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PubMedDate not supplied

Preliminary evidence of neurotoxicity associated with eating fish from the Upper St. Lawrence River Lakes.

Pollution of hydrographic basins has affected the flora and fauna that thrive in these aquatic ecosystems, and fish, which constitute an important food resource, often contain a plethora of potentially toxic chemicals. In a major research project on early neurotoxic effects of environmental exposure to manganese among residents in Southwest Quebec, fish consumption from 2 lakes of the Upper St. Lawrence River System, was surveyed as a potential confounding factor. Participants were selected using a random, stratified sampling strategy from lists of the Quebec Health Plan. Following exclusions, 273 men and women between 20-69 years were retained for the present analysis. A total of 103 (37.7%) reported eating fish from the Upper St. Lawrence. Although fisheaters and non-fisheaters were similar for most socio-demographic variables, significantly more fisheaters (65.2%) reported consuming alcoholic beverages as compared to non-fisheaters (42.4%) (Chi Sq. <0.01). To eliminate this possible bias, fisheaters were matched to non-fisheaters for the variables sex, alcohol consumption (never or occasionally vs. regularly), age (+/-5y) and education (+/-2y). A total of 63 matched pairs were thus created. Paired analyses (t-test or Signed Rank) showed that fisheaters had higher levels of blood organic mercury and lead. Analysis of nervous system functions revealed that both groups performed similarly on tests of sensory function, visual memory and recognition, fine motor performance and some motor tests, but fisheaters performed significantly more poorly (p<0.05) on tests requiring cognitive flexibility, word naming, auditory recall, and more complex motor tasks. The profile of deficits is consistent with diminished capacity for information processing. These observations were made within a study that was not specifically designed to examine the effects of fish eating from these two lakes, and the characterization of fish dietary habits has many limitations. Nevertheless, the findings are sufficiently compelling to warrant further studies, since fish from the Upper St. Lawrence Lakes are known to contain multiple neurotoxic substances.

Adult↗

PubMed2003

Comparison of e-mail, fax, and postal surveys of pediatricians.

OBJECTIVES: To compare 3 communication modes (postal, fax, and e-mail) in a rotavirus vaccine physician survey. METHODS: We used 3 communication modes to distribute a survey to physicians listed in the membership directory of the Georgia Chapter of the American Academy of Pediatrics. The directory listed 1391 members; however, 404 were deemed ineligible on the basis of their listing as a specialist, retiree, resident in training, or government public health employee. Of the 987 members expected to administer vaccines, 150 were selected randomly to receive the postal survey (postal group). Of the remaining listings, 488 (58%) of 837 listed a fax number; 150 members were selected randomly and faxed a survey (fax group). Of the remaining members, 266 (39%) of 687 had e-mail addresses listed; 150 members were selected randomly for the e-mail survey (e-mail group). A follow-up survey was sent by the same mode at 2 weeks. A final survey was sent via another mode (mixed mode) at 1 month: by fax to e-mail and postal nonresponders and by post to fax nonresponders and those without fax. RESULTS: Eligible respondents in the 3 survey groups were similar in their practice setting and location. Although the e-mail group had fewer median years (8 years) since medical school graduation than the fax group (19 years) and postal group (17 years), a similar percentage of responders in all groups had computers (>85%) and Internet access (> or =70%) at work. However, only 39% of members listed an e-mail address in the directory. In the 2 weeks after the first mailing, 39 surveys were completed via postal mail, 50 via fax, and 16 via e-mail. In the 2 weeks after the second contact (sent at 2 weeks), 20 surveys were completed via postal mail, 15 via fax, and 17 via e-mail. The response rate after the first 2 mailings was 41% (59 of 143) for postal, 47% (65 of 137) for fax, and 26% (33 of 125) for e-mail surveys. The third and final survey (sent 1 month after the first mailing) was sent by a different (ie, mixed) mode and elicited an additional 73 responses: 19 responses (15 postal, 4 fax) from the postal group, 19 responses (18 postal, 1 fax) from the fax group, and 35 responses (15 postal, 13 fax, 7 e-mail) from the e-mail group. Twenty-three percent (9 of 40) of the e-mail and 18% (15 of 83) of the fax surveys completed were returned on the same or subsequent day they were sent, compared with none of the postal surveys. There were significant differences among the 3 groups for invalid addresses/numbers (4% postal, 8% fax, and 16% e-mail) listed in the directory. Using mixed modes as the third contact, the overall response rate increased from 39% before mixed mode to a final of 53%. On the basis of the 3 initial groups, responses to 1 of 12 rotavirus questions differed significantly. CONCLUSIONS: Future use of e-mail surveys in selected circumstances is promising, because the majority of providers have Internet access and acknowledged interest in participating in e-mail surveys. E-mail surveys could be especially useful if rapid response time is necessary. There were fewer incomplete questions by participants who completed the e-mail survey compared with postal or fax participants. Updating membership e-mail addresses and routinely using e-mail as a communication tool should improve the ability to use e-mail surveys. There may need to be ongoing evaluations that critically evaluate providers' responses to e-mail surveys compared with other survey modes before e-mail surveys can become a standard survey tool. In the meantime, mixed-mode surveys may be an option.

