of the world's healthiest foods not only taste great, they also come in a vast array of vibrant colors. Many require little, if any preparation, yet provide you with the energy and stamina to get through the day. They are the ultimate fast food!

Although fresh, whole fruits and veggies are amongst the world's healthiest foods, it's also important to consume an assortment of grains, nuts, seeds and foods rich in essential fatty acids. Experts recommend consuming a daily total of 3-5 servings of vegetables, 2-4 servings of fruit, 6-11 servings of grains, and 1-2 servings of nuts and seeds.

One serving of vegetables is equivalent to1/2 cup cooked or chopped raw vegetables, or 3/4 cup vegetable juice, or 1 cup of raw leafy vegetables (cabbage, lettuce, collard greens). One serving of grains equals 1/4 cup of cooked grains. A serving of nuts and seeds equals one ounce or approximately two tablespoons sunflower seeds or 12 whole almonds.

Essential fatty acids are obtained through a variety of fruits, vegetables, nuts, seeds and grains. Daily intake should be between 1 and 3 grams. The omega-3 and omega-6 oils are the essential fatty acids. There are omega-9 oils, but these are not essential because the body can produce them naturally.

Omega-3 and omega-6 oils must come from your diet because the body cannot make them. Not only must you consume both oils, you must consume them in the proper balance. The human brain contains omega-3 and omega-6 in a ration of 1:1. Unfortunately, the typical American diet has most people consuming the omegas at a 1:10 ratio.

Foods rich in omega-6 EFAs include vegetables, fruits, nuts, seeds and grains. Foods rich in omega-3 EFAs include flax seeds, pumpkin seeds, green leafy vegetables, grains, and spirulina.

Scientific research has shown eating a balanced diet provides a host of benefits. Eating healthy foods can provide you with more energy, brain clarity, less aches and pains, restful sleep and more.

Here you will find twenty of the world's healthiest foods and the health benefits they provide. Start by adding one new food each day. In just 20 days you will be well on your way to a healthier you!

FRUITS:

Apricots: These beauties are rich in the antioxidant beta carotene; the molecule that gives fruits and vegetables their orange color. Apricots also contain an abundant supply of iron and potassium. They help regulate blood pressure and maintain regular bowel function. If you ever experience constipation, eat an apricot!

One fresh apricot or a handful of dried apricots, provide an adult with one-fifth of the daily recommended value of potassium. It also packs a whopping 20 percent of the RDA of vitamin A, 8 percent vitamin C, and 5 percent fiber. Apricots contain tryptophan, which helps to induce sleep and relaxation.
Avocados: Oftentimes, people shy away from avocados because of their fat content. However, avocados contain "good" fat and are rich in vitamins C, E, and B6. They are also a good source of potassium.

Studies have shown avocados possess the ability to reduce cholesterol. Individuals diagnosed with atherosclerosis (hardening of the arteries) can obtain health benefits by consuming two to three avocados per week. Avocados are high in calories, so limit weekly consumption to a maximum of three.

Bananas: Need a quick energy boost? Eat a banana. This delectable fruit contains only 62 calories and is rich in potassium and vitamin B6. It also boasts a healthy dose of vitamin C and dietary fiber. Look for bananas which are fully ripened because they contain more starch than "green" bananas. Banana starch is converted to sugar, making this fruit a good choice for people with hypoglycemia (low blood sugar).

Bananas are probably one of the most versatile health foods available. They can be eaten with every meal, as a snack or dessert. You can add them to frozen yogurt or a fruit salad. They can be grilled, broiled, sautéed or flambéed. One of my all-time favorite banana recipes is to insert a popsicle stick into a banana, coat in melted carob, roll in chopped nuts and freeze. There's nothing better on a hot summer night!

Blueberries: This tart berry has been shown to reduce inflammation; making blueberries a good choice for individuals with arthritis and other inflammatory diseases. Research shows that eating thirty blueberries per day can help alleviate aches and pains in the joints.

In addition to being an anti-inflammatory fruit, blueberries also offer anti-blood clotting and antibacterial effects. They can help ease the pain associated with diarrhea or food poisoning. Blueberries contain the highest level of antioxidants and are said to possess anti-aging properties.

One cup of blueberries contains less than 100 calories, yet provides nearly 30 percent of the RDA for vitamin C, 10 percent vitamin E, and 15 percent dietary fiber. They can be added to cereal, oatmeal, fruit salads, and yogurt or eaten plain. Add dried blueberries to granola and eat as an afternoon snack for a quick-pick-me-up.

