Case-control study of risk factors for the development of post-transplant lymphoproliferative disease in a pediatric heart transplant cohort

PTLD is an important complication following heart transplantation. To better define the risk factors of PTLD in children, we performed a case-control study. All pediatric cardiac transplant recipients who developed their first episode of PTLD were matched by age (+/-1 yr) and time since transplant (+/-1 yr) with those who did not. PTLD occurred in nine of 95 cardiac transplant recipients (9%), 0.3-7.8 yr following cardiac transplantation (median = 2.5 yr). Patients were 0.1-16.4 yr (median = 3.7) at transplantation. Biopsies revealed polymorphic B cell hyperplasia (three), polymorphic B cell lymphoma (one), monomorphic diffuse large cell B cell lymphoma (three) and monomorphic Burkitt's-like lymphoma (two). Patients who developed PTLD were at no greater risk of death (p = 0.31). Recipient EBV seronegativity at time of transplant (p = 0.08), EBV seroconversion (p = 0.013) and recipient CMV seronegativity (p = 0.015) were associated with the development of PTLD by conditional logistic regression; sex, race, donor age, recipient diagnosis, donor CMV seropositivity, recipient treatment for CMV infection, EBV seropositivity at the time of PTLD diagnosis, and number of rejection episodes, treated rejection episodes, and lympholytics used were not. There was no significant association between PTLD and death in our recipients. EBV seroconversion and recipient CMV seronegativity were associated with the development of PTLD.

Effectiveness and cost-effectiveness of salicylic acid and cryotherapy for cutaneous warts. An economic decision model

OBJECTIVES

To estimate the costs of commonly used treatments for cutaneous warts, as well as their health benefits and risk. To create an economic decision model to evaluate the cost-effectiveness of these treatments, and, as a result, assess whether a randomised controlled trial (RCT) would be feasible and cost-effective.

DATA SOURCES

Focus groups, structured interviews and observation of practice. Postal survey sent to 723 patients. A recently updated Cochrane systematic review and published cost and prescribing data.

REVIEW METHODS

Primary and secondary data collection methods were used to inform the development of an economic decision model. Data from the postal survey provided estimates of the effectiveness of wart treatments in a primary care setting. These estimates were compared with outcomes reported in the Cochrane review of wart treatment, which were largely obtained from RCTs conducted in secondary care. A decision model was developed including a variety of over-the-counter (OTC) and GP-prescribed treatments. The model simulated 10,000 patients and adopted a societal perspective.

RESULTS

OTC treatments were used by a substantial number of patients (57%) before attending the GP surgery. By far the most commonly used OTC preparation was salicylic acid (SA). The results of the economic model suggested that of the treatments prescribed by a GP, the most cost-effective treatment was SA, with an incremental cost-effectiveness ratio (ICER) of 2.20 pound/% cured. The ICERs for cryotherapy varied widely (from 1.95 to 7.06 pound/% cured) depending on the frequency of applications and the mode of delivery. The most cost-effective mode of delivery was through nurse-led cryotherapy clinics (ICER = 1.95 pound/% cured) and this could be a cost-effective alternative to GP-prescribed SA. Overall, the OTC therapies were the most cost-effective treatment options. ICERs ranged from 0.22 pound/% cured for OTC duct tape and 0.76 pound/% cured for OTC cryotherapy to 1.12 pound/% cured for OTC SA. However, evidence in support of OTC duct tape and OTC cryotherapy is very limited. Side-effects were commonly reported for both SA and cryotherapy, particularly a burning sensation, pain and blistering.

CONCLUSIONS

Cryotherapy delivered by a doctor is an expensive option for the treatment of warts in primary care. Alternative options such as GP-prescribed SA and nurse-led cryotherapy clinics provide more cost-effective alternatives, but are still expensive compared with self-treatment. Given the minor nature of most cutaneous warts, coupled with the fact that the majority spontaneously resolve in time, it may be concluded that a shift towards self-treatment is warranted. Although both duct tape and OTC cryotherapy appear promising new self-treatment options from both a cost and an effectiveness perspective, more research is required to confirm the efficacy of these two methods of wart treatment. If these treatments are shown to be as cost-effective as or more cost-effective than conventional treatments, then a shift in service delivery away from primary care towards more OTC treatment is likely. A public awareness campaign would be useful to educate patients about the self-limiting nature of warts and the possible alternative OTC treatment options available. Two future RCTs are recommended for consideration: a trial of SA compared with nurse-led cryotherapy in primary care, and a trial of home treatments. Greater understanding of the efficacy of these home treatments will give doctors a wider choice of treatment options, and may help to reduce the overall demand for cryotherapy in primary care.

