Patient-Reported Questionnaires to Identify Adverse Drug Reactions: A Systematic Review

Background: This systematic review aims to summarise available patient-reported questionnaires to detect adverse drug reactions (ADRs) that can be utilised by healthcare professionals in clinical practice and to summarise the psychometric properties (validity, reliability, and responsiveness) of the questionnaires. Methods: A systematic literature search was conducted using Medline, Pubmed, Embase, and Emcare databases to screen for articles published between January 2000 and July 2020. Data items regarding validity, reliability, and responsiveness were extracted independently by two authors. The methodological quality was assessed using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) checklist. Results: A total of 1563 unique article titles were identified after removing duplicates. Following shortlisting of relevant articles, 19 patient-reported ADR questionnaires were identified. Questionnaires most commonly focused on mental health medications (42.1%, n = 8), followed by general questionnaires applicable to any medication (21.1%, n = 4). Many questionnaires did not report assessing the validity and reliability of the measurement tool. For example, only 11 questionnaires (58%) mentioned assessing content validity, in addition to criterion or construct testing. Conclusion: This systematic review summarised the available patient-reported questionnaires that can be used in research and clinical practice to identify ADRs. Results of this systematic review highlight the need for more robust validity and reliability testing when developing patient-reported ADR questionnaires.

Third-generation modular mandible endoprosthesis in Macaca fascicularis

The aim of this study was to develop a third-generation modular mandible endoprosthesis that would experience less stress concentration at its stems compared to earlier generations, thereby minimizing micromotion and achieving long-term stability. In this three-piece modular design, different degrees of movement were incorporated between the endoprosthesis module interfaces. It was hypothesized that this unique feature would minimize stress concentration at the stems and hence promote osseointegration during the early phase of implantation. The endoprosthesis system was made of commercially pure grade 4 titanium, machined and surface-treated, then sterilized and implanted in segmental mandible defects of nine Macaca fascicularis. Clinical, radiological, histological, and histomorphometric evaluations were performed 4 months post-implantation. The endoprosthesis systems with a degree of movement incorporated, exhibited superior performance compared to the rigid system: 30.9-34.8 times higher percentage bone-implant contact (P< 0.0001) and 3.4-4.1 times higher percentage bone area (P<0.0001), with osseointegration noted at the posterior stems. However, fibrous tissue encapsulation was noted around the majority of the anterior stems in all groups. Although the degree of movement was favourable for improving bone healing and stability of the endoprosthesis system, more work needs to be done to investigate other strategies to further reduce loading on the endoprosthesis to achieve predictable osseointegration at the stems.

Effects of vitamin E on stroke: a systematic review with meta-analysis and trial sequential analysis

There are several previous studies on the association of vitamin E with prevention of stroke but the findings remain controversial. We have conducted a systematic review, meta-analysis together with trial sequential analysis of randomised controlled trials to evaluate the effect of vitamin E supplementation versus placebo/no vitamin E on the risk reduction of total, fatal, non-fatal, haemorrhagic and ischaemic stroke. Relevant studies were identified by searching online databases through Medline, PubMed and Cochrane Central Register of Controlled Trials. A total of 18 studies with 148 016 participants were included in the analysis. There was no significant difference in the prevention of total stroke (RR (relative risk)=0.98, 95% CI 0.92-1.04, p=0.57), fatal stroke (RR=0.96, 95% CI 0.77-1.20, p=0.73) and non-fatal stroke (RR=0.96, 95% CI 0.88-1.05, p=0.35). Subgroup analyses were performed under each category (total stroke, fatal stroke and non-fatal stroke) and included the following subgroups (types of prevention, source and dosage of vitamin E and vitamin E alone vs control). The findings in all subgroup analyses were statistically insignificant. In stroke subtypes analysis, vitamin E showed significant risk reduction in ischaemic stroke (RR=0.92, 95% CI 0.85-0.99, p=0.04) but not in haemorrhagic stroke (RR=1.17, 95% CI 0.98-1.39, p=0.08). However, the trial sequential analysis demonstrated that more studies were needed to control random errors. Limitations of this study include the following: trials design may not have provided sufficient power to detect a change in stroke outcomes, participants may have had different lifestyles or health issues, there were a limited number of studies available for subgroup analysis, studies were mostly done in developed countries, and the total sample size for all included studies was insufficient to obtain a meaningful result from meta-analysis. In conclusion, there is still a lack of statistically significant evidence of the effects of vitamin E on the risk reduction of stroke. Nevertheless, vitamin E may offer some benefits in the prevention of ischaemic stroke and additional well-designed randomised controlled trials are needed to arrive at a definitive finding. PROSPERO registration number: CRD42020167827.

