Attitudes towards and beliefs about genetic testing in the haemophilia community: a qualitative study

Widespread genetic testing for haemophilia has recently been introduced in Victoria, Australia. While attitudes towards predictive testing have been studied in other conditions, such as cancer, there is limited knowledge about the attitudes of members of the haemophilia community towards predictive testing. This study aimed at exploring attitudes towards, and beliefs about, genetic testing amongst members of the haemophilia community in Victoria prior to the widespread introduction of testing. The study was qualitative and descriptive. In-depth face to face interviews were held with a sample of 39 individuals, including men with haemophilia, female carriers and family members. Data were analysed thematically using cross-case analysis techniques. There was considerable knowledge about the proposed introduction of widespread genetic testing. However, not everyone thought that testing was accessible or user friendly, and there was confusion about who needed to be tested. Most thought that testing was necessary for adolescent girls to determine carrier status to help prepare families for a child with haemophilia, rather than leading them to choose to terminate a pregnancy or not to have children. A minority of women stated that if there was a history of inhibitors in a family then a termination might be considered. The study revealed strong religious beliefs among those studied, which may have influenced attitudes and approaches towards testing. Further investigation is needed into how people with a possible haemophilia genotype negotiate decisions about their further identification, and how this knowledge is placed within cultural, religious and family contexts.

Efficacy and safety of a high purity, double virus inactivated factor VIII/von Willebrand factor concentrate (Biostate�) in patients with von Willebrand disorder requiring invasive or surgical procedures

Biostate is a double virally inactivated, plasma derived coagulation factor VIII (FVIII)/von Willebrand factor (VWF) concentrate registered and used in Australia, New Zealand and Asia for the treatment of patients with haemophilia A. Although Biostate has been well characterized for FVIII and VWF (ratio 1:2 respectively) and shows a similar VWF multimeric pattern to normal plasma, limited published data is available on its clinical efficacy and safety in patients with von Willebrand disorder (VWD) who require surgical procedures. We retrospectively assessed the efficacy and safety of Biostate in all VWD patients treated at three Australian haemophilia treatment centres undergoing invasive procedures or surgery over a 29-month period between April 2003 and September 2005. A chart review of 43 VWD patients (26 VWD type 1, 12 VWD type 2, 5 VWD type 3; 21 male, 22 female; mean age 52 years, range 19-80 years) undergoing 58 surgical procedures (24 major, 34 minor) was performed. For each procedure, data were collected on Biostate dosage and administration, adverse reactions, haemostatic efficacy and bleeding events. Haemostatic efficacy of Biostate was assessed as excellent in 78% or good in 22% of procedures. There were no bleeding events attributable to lack of efficacy in any patients. No adverse reactions related to the administration of Biostate were observed. These results suggest that Biostate is both safe and efficacious for the prevention of excessive bleeding in VWD patients undergoing surgery or invasive procedures.

Increased health care utilization and increased antiretroviral use in HIV-infected individuals with mental health disorders

OBJECTIVES

The aims of the study were to describe the prevalence and associations of mental health disorder (MHD) among a cohort of HIV-infected patients attending the Victorian HIV/AIDS Service between 1984 and 2000, and to examine whether antiretroviral therapy use or mortality was influenced by MHD (defined as a record of service provision by psychiatric services on the Victorian Psychiatric Case Register). It was hypothesized that HIV-positive individuals with MHD would have poorer treatment outcomes, reduced responses to highly active antiretroviral therapy (HAART) and increased mortality compared with those without MHD.

METHODS

This is a retrospective cohort of 2981 individuals (73% of the Victorian population diagnosed with HIV infection) captured on an HIV database which was electronically matched with the public Victorian Psychiatric Case Register (VPCR) (accounting for 95% of public system psychiatry service provision). The prevalence, dates and recorded specifics of mental health disorders at the time of the electronic match on 1 June 2000 are described. The association with recorded MHD, gender, age, AIDS illness, HIV exposure category, duration and type of antiviral therapy, treatment era (prior to 1986, post-1987 and pre-HAART, and post-HAART) on hospitalization and mortality at 1 September 2001 was assessed.