Applying preventable drug-related morbidity indicators to the electronic patient record in UK primary care: methodological development

BACKGROUND AND OBJECTIVE

Measuring and assessing the quality of health care services is an issue of high international importance. Providing data can be reliably extracted, making use of the electronic patient record (EPR) could help practitioners fulfil clinical governance obligations and ultimately improve the quality of patient care. The objective of this paper is to describe (i) the process used to apply a series of clinical indicators for preventable drug-related morbidity (PDRM) in the EPR, (ii) problems encountered and (iii) our attempts to resolve them.

METHOD

The PDRM indicators were applied retrospectively in the EPR of all patients aged 18 years and over in nine general practices using the Morbidity Information and Query Export Syntax (MIQUEST) computer software programme.

RESULTS

Issues identified as requiring attention when attempting to extract data from the EPR include considering the ranges to be used for age and biochemical test results, accuracy of diagnosis and drug coding, the level of complexity of the information needed, and how best to manipulate the resulting data. Practical difficulties encountered were ensuring the query coding schemes were sufficiently robust and comprehensive to secure reliable data extraction, the number of MIQUEST queries required to express each indicator, the time-consuming nature of the stages involved in the data manipulation process.

DISCUSSION

Despite some practical difficulties, we have successfully used MIQUEST to identify potential preventable drug-related morbidities from the EPR. The quality of information that can be extracted from the EPR is obviously limited by the accuracy and completeness of the data on the system and the ability of the enquirer to reliably extract and manipulate that data.

CONCLUSION

Although some of the problems encountered were specific to the MIQUEST software, many, including considering appropriate ranges for age and biochemical test results and paying careful attention to the reliability of drug and diagnosis coding, are relevant whenever data are extracted from the EPR for any purpose.

School re-entry of the pediatric heart transplant recipient

Pediatric cardiac transplant has become increasingly frequent in the last decade and survival rates have improved remarkably. Outcome research on this population suggests that the majority of children have the capacity for healthy adaptation although 25-40% have been shown to have some type of psychiatric difficulties. As school plays a major role in these children's lives, early intervention and close liaison with schools is indicated to reduce psychological morbidity, enhance adaptation within the school environment and enhance overall adjustment. This paper proposes a model for a school re-entry program for this population. The school re-entry program is aimed at children who are undergoing cardiac transplant and will be entering or re-entering the school system. They may range in academic age from preschool to college level and have been attending private or public schools with placements in regular education programs, regular education programs with resource support, special education programs, and alternative school programs. Others may not have been attending school because of the severity of their medical condition and have been receiving in-home tutoring. Each child is offered school re-entry assistance by a multi-disciplinary team composed of members from the Cardiology Transplant Service. The re-entry program includes cognitive and psychosocial assessment, liaison with the child's school pre- and post-transplant, academic planning and provision of academic, emotional, and behavioral support before, during, and immediately after transplant, a school re-entry visit, and an ongoing school consultation. The goal is to address issues necessary for a successful school re-entry including appropriate academic placement and support, psychosocial adjustment, education of school personnel and ongoing health needs of the student. The next step is to formally evaluate the efficacy of this program in successful school re-entry.

Thiazide diuretic prescription and electrolyte abnormalities in primary care

AIMS

Thiazide diuretics have a number of well-documented metabolic adverse effects. The aim of this study was to estimate the frequency of hyponatraemia and hypokalaemia amongst patients taking a thiazide diuretic in primary care.

METHODS

A computerized search of the electronic prescribing and laboratory records of six UK general practices was performed. Of the 32 218 adult patients identified, 3773 had received at least one prescription for a thiazide between the years 1990 and 2002.

RESULTS

Detailed prescribing data were available for 2942 patients of whom 951 (32.3%) had a recorded check of their electrolytes. One hundred and ninety-six (20.6%) had a sodium and/or potassium concentration below the normal range. The sodium distribution had a negative skew (-1.8) and in 130 (13.7%) patients was within the hyponatraemic range. Hypokalaemia was less common, occurring in 79 (8.5%) patients. Hyponatraemia was significantly associated with increased age; the odds ratio for developing hyponatraemia in patients over 70 years was 3.87 compared with those of < or = 70 years. Hypokalaemia was significantly associated with increased thiazide dose.

CONCLUSIONS

Prescription of a thiazide diuretic in primary care is associated with a high frequency of hyponatraemia and hypokalaemia. Thiazides should be prescribed at low dose and the risk of hyponatraemia, especially in the elderly, should be considered and monitored for when prescribing these agents.

