Monitoring adverse drug reactions: scales, profiles, and checklists

BACKGROUND

Globally, adverse drug reactions (ADRs) make a substantial contribution to ill health. Introducing a systematic approach to patient surveillance could mitigate these problems. Formalized medication monitoring schedules have been proposed as one strategy to diagnose and action side-effects and the problems emanating from adverse drug reactions. To date, most developments have been linked to antipsychotic medications. Several scales, checklists, and side-effect profiles are available, including the West Wales ADR (adverse drug reaction) profile. However, relatively little work has been undertaken on the clinical validity, reliability, and sensitivity of these instruments.

AIM

This paper describes the development of the monitoring schedule approach to medication management. It also reviews and compares the instruments available for monitoring the adverse drug reactions of antipsychotic medications. The UKU (Udvalg for Kliniske Undersogelser) scale and the West Wales ADR profile assess a broader range of physiological parameters and potential problems than other instruments. However, to be adopted in practice, such instruments must achieve a balance between clinical gain and practical cost, including the time spent in administration.

CONCLUSION

Further work is needed to explore the translation of formalized ADR surveillance programmes into clinical gains and improved outcomes for clients.

Ultimate low loss of hollow-core photonic crystal fibres

Hollow-core photonic crystal fibres have excited interest as potential ultra-low loss telecommunications fibres because light propagates mainly in air instead of solid glass. We propose that the ultimate limit to the attenuation of such fibres is determined by surface roughness due to frozenin capillary waves. This is confirmed by measurements of the surface roughness in a HC-PCF, the angular distribution of the power scattered out of the core, and the wavelength dependence of the minimum loss of fibres drawn to different scales.

Time-spectrally-resolved ultrafast nonlinear dynamics in small-core photonic crystal fibers: Experiment and modelling

Nonlinear dynamics of ultrashort optical pulses in the vicinity of the second zero-dispersion point of a small-core photonic crystal fiber is visualized and studied using cross-correlation frequency-resolved optical gating. New spectral features observed in the experiments match well with recent theoretical predictions of the generation of new frequencies via mixing of solitons and dispersive waves. Power- as well as length-dependent dynamics is obtained showing strong interaction between solitons and dispersive waves, soliton-soliton interaction, soliton stabilization against Raman self-frequency shift and Cherenkov continuum generation.

Breast screening outcomes in women with and without a family history of breast and/or ovarian cancer

OBJECTIVES

To compare breast screening outcomes between women with a moderate or strong family history of breast and/or ovarian cancer with those without such a history.

SETTING

The Ontario Breast Screening Programme (OBSP) is a population-based programme offering mammography and clinical breast examination to Ontario women of 50 and older.

METHODS

Data from a cohort of 143,574 women screened by the OBSP from 1996 to 1997 were included. Referral rates, cancer detection rates, positive predictive values and the histological features of screen-detected cancers were examined within family history groups, age groups and screening modalities. Logistic regression analysis of cancer detection was conducted to adjust for potential confounding variables; subgroup analysis by hormone replacement therapy (HRT) use was also undertaken.

RESULTS

Compared with women with no family history, women with a moderate or strong family history of breast and/or ovarian cancer were more likely to have their cancer detected (odds ratio [OR]=1.44, 95% confidence interval [CI] 1.20-1.74 and OR=1.42, 95% CI 1.10-1.83, respectively). Among women using HRT, however, there was no association observed between family history and cancer detection (moderate: OR=0.98, 95% CI 0.65-1.48; strong: OR=1.17, 95% CI 0.68-2.02) with history. The histological features of invasive tumours were similar among family history groups.

CONCLUSIONS

Greater cancer detection rates and high proportions of invasive tumours with good prognosis indicate that women aged 50 and over with a family history may have the potential to benefit from regular breast cancer screening. Further studies are required to identify optimal screening guidelines and to examine whether HRT reduces the ability to detect cancer in these women.

Diagnosis and treatment of sialolithiasis

Sialolithiasis is the most common disorder of the salivary glands, and may range from tiny particles to several centimeters in length. While the majority of salivary stones are asymptomatic or cause minimal discomfort, larger stones may interfere with the flow of saliva and cause pain and swelling ... if left untreated, they can result in chronic sialadenitis and glandular atrophy. Conservative treatment may consist of oral analgesics and antibiotics. Surgical management may include salivary lithotripsy, basket retrieval and sialendoscopy.

