A comparative study of pharmacist and GP management of anticoagulant therapy following deviation from the target international normalised ratio

Focal points

Poor correlation between predicted ideal and prescribed digoxin dose: a community-based pharmacokinetic study in the elderly

Focal points

Expanding CEP290 mutational spectrum in ciliopathies

Ciliopathies are an expanding group of rare conditions characterized by multiorgan involvement, that are caused by mutations in genes encoding for proteins of the primary cilium or its apparatus. Among these genes, CEP290 bears an intriguing allelic spectrum, being commonly mutated in Joubert syndrome and related disorders (JSRD), Meckel syndrome (MKS), Senior-Loken syndrome and isolated Leber congenital amaurosis (LCA). Although these conditions are recessively inherited, in a subset of patients only one CEP290 mutation could be detected. To assess whether genomic rearrangements involving the CEP290 gene could represent a possible mutational mechanism in these cases, exon dosage analysis on genomic DNA was performed in two groups of CEP290 heterozygous patients, including five JSRD/MKS cases and four LCA, respectively. In one JSRD patient, we identified a large heterozygous deletion encompassing CEP290 C-terminus that resulted in marked reduction of mRNA expression. No copy number alterations were identified in the remaining probands. The present work expands the CEP290 genotypic spectrum to include multiexon deletions. Although this mechanism does not appear to be frequent, screening for genomic rearrangements should be considered in patients in whom a single CEP290 mutated allele was identified.

An interim report of health needs assessment of asylum seekers in Sunderland and North Tyneside

A health needs assessment questionnaire was developed and administered to 397 asylum seekers, 291 males and 106 females, in Sunderland and North Tyneside in the North East of England. The data from the questionnaires were analysed using SPSS Version 10. Individuals retained a copy of their own questionnaire to be used as a hand held record. There was much heterogeneity of country of origin, culture, religion and previous employment and language backgrounds within the sample. A range of health needs was identified which has implications for healthcare provision. Vaccination rates were low as was screening for tuberculosis and cervical cancer. Many asylum seekers identified symptoms related to mental health and requested help in this area. Access to dental treatment was an area of high priority for many respondents.

Emergency hormonal contraception: the community pharmacy perspective

OBJECTIVE

To explore the views of community pharmacists in the North West of England towards the deregulation of emergency hormonal contraception (EHC) and to examine their support and training needs.

DESIGN

Two focus group discussions.

SUBJECTS

Fourteen community pharmacists, of whom eight were currently participating in a scheme to supply EHC free of charge through a patient group direction (PGD).

RESULTS

A number of themes emerged from the discussions, which appeared to influence participants' views towards the use of EHC and towards deregulation. A number of participants appeared to lack detailed knowledge about the mode of action of EHC and misunderstandings about this, coupled with erroneously held beliefs about the adverse effects of the drug, appeared to influence their attitudes to deregulation. Participants identified risks associated with pharmacy supply of EHC, both to women and to themselves, in the form of litigation. EHC was accorded a special status which seemed to go beyond its pharmacological properties and risk-benefit profile. A key and recurring theme was abuse, an ill-defined concept which appeared to refer to multiple or repeated use. It is interesting to note that none of those participants supplying EHC under a PGD could provide any examples of such abuse from their own experience.

CONCLUSIONS

This small-scale study provides useful insights into the attitudes of these pharmacists towards EHC, the impact of increased availability of the drug, and the type of women who they believed would use EHC.