Indicators for preventable drug related morbidity: application in primary care

AIM

To apply in practice a series of validated indicators for preventable drug related morbidity (PDRM).

DESIGN

A pilot study to identify retrospectively potential PDRM events over a 2 year 3 month time frame using the MIQUEST computer software program.

SUBJECTS AND SETTING

The electronic patient record of all patients aged 18 years and over in nine English general practices.

OUTCOME MEASURES

The number of potential PDRM events identified, as defined by the indicators.

RESULTS

Five hundred and seven potential PDRM events were identified from 49 658 electronic patient records, giving an overall incidence of 1.0%. A small number of the indicators (n = 4) accounted for approximately 60% of the events, while for many indicators few events were identified. The most common events related to the use of non-steroidal anti-inflammatory drugs in patients with congestive heart failure or hypertension, lack of monitoring in patients prescribed angiotensin converting enzyme inhibitors, and the use of hypnotic-anxiolytic agents.

CONCLUSIONS

A small number of indicators contributed to the majority of the PDRM events. Interrogation of electronic patient records in primary care using computerised queries shows potential for detecting PDRM.

Indicators for preventable drug related morbidity: application in primary care

AIM

To apply in practice a series of validated indicators for preventable drug related morbidity (PDRM).

DESIGN

A pilot study to identify retrospectively potential PDRM events over a 2 year 3 month time frame using the MIQUEST computer software program.

SUBJECTS AND SETTING

The electronic patient record of all patients aged 18 years and over in nine English general practices.

OUTCOME MEASURES

The number of potential PDRM events identified, as defined by the indicators.

RESULTS

Five hundred and seven potential PDRM events were identified from 49 658 electronic patient records, giving an overall incidence of 1.0%. A small number of the indicators (n = 4) accounted for approximately 60% of the events, while for many indicators few events were identified. The most common events related to the use of non-steroidal anti-inflammatory drugs in patients with congestive heart failure or hypertension, lack of monitoring in patients prescribed angiotensin converting enzyme inhibitors, and the use of hypnotic-anxiolytic agents.

CONCLUSIONS

A small number of indicators contributed to the majority of the PDRM events. Interrogation of electronic patient records in primary care using computerised queries shows potential for detecting PDRM.

Diagnostic criteria for exercise dependence in women

OBJECTIVE

To formulate diagnostic criteria for exercise dependence.

METHOD

Fifty six adult female exercisers were interviewed about their exercise behaviour and attitudes. The eating disorders examination, a semistructured clinical interview, was used to diagnose eating disorders. Interviews were taped, transcribed verbatim, and analysed from a social constructionist perspective using QSR NUD*IST. Participants also completed the exercise dependence questionnaire.

RESULTS

Two diagnostic criteria emerged from analysis of the interview data: impaired functioning and withdrawal. Impaired functioning was manifest in four areas: psychological, social and occupational, physical, and behavioural. Impairment in at least two areas was considered necessary for diagnosis. Withdrawal was evident as either an adverse reaction to the interruption of exercise or unsuccessful attempts at exercise control. Either sufficed for diagnosis. The absence or presence of an eating disorder was used to distinguish between primary and secondary exercise dependence. Ten women met these criteria for exercise dependence. All 10 also exhibited eating disorders and, accordingly, should be regarded as showing secondary, rather than primary, exercise dependence. Exercise dependent women had significantly higher scores on the exercise dependence questionnaire than non-dependent women.

CONCLUSION

These new diagnostic criteria should now be adopted and explored further, particularly among men and individuals with possible primary exercise dependence.

Inhibition of nonproteolytic Clostridium botulinum with lactic acid bacteria and their bacteriocins at refrigeration temperatures

Nonproteolytic Clostridium botulinum (strains 17B, Beluga, and 202F) was found to be inhibited by Lactobacillus, Lactococcus, Streptococcus, and Pediococcus species in tests by the spot-on-the-lawn simultaneous-antagonism method at 10, 15, and 25 degrees C. C. botulinum 17B was the most resistant strain. Inhibition zone size increased with decreasing incubation temperature. Six strains of Lactobacillus acidophilus and seven strains of bifidobacteria failed to produce an inhibition zone on buffered reinforced clostridium Prussian blue agar seeded with spores of any of the selected C. botulinum strains. C. botulinum 17B was sensitive to 50 to 100 IU of nisin per ml and to 10 to 20 AU of pediocin A per ml.