Cross-Sectional Studies↗

PubMed2006

Self-help treatments for disorders of recurrent binge eating: a systematic review.

OBJECTIVE: To evaluate self-help interventions for patients with binge eating disorder (BED) and bulimia nervosa (BN), tested in randomized controlled trials, and compared with waiting list or any other type of control group. METHODS: A systematic review including quality appraisal was conducted of randomized controlled trials, using self-help techniques in patients with BED and/or BN. Six databases were searched during the period between January 1994 and June 2004. RESULTS: A total of 2686 articles were identified, 1701 abstracts were evaluated in detail and, nine studies fulfilled the inclusion criteria for this review. All studies indicated that patients treated with active interventions had a reduced number of binge eating episodes at end of treatment. CONCLUSION: The results support self-help interventions but shall be interpreted with caution. Because of the small number of studies using self-help techniques for BED and BN, further larger randomized, multi-center controlled studies that apply standardized inclusion criteria, evaluation instruments and self-help materials, are needed.

Bulimia↗

PubMed2000

A 3-year follow-up of a prospective randomized trial comparing transurethral electrovaporization of the prostate with standard transurethral prostatectomy.

OBJECTIVE: To compare the safety, efficacy and durability of transurethral electrovaporization of the prostate (TUVP) with standard transurethral resection of the prostate (TURP). PATIENTS AND METHODS: In all, 104 patients admitted from the waiting list for surgery for BPH were randomized to either TUVP (52 patients, mean age 67.5 years) or TURP (52 patients, mean age 70.2 years); 51, 47 and 40 patients in each arm completed 1, 2 and 3 years of follow-up, respectively. Patients were assessed at baseline and during the follow-up using the International Prostate Symptom Score (IPSS), the associated quality-of-life score (QoL), postvoid residual volume (PVR) and maximum urinary flow rate (Qmax). RESULTS: Both groups had comparable mean IPSS, QoL, Qmax and PVR at baseline. The mean (SD) values for TUVP and TURP, respectively, at 3 years showed a significant and maintained improvement in IPSS, at 4.1 (3.3) and 7.1 (6.2) (P = 0.01), in QoL, at 1.0 (0.9) and 1.6 (1.4) (P = 0.04), and in Qmax, at 22.2 (8.5) and 18 (7.1) mL/s (P = 0.02), with decreases in PVR of 30 (38) and 21.9 (26.2) mL (P = 0.27). The re-operation rate in each group was 4% during the first year, 4% during the second year and 5% during the third year. After surgery and at 1, 2 and 3 years of follow-up, impotence was reported in 17% of the TUVP group and 11% of the TURP group (P = 0.49), and retrograde ejaculation in 72% of the TUVP group and 89% of the TURP group (P = 0.47). CONCLUSION: The 3-year follow-up results confirm that TUVP is as effective as standard TURP in the treatment of moderate-sized BPH. The long-term side-effects and complications were comparable and the initial improvement was maintained over 3 years in most patients in both groups.

Aged↗

PubMed1991

A randomised trial of invitations to attend for screening mammography.