RESULTS

Five hundred and twenty-five individuals (17.6% of the Victorian HIV-positive population) were recorded with MHD, most frequently coded as attributable to substance dependence/abuse or affective disorder. MHD was diagnosed prior to HIV in 33% and, of those diagnosed after HIV, 93.8% were recorded more than 1 year after the HIV diagnosis. Schizophrenia was recorded in 6% of the population with MHD. Hospitalizations for both psychiatric and nonpsychiatric illness were more frequent in those with MHD (relative risk 5.4; 95% confidence interval 3.7, 8.2). The total number of antiretrovirals used (median 6.4 agents vs 5.5 agents) was greater in those with MHD. When adjusted for antiretroviral treatment era, HIV exposure category, CD4 cell count and antiretroviral therapy, survival was not affected by MHD.

CONCLUSIONS

MHD is frequent in this population with HIV infection and is associated with increased healthcare utilization but not with reduced survival.

Haemophilia and ageing

Men with haemophilia have not only the challenges of living with HIV and/or HCV infection and premature arthritis as complications of their disorder, but they also confront the other ails of ageing. These include genitourinary problems such as prostatic hypertrophy, prostatic cancer and renal stone disease, and arterial disease for which haemophilia is not protective. Progressive arthritis and declining fitness may lead to loss of independence which causes great concern. Associated with the physical aspects of ageing, many patients also suffer from psychological symptoms which may be precipitated by changes in work such as early retirement and altered family dynamics. Many older men with haemophilia may never have consulted primary care physicians because of the rarity and complexity of their disorder. Haemophilia centre staff often assume responsibility for the identification and management of all health problems of their patients. Even when other clinicians are involved, patients require their centre's involvement in the investigation and support of many procedures such as coronary artery surgery and urological surgery. This paper addresses falls in the older man with haemophilia, their causes and consequences and cardiovascular problems in particular. Very little literature has been published about these common problems. We need to be aware of the ageing issues in haemophilia and develop 'wellness' programs which are directed to the early identification of disease as well as preventative strategies to reduce the physical and psychological impacts of ageing.

Providing guidelines and education is not enough: an audit of gentamicin use at The Royal Melbourne Hospital

BACKGROUND

Aminoglycoside antibiotics are commonly prescribed for the treatment of Gram-negative infections. Appropriate dosing and therapeutic monitoring of aminoglycosides are important because these agents have a narrow therapeutic index.

AIM

To audit gentamicin use at our hospital, focusing on selection of the initial dose and therapeutic monitoring practices, and to compare the results against recommendations in the existing hospital aminoglycoside guidelines, which had recently been promoted to doctors.

METHODS

This audit included all inpatients receiving gentamicin at The Royal Melbourne Hospital from 1 February to 12 March 2004. The principal researcher checked the drug charts of all inpatients to identify those receiving gentamicin and collected data from the medical records and the pathology database. Doses were considered 'concordant' if the dose given was within the recommended dosing range +/-20 mg.

RESULTS

A total of 132 courses of gentamicin was included in the study. Gentamicin was prescribed for prophylaxis in 31.1% of courses. Thirty-six per cent of patients prescribed gentamicin were more than 65 years of age. Eighty-two per cent of the gentamicin used therapeutically was given as a single daily dose. Sixty-six per cent of gentamicin initial dosing was not in accordance with existing hospital guidelines. Seventy-seven per cent of gentamicin courses requiring therapeutic drug monitoring received such monitoring; however, in only 8.8% of these was the monitoring conducted according to guidelines.

CONCLUSION

Aminoglycoside prescribing practices at our hospital are suboptimal, despite ready access to prescribing guidelines. Provision of a guideline and education sessions with doctors do not necessarily lead to widespread adoption of recommended practices. We suggest that changes to hospital systems related to prescribing and monitoring of aminoglycosides are required.