GPs' views on computerized drug interaction alerts: questionnaire survey

BACKGROUND

There is evidence that patients are being prescribed potentially hazardous drug-drug combinations in general practice despite the use of computerized drug interaction alert systems. One reason for this may be that general practitioners (GPs) are overriding these alerts without properly checking them.

AIMS

(i) To assess GPs views on the relevance of information provided by alert systems; (ii) To determine the proportion of GPs that admit to frequently overriding interaction alerts without properly checking them and (iii) To explore factors that might be associated with a tendency to override alerts.

METHODS

Questionnaire survey of GPs in four primary care trusts in the Nottingham area of the UK.

RESULTS

The response rate was 70% (236 of 336) and detailed analysis was conducted on the 220 respondents who had drug interaction alert systems on their practice computers. Of these, 22% (49 of 220) admitted to frequently or very frequently overriding drug interaction alerts without properly checking them. Potential reasons for overriding alerts included the perception that the alerts were frequently irrelevant. Nevertheless 90% (198 of 219) agreed that it should be more difficult to override alerts for potentially lethal drug combinations. Logistic regression analysis showed that users of the EMIS (Egton Medical Information Systems) computer system were much less likely to admit to overriding alerts without properly checking them than users of other computer systems.

CONCLUSION

A minority of GPs admit to frequently overriding their drug interaction alert systems without properly checking them. The type of computer system used by GPs may make it more or less likely that they override alerts.

Neonatal alloimmune thrombocytopenia due to HPA-3a antibodies: a case report

A healthy infant was born at term by elective cesarean section to a 32-year-old para 4, gravida 4, mother. Within 24 hours, the infant was noted to have fairly extensive bruising on the back and shoulders. A full blood count evaluation was remarkable for severe thrombocytopenia (platelet count of 29 x 10(9)/L). Other hematologic parameters were normal. Human leukocyte antigen (HLA) class-1 antibodies but not platelet-specific antibodies were detectable in the maternal serum using a commercial antigen-capture ELISA (GTI-PakPlus kit). Anti-HPA-3a antibodies, while weakly reactive in the monoclonal antibody immobilization of platelet antigens (MAIPA) assay in the immediate postpartum serum, were readily detectable using this assay in a sample taken 4 weeks later. Genotyping for human platelet antigens (HPA) 1-5 by the polymerase chain reaction technique with sequence-specific primers (PCR-SSP) revealed the infant's platelet genotype to be HPA-1a/1a, 3a/3b, while that of the mother was HPA-1a/1a, 3b/ 3b, consistent with a diagnosis of anti-HPA-3a neonatal alloimmune thrombocytopenia (NAIT). This case illustrates the increased sensitivity of the MAIPA technique for the detection of platelet-specific antibodies. We believe this to be the first serologically confirmed case of NAIT due to anti-HPA-3a to be reported in the republic of Ireland.

The reporting of crime and violence in the Los Angeles Times: is there a public health perspective?

The authors examine how crime and violence is reported and framed by the Los Angeles Times. Using a public health perspective, we examine whether health-oriented variables, such as causal factors and societal effects of crimes, are present in crime news stories. The classic stereotyping of crime and violence framing is strongly present in the Times. We discuss what changes would be useful to provide news consumers with a more accurate picture of crime in their community.

"It's exercise or nothing": a qualitative analysis of exercise dependence

OBJECTIVES

To explore, using qualitative methods, the concept of exercise dependence. Semistructured interviews were undertaken with subjects screened for exercise dependence and eating disorders.

METHODS

Female exercisers, four in each case, were allocated a priori to four groups: primary exercise dependent; secondary exercise dependent, where there was a coincidence of exercise dependence and an eating disorder; eating disordered; control, where there was no evidence of either exercise dependence or eating disorder. They were asked about their exercise and eating attitudes and behaviour, as well as about any history of psychological distress. Their narratives were taped, transcribed, and analysed from a social constructionist perspective using QSR NUD*IST.

RESULTS

Participants classified as primary exercise dependent either showed no evidence of exercise dependent attitudes and behaviour or, if they exhibited features of exercise dependence, displayed symptoms of an eating disorder. Only the latter reported a history of psychological distress, similar to that exhibited by women classified as secondary exercise dependent or eating disordered. For secondary exercise dependent and eating disordered women, as well as for controls, the narratives largely confirmed the a priori classification.

CONCLUSIONS

Where exercise dependence was manifest, it was always in the context of an eating disorder, and it was this comorbidity, in addition to eating disorders per se, that was associated with psychological distress. As such, these qualitative data support the concept of secondary, but not primary, exercise dependence.