Mangoes: Mangoes contain beta-cryptoxanthin, a potent antioxidant that prevents free radicals from damaging your cells and DNA. Recent studies have shown that mangoes may help to reduce the risk of colon and cervical cancer. Mangoes are rich in beta carotene, which is converted to vitamin A within the body. It's important to note that beta-cryptoxanthin is best absorbed by the body when eaten with fat. For best results, consume mangoes as part of a meal.

Mango salsa makes an excellent companion with chicken and pork. They add a tart, yet sweet flavor to fruit salads and smoothies. Mangoes can be frozen, but be certain to remove the skin and core and store in a freezer bag.

VEGETABLES:
Artichokes: This odd-looking vegetable is fat-free, a good source of complex carbohydrates, and contains fructooligosaccharides (FOS), a non-digestible fiber. The human body does not possess the enzymes required to break down FOS. However, bacteria found in the large intestine and colon does contain the enzymes. For this reason, artichokes are beneficial to people who experience bowel problems.

Artichokes are a good source of iron, potassium, magnesium, copper and manganese. They provide nearly 20 percent of the RDA for vitamin C, 23 percent of vitamin K and 17 percent folate.One artichoke contains around 76 calories.

Broccoli: Research has proven broccoli has the potential to prevent cancer. That fact alone should make you want to eat it on a daily basis. Broccoli has also been proven effective in lowering the risk of heart disease and stroke.

Broccoli is rich in beta carotene, calcium, iron, folate, vitamin C and E, and zinc. Broccoli contains about 15 percent of tryptophan; an essential amino acid that aids in sleep and relaxation. Eat this food throughout the day and for an evening snack to keep your nerves calm and to obtain a peaceful sleep.

Garlic: One of the most notable benefits of garlic is its ability to reduce blood pressure. Garlic is also known for its antibacterial properties, which can reduce the risk of infection and illness. Recent studies show garlic may also help reduce the risk of heart disease and cancer.

At only 9 calories per clove, it is a perfect vegetable for those watching their weight. Garlic is a good source of manganese, vitamin B6, vitamin C and calcium. Garlic can be eaten raw, added to nearly every recipe, or baked for a delicious garlic spread. Garlic salt or garlic powder can be used as a salt substitute.

Onions: Not only are onions a good source of fiber, potassium, and B vitamins, they also possess anti-inflammatory and anti-cancer properties. Research indicates onions may help to reduce the risk of heart attack and stroke, and relieve bronchial congestion.

At only 36 calories per medium-sized onion, these flavorful veggies can be abundantly consumed on a daily basis. Raw onions provide the highest level of health benefits. Add a splash of extra virgin olive oil to onion slices and toss on the grill. Fresh herbs and spices can be added for an extra punch of flavor.

Tomatoes: Perhaps one of the most versatile vegetables is the tomato. It can be eaten raw, cooked, steamed, grilled, baked, juiced, or pureed. Tomatoes are compatible with nearly every type of food including meats, vegetables, potatoes and rice.

One tomato contains a mere 17 calories, making it an excellent choice for those following a weight management program. Tomatoes contain a high level of antioxidants and are a good source of vitamins C and E. Just one cup will provide you with more than 50 percent of the RDA of vitamin C, 20 percent of vitamin A and 15 percent of vitamin K. Tomatoes also contain lycopene, a phytochemical known to reduce the risk of heart disease.

GRAINS

Barley and rye: These grains are high fiber whole grains and contain five times more fiber than any other whole grain. Studies show barley can slow the progression of atherosclerosis and may lower the risk of type 2 diabetes. It is believed these grains reduce estrogen levels, help prevent the risk of heart disease, and stabilize blood sugar levels.
Barley and rye are both good sources of potassium and fiber. They contain small amounts of iron, Pantothenate, vitamins B1 and B6, and zinc. One cup of cooked grains contains 270 calories. These grains are a good choice for dinner, as they are high in tryptophan and can aide in restful sleep.

Oats: Starting your day off with a bowl of steaming oats can provide you with energy and brain clarity. Studies have shown eating oats on a daily basis can help to lower blood cholesterol. Oats also have the ability to stabilize blood sugar levels and maintain regular bowel function.

Oats are a good source of fiber, magnesium, zinc, and vitamin E. One cup contains less than 150 calories, making it an excellent choice for those who are watching their waistline.