Haplotype analysis of SNAP-25 suggests a role in the aetiology of ADHD

Several lines of evidence suggest a role for SNAP-25 (synaptosomal-associated protein of 25 kDa) in the genetic aetiology of ADHD. Most notable is the coloboma mouse mutant, which displays spontaneous hyperactivity and is hemizygous for a deletion spanning this gene. We have screened the SNAP-25 gene using denaturing high-performance liquid chromatography and sequencing, and genotyped six polymorphic single-nucleotide polymorphisms and two microsatellites in a clinically ascertained sample of 188 probands. Several markers were found to show association with ADHD, both individually and in combination with other markers to form multimarker haplotypes. Analyses of transmission by parental sex suggested that the association of SNAP-25 with ADHD is largely due to transmission of alleles from paternal chromosomes to affected probands, suggesting that this locus may be subject to genomic imprinting. Overall our data provide some evidence for a role of this gene in ADHD, although the precise causal functional variant is yet to be ascertained.

Observation of the parametric two-ion decay instability with thomson scattering

We present the first direct experimental observation of the parametric two-ion decay instability of ion-acoustic waves driven by a high intensity (5 x 10(15) W cm(-2)) laser beam in a laser produced high-Z plasma. Using two separate Thomson scattering diagnostics simultaneously, we directly measure the scattering from thermal ion-acoustic fluctuations, the primary ion waves that are driven to large amplitudes by the high intensity beam, and the two-ion decay products. The decay products are shown to be present only where the interaction takes place and their k spectrum is broad.

Haplotype association analysis of discrete and continuous traits using mixture of regression models

We present a regression-based method of haplotype association analysis for quantitative and dichotomous traits in samples consisting of unrelated individuals. The method takes account of uncertain phase by initially estimating haplotype frequencies and obtaining the posterior probabilities of all possible haplotype combinations in each individual, then using these as weights in a finite mixture of regression models. Using this method, different combinations of marker loci can be modeled, to find a parsimonious set of marker loci that are most predictive and therefore most likely to be closely associated with the a quantitative trait locus. The method has the additional advantage of being able to use individuals with some missing genotype data, by considering all possible genotypes at the missing markers. We have implemented this method using the SNPHAP and Mx programs and illustrated its use on published data on idiopathic generalized epilepsy.

Direct telemarketing of smoking cessation interventions: will smokers take the call?

AIMS

Few smokers currently make use of available and effective cessation strategies, despite their expressed desire to quit and reported interest in cessation support. This study aimed to explore the feasibility of a telephone-based direct-marketing approach to delivering cessation strategies. DESIGN, SETTING, MEASUREMENTS AND PARTICIPANTS: A community survey was conducted to explore the views of current adult smokers regarding the acceptability, likely uptake and barriers to uptake of smoking cessation services offered by direct telephone marketing.

FINDINGS

Three quarters (73.8%) of smokers contacted agreed to be surveyed. Of the 194 study participants, 75.3% reported that they would utilize vouchers for discount nicotine replacement therapy (NRT), 66.5% would use a mailed self-help booklet, 57.2% would take up the offer of regular mailings of personalized letters and self-help materials and 46.4% would utilize a 'we-call-you' telephone counselling service. The characteristics of those indicating likely uptake of these services were also explored. The two major barriers to uptake of services were preferring to quit without help and a belief that a particular service would not help the participant.

CONCLUSIONS

The data suggest strong support for the direct marketing of smoking cessation strategies; they also highlight the need for further study of the cost-effectiveness of telephone-based direct marketing of smoking cessation strategies as a population-based strategy for reducing the prevalence of smoking in the community.