Impaired exercise parameters in pediatric heart transplant recipients: comparison of biatrial and bicaval techniques

The exercise performance of pediatric heart transplant recipients and the effects of bicaval anastomosis were studied in 19 children using a Bruce protocol. Although all children had decreased exercise capacity and heart rates when compared with normals, the bicaval anastomosis patients had similar endurance and peak heart rates as the standard biatrial group.

A prescription for improvement? An observational study to identify how general practices vary in their growth in prescribing costs

OBJECTIVE

To identify how some general practices have low growth in prescribing costs relative to other practices.

DESIGN

Observational study.

SETTING

Trent region of England.

PARTICIPANTS

162 general practices: 54 with low growth in prescribing costs, 54 with average increases in costs, and 54 with large increases in costs.

MAIN OUTCOME MEASURES

Changes in prescribing costs in therapeutic categories in which it has been suggested that savings can be made.

RESULTS

There were significant differences between the three groups of practices in terms of their changes in prescribing costs for almost all the variables studied. For the group of practices with lowest growth in costs the most important factors were reducing numbers of prescription items and costs per item; relatively low growth in the costs of "new and expensive" drugs; increasing generic prescribing; and reducing costs for modified release products. This group of practices did not increase costs as much as the others for lipid lowering drugs (P=0.012) and hormone replacement therapy (P=0. 007). The practices with the greatest increases in costs had particularly large increases for proton pump inhibitors, selective serotonin reuptake inhibitors, and modified release products. Compared with the other groups these practices had larger increases in costs for "expensive hospital initiated drugs" (P=0.009).

CONCLUSION

General practices vary in their growth in prescribing costs in many ways, with growth in costs for "new and expensive" drugs being particularly important.

Deletion of the 6-kDa subunit affects the activity and yield of the bc1 complex from Rhodovulum sulfidophilum

The cytochrome bc1 complex from Rhodovulum sulfidophilum purifies as a four-subunit complex: the cytochrome b, cytochrome c1 and Rieske iron-sulphur proteins, which are encoded together in the fbc operon, as well as a 6-kDa protein. The gene encoding the 6-kDa protein, named fbcS, has been identified. It is located within the sox operon, which encodes the subunits of sarcosine oxidase. The encoded 6-kDa protein is very hydrophobic and is predicted to form a single transmembrane helix. It shows no sequence homology to any known protein. The gene has been knocked-out of the genome and a three-subunit complex can be purified. This deletion leads to a large reduction in the yield of the isolated complex and in its activity compared to wild-type. The high quinone content found in the wild-type complex is, however, maintained after removal of the 6-kDa protein. Surprisingly, a fourth subunit of approximately 6 kDa is again found to copurify with the Rhv. sulfidophilum bc1 complex when only the fbc operon is expressed heterologously in a near-relative, Rhodobacter capsulatus, which lacks this small subunit in its own bc1 complex.

Reversal of severe late left ventricular failure after pediatric heart transplantation and possible role of plasmapheresis

Late acute cardiac graft failure carries a high mortality in adults. Vascular mediators and factors other than classic T-cell-mediated rejection may play a role in this process, and aggressive multimodality therapy may improve survival. We report experience with plasmapheresis in treating late severe acute left ventricular dysfunction in a group of pediatric heart transplant recipients. We retrospectively reviewed clinical records, echocardiograms, hemodynamics, coronary angiograms, biopsy specimens, and treatment regimens for 5 patients with 7 episodes of late-onset severe graft failure who recovered. Plasmapheresis was applied in all cases, in addition to methylprednisolone, cyclophosphamide, lympholytic agents, and aggressive supportive care including mechanical ventilation and hemofiltration. All patients presented with acute severe left ventricular dysfunction 1.4 to 7.9 years (mean 3.6) after orthotopic heart transplantation. Mean shortening fraction at presentation was 13 to 23% (mean 16), initial endomyocardial biopsy specimens were grade 0 to 3B, and immunofluorescence studies were negative. Treatment included plasmapheresis, cyclophosphamide, mechanical ventilation, hemofiltration, and inotropes. Clinical recovery was slow, with 4 to 8 weeks until left ventricular function normalized, and 2.2 to 9.4 (mean 4.6) weeks to hospital discharge. At follow-up (50 to 38 months, mean 24), all are alive. Two patients are well, whereas coronary vasculopathy developed in 3. Thus, survival may improve in patients with late graft failure with low biopsy score and plasmapheresis combined with multimodality therapy.