Use of the Delphi technique to determine safety features to be included in a neonatal and paediatric prescription chart

BACKGROUND

Neonatal and paediatric patients are especially vulnerable to serious injury as a result of medication errors due to their small size, physiological immaturity and limited compensatory abilities. The prescription chart remains an essential form of communication of prescribing decisions and instructions. Modifications to the safety features of prescription charts have been shown to reduce the frequency of medication errors.

OBJECTIVE

To determine, using the Delphi technique, which safety features should be included in the inpatient neonatal and paediatric prescription chart to help minimise the risk of medication errors associated with the use of the chart.

SETTING

Acute general hospital in Malta.

METHOD

A two-round modified e-Delphi process was conducted. The Delphi questionnaire was developed from a mapping process, a literature search and references supporting the literature review. It comprised 155 safety features for consensus. The Delphi panel consisted of nine doctors, five nurses and four pharmacists. Participants were asked to rate their agreement to the inclusion of these features in the local chart using a three-point Likert scale, and to add further comments as necessary at the end of each section. In the second round, participants were given the opportunity to change their individual response in view of the groups' response.

MAIN OUTCOME MEASURE

This was set at a 70% level of agreement.

RESULTS

Results from each round were analysed to provide the percentage frequencies and number of participants who chose each point from the Likert scale provided, and the response count for each safety feature. A ≥70% consensus level was achieved on: 115 safety features in Round 1 (total: 155 safety features) and 23 safety features in Round 2 (total: 40 safety features) while only 17 safety features did not achieve consensus at the end of the process.

CONCLUSION

Consensus was achieved on 133 safety features to be included in the neonatal and paediatric prescription chart. Five safety features achieved consensus disagreement for their inclusion in the chart. Identifying the appropriate safety features forms part of an essential strategy to reduce the incidence of medication errors associated with the use of the chart in these patients.

Systematic review of diet quality indices and their associations with health-related outcomes in children and adolescents

BACKGROUND

Diet quality indices add an important dimension to dietary assessment. The aim of this systematic review was to: (i) identify and describe the attributes and applications of diet quality indices developed for use or used in paediatric populations; (ii) describe associations between these diet quality indices and health-related variables in paediatric populations; and (iii) identify factors that are associated with diet quality in paediatric populations worldwide.

METHODS

Studies were identified by searching electronic databases for relevant papers from 1980 to October 2013 using keywords. Inclusion criteria were original studies that utilised a quantitative measure of diet quality in children and adolescents aged 0-18 years.

RESULTS

One hundred and nineteen studies met the inclusion criteria, from which 80 different diet quality indices were identified. The majority of studies had >1000 participants and were of acceptable quality. Of the 56 studies that investigated health-related outcomes, weight status was the most researched. Europe produced the most number of diet quality indices (n = 27 indices). Of the 119 studies, seven intervention studies were identified. Paediatric diet quality indices were found to be associated with environmental, behavioural and maternal factors.

CONCLUSIONS

The use of diet quality indices in paediatric populations is a rapidly expanding area of research in diverse populations internationally. In economically disadvantaged countries, diet quality indices may be predictive of child growth. However, prospective cohort, intervention and validation studies are required to draw stronger conclusions concerning risk of future disease in paediatric populations in general.

Development and evaluation of a driving observation schedule (DOS) to study everyday driving performance of older drivers