Quinoa: Pronounced keen-wa, and known as the "Mother of all Grains", this grain contains more protein than any other. Quinoa is an excellent source of manganese, magnesium, iron, and copper. It is a light grain that can be substituted for rice or pasta and makes a nice addition to soups and stews.

Rice: Rice is a good source of both magnesium and potassium. It also contains fiber, iron, niacin, vitamins B1 and B2, and zinc. Rice provides a quick energy boost and is easily digested. Rice helps to maintain bowel health and stabilizes blood sugar levels. There are many varieties of rice including white, brown, basmati, jasmine and saffron.

Wheatgerm: This super grain has been used for centuries to relieve constipation. Studies show wheatgerm supports the heart and may reduce the risk of heart disease. It strengthens the immune system and may help maintain cognitive function as we age.

Wheatgerm is rich in antioxidants and folate. It also contains vitamins B1, B6, and E and is a good source of potassium and zinc. It is recommended to consume two tablespoons of fresh wheatgerm on a daily basis. Sprinkle wheatgerm on cereal, oatmeal, fruit salad or yogurt.

NUTS and SEEDS:

Almonds: Classified as a nut, almonds are actually the seed of the fruit of an almond tree. They offer a delicate and mild flavor to dishes and can be added to vegetables, meats, fruits and desserts.

Eating twelve almonds per day can provide you with the recommended daily allowance of essential fatty acids. Almonds are rich in potassium and are considered a "good" fat. These fruit seeds are high in calories, so limit your intake to no more than twelve per day. Unblanched almonds are considered to be the healthiest choice. Avoid dry roasted almonds or almonds covered in sugar, honey or salt.

Brazil nuts: Brazil nuts contain all the essential amino acids, making them a complete protein. Brazil nuts contain exceptionally high levels of selenium; a powerful antioxidant that can help reduce the risk of heart disease and cancer.

Brazil nuts are an excellent source of zinc, which is essential to digestion and metabolism. Brazil nuts contain a high level of fat and should not be consumed more than three times per week. One serving equals eight nuts and is equivalent to 30 grams of fat.

Chestnuts: These nuts pack a wallop of beneficial carbohydrates, making them an excellent choice for people trying to gain weight. Chestnuts are cholesterol-free, low in sodium, and a good source of dietary fiber.
Additionally, chestnuts contain small amounts of vitamin C, thiamine, and riboflavin. Although chestnuts are considered a "good" fat, they should not be consumed more than four times per week. One serving of chestnuts equal five whole nuts. It's best to roast chestnuts at home by baking them at 350 degrees Fahrenheit for approximately 5-6 minutes.

Pumpkin seeds: Research shows pumpkin seeds to be effective in lowering cholesterol levels, promoting prostate health, and supporting the function of the immune system. Pumpkin seeds are a rich source of potassium, omega-3 fatty acids and zinc. One and one-half ounces of pumpkin seeds can provide over one-third of an adult's daily zinc requirements. However, pumpkin seeds are high in calories and should be eaten in moderation. Limit consumption to no more than three times weekly.

Sunflower seeds: One of the most popular seeds consumed, sunflower seeds are rich in vitamin E and known to reduce the risk of heart disease and cancer. Studies have also shown them effective in guarding against cataracts. Experts recommend eating two tablespoons of sunflower seeds each day. Doing so will double your intake of vitamin E. However, they are high in calories and should be eaten in limited quantities.

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Identifying "Triggers"

Several tools and tips are available to help healthcare professionals establish that an ADE has occurred. "Triggers" are surrogate markers suggesting that some unfavorable outcome has occurred with a drug therapy. One of the simplest ways to identify triggers is to review a patient's medication profile and search for any drugs that were recently or abruptly discontinued. Although there are many reasons why a drug might have been discontinued, at least one possibility is that the patient experienced an ADR.

Clinicians also can review a patient's medication profile and look for any new allergies that have been added to the patient's history. For example, if someone is listed as "NKDA" (no known drug allergies) upon hospital admission, but then a new drug allergy is added to the patient's chart during the hospitalization, that would suggest that an adverse event may have occurred, such as an allergic reaction to a prescribed drug.