Comprehensive care for haemophilia around the world

Comprehensive haemophilia care has been defined as the continuing supervision of all medical and psychosocial factors affecting the person with haemophilia family. Services offered by haemophilia treatment centres (HTCs) adopting the comprehensive care model include establishing prophylaxis and other treatment protocols, development of psychosocial, education and research programme, maintenance of a patient registry, genetic and reference diagnostic services and orchestration and management of a wide variety of multidisciplinary interventions. Most centres practising this model of care are based in developed countries and can meet costs for plentiful treatment products through government or insurance-company funding. Not all the programmes are dependent on the level of product supply, however, and many have been supported in countries with emerging economies as part of national healthcare systems, particularly in relation to blood management. In this paper we present perspectives from different areas of the world on how to adopt, adapt and achieve economically appropriate models of comprehensive care.

Laboratory diagnosis of von Willebrand's disorder: quality and diagnostic improvements driven by peer review in a multilaboratory test process

Regular multilaboratory surveys of laboratories derived primarily from Australia, New Zealand and Southeast Asia have been conducted over the past 7 years to evaluate testing proficiency in the diagnosis of von Willebrand's disorder (VWD) and to assess changes to test practice. Participating laboratories (currently 45) are asked to perform their usual panel of tests for VWD, and then to self-interpret test results as to the likelihood (or not) of VWD, as well as to the potential subtype identified. Samples provided in the past two survey distributions (both conducted in 2003) were as follows. Survey part A/distribution 1: Normal donor plasma, plasma with borderline normal/reduced levels of VWF (x2) and plasma from an individual with type 2 A VWD. Survey part B/distribution 2 (family VWD study): Plasma from a father, mother and son with borderline normal/reduced von Willebrand factor (VWF), and a daughter with type 3 VWD. In line with previously published survey results, the interassay and within method coefficients of variation (CV) were similar for all assays (around 15-25%), although tending to be slightly higher for VWF:RCo and VWF:CB than VWF:Ag and FVIII:C. Most laboratories reported test values consistent with expected findings, and made correct interpretations or predictions regarding the nature of the samples, although discrepant assay results or interpretations are still seen in approximately 5-10% of responses (typically from laboratories using a more limited test panel or not performing the VWF:CB). Overall, problems with the non-identification of functional VWF discordance in type 2 VWD, the misidentification of functional VWF discordance in type 1 VWD, and difficulties in discriminating types 1 and 3 VWD appear to predominate. In comparison with previous surveys, performance of electro-immuno diffusion (EID) (or Laurel gel) procedures has now ceased, and a reduction in VWF:RCo and VWF:Multimer testing and an increase in latex immunoassay (LIA) testing is sustained. We conclude that laboratories are generally proficient in tests for VWD, and that diagnostic error rates are reduced when test panels are more comprehensive and include the VWF:CB.

Dispensing death, desiring death: an exploration of medical roles and patient motivation during the period of legalized euthanasia in Australia

A qualitative case study was conducted to explore the clinical decision making processes that underpinned the practice of euthanasia under the Rights of the Terminally Ill (ROTI) Act. The key informant for this research was Philip Nitschke, the general practitioner responsible for the legal cases of euthanasia. His information was supported by extensive document analysis based on the public texts created by patients in the form of letters and documentaries. Further collaborating sources were those texts generated by the media, rights groups, politicians, the coroner's cort, and the literature on euthanasia and assisted suicide. A key study finding was that the ROTI legislation did not adequately provide for the specific medical situation in the Northern Territory, Australia. The medical roles, as proscribed by the legislation, carried many inherent assumptions about the health care context and the availability of appropriately qualified medical staff committed to providing euthanasia. These assumptions translated into difficulties in establishing clinical practices for the provision of euthanasia. A further finding concerned the motivations of those who requested euthanasia. This article addresses the medical roles and the motivations of those seeking euthanasia.

Vitamin D deficiency is common and unrecognized among recently arrived adult immigrants from The Horn of Africa

The prevalence of and risk factors for vitamin D deficiency were examined for recent adult immigrants from East Africa living in Melbourne. Demographic data were collected via a face-to-face questionnaire and risk factors predicting deficiency were examined. Suboptimal levels <25 nmol/L were found in 61 patients (53%; 74% of women; 20% of men). Lower levels were more likely in: (i) patients with a longer duration of residence in Australia, (ii) patients who were mostly covered when outdoors and (iii) women. Routine assessment for vitamin D deficiency should be considered for male and female immigrants from East Africa.