A cross-sectional assessment of the relationship between sedative medication and anticholinergic medication use and the movement behaviour of older adults living in residential aged care

Objectives

Medications with anticholinergic or sedative effects are frequently used by older people but can increase risk of falls and adverse events; however, less is known about their effect on movement behaviour. Here we examine the cross-sectional association between medication use and movement behaviour in older adults living in residential aged care.

Materials and Methods

Twenty-eight older adults living in residential aged care in metropolitan Australia participated. Medication data were collected from participants’ medical charts and sedative load and anticholinergic burden were determined. Seven-day movement behaviour was objectively assessed by a wrist-worn triaxial accelerometer. Raw accelerations were converted to sleep, sedentary time, and time in light, moderate, and moderate-to-vigorous physical activity. To explore the relationship between medication and movement behaviour, Spearman’s Rho correlations were conducted, as the data were not normally distributed.

Results

Analyses indicated that while anticholinergic burden was not associated with movement behaviour, sedative load was negatively correlated with a number of variables, accounting for 14% variance in moderate-to-vigorous physical activity (MVPA), and 17% in the bout length of MVPA (p < .02).

Conclusion

The findings of this study showed a negative association between sedative load, due to medicines, and an individual’s movement behaviour. The impact of this could be a reduction in the ability of this population to maintain or improve their functional mobility, which may overshadow any benefits of the medicine in some circumstances.

Reducing medicine-induced deterioration and adverse reactions (ReMInDAR) trial: study protocol for a randomised controlled trial in residential aged-care facilities assessing frailty as the primary outcome

INTRODUCTION

Many medicines have adverse effects which are difficult to detect and frequently go unrecognised. Pharmacist monitoring of changes in signs and symptoms of these adverse effects, which we describe as medicine-induced deterioration, may reduce the risk of developing frailty. The aim of this trial is to determine the effectiveness of a 12-month pharmacist service compared with usual care in reducing medicine-induced deterioration, frailty and adverse reactions in older people living in aged-care facilities in Australia.

METHODS AND ANALYSIS

The reducing medicine-induced deterioration and adverse reactions trial is a multicentre, open-label randomised controlled trial. Participants will be recruited from 39 facilities in South Australia and Tasmania. Residents will be included if they are using four or more medicines at the time of recruitment, or taking more than one medicine with anticholinergic or sedative properties. The intervention group will receive a pharmacist assessment which occurs every 8 weeks. The pharmacists will liaise with the participants' general practitioners when medicine-induced deterioration is evident or adverse events are considered serious. The primary outcome is a reduction in medicine-induced deterioration from baseline to 6 and 12 months, as measured by change in frailty index. The secondary outcomes are changes in cognition scores, 24-hour movement behaviour, grip strength, weight, percentage robust, pre-frail and frail classification, rate of adverse medicine events, health-related quality of life and health resource use. The statistical analysis will use mixed-models adjusted for baseline to account for repeated outcome measures. A health economic evaluation will be conducted following trial completion using data collected during the trial.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from the Human Research Ethics Committee of University of South Australia (ID:0000036440) and University of Tasmania (ID:H0017022). A copy of the final report will be provided to the Australian Government Department of Health.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Trials Registry ACTRN12618000766213.

USA Department of Defense audit of surgical antibiotic prophylaxis prescribing patterns in inguinal hernia repair

PURPOSE

Antibiotic prophylaxis in inguinal hernia repair (IHR) is contentious in literature and practice. In low-risk patients, for whom evidence suggests antibiotic prophylaxis is unnecessary, many surgeons still advocate for its routine use. This study surveys prescription patterns of Department of Defense (DoD) general surgeons.

METHODS

An anonymous survey was sent electronically to approximately 350 DoD general surgeons. The survey asked multiple-choice and free text answers about prescribing patterns and knowledge of current evidence for low-risk patients undergoing elective open inguinal hernia repair without mesh (OIHRWOM), open inguinal hernia repair with mesh (OIHRWM), or laparoscopic inguinal hernia repair (LIHR).

RESULTS

110 DoD general surgeons consented to participate. 58.6, 95 and 84.2% of surgeons always administer antibiotic prophylaxis in OIHRWOM, OIHRWM, and LIHR, respectively. 37.9, 70.9, and 63.2% of surgeons believe that it reduces rates of surgical site infection in OIHRWOM, OIHRWM, and LIHR, respectively. The most common reasons for empirically prescribing antibiotic prophylaxis include "I think the evidence supports it" (27 of 72 responses), "I would rather be conservative and safe" (15 of 72 responses), and "I am following my hospital/department guidelines" (9 of 72 responses). 11.8, 40.8, and 32.9% of surgeons believe current evidence supports antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. 50, 18.4, and 22.4% of surgeons believe current evidence refutes antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively.