Similarly, a review of the patient's medication profile may reveal new orders for medications that are antidotes or alternative therapies, which also may suggest that an ADR has occurred. Consider, for example, a patient who is listed as NKDA and who receives the drug piperacillin during a hospital stay. A review of the patient's record reveals that at some point, the piperacillin was discontinued and the drug aztreonam was initiated. The "trigger" here is the switch from one antibiotic to another. Aztreonam is a beta-lactam antibiotic of the monobactam class, and it is used almost exclusively in patients with a beta-lactam antibiotic allergy. In aztreonam, the primary allergenic determinant -- the intact beta-lactam ring -- is "split" by a carbohydrate chain, disallowing for cross-reactivity in patients who are allergenic to that particular intact ring structure.

Table 3 lists some known drug "triggers" that, when added to a patient's orders during a hospitalization, suggest that an ADR has occurred.

Table 3. Drug "Triggers"

Healthcare workers often are hesitant to report potential ADRs if they are not absolutely certain that the drug was the cause of the adverse outcome. Although probability is sometimes difficult to determine, it is important to realize that a 100% certainty is more the exception than the rule. Thus, a degree of uncertainty should not deter the reporting of any event with some type of temporal relationship to a specific drug therapy.

Still, clinical judgment alone may not be sufficient for a clinician to decide whether a drug was the likely cause of a certain adverse event, and in fact, reliance on clinical judgment alone has shown poor correlation with the correct identification of ADRs. Fortunately, there are tools available to augment the clinician's judgment call.

One of the most widely used and validated tools to assess the likelihood that a specific drug is the cause of an ADR is the Naranjo algorithm^[23] (Table 4). This algorithm uses a series of 10 questions, with numerical values assigned to each answer, to determine an overall score for drug-related probability.

Table 4. Naranjo Algorithm*

*Adapted from Naranjo CA, Busto U, Sellars EM, et al. Clin Pharmacol Ther. 1981;30:239-245.

The total score is calculated by adding the scores for each of the 10 questions, and these final scores indicate the likelihood that the event in question was an ADE:

Definite ≥ 9
Probable 5-8
Possible 1-4
Doubtful <>

Along with a probability assessment, an ADE report should provide a meaningful description of the event and its outcome, as well as any contributing or competing factors, and, of course, the patient's medication history. Contributing and competing factors may be present when concurrent disease states or conditions make a patient more susceptible to an ADR. The next case illustrates this concept:

Mr. B is a 68-year-old man with a history of colon cancer. He also has a past medical history that is significant for heart failure and atrial fibrillation. His regular medications include dofetilide 250 mg every 12 hours for atrial fibrillation, furosemide 40 mg once daily, and warfarin 5 mg daily. He also recently received treatment for his colon cancer with 5-fluorouracil (5-FU). A week after this last treatment, he developed significant diarrhea. He continued to take all of his other medications as prescribed. He presents to the emergency department after experiencing new palpitations, and he also exhibits unusual bruises on his extremities. On admission, he is noted to have an INR (international normalized ratio) of 7.5 and a potassium level of 2.5 mEq/L. An EKG reveals a QTc interval of 686 msec with ventricular polymorphism.

After reviewing and analyzing this case, we can conclude that all of Mr. B's conditions are drug-induced. What are the factors involved, and how do they exacerbate each other?

1. Diarrhea is an adverse effect of 5-FU.
2. Diarrhea can lead to hypokalemia and other electrolyte imbalances.
3. Furosemide can lead to hypokalemia, and in the setting of concomitant diarrhea, this effect is augmented.
4. Hypokalemia is a predisposing factor to increase QTc prolongation in the setting of a patient's use of antiarrhythmic agents such as dofetilide.
5. 5-FU also has an interaction with warfarin, increasing INR levels.

In this case, there was no one drug that was responsible for this hospital admission, but rather a series of events involving "side effects" of drug therapies as well as drug interactions, both pharmacokinetic and pharmacodynamic. Communication between patients and clinicians is crucial to identify such adverse effects, and increased monitoring is needed to prevent another drug-induced hospital admission such as this.

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Taking the First Step: Reporting ADEs

As discussed earlier, ADEs are a significant patient safety and public health problem. However, it is possible to use these incidents to improve patient care; the key is reporting them. Reporting is critical not only for postmarket surveillance of drugs, but also for developing a pharmacoepidemiologic surveillance program, at both the institutional and national levels.

It is important to keep in mind that although clinical trials have highly regulated methodologies, they also have significant limitations in defining a drug's safety profile. Because of the sample size used in clinical trials, the only adverse reactions that are usually discovered are those that occur frequently.