The aim of this study was to evaluate the effectiveness of invitations for mammographic screening. Women aged 45 to 69 who had not attended for screening at the mobile Breast X-Ray Programme of the Central Sydney Area Health Service were randomly selected from the 1989 electoral listing. In the geographical area in which the study was conducted (Drummoyne local government area), 36 per cent of women had attended for screening before the intervention, indicating that the invitations were aimed at the reluctant participant. Women were randomly allocated to a control group who did not receive invitations (n = 80), and an intervention group who received letters from the Program inviting them to attend at a specified time (n = 163). Overall 33 per cent of women (53 of 163) who were sent invitations attended for screening compared to 9 per cent of those not invited (7 of 80) (P less than 0.001). Older women responded at least as well as younger women. In addition, the distribution of language spoken at home was similar for electoral listing attenders and the community as a whole, suggesting that this intervention works as well for women of English- and non-English-speaking backgrounds. The results suggest that the response to an invitation for screening from a source not personally known to women achieves comparable attendance to an invitation from their general practitioner, as assessed in a previous study.

Aged↗

PubMed1981

A strategy for surveying nursing practice in institutional settings.

Two major obstacles encountered when surveying nursing practice in institutional settings are obtaining a representative sample and collecting an adequate number of observations at a reasonable cost. Past efforts to deal with these problems are reviewed briefly, and results are reported from a two-stage mail survey of a national sample of critical-care nurses. The first stage involved attempts to procure a list of staff nurses from head nurses of critical-care units at 240 randomly selected institutions. An 86% response rate was obtained. The second stage involved mailing questionnaires to a random sample of 600 critical-care nurses listed. Completed, mailed questionnaires were obtained from 87%. Little evidence of bias due to administrative selection and/or volunteerism was found in the lists of staff nurses. An analysis of membership in professional nursing organizations indicates that more than one half of the nurses who responded to this survey would not have been included had the sample been selected from organizational membership lists.

Data Collection↗

PubMed2005

Teaching pediatrics residents how to obtain informed consent.

BACKGROUND: Few physicians view informed consent as a critical component of the physician-patient relationship or as a way to improve individual and population health. We hypothesized that formal education about informed consent would affect first-year pediatrics residents' knowledge and attitudes. METHOD: Twenty-seven first-year pediatrics residents participated in a randomized controlled trial with a wait-list control group. The one-hour interactive intervention consisted of a lecture, video, and small-group discussion. Outcomes were measured after randomization at baseline and after the intervention group received the intervention. Data were analyzed using multivariate analysis and between and within group t tests. Qualitative data were obtained after the wait-list control group's exposure to the intervention. RESULTS: The quantitative analyses demonstrated that the intervention yielded statistically significant improvements in the measured outcomes. The qualitative analyses confirm the quantitative findings. CONCLUSION: A formal session on informed consent in the pediatrics residency educational program positively affects residents' knowledge and attitudes about informed consent.

Adult↗

PubMed2002

Psychosocial intervention for postdisaster trauma symptoms in elementary school children: a controlled community field study.

CONTEXT: Natural disasters negatively affect children's emotional and behavioral adjustment. Although treatments to reduce psychological morbidity following disasters are needed, it has been difficult to conduct treatment research in postdisaster environments because of the sensitivity of victims to perceived intrusiveness and exploitation. OBJECTIVE: To evaluate the efficacy of a public health--inspired intervention combining school-based screening and psychosocial treatment to identify and treat children with persistent disaster-related trauma symptoms. DESIGN: To identify children with continued high levels of trauma-related symptoms 2 years after a major disaster, we conducted a community-wide school-based screening of disaster-exposed public elementary school children. Children with the highest levels of trauma-related symptoms were randomly assigned to 1 of 3 consecutively treated cohorts. Children in the cohorts awaiting treatment served as wait-list controls. Within each cohort, children were randomly assigned to either individual or group treatment to allow comparison of the efficacy of the 2 treatment modalities. SETTING: All 10 public elementary schools on the island of Kauai (one of the Hawaiian Islands) 2 years after Hurricane Iniki. PARTICIPANTS: All 4258 children in second through sixth grade were screened. The 248 children with the highest levels of psychological trauma symptoms were selected for treatment. INTERVENTION: Children were randomly assigned to either individual or group treatment provided by specially trained school-based counselors. Treatment comprised 4 sessions. MAIN OUTCOME MEASURES: The Kauai Reaction Inventory, a self-report measure of trauma symptoms, and the Child Reaction Inventory, a semistructured clinical interview for posttraumatic stress disorder symptoms. RESULTS: After treatment, children reported significant reductions in self-reported trauma-related symptoms. This symptom reduction was maintained at the 1-year follow-up. Clinical interviews also indicated that treated children had fewer trauma symptoms compared with untreated children. CONCLUSIONS: School-based community-wide screening followed by psychosocial intervention seems to effectively identify and reduce children's disaster-related trauma symptoms and may facilitate psychological recovery. While group and individual treatments did not differ in efficacy, fewer children dropped out of the group treatment. This approach may be applicable to screening and treating children exposed to a variety of large-scale disasters.