This paper describes the development and evaluation of an on-road procedure, the Driving Observation Schedule (DOS), for monitoring individual driving behavior. DOS was developed for use in the Candrive/Ozcandrive five-year prospective study of older drivers. Key features included observations in drivers' own vehicles, in familiar environments chosen by the driver, with start/end points at their own homes. Participants were 33 drivers aged 75+ years, who drove their selected route with observations recorded during intersection negotiation, lane-changing, merging, low speed maneuvers and maneuver-free driving. Driving behaviors were scored by a specialist occupational therapy driving assessor and another trained observer. Drivers also completed a post-drive survey about the acceptability of DOS. Vehicle position, speed, distance and specific roadways traveled were recorded by an in-vehicle device installed in the participant's vehicle; this device was also used to monitor participants' driving over several months, allowing comparison of DOS trips with their everyday driving. Inter-rater reliability and DOS feasibility, acceptability and ecological validity are reported here. On average, drivers completed the DOS trip in 30.48min (SD=7.99). Inter-rater reliability measures indicated strong agreement between the trained and the expert observers: intra-class correlations (ICC)=0.905, CI 95% 0.747-0.965, p<0.0001; Pearson product correlation, r (18)=.83, p<0.05. Standard error of the measurement (SEM), method error (ME) and coefficient of variation (CV) measures were consistently small (3.0, 2.9 & 3.3%, respectively). Most participants reported being 'completely at ease' (82%) with the driving task and 'highly familiar with the route' (97%). Vehicle data showed that DOS trips were similar to participants' everyday driving trips in roads used, roadway speed limits, drivers' average speed and speed limit compliance. In summary, preliminary findings suggest that DOS can be scored reliably, is of feasible duration, is acceptable to drivers and representative of everyday driving. Pending further research with a larger sample and other observers, DOS holds promise as a means of quantifying and monitoring changes in older drivers' performance in environments typical of their everyday driving.

Manipulating the lateral diffusion of surface-anchored EGF demonstrates that receptor clustering modulates phosphorylation levels

Upon activation, the epidermal growth factor (EGF) receptor becomes phosphorylated and triggers a vast signaling network that has profound effects on cell growth. The EGF receptor is observed to assemble into clusters after ligand binding and tyrosine kinase autophosphorylation, but the role of these assemblies in the receptor signaling pathway remains unclear. To address this question, we measured the phosphorylation of EGFR when the EGF ligand was anchored onto laterally mobile and immobile surfaces. We found that cells generated clusters of ligand-receptor complex on mobile EGF surfaces, and displayed a lower ratio of phosphorylated EGFR to EGF when compared to immobilized EGF that is unable to cluster. This result was verified by tuning the lateral assembly of ligand-receptor complexes on the surface of living cells using patterned supported lipid bilayers. Nanoscale metal lines fabricated into the supported membrane constrained lipid diffusion and EGF receptor assembly into micron and sub-micron scale corrals. Single cell analysis indicated that clustering impacts EGF receptor activation, and larger clusters (>1 μm(2)) of ligand-receptor complex generated lower EGF receptor phosphorylation per ligand than smaller assemblies (<1 μm(2)) in HCC1143 cells that were engaged to ligand-functionalized surfaces. We investigated the mechanism of EGFR clustering by treating cells with compounds that disrupt the cytoskeleton (Latrunculin B), clathrin-mediated endocytosis (Pitstop2), and inhibit EGFR activation (Gefitinib). These results help elucidate the nature of large-scale EGFR clustering, thus underscoring the general significance of receptor spatial organization in tuning biochemical function.

Assessment of Maraviroc Exposure-Response Relationship at 48 Weeks in Treatment-Experienced HIV-1-Infected Patients in the MOTIVATE Studies

Efficacy exposure–response relationships of the CCR5 antagonist maraviroc were evaluated across two phase III clinical trials. This post-hoc analysis used 48-week efficacy data from 841 treatment-experienced patients infected with CCR5-tropic human immunodeficiency virus type 1 (HIV-1), identified by the enhanced sensitivity Trofile assay. Probability of treatment success (viral RNA <50 copies/ml) was modeled using generalized additive logistic regression, testing exposure, clinical, and virologic variables. Prognostic factors for treatment success (in decreasing order of Akaike information criterion (AIC) change) were: maraviroc treatment, high-weighted overall susceptibility to background treatment, absence of an undetectable maraviroc concentration, high baseline CD4 count (BCD4), low viral load (VL), race (other than black), absence of non-R5 baseline tropism (BTRP), and absence of fosamprenavir (FPV). No concentration–response relationship was found with treatment (maraviroc vs. placebo) and presence/absence of undetectable maraviroc concentration (adherence marker) in the model. The maraviroc doses studied (300 or 150 mg with potent CYP3A4 inhibitors once (q.d.)/twice daily (b.i.d.)) deliver concentrations near the top of the concentration–response curve.