Studies of quantitative parameters of virus excretion and transmission in pigs and cattle experimentally infected with foot-and-mouth disease virus

Foot-and-mouth disease virus (FMDV) can be spread by a variety of mechanisms and the rate of spread, the incubation period and the severity of disease depend on a multitude of parameters, including the strain of virus, the dose received, the route of introduction, the animal species and the husbandry conditions. More knowledge with regard to these parameters is urgently needed to improve resource-efficient disease control. This report describes detailed studies of FMDV load, excretion and transmission in pigs infected with FMDV O UKG 2001, O TAW 1997 and C Noville virus and in cattle infected with the O UKG 2001 virus to facilitate use of a "FMDV load framework" for the assessment of transmission risks. Virus replicated rapidly in pigs and cattle exposed by direct contact. The mean incubation period was around 3-4 days for cattle-to-cattle and 1-3 days for pig-to-pig transmission, depending on the intensity of contact. The results confirmed that a strong relation exists between dose and length of incubation period. Clinical disease was severe in pigs but relatively mild in inoculated cattle; contact infection of cattle appeared to increase the severity of lesions. FMDV RNA was recovered in nasal and mouth swabs from inoculated animals soon after they developed a viraemia and probably reflected the early production and excretion of virus. FMDV RNA in nasal and mouth swabs from contact animals could be detected several days before they showed other signs of infection, indicating the possibility of detecting exposed animals during the incubation period. FMDV RNA could also be detected in swab samples after the viraemic phase. This may have represented background environmental virus that had been trapped in the respiratory tract and mouth. Alternatively, it may have indicated a somewhat slower clearance or half-life of viral RNA or an extended low level of FMDV replication at these sites. The pattern of FMDV RNA concentrations in pigs was closely similar to that in cattle, but the amounts of FMDV RNA were higher.

Long-term safety and tolerability of tadalafil in the treatment of erectile dysfunction

OBJECTIVE

To assess the long-term safety and tolerability of tadalafil for patients with erectile dysfunction (ED).

PATIENTS AND METHODS

This was a multicentre, open-label, 24-month extension trial involving 1173 men with ED. The mean age was 57 (range 23-83) years and 74.8% of patients were taking concomitant medications for comorbid conditions, including diabetes mellitus in 30.5% of men and hypertension in 29.5%. These patients had participated in 1 of 5 previous 8-week or 12-week randomised, double-blind, placebo-controlled tadalafil studies. In the present trial, the starting 10mg dose of tadalafil could be increased to 20mg if the patient could not achieve satisfactory intercourse or reduced to 5mg for an adverse event that was persistent, intolerable and judged by the investigator to be related to tadalafil.

RESULTS

Four hundred ninety-three (42.0%) men completed 24 months of treatment. In addition, a further 234 (19.9%) completed 18 months of treatment due to a sponsor decision to reduce the study duration. The total tadalafil exposure was 1676.0 patient-years. Tadalafil was safe and well tolerated. Headache (15.8%), dyspepsia (11.8%), nasopharyngitis (11.4%), and back pain (8.2%) were the most common treatment-emergent adverse events. The rate of discontinuations due to adverse events for this 18-24-month study was 6.3% and the rate for any individual event was <1%. Serious adverse events occurred in 8.6% of patients. No consistent pattern of serious adverse events assessed as causally associated with tadalafil administration was observed. None of the four deaths that occurred during the study was assessed as tadalafil related. There were no clinically significant laboratory or electrocardiographic findings or changes in vital signs in mean baseline-to-endpoint analysis attributable to tadalafil. Tadalafil administration was not causally associated with drug-induced hepatotoxicity, neutropenia, thrombocytopenia, or renal dysfunction.

CONCLUSION

Tadalafil at doses of 5, 10, or 20mg taken as needed up to once daily for 18 to 24 months was safe and well tolerated. These findings support the long-term use of tadalafil in the clinical management of erectile dysfunction.

Communicating information on cardiopulmonary resuscitation to hospitalised patients

AIM

The primary aim of the study was to evaluate two different methods of communicating information on cardiopulmonary resuscitation (CPR) to patients admitted to general medical and elderly care wards. The information was either in the form of a detailed information leaflet (appendix I) or a summary document (appendix II). The study examined the willingness of patients in seeking detailed information on cardiopulmonary issues.

SETTING

The study was conducted over three months on a general medical ward and an acute elderly care ward in two district general hospitals.

METHODS

A detailed information leaflet on CPR was provided to the nursing staff on the wards. An A4 summary document summarising the CPR decision making process and basic information on cardiopulmonary issues was placed in a folder at the foot of each bed on the elderly care ward. On the general medical ward it was displayed prominently over the head of all beds.

RESULTS

Out of the 274 patients admitted to the general medical ward only two requests were received for the detailed information leaflet. On the elderly care ward there were 182 admissions but no patients or their relatives requested the leaflet.