MonoFIX-VF, a new mono-component factor IX concentrate: a single-centre continuous-infusion study

MonoFIX-VF, a monocomponent factor IX concentrate, has replaced the use of Prothrombinex-HT as the treatment of choice for patients with factor IX deficiency in Australia. The haemostatic effect of MonoFIX-VF, administered by continuous infusion, was assessed in four subjects being treated for 10 bleeding episodes including five surgical procedures. MonoFIX-VF was found to be a safe and effective treatment for patients with haemophilia B.

Costing hospital activity: the experience with healthcare resource groups in England

Development of an English measure of hospital casemix can be traced back to the early 1980s and has resulted in the creation of healthcare resource groups (HRGs). Despite the availability of this casemix classification system, less use has been made of HRG costs than might be expected, primarily because hospitals are not funded on the basis of their casemix adjusted activity. Instead, the main use of casemix information has been in benchmarking exercises, such as the recent example of the government's use of HRG costs to set hospital efficiency targets. This paper outlines the historical context in which HRGs were developed, the data used for classification purposes and the calculation of HRG costs. The responses of hospitals to efficiency targets based on HRG costs are considered, including the options of improving data quality, reducing costs, and ignoring the targets. It is argued that the latter strategy is most evident in England.

Suicidal behaviour in people with HIV/AIDS: a review

OBJECTIVE

To review the existing literature on suicidal behaviour in people with HIV/AIDS infection.

METHOD

A search on the Index Medicus/MEDLINE database was performed, for articles that investigated and/or reviewed suicidal behaviour in people with HIV at any stage of the illness. Only articles written in English were used in this review.

RESULTS

Most studies have been done on homosexual/bisexual groups, with little data available for heterosexual populations or women. Studies show an increased rate of suicidal ideation, suicide attempts and completed suicide in individuals with HIV/AIDS. Of note, there is a high prevalence of psychiatric illness and substance abuse in those with suicidal behaviour.

CONCLUSIONS

The increased rate of suicidal behaviour in HIV-infected persons is consistent with findings in other medically ill groups with chronic, life-threatening disorders. However, assessment of any possible direct effect of HIV/AIDS on suicidal behaviour is confounded by methodological limitations of many of the studies. More longitudinal studies encompassing other affected groups including heterosexual populations and women are needed to elucidate the relationship between suicidal behaviour and HIV/AIDS.

Health system goals: life, death and ... football

OBJECTIVES

Both the World Health Organization (WHO) and the Fédération Internationale de Football Association (FIFA) have developed sophisticated ways of defining and aggregating performance to produce overall, single-number indices. These are used to illustrate some of the problems of measuring, comparing and improving health system performance.

METHODS

Possible associations between FIFA football rankings for international 'A' sides for 176 countries and rankings on the WHO overall health system performance index were explored using econometric techniques.

RESULTS

There is a significant relationship between a country's FIFA ranking and its ranking by the WHO. Taken at face value, the statistical analysis suggests that, if the national football team does well, the WHO score improves.

CONCLUSIONS

The relationship between FIFA and WHO ranks is entirely spurious. However, comparison of the two indices illustrates problems with the WHO exercise, including measurement difficulties, how policy-makers may use the information to improve health system performance, what the public are to make of the data and how different dimensions of overall performance may be subject to trade-offs.