Analysis of Variance↗

PubMed1999

Generalizing from a controlled trial: the effects of patient preference versus randomization on the outcome of inpatient versus outpatient chronic pain management.

Patients accepting randomization in a randomized controlled trial (RCT) may not be representative of the clinical population from which they are drawn, calling into question the generalizability of study findings. Comparison of randomized and non-randomized inpatient and outpatient samples at baseline and in treatment outcomes up to one year was made to determine whether the findings of the RCT generalized to non-randomized patients in the same treatment program. One hundred and twenty one patients with intractable pain, randomized between inpatient, outpatient and waiting list control, were compared with 128 who elected for either inpatient or outpatient treatment. Treatment was a group-based multidisciplinary cognitive-behavioral treatment program aimed at enabling patients to return to more normal function despite persistent pain, delivered to mixed groups of randomized and elective patients, and outcome was measured by physical performance, pain impact on function, mood, and drug use. Agreement to randomization was a function of travelling distance from home to hospital. Non-randomized patients largely resembled their randomized counterparts before and after treatment. In order to indicate the clinical significance of results, analyses were conducted using numbers needed to treat (NNTs). NNTs estimate the number of patients required in the treatment condition for one of them to achieve the specified outcome who would not have achieved it in the comparison condition. Across a range of measures at one month follow-up, comparison of inpatients with outpatients gave NNTs between 2.3 and 7.5, and comparison of inpatients with waiting list controls gave NNTs between 2.3 and 3.6. At one year inpatients showed greater likelihood than outpatients of maintaining these treatment gains.

Adult↗

PubMed2003

Laser prostatectomy versus transurethral resection for treating benign prostatic obstruction: a systematic review.

PURPOSE: We conducted a systematic review of randomized controlled trials evaluating the efficacy and safety of laser prostatectomy techniques compared to transurethral resection of the prostate for symptomatic benign prostatic obstruction. MATERIALS AND METHODS: We searched MEDLINE, the Cochrane library and reference lists of retrieved studies to identify randomized trials of 6 months or greater in duration with at least 10 subjects in each treatment arm. We extracted data on study design, subject and treatment characteristics, adverse events, urinary symptoms and urinary flow. RESULTS: A total of 16 studies involving 1,488 subjects were evaluated, including 8 comparisons of transurethral resection with contact lasers, 7 with noncontact lasers and 4 with hybrid techniques. Study duration ranged from 6 to 36 months. Mean patient age (67.4 years), baseline symptom score (20.2) and peak urinary flow (9.5 ml. per second) did not differ by treatment group. Transurethral resection of the prostate provided slightly greater improvement in urinary symptoms and flow. The pooled mean percentage improvement for urinary symptoms ranged from 59% to 68% with lasers and 63% to 77% with transurethral resection. Improvement for peak urinary flow ranged from 56% to 119% with lasers and 96% to 127% with transurethral resection of the prostate. Laser procedures resulted in fewer transfusions (less than 1% versus 7%) and strictures (0% to 7% versus 8%), and required shorter hospitalizations. Reoperation occurred more often (RR = 5.7) following laser procedures. CONCLUSIONS: Laser techniques are a useful alternative to transurethral resection of the prostate for treating benign prostatic obstruction. Small sample sizes and differences in study design limit any definitive conclusions regarding the preferred type of laser technique.

Aged↗

PubMed1990

Effectiveness of booster sessions in the maintenance and enhancement of treatment gains following assertion training.

Forty-six unassertive Ss were randomly assigned to assertion training (AT) or waiting-list control conditions. Ss receiving AT showed significantly greater improvements from pretreatment to post-treatment on 8 out of 10 questionnaire measures of assertiveness and 3 out of 5 direct behavioral observation measures compared with the waiting-list group. 27 Ss who had completed the AT program were then randomly assigned to 1 of 3 booster conditions, namely, monthly assertion training boosters (ATB), monthly attention placebo boosters (APB), or no boosters (NB). At the 3-month follow-up there was minimal difference between booster conditions. By the 6-month follow-up the results favored the ATB condition. Although the APB procedure was effective in preventing the relapse shown by the NB subjects, the ATB group actually showed further improvements on some measures of assertiveness during the 6-month follow-up period.