CONCLUSIONS

Availability of basic information on cardiopulmonary resuscitation to all patients is practical and does not lead to unnecessary distress or offence to patients or their carers. It makes the decision making process more transparent. Detailed information leaflets are of value for a minority of hospitalised patients.

Effect of nonlocal transport on heat-wave propagation

We present the first direct measurements of spatially and temporally resolved temperature and density profiles produced by nonlocal transport in a laser plasma. Absolutely calibrated measurements have been performed by Rayleigh scattering and by resolving the ion-acoustic wave spectra across the plasma volume with Thomson scattering. We find that the electron temperature and density profiles disagree with flux-limited models, but are consistent with nonlocal transport modeling.

Hollow core photonic crystal fibers for beam delivery

Hollow-core photonic crystal fibers have unusual properties which make them ideally suited to delivery of laser beams. We describe the properties of fibers with different core designs, and the observed effects of anti-crossings with interface modes. We conclude that 7-unit-cell cores are currently most suitable for transmission of femtosecond and sub-picosecond pulses, whereas larger cores (e.g. 19-cell cores) are better for delivering nanosecond pulsed and continuous-wave beams.

Femtosecond soliton pulse delivery at 800nm wavelength in hollow-core photonic bandgap fibers

We describe delivery of femtosecond solitons at 800nm wavelength over five meters of hollow-core photonic bandgap fiber. The output pulses had a length of less than 300fs and an output pulse energy of around 65nJ, and were almost bandwidth limited. Numerical modeling shows that the nonlinear phase shift is determined by both the nonlinearity of air and by the overlap of the guided mode with the glass.

High energy nanosecond laser pulses delivered single-mode through hollow-core PBG fibers

We report on the development of hollow-core photonic bandgap fibers for the delivery of high energy pulses for precision micromachining applications. Short pulses of (65ns pulse width) and energies of the order of 0.37mJ have been delivered in a single spatial mode through hollow-core photonic bandgap fibers at 1064nm using a high repetition rate (15kHz) Nd:YAG laser. The ultimate laser-induced damage threshold and practical limitations of current hollow-core fibers for the delivery of short optical pulses are discussed.

Endothelial nitric oxide gene haplotypes and risk of cerebral small-vessel disease

BACKGROUND AND PURPOSE

Genetic influences are important in multifactorial cerebral small-vessel disease (SVD) and may act via endothelial dysfunction. Nitric oxide (NO) synthesized by endothelial nitric oxide synthase (eNOS) is a key mediator of endothelial function. We determined the role of 3 potentially functional eNOS polymorphisms (T-786C, intron 4ab, G894T) located toward the 5' flanking end of the gene as risk factors for SVD and different SVD subtypes: isolated lacunar infarction (n=137) and ischemic leukoaraiosis (n=160).

METHODS

Three hundred patients with SVD and 600 community controls were studied. Genotypes were determined through polymerase chain reaction with or without restriction fragment digestion. Nitrate (NO(x)) levels were determined in a subgroup by use of a Griess method. Polymorphisms were tested individually and in combination with haplotype analysis.

RESULTS

The intron 4a variant was protective against SVD. This effect was confined to isolated lacunar infarction (odds ratio, 0.55; 95% confidence interval, 0.35 to 0.86; P=0.01). Haplotypes encountered were significantly different in this subtype compared with controls (P=0.001), with the -786C promoter/intron 4a combination particularly underrepresented. NO(x) levels were associated with the T-786C locus (P=0.03) but only in the presence of the intron 4a allele (P=0.07 for interaction).

CONCLUSIONS

The intron 4ab insertion/deletion genotype was associated with isolated lacunar infarction. Haplotype and functional studies suggested that the protective effect of the 4a variant could be mediated through changes in eNOS promoter activity and increased NO levels. The specific association with isolated symptomatic lacunar infarction and not ischemic leukoaraiosis may reflect different etiopathogeneses of the 2 subtypes. Lack of NO could predispose to localized microatheroma in proximal arterioles rather than diffuse arteriosclerosis affecting distal perforating vessels.