For example, if a study enrolls 10,000 patients and not a single patient has a particular serious reaction, one can still only be 95% confident that the likelihood of that reaction occurring in that sample size is less than 1 in 3333.^[16] In order to raise the threshold of safety to a confidence level of 99%, the study would need to involve 46,000 patients^16]; however, clinical trials generally do not enroll that many patients, and even some of the largest clinical trials enroll only 5000-10,000 patients.

An example of how serious drug reactions were not detected in clinical trials can be seen with the drug bromfenac. Bromfenac is an NSAID that was marketed for acute pain and inflammation. During the postmarketing experience, however, a number of adverse events were reported involving the use of this drug, including reports of fatal liver toxicity. Unfortunately, serious liver damage occurred in about 1 in 20,000 patients who used bromfenac for more than 10 days. However, the incidence of death due to hepatotoxicity was below the practical detection limit of most clinical trials. In order to have reliably detected serious liver toxicity at the clinical trial level, the researchers would have had to expose 10,000 patients to the drug.^[17] After weighing the postmarketing reports of hepatotoxicity, the FDA decided only to issue a recommendation that bromfenac be used for less than 10 days. This labeling change, however, did not stop prescribers or patients from using this drug for longer periods of time. Eventually, the FDA concluded that the risk for hepatotoxicity outweighed any benefit of bromfenac, given the availability of other drugs in the class that were not associated with such serious adverse effects. As a result, the FDA and the manufacturer (Wyeth-Ayerst) agreed to withdraw the product from the market -- after it had been used by 2.5 million patients.

The effectiveness of postmarketing surveillance and ADE reporting can also be seen in the cases of several other drugs that were removed from the market after unexpected adverse reactions were reported (see Table 2). None of these reactions had been evident during clinical trials of these drugs.^[17]

Table 2. Scope of Patient Exposure to Drugs Removed From Market

For healthcare professionals, it can be a challenge to know what, when, and where to report an ADE. The FDA's MedWatch program^[18] was created to collect reports of serious adverse events. The agency has defined an ADE as "serious" when one or more of the following patient outcomes occur as a result of the ADE:

• Death;
• Life-threatening condition;
• New hospitalization;
• Prolonged hospitalization;
• Permanent disability or damage; and
• Congenital anomaly or birth defect.

The FDA's definition also includes ADEs that required some type of intervention to prevent permanent impairment or damage to the patient.

Most individuals prefer to report an ADE to the FDA's MedWatch program, which provides a convenient online form with directions on how to file the report.^[19] Some clinicians may feel more comfortable reporting the event directly to the drug manufacturer by contacting the company's adverse event department, usually by phone. Regardless of how these "serious" events are reported, the FDA and the pharmaceutical companies are required to share these reports with each other. This allows them to determine whether further action needs to be taken, such as updating the drug safety information for the drug involved. The key is for healthcare providers to use whatever mechanism is most comfortable for them to report the adverse events that they see in their practices.

In addition to reporting ADRs to the FDA and drug manufacturers, internal reporting systems within medical institutions can also have a significant impact on improving patient care. Although filing institutional reports is usually voluntary, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) does require that hospitals have procedures and methods in place so that employees can report ADEs. In fact, the establishment of such a reporting system is a key element in hospital accreditation evaluations. The JCAHO medication management standard MM.6.20 also requires that the hospital respond appropriately to actual or potential ADEs that are reported.^[20]

The key to producing effective ADE reports is knowing which incidents to report and what information to include. Many times, healthcare workers believe that ADRs are limited to events such as rashes and hives caused by antibiotics, or other characteristic events that involve the immune system. As mentioned earlier, these "type B" reactions are unpredictable because they are specific to individual patients, and the mechanism of what causes these reactions is not clearly elucidated. Therefore, due to their idiosyncratic nature, there is little that can be learned from these events that will improve patient outcomes, other than identifying a given patient as allergic to that specific drug, to prevent future occurrences.

In fact, type B reactions comprise only about 10% to 20% of all ADRs, so why do they tend to be reported more than type A events? One reason is that many healthcare professionals view type A events -- those related to a drug's pharmacologic effects -- as merely "side effects." However, these types of ADRs make up the most frequently occurring adverse reactions, and they are, by definition, generally predictable and dose dependent.^[21] Due to these factors, they represent the most preventable ADRs.