Abstract 65: Flavin Monoxygenase 3 (FMO3) is a Novel Regulator of Hepatic Cholesterol Metabolism and Transintestinal Cholesterol Efflux (TICE)

Recent studies have revealed a novel route for cholesterol disposal through intestine known as transintestinal cholesterol efflux (TICE) that significantly contributes to fecal neutral sterol loss. This pathway is an integral part of reverse cholesterol transport (RCT), yet major mechanisms regulating TICE are not well understood. Using an unbiased transcriptional profiling approach in mouse models of augmented TICE, we found that hepatic expression of the enzyme Flavin monoxygenase 3 (FMO3) was dramatically repressed. At the same time we identified this enzyme through transcriptional profiling, it was reported that plasma levels of its product trimethylamineoxide (TMAO) are highly predictive of atheroslcerosis in humans, and TMAO is proatherogenic in mice. To further understand FMO3’s role as a regulator of cholesterol metabolism we used antisense oligonucleotides (ASO) to knockdown FMO3 expression in mouse liver in C57BL/6 mice fed either low (0.02%) or high (0.2%) levels of dietary cholesterol. As expected, FMO3 knockdown (>90% knockdown in the liver) increased the TMA/TMAO ratio in plasma more than 3-fold. Interestingly, knockdown of FMO biliary cholesterol levels were reduced by 60%, whereas fecal cholesterol loss was quite normal in FMO3 ASO treated mice fed a high cholesterol diet, which phenocopies a previously described mouse model where TICE predominates (NPC1L1-liver transgenic mice). ASO-mediated knockdown of FMO3 also unexpectedly reduced hepatic cholesteryl ester (CE) storage by 70% in mice fed 0.2% cholesterol. In parallel, knockdown of FMO3 reduces plasma VLDL cholesterol levels and the secretion rate of VLDL cholesteryl ester, but not triacylglycerol in cholesterol fed mice. FMO3 knockdown also reduced the hepatic expression of several liver X receptor (LXR) target genes, while increasing expression of genes involved in cholesterol synthesis. Collectively, these studies have identified FMO3 as a novel regulator of hepatic cholesterol metabolism and TICE. Given that plasma levels of FMO3’s product (TMAO) are strongly associated with atherosclerosis development in humans, and production of TMAO promotes atherosclerosis in mice, these studies have important implications for future cardiovascular drug discovery.

Are informal carers and community care workers effective in managing malnutrition in the older adult community? A systematic review of current evidence

BACKGROUND

Enhancing the effectiveness of the community and aged care workforce to prevent malnutrition and functional decline is important in reducing hospital and aged care facility demand.

OBJECTIVE

To investigate the impact of nutrition-related interventions delivered to or by informal carers and non-clinical community care workers on malnutrition-related health outcomes of community-dwelling older adults (≥65 years).

METHODS

Intervention studies were searched for using six electronic databases for English-language publications from January 1980 to 30 May 2012.

RESULTS

Nine studies were eligible for inclusion. The strength and quality of the evidence was moderate (six studies with level II intervention evidence, five with positive quality). Types of interventions used were highly varied. The majority of interventions were delivered to informal carers (6 studies), with three of these studies also involving older adult care recipients. Five interventions were targeted at identifying, preventing and/or treating malnutrition specifically (two positive quality, three neutral quality, n=2368). As a result of these interventions, nutritional status improved or stabilized (two positive quality, two neutral quality, n=2333). No study reported an improvement in functional status but two successfully prevented further decline in their participants (two neutral quality, n=1097).

CONCLUSION

Interventions targeted at identifying, preventing and/or treating malnutrition were able to improve or prevent decline in nutritional and functional status, without increasing informal carer burden. The findings of this review support the involvement of non-clinical community care workers and informal carers as part of the nutritional care team for community-dwelling older adults.