Supercontinuum and four-wave mixing with Q-switched pulses in endlessly single-mode photonic crystal fibres

Photonic crystal fibres exhibiting endlessly single-mode operation and dispersion zero in the range 1040 to 1100 nm are demonstrated. A sub-ns pump source at 1064 nm generates a parametric output at 732 nm with an efficiency of 35%, or parametric gain of 55 dB at 1315 nm. A broad, flat supercontinuum extending from 500 nm to beyond 1750 nm is also demonstrated using the same pump source.

Supercontinuum generation with 200 pJ laser pulses in an extruded SF6 fiber at 1560 nm

We report an all-fiber diode-pumped Erbium-fiber oscillator-amplifier system as a source for supercontinuum generation in a photonic crystal fiber at 1560 nm. The passively mode-locked oscillator-amplifier system provides linearly polarized output pulses of 60 fs and an average output power of 59 mW at a repetition rate of 59.1 MHz. The laser pulses were launched into an extruded SF6-fiber for generation of an ultra-broadband supercontinuum. The evolution of the supercontinuum as a function of launched pulse energy was investigated. With pulse energies of about 200 pJ we observed a more than octave-spanning supercontinuum from 400 nm to beyond 1750 nm.

A protein interaction map of Drosophila melanogaster

Drosophila melanogaster is a proven model system for many aspects of human biology. Here we present a two-hybrid-based protein-interaction map of the fly proteome. A total of 10,623 predicted transcripts were isolated and screened against standard and normalized complementary DNA libraries to produce a draft map of 7048 proteins and 20,405 interactions. A computational method of rating two-hybrid interaction confidence was developed to refine this draft map to a higher confidence map of 4679 proteins and 4780 interactions. Statistical modeling of the network showed two levels of organization: a short-range organization, presumably corresponding to multiprotein complexes, and a more global organization, presumably corresponding to intercomplex connections. The network recapitulated known pathways, extended pathways, and uncovered previously unknown pathway components. This map serves as a starting point for a systems biology modeling of multicellular organisms, including humans.

Robust photonic band gaps for hollow core guidance in PCF made from high index glass

We report a new type of photonic bandgap that becomes substantial at remarkably low air-filling fractions (~60%) in triangularlattice photonic crystal fibres (PCF) made from high index glass (n / 2.0). The ratio of inter-hole spacing to wavelength makes these new structures ideal for the experimental realisation of hollow-core PCF in the mid/farinfrared, where suitable glasses (e.g., tellurites and chalcogenides) tend to have high refractive indices.

Tellurite photonic crystal fiber

We report the fabrication of a Tellurite photonic crystal fiber, and demonstrate its waveguiding properties. The measured minimum loss is 2.3 dB/m at a wavelength of 1055 nm. The fiber supports several modes, but in practice just the fundamental mode can be used. We have observed strong stimulated Raman scattering in a fiber with an effective area Aeff=21.2microm2, using sub-ns, ~ 1 microJ pump pulses at 1064.

Enhanced visualization of choroidal vessels using ultrahigh resolution ophthalmic OCT at 1050 nm

In this article the ability of ultrahigh resolution ophthalmic optical coherence tomography (OCT) to image small choroidal blood vessels below the highly reflective and absorbing retinal pigment epithelium is demonstrated for the first time. A new light source (lambdac= 1050 nm, Deltalambda = 165 nm, Pout= 10 mW), based on a photonic crystal fiber pumped by a compact, self-starting Ti:Al2O3 laser has therefore been developed. Ex-vivo ultrahigh resolution OCT images of freshly excised pig retinas acquired with this light source demonstrate enhanced penetration into the choroid and better visualization of choroidal vessels as compared to tomograms acquired with a state-of-the art Ti:Al2O3 laser (Femtolasers Compact Pro, lc= 780 nm, Deltalambda= 160 nm, Pout= 400 mW), normally used in clinical studies for in vivo ultrahigh resolution ophthalmic OCT imaging. These results were also compared with retinal tomograms acquired with a novel, spectrally broadened fiber laser (MenloSystems, lambdac= 1350 nm, Deltalambda= 470 nm, Pout = 4 mW) permitting even greater penetration in the choroid. Due to high water absorption at longer wavelengths retinal OCT imaging at ~1300 nm may find applications in animal ophthalmic studies. Detection and follow-up of choroidal neovascularization improves early diagnosis of many retinal pathologies, e.g. age-related macular degeneration or diabetic retinopathy and can aid development of novel therapy approaches.