CONCLUSION

The survey results indicate that the majority of practicing DoD general surgeons still empirically prescribe surgical antibiotic prophylaxis in IHR despite more conflicting opinions that it has no meaningful effect or that current evidence does not supports its use.

Association of blood mercury levels with nonmelanoma skin cancer in the U.S.A. using National Health and Nutrition Examination Survey data (2003-2016)

BACKGROUND

Some studies have reported increased incidence or mortality of lung and brain cancers associated with occupations involving potential mercury exposure. Epidemiological evidence related to skin cancer is also limited.

OBJECTIVES

To investigate the association between blood mercury (Hg) levels and nonmelanoma skin cancer (NMSC).

METHODS

We used National Health and Nutrition Examination Survey data from 2003 to 2016. The exposures were blood total (tHg), inorganic (iHg) and methylmercury (MeHg). The outcome was a self-reported diagnosis of NMSC. We included participants aged ≥ 20 years who had information on blood mercury and sociodemographic factors. We conducted a logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of NMSC associated with quartiles of blood Hg, after adjusting for the sociodemographic factors and survey year.

RESULTS

The number of participants was 29 413; mean age was 49 years and 52% were female. Compared with those with a tHg ≤ 0·47 μg L^-1 (Q1), those with a tHg > 1·74 μg L^-1 (Q4) had nearly double the odds of NMSC (OR 1·79, 95% CI 1·19-2·71; P_trend = 0·004). Similarly, those in the highest quartile of MeHg (> 1·44 μg L^-1 ) had 1·7 times greater odds of NMSC (OR 1·74, 95% CI 1·13-2·70; P_trend = 0·01) than those in the lowest quartile (≤ 0·21 μg L^-1 ). iHg levels were nonsignificantly positively associated with NMSC (P_trend = 0·08).

CONCLUSIONS

We found that higher blood tHg and MeHg levels were associated with a higher prevalence of NMSC. Linked Comment: Taylor. Br J Dermatol 2020; 183:413-414.

A review of efferent cholinergic synaptic transmission in the vestibular periphery and its functional implications

It has been over 60 years since peripheral efferent vestibular terminals were first identified in mammals, and yet the function of the efferent vestibular system remains obscure. One reason for the lack of progress may be due to our deficient understanding of the peripheral efferent synapse. Although vestibular efferent terminals were identified as cholinergic less than a decade after their anatomical characterization, the cellular mechanisms that underlie the properties of these synapses have had to be inferred. In this review we examine how recent mammalian studies have begun to reveal both nicotinic and muscarinic effects at these terminals and therefore provide a context for fast and slow responses observed in classic electrophysiological studies of the mammalian efferent vestibular system, nearly 40 years ago. Although incomplete, these new results together with those of recent behavioral studies are helping to unravel the mysterious and perplexing action of the efferent vestibular system. Armed with this information, we may finally appreciate the behavioral framework in which the efferent vestibular system operates.

Nursing teamwork in the care of older people: A mixed methods study

Healthcare is increasingly complex and requires the ability to adapt to changing demands. Teamwork is essential to delivering high quality care and is central to nursing. The aims of this study were to identify the processes that underpin nursing teamwork and how these affect the care of older people, identify the relationship between perceived teamwork and perceived quality of care, and explore in depth the experience of working in nursing teams. The study was carried out in three older people's wards in a London teaching hospital. Nurses and healthcare assistants completed questionnaires (n = 65) on known dynamics of teamwork (using the Nursing Teamwork Survey) together with ratings of organisational quality (using an adapted AHRQ HSPS scale). A sample (n = 22; 34%) was then interviewed about their perceptions of care, teamwork and how good outcomes are delivered in everyday work. Results showed that many care difficulties were routinely encountered, and confirmed the importance of teamwork (e.g. shared mental models of tasks and team roles and responsibilities, supported by leadership) in adapting to challenges. Perceived quality of teamwork was positively related to perceived quality of care. Work system variability and the external environment influenced teamwork, and confirmed the importance of team adaptive capacity. The CARE model shows the centrality of teamwork in adapting to variable demand and capacity to deliver care processes, and the influence of broader system factors on teamworking.