The following scenario illustrates how certain "side effects" can be classified as adverse reactions:

Mrs. M. is a 70-year-old woman admitted to the hospital with dehydration and anorexia. She has a history of diabetes mellitus and osteoporosis. Her medications prior to admission included insulin glargine 50 units at bedtime, glyburide 2.5 mg twice per day, and alendronate 70 mg once per week. She is believed to have a gastrointestinal viral syndrome and has a poor oral intake of food, yet her oral insulin glargine and glyburide are still being administered. She is found at 6 am to be diaphoretic with an acute change in mental status, and her glucose level is found to be 10 mg/dL. She is treated with dextrose 50% and administered an infusion of dextrose 10%. Her diet is advanced because she will require a continuous intake of carbohydrates to prevent repeat events of hypoglycemia throughout the day. Meanwhile, insulin glargine and glyburide are temporarily discontinued.

Should this case be reported as an ADE? Is the patient's hypoglycemia "just a side effect" or potentially more serious? According to the WHO definition, this is indeed an ADR. Criteria established by the American Society of Health-System Pharmacists (ASHP) also confirm that this patient has experienced an adverse event. These criteria^[22] state that an ADR is a reaction that is potentially life-threatening, causes permanent damage or even death, or requires intensive medical intervention (similar to the FDA MedWatch definition of a serious ADR). The ASHP definition also includes reactions to drugs that require a change in drug therapy (usually discontinuation or a dose reduction) and/or initiation of a specific treatment to prevent further harm to the patient.

Only by reporting these types of drug reactions can changes be implemented to improve patient outcomes. These events must be analyzed to identify which aspects could have been prevented, and then multidisciplinary changes can be adopted to avoid -- or at least lessen -- the likelihood of such events recurring.

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What Constitutes an Adverse Drug Event?

"Adverse drug event" is a broad term that encompasses a variety of incidents with problematic outcomes that occur within the context of drug therapy. Simply put, an ADE is any unfavorable event associated with the use of a medication. One of the most commonly accepted definitions is based on the International Conference on Harmonization Guidelines^[13]: "any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have to have a causal relationship with this treatment." The definition continues: "any unfavorable or unintended sign, symptom, or disease temporally associated with the use of any dose of a medicinal product, whether or not considered related to the medicinal product."

Although the definition of an ADE may seem broad, it is designed to be very inclusive. Physicians, pharmacists, nurses, and consumers often mistakenly believe that an ADE must have a definite temporal relationship with a drug therapy, or that a drug must be the sole cause of the event; this is not true, and this misunderstanding may partially explain why many ADEs are not recognized or reported. Causality and probability that an event is related to drug therapy will be discussed further.

There are 5 different categories of ADEs:

1. Adverse drug reactions
2. Medication errors
3. Therapeutic failures
4. Adverse drug withdrawal events
5. Overdoses

Adverse Drug Reactions

Causality comes into play within the first category, adverse drug reactions (ADRs). In these cases, there is a defined temporal relationship between the adverse event and the administration of the drug. A commonly cited definition of an ADR is delineated by the World Health Organization (WHO) as "any response to a drug that is noxious and unintended, and that occurs at doses normally used in man for the prophylaxis, diagnosis, or therapy of disease."^[10]

ADRs generally are assigned to 1 of 2 subgroups. Events that fall within the first subgroup are known as type A reactions: an "A"ugmentation of a drug's primary or secondary pharmacologic effect. A simple example of a type A reaction is coagulopathy with warfarin. The primary therapeutic effect is to interfere with the hepatic synthesis of vitamin K-dependent coagulation factors, but when there is too much inhibition, unwanted hypoprothrombinemia and bleeding episodes may result.

Drugs also may exhibit adverse reactions due to a secondary pharmacologic effect. For example, this is sometimes seen with fluoroquinolones. Their primary pharmacologic effect is to inhibit certain bacterial enzymes, exerting their antimicrobial activity. However, fluoroquinolones can also inhibit gamma-amino butyric acid (GABA), an inhibitory central nervous system neurotransmitter; inhibition of this neurotransmitter is believed to be the mechanism of fluoroquinolone-induced seizures, which represent a rare adverse reaction to this class of drugs.

The other general subgroup of ADRs encompasses type B reactions, which are considered "B"izarre, or idiosyncratic, in nature. Such reactions are not related to a drug's primary or even secondary pharmacologic effect. The best examples in this group are allergic reactions such as rashes, hives, and systemic anaphylaxis.

Table 1 offers a comparison of the 2 types of ADRs.