Use of recombinant factor VIIa (NovoSeven) in patients with Glanzmann thrombasthenia

Recombinant factor VIIa (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark) appears effective and relatively safe for the treatment of bleeding and for surgical prophylaxis in patients with Glanzmann thrombasthenia as reported to the International Registry on rFVIIa and Congenital Platelet Disorders. One of the shortcomings of the Registry data is the heterogeneity of treatment protocol, including dosage, number of doses used, duration of treatment before declaration of failure, and mode of rFVIIa administration (bolus v continuous infusion). The data are not yet sufficient to define optimal regimens for various indications such as the type of bleeding or the type of procedures. The place of this drug compared to platelet transfusion in the overall management of patients with Glanzmann thrombasthenia will need to be determined in relationship to a number of challenges and unresolved issues in the clinical care of these patients. These issues include: how to improve local measures for patients with mucosal bleeds, optimal management of young women during menarche, optimal platelet transfusion regimens for various indications, the relationship between antiplatelet antibodies detected by monoclonal antibody-specific immobilization of platelet antigens (MAIPA) and effectiveness of platelet transfusion, whether there are other biological tests that may correlate with effectiveness of platelet transfusion, and management of pregnancy and delivery regarding antiplatelet immunization.

Improving performance in public hospitals: a role for comparative costs?

In order to encourage performance improvements, the English government has set targets for acute hospitals to reduce their unit costs. Targets are based on analysis of costs across all acute hospitals. This policy has parallels with that of 'yardstick competition', advocated as a means to encourage efficiency in industries that lack competitive pressures. However, the prospect of cost improvements may not be realised in England. Firstly, there are insufficient incentives to respond appropriately to the provision of comparative cost information. Secondly, there is more than one index purporting to measure relative hospital costs. As comparison of unit costs is highly dependent on the measurement technique adopted, caution should be exercised when setting performance targets.

Communication issues for the interdisciplinary community palliative care team

This paper discusses the findings of a critical study that examined the communication patterns between nurses and general practitioners (GPs) providing palliative care in Australia. Interviews and focus groups involved 40 palliative care nurses who worked in the three settings of care: community, hospice and hospital. Issues that impeded effective communication strategies between palliative care nurses and GPs were networking, case management, multiple service providers, lack of standardized documentation and formal tracking of clients, along with difficulties in transmission of relevant practice knowledge. Supporting strategies for effective formal modes of communicating and reporting are described.

Nurse-doctor interactions during critical care ward rounds

This paper describes the participation of critical care nurses in ward rounds, and explores the power relations associated with the ways in which nurses interact with doctors during this oral forum of communication. The study comprised a critical ethnographic study of six registered nurses working in a critical care unit. Data collection methods involved professional journalling, participant observation, and individual and focus group interviews with the six participating nurses. Findings demonstrated that doctors used nurses to supplement information and provide extra detail about patient assessment during ward rounds. Nurses experienced enormous barriers to participating in decision-making activities during ward round discussions. By challenging the different points of view that doctors and nurses might hold about the ward round process, the opportunity exists for enhanced participation by nurses.

Improving patient recruitment to multicentre clinical trials: the case for employing a data manager in a district general hospital-based oncology centre

One of the most frequently cited reasons for poor recruitment to multicentre randomized clinical trials is the additional workload placed on clinical staff. We report the effect on patient recruitment of employing a data manager to support clinical staff in an English district general hospital (DGH). In addition, we explore the effect data managers have on the quality of data collected, proxied by the number of queries arising with the trial organizers. We estimate that the cost of employing a data manager on a full-time basis is 502 per patient recruited but may amount to 326 if the appointment is part-time. Data quality is high when full responsibility lies with a data manager but falls when responsibility is shared. Whether the costs of employing a data manager to recruit patients from a DGH are worth incurring depends on the value placed on the speed at which multicentre trials can be completed, how important it is to broaden the research base beyond the traditional setting of teaching hospitals, and the amount of evaluative data required.

The role of the palliative care nurse consultant in promoting continuity of end-of-life care

The provision of end-of-life care through a multidisciplinary integrated palliative-care approach is dependent on effective communication between professional groups and services. We did a qualitative study, using semi-structured individual and focus group interviews, in Melbourne, Australia. The research aim was to explore the experiences and strategies used by palliative care nurses to communicate with general practitioners. We found that palliative care nurse consultants in acute hospitals not only provided inpatient consultation, but also played an important part in facilitating continuity of care across healthcare services by improving existing communication strategies and establishing further communication networks. However, there were several issues that had the potential to disrupt communication, and this article reports on the role of the palliative care nurse consultant in addressing these issues.