Adult↗

PubMed1977

Transfer of associative-clustering tendencies in borderline mentally retarded and nonretarded adolescents.

Twenty-four sixth graders, 24 seventh graders, and 24 special-education students with MAs roughly equivalent to the sixth graders were randomly assigned to the cells of a 3 (grade level) X 2 (list novelty) X 2 (list organization) factorial design. In the list-novelty condition, subjects were immediately transferred to either a same-categories or a new-categories list on the third and fourth trials. In the list-organization condition, subjects received the lists on the first two trials in either a random or blocked format. For all subjects, the last two trials were presented randomly and contained new words. The results of the analyses revealed that there was significant negative transfer over trial blocks for the same-categories transfer condition. In addition, the new-categories group clustered significantly more on the second than the first trial block. There was no significant interaction between subject and treatment factors, suggesting that the processes involved in recall were similar for nonretarded and borderline retarded subjects.

Adolescent↗

PubMed1994

Waiting times: monitoring the total postreferral wait.

OBJECTIVES: To determine whether the period spent on the true inpatient waiting list is a valid indication of the total time that patients have to wait for an operation; and to assess the feasibility of monitoring the total "postreferral waiting time" by using existing computerised information systems. SETTING: Three randomly selected Scottish hospitals. SUBJECTS: Waiting list patients admitted to hospital for operations during June to August 1993 in six major specialties, separate attention being focused on cataract operations and hip and knee replacements. MAIN OUTCOME MEASURE: The total time that patients have to wait for an operation after the initial general practitioner referral--the postreferral waiting time--compared with that spent at the final stage of the process on the true inpatient waiting list. RESULTS: In the specialties investigated roughly half (58 days; 53%) of the average postreferral wait of 110 days was spent on the true inpatient waiting list, one third (35 days; 32%) being spent on the outpatient waiting list and one sixth (17 days; 15%) waiting between waiting lists. Only a quarter of cataract patients (73/292) were treated within three months of general practitioner referral compared with over three quarters (228/292) within three months of being placed on the inpatient waiting list. Nevertheless, within a year over 99% of patients (290) had been treated whichever date was taken as the starting point. CONCLUSIONS: Monitoring postreferral waiting times would provide a much more accurate picture for purchasers and patients of waiting times for treatment than is obtained by focusing exclusively on the true inpatient waiting list and facilitate fairer comparisons between NHS trusts in national league tables. Stringent national and local monitoring is essential to ensure (a) that future reductions in the time waiting on true inpatient waiting lists are not gained at the expense of longer periods waiting to be placed on the lists, and (b) that no increases occur in the number of patients placed instead on deferred waiting lists or exempted from the normal maximum waiting time guarantees.

Cataract Extraction↗

PubMed1990

Word-to-word variation in ERP component latencies: spoken words.

Data were collected shedding light on the brain electrical activity underlying word recognition. Subjects listened to a list of 48 spoken words in six random orders under two instructional sets: first to "think about the meanings of the words," and second, to learn the list. The scalp EEG associated with hearing and identifying the words was recorded at F3, F4, Cz, P3, P4, Pz, and Oz. Standard within-subjects time-locked averaging across words showed a late negative-positive complex with N2-P3 topography, the negative component peaking around 480 msec, the positive component peaking around 830 msec. Averaging within words across subjects uncovered considerable latency variability in both components. Within-word N2 and P3 component latencies covaried with word durations and with the "recognition points" predicted for the words by the "cohort theory" of word recognition. N2 latencies corresponded closely to the "N400" effect elicited with semantically incongruous sentence-final spoken words. Implications for ERP investigations of language processing are discussed.