Analysis of anticholinergic and sedative medicine effects on physical function, cognitive function, appetite and frailty: a cross-sectional study in Australia

OBJECTIVE

To test the association between use of medicines with anticholinergic or sedative properties and physical function, cognitive function, appetite and frailty.

DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study analysed baseline data collected as part of the Australian Longitudinal Study of Ageing, a population-based cohort of 2087 participants aged 65 years or over living in South Australia.

MAIN OUTCOME MEASURES

Physical function was measured at baseline using measures including hand grip strength, walking speed, chair stands, activities of daily living and instrumental activities of daily living (IADL). Cognitive function was measured using Mini-Mental State Examination. Appetite was measured using Center for Epidemiologic Studies Depression question 2. Frailty was measured using frailty index. The association between use of anticholinergics or sedatives and physical or cognitive function, appetite, or frailty was assessed using analysis of covariance and ordinal or binary logistic regression.

RESULTS

Almost half of the population were using anticholinergics or sedatives (n=954, 45.7%). Use of anticholinergics was significantly associated with poorer grip strength, slower walking speed, poorer IADL and poorer appetite. Use of sedatives was significantly associated with poorer grip strength, slower walking speed and poorer IADL. We found no significant association between medicine use and cognitive function. Users of anticholinergics or sedatives were significantly more likely to be frail compared with non-users.

CONCLUSION

Use of medicines with anticholinergic or sedative properties is significantly associated with poorer physical function, poorer appetite and increased frailty. Early identification of signs and symptoms of deterioration associated with medicine use is particularly important in older people so that worsening frailty and subsequent adverse events are prevented.

Impact of myocardial infarction on intraventricular vortex and flow energetics assessed using computational simulations

Flow energetics have been proposed as early indicators of progressive left ventricular (LV) functional impairment in patients with myocardial infarction (MI), but its correlation with individual MI parameters has not been fully explored. Using electro-fluid-structure interaction LV models, this study investigated the correlation between four MI parameters: infarct size, infarct multiplicity, regional enhancement of contractility at the viable myocardium area (RECVM), and LV mechanical dyssynchrony (LVMD) with intraventricular vortex and flow energetics. In LV with small infarcts, our results showed that infarct appearance amplified the energy dissipation index (DI), where substantial viscous energy loss was observed in areas with high flow velocity and near the infarct-vortex interface. The LV with small multiple infarcts and RECVM showed remarkable DI increment during systole and diastole. In correlation analysis, the systolic kinetic energy fluctuation index (E') was positively related to ejection fraction (EF) (R²  = 0.982) but negatively correlated with diastolic E' (R²  = 0.970). Diastolic E' was inversely correlated with vortex kinetic energy (R²  = 0.960) and vortex depth (R²  = 0.876). We showed an excessive systolic DI could differentiate infarcted LV with normal EF from healthy LV. Strong flow acceleration, LVMD, and vortex-infarct interactions were predominant factors that induced excessive DI in infarcted LVs. Instead of causing undesired flow turbulence, high systolic E' suggested the existence of energetic flow acceleration, while high diastolic E' implied an inefficient diastolic filling. Thus, systolic E' is not a suitable early indicator for progressive LV dysfunction in MI patients, while diastolic E' may be a useful index to indicate diastolic impairment in these patients.

Making global river ecosystem health assessments objective, quantitative and comparable

Assessing and comparing global river ecosystem health in an objective and quantitative way remains a major challenge. In this study the widely-used semi-quantitative methods Rapid Biological assessment Protocols (RBPs) was used to determine the health of rivers. The findings were then compared to the results derived from our new UAV (Unmanned aerial vehicles) orthophotographic imagery method. This method quantitatively and objectively assesses river ecosystem health. As a comparison, our method was used to quantitatively measure distance and areas of a range of hydrological and biological attributes thus improving the accuracy of distance- and area-related indices, consequently avoiding subjective errors in these estimations that is fraught in methods like the RBPs. To strengthen the objectivity of the assessment the weights of these indices were objectively determined using the entropy weighting method. This new method was then tested using 9551 UAV orthophotographs taken over six field campaigns. It performed satisfactorily, showing that in our study area the health status of mountain rivers was the best with the highest score of 0.94 out of 1.0. Temporally, the health of the river was better in summer (0.65) compared with that in autumn (0.40). Changes in river ecosystem health were driven by variations in biology and water quality. In contrast the outputs of RBPs, especially in relation to distance and area indices, had ~ 20% uncertainty due to visual errors and subjectivity in estimations by observers. The UAV orthophotographic imaging method proposed in this study can improve the ability to compare the health of rivers across different periods and regions throughout the globe.