Table 1. Descriptions of Adverse Drug Reactions (ADRs)

Medication Errors

Medication errors represent another classification of ADEs. Medication errors are defined as "unintended acts (either of commission or omission) resulting in actual or potential harm to a patient, or an act that does not achieve its intended outcome when dealing with drug therapy."^[14] Medication errors of commission are generally blatant even though usually unintended; for example, a patient who is supposed to receive the drug Lamictal (lamotrigine) for seizure control instead receives the drug Lamisil (terbinafine) for onychomycosis. This type of error often occurs when different drug names look or sound alike.

Another type of medication error of commission is that which results from unclear or misinterpreted handwriting. An example is the patient who is supposed to receive 1 mg of a drug but instead receives 10 mg when the order for 1.0 mg is misinterpreted as 10 mg, because the decimal point was either overlooked or poorly written. Whether such an error results in patient harm may depend on when it is discovered during the medication-use process system. (When such errors are corrected before any patient harm occurs, they are often described as "near misses.")

Medication errors of omission are those that occur when a clinician fails to detect an important factor in a patient's drug therapy regimen, such as a clinically significant drug interaction, allergy history, or disease state contraindication. Errors of omission also may occur when important drug information is not adequately conveyed to prescribers or patients. All of these omitting factors have the potential to result in patient harm.

Consider, for example, the case of a pharmacist who dispenses the fertility drug clomiphene citrate to a young woman; within the next 3 months, the pharmacist dispenses to this same patient the drug misoprostol to prevent gastrointestinal distress caused by a nonsteroidal anti-inflammatory drug (NSAID) that she is taking. The error here is that misoprostol is labeled by the US Food and Drug Administration (FDA) as a category X pregnancy risk drug, which is contraindicated for women who are pregnant and or who are planning to become pregnant. A woman who is taking clomiphene citrate is clearly trying to get pregnant, and the misoprostol could cause a spontaneous abortion or could result in congenital defects in the baby, representing a most egregious error. In this scenario, the errors of omission are the pharmacist's failure to conduct a full prospective drug-utilization review and the failure to communicate warnings associated with the drug's labeling to the patient.

Therapeutic Failures and Adverse Drug Withdrawal Events

The third and fourth types of ADEs occur when drug therapy is "not given" or "not optimally given." In a therapeutic failure, suboptimal amounts of a medication are given to a patient, and the patient's condition fails to stabilize or symptoms become even worse as a result. For example, certain antibiotics bind to the minerals found in some other drugs, and if taken together, the amount of antibiotic available for absorption will be lowered. This may result in a treatment failure.

Sometimes a patient may not fully understand the importance of the drug regimen and may not take the drug as prescribed or may discontinue therapy altogether; this often occurs in patients with chronic disease states. Medication nonadherence is a major factor in therapeutic failures.

In contrast, an adverse drug withdrawal event (ADWE) occurs when a patient on long-term drug therapy experiences a withdrawal syndrome after discontinuing taking the drug, especially when this is an abrupt change. Examples of ADWEs include rebound hypertension in patients on long-term clonidine use, as well as agitation and/or seizures in patients abruptly discontinuing long-term benzodiazepine therapy.

Drug Overdoses

The final class of ADEs includes drug overdoses, whether intentional or accidental. These events differ from adverse reactions in that the doses are not "those that are normally used to treat disease." Accidental overdoses occur most commonly in 2 patient populations at opposite ends of the age spectrum: the very young and the very old. In these instances, the root causes generally are medication compliance problems and patient or caregiver knowledge deficits about the drugs involved.

One must keep in mind that these definitions are not always exclusive of each other. Some ADEs have a facet of preventability and thus represent a form of medication error, even though they technically belong in one of the other subgroups. One example of this was seen when a heart transplant patient taking the drug azathioprine developed an adverse reaction, pancytopenia.^[15] The patient was also taking the drug allopurinol for hyperuricemia, even though a drug interaction between these 2 agents is well documented. When allopurinol therapy is initiated with concomitant azathioprine therapy, the dose of azathioprine must be decreased by 50% to 75% in order to avoid the adverse reaction of bone marrow suppression and resultant pancytopenia. In this case, unfortunately, the interaction was not detected nor acted upon. This example involved both an ADR and a medication error: the omission of detecting a clinically significant drug interaction.