Adult↗

PubMed2000

Structure predictions allowing more than one molecule in the asymmetric unit

The UPACK program for crystal structure prediction was extended to allow the possibility of more than one molecule in the asymmetric unit. A search method was developed where the essential parameters (including torsional angles of hydroxyl groups) take random values. Energy minimization and clustering then lead to a list of hypothetical structures. In a test for six hexapyranoses this random search method was found to be approximately equally as efficient as the previously used systematic grid search method for one independent molecule. As a second test, the generation of structures with more than one independent molecule was performed for ethanol. A multitude of possible structures was found, the experimental one (two independent molecules in space group Pc) always being present. However, for alpha-D-mannose (two independent molecules with five unknown hydroxyl torsional parameters each) the number of hypothetical structures was so large that the experimental structure was never encountered. Finally, a crystal structure generation for hydrates of pyranoses and polyalcohols was carried out. When the total number of unknown parameters was less than 20, the experimental structure was encountered. As usual, the empirical energies were not adequate to select that structure from the list of possible ones. Even then, the procedure proved to be valuable in identifying the most probable hydrogen-bonded network in cases where hydrogen positions in the experimental crystal structure were missing.

Journal Article↗

PubMed2004

Transurethral microwave thermotherapy vs transurethral resection for treating benign prostatic hyperplasia: a systematic review.

OBJECTIVE: To conduct a systematic review of randomized controlled trials evaluating the efficacy and safety of transurethral microwave thermotherapy (TUMT) compared with transurethral resection of the prostate (TURP) in treating men with symptomatic benign prostatic hyperplasia (BPH). METHODS: We searched Medline, the Cochrane Library and reference lists of retrieved studies to identify randomized trials of >/= 6 months duration with >/= 10 patients in each treatment arm. Data were extracted on study design, patient and treatment characteristics, urinary symptoms, urinary flow, adverse events and repeat treatment for BPH. RESULTS: Six studies were evaluated, involving 540 patients. The mean age (67.8 years), baseline symptom score (19.5), and peak urinary flow (PUF, 8.6 mL/s) did not differ by treatment group. The pooled mean urinary symptom score decreased by 65% with TUMT and 77% with TURP. The weighted mean (95% confidence interval) difference for the symptom score at the follow-up was -1.83 (-3.09 to -0.58) points, favouring TURP. The pooled mean PUF increased by 70% with TUMT and 119% with TURP. The weighted mean difference for the PUF at the follow-up was 5.37 (4.22-6.51) mL/s, favouring TURP. Retrograde ejaculation (57.6% vs 22.2%), transfusions (5.7% vs 0%) and re-treatment for strictures (relative hazard 9.76) were all significantly more common after TURP, but re-treatment for BPH was significantly more common after TUMT (relative hazard 10.0). CONCLUSIONS: TUMT techniques are effective and safe short-term alternatives to TURP for treating BPH. However, TURP provided greater symptom and urinary flow improvements and fewer subsequent BPH treatments than TUMT.

Aged↗

PubMed2006

It's not just what you do, it's the way that you do it: the effect of different payment card formats and survey administration on willingness to pay for health gain.

A general population sample of 314 Australian respondents were randomly allocated to complete a contingent valuation survey administered by face-to-face or telephone ('phone-mail-phone') interview. Although the telephone interview was quicker to complete, no significant difference was found in values obtained through either method. Within each sub-sample, respondents were also randomly allocated to the three different versions of the payment card (PC) questionnaire format: values listed from high-to-low, values listed from low-to-high and values randomly shuffled. The high-to-low version resulted in significantly higher values than the other versions. Further analyses indicate that the randomly shuffled PC version may produce the most 'valid' values.

Adult↗

PubMed2004

[Do general practitioners know what medication community nurses give their shared patients?].

BACKGROUND: Frail elderly outpatients often receive medicines from community nurses. There is little knowledge of how general practitioners (GPs) and nurses update and coordinate their medication lists for their shared patients. MATERIAL AND METHODS: Lists of regular medication for 90 randomly selected shared patients from GPs as well as community nurses were assessed with respect to agreement. An agreement score was calculated for number of medicines and for each drug: total daily dosage and dose regimen. Routines for updating medication lists were addressed in a questionnaire to GPs and community nurses. RESULTS: For three out of four patients, discrepancies were found between physicians' and nurses' lists of regular medication. 52% of the discrepancies were in relation to cardiovascular drugs and psychotropic drugs. Only 41% of the GPs reported explicit routines for updating their medication lists. INTERPRETATION: The GPs' lack of knowledge of what their patients actually receive may contribute to medication errors and adverse drug reactions.

Aged↗