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MANAGING ADVERSE DRUG EFFECTS (ADEs)

Introduction

Adverse drug events (ADEs) are a significant cause of morbidity and mortality. In the United States, the annual cost of these events has been estimated at nearly $150 billion.^[1] Within the past decade, ADEs have been the focus of many studies in patient safety and quality control, and have been recognized as a top priority in safety efforts due to their iatrogenic nature.^[2-4]

Epidemiologic studies regarding the scope of these adverse events have found:

• About 3% to 28% of all hospital admissions are related to ADEs^[5-9];
• An estimated 5% to 20% of patients experience an ADE during their hospitalizations^[10];
• Elderly patients (> 65 years) are 2.5 times as likely to have an ADE that requires an emergency room visit compared with the general population, and they are 8 times as likely to require hospitalization^[11];
• Drugs with narrow therapeutic indices and/or those that require outpatient therapy monitoring account for 41.5% of all drug-induced hospitalizations^[11]; and
• Nearly two thirds of adverse drug reactions that required hospitalizations were considered to be potentially preventable.^[12]

The potential for preventing ADEs is a key element of efforts to improve patient care.

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CHAKA MOMENTS

BROADCAST EDITION

March 8, 2008

HEADLINES

1. BABY NG XAT PINANGANAK NA NOONG MARSO A-SINGKO!

· Note: The details of this headline is too private to be posted. This is upon the request of the child’s father that the child should not be in the Chaka Headlines. However, due to the euphoria that the blessing (child) has given to the NJ family, the CHAKA AUTHORITY would like to acknowledge and welcome her existence in this world, especially to the family of NURSE JOURNALS

2. STATGIRL A.K.A. CHUN-LI – BUGAW NG XAT

· STATGIRL, ang beauty queen ng dumaguete ay nagsimula kani-kanina lamang na magbugaw kina KEN at COOL_MHACK sa dating bahay. Limang Piso umano ang halaga ng bawat isa. Subalit, ang beauty queen ay tila naghihinayang sa kanyang pagbubugaw sapagkat gusto daw nyang iKENdi si KEN… hmmnnnn??? Siwalat na pagnanasa sa KENdi, huh?wakokaks…

3. GUPITAN PANSINAN

· Kani-kanina lamang sa main ng NJ ay natagpuang nasa AVATAR ni SHECMOSA ang kanyang piktyur na bagong gupit at sila-sila lamang nina SHEC, TIN at COUNTDOWN (AKA ClearmirrorstillH20). Napag-alaman ng bubwit na si shecmosa ay mayroon paring kapiranggot na pagnanasa sa mapagnasang si ClearmirrorstillH20 sapagkat sya diumano’y nagpagupit para syay mapansin ni LOHLOH AKA ClearmirrorstillH20. At… eto ang kakilig-kilig na moments: NAGPAKALBO naman si LOHLOH para din mapansin ni SHECMOSA

4. DEEPLY MADLY INLOVE
1. SPOILED_ROTTEN and [VIN]

· Si Spoiled_rotten po ay nalulumo sapagkat wala pa umanong text itong kanyan pinakamamahal na si [vin]. Siya sana’y aalis na kanina nang biglang magtxt si [vin] sa kanya at kanyang ipinahayag ang kanyang kasiyahan sa buong Xat. At nang dumating ang kanyang iniirog, ay siya naming lundag nya sa tuwa at isinigaw pa na I LOVE YOU VIN! She is really deeply, madly in love…

2. AMORGATORY and DR. MARTEN

* Unang araw ng marso ay nagkita sina AMORGATORY at DR. MARTEN sa mall. Una umanong bati ni amor kay doc ay “WAAAAAAHHH!!!”. Ganti naman ni doc ay tulakan… Di umano, nung nasa mall sila ay may naganap na NAKAWAN… NAKAWAN NG HALIK! [Weeee… at ang chakadora ay kinilig!]… kinilig ang chakadora nang siya ay kinwentuhan ng dalawang deeply madly in love na amor at doc sapagkat sila mismo ay kinikilig na nagkukwento..

BLIND ITEM

1. Sinech iteng lalash na iteng na nagbigay ng ADDRESS sa dati umanong may gusto sa kanya? Ang balita: iteng na dating may crush sa kanya ay reregaluhan umano nya ang lalash na iteng ng PASTILLAS kung kayat iteng lalash na paborito ang MALAPOT AT MAPUTI na GATAS ay binigay nga ang pinakaingat-ingatang address nya… hmmnn…

CLUE: B5 16 FIREZ churva chenes, An-an-an, Philippines!

JUDINGPEDIA

JUDINGWORD: JUNTAX

DEFINITION: Pregnant

ETYMOLOGY: BUNTIS prefixed with J- and suffixed with -AX to make it vague

SYNONYMS: Preggy, Bunchakchak

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