Attrition in the new beneficiary survey and followup, and its correlates

Panel surveys interview the same individuals more than once over a period of time. Attrition from the survey occurs when those individuals die, refuse to be interviewed again, or, for some other reason, cannot be contacted. If the original sample was representative of a specific population, then survey analysis may provide misleading conclusions about changes in population characteristics over time if these individuals leave the sample in a nonrandom way. Therefore, it is important to identify the characteristics of individuals who leave the survey for various reasons. This article explores the extent of and reasons for attrition in the New Beneficiary Survey (NBS) between the first interview in 1982 and the followup interview in 1991. Presented is a comparison of the characteristics of survivors (the reinterviewed sample) with attriters (those in the sample not reinterviewed) from the retired-worker and disabled-worker samples. The article explores a variety of potential determinants of attrition to the probability of attrition. These determinants are examined alone and in a multivariate framework. The NBS sample population is drawn from and linked to Social Security Administrative records, which have exact matched data on mortality as a cause of attrition. These data do not depend on survey-reported reasons for attrition; hence, it allows the examination of the differences in the patterns and predictors of attrition due to death and due to other reasons, primarily, the refusal to be interviewed. Attrition due to death must be identified precisely because misidentification of death as refusal to be interviewed may lead researchers to infer more selective attrition than might be the case. Different patterns of attrition are evident in the comparison of attrition levels and the determinants of attrition for the retired and disabled samples, both composed of persons with relatively high mortality risk. In particular, individuals' health, health insurance coverage, and level of education have different impacts on their likelihood of attrition. In general, it appears that refusal to be interviewed is more evenly spread across populations and characteristics than is death. The analysis shows that attrition due to death and attrition due to refusal are quite different processes, even though health conditions play a role in both processes. The results suggest that because attrition patterns (including death) may be quite different across population samples, sample-specific attrition patterns must be analyzed over the lifetime of any panel study. Long-term studies of panel attrition are necessary to provide researchers analyzing the data with information on potential biases due to nonrandom attrition.

Managed substitution of modified release nitrates with an asymmetric dosing regimen

BACKGROUND

Orally administered modified release organic nitrates are used commonly in the prophylaxis of myocardial ischaemia, although little evidence indicates a clinically superior response compared with standard formulated preparations administered symmetrically.

AIM

To investigate the clinical success of transfer of suitable patients from MR to SF nitrates.

METHOD

Suitable candidates for therapeutic substitution, assessed by a pharmacist, completed a baseline study to estimate frequency and timing of chest pain, the number of rescue doses of sublingual nitrates required, together with an assessment of adverse effects experienced. Following substitution to an eccentric dosing schedule, a further one month's assessment of chest pain frequency, rescue nitrate use and adverse effects was recorded and compared with baseline.

RESULTS

Twelve (37.5%) patients from a possible 32 candidates were invited to complete a baseline symptoms and adverse event diary. Eight patients entered the study phase (66.7% of the 12 included in the baseline phase of the study). These candidates showed no evidence of loss of control of chest pain symptoms, 3.5 +/- 1.16 (mean +/- standard error of mean) episodes/patient/28 days compared with 1.9 +/- 0.96 episodes/patient/28 days during the test phase (P > 0.05). Similarly, there was no difference in the number of doses of rescue nitrates required when the trial phase (2.6 +/- 1.63 doses/patient/28 days) was compared with the control (2.0 +/- 1.31 doses/patient/28 days, P > 0.05). There was no evidence of an increased incidence of adverse effects during the trial period of the study.

CONCLUSION

This small study suggests that, if selected carefully, therapeutic substitution of MR oral nitrates can be managed successfully without apparent risk of loss of symptom control or increased incidence of adverse effects.

An assessment of the wealth holdings of recent widows

OBJECTIVES

This study examines the wealth holdings of recent widows, how they compare to those of married couple households, and the potential to use this wealth to augment the incomes of widowed women.

METHODS

Data from the Survey of Income and Program Participation are used to investigate the amount and composition of wealth held by four different groups: always married women, about-to-be-widowed women, recent widows, and long-standing widows. Regression analyses assess the impact of group membership on wealth holding controlling for other sociodemographic factors, and annuity calculations assess the potential for wealth to augment income.

RESULTS

About-to-be widowed women have fewer assets than intact couples, and there is a further decline in assets at the time of the husbands' deaths and in the ensuing period. Estimates of the annuity value of widows' wealth show that its liquidation would do little to improve the economic situation of the poorest widows.

DISCUSSION

These findings parallel what is known about income changes that surround the death of a spouse. They also point to the need for additional research on the relationship between wealth holdings and mortality as well as the roles that health care costs, life insurance, and bequests may play in altering widows' wealth.

Pharmacist's perceptions of nurse prescribing of emergency contraception

Proposed strategies to reduce the rate of unplanned pregnancy in the UK include widening access to hormonal emergency contraception (HEC) through nurse prescribing and over-the-counter sales by pharmacists. This article reports on the perceptions of pharmacists regarding the appropriateness of nurse prescribing of HEC drawn from a survey of pharmacists' attitudes towards HEC deregulation. A 10% sample (n = 3999) of all members of the Royal Pharmaceutical Society of Great Britain was surveyed and a response rate of 38.6% (1543 respondents) achieved. Pharmacists were asked whether or not nurses should prescribe HEC and in what capacity. In respect of the statement that: 'Nurses should not be allowed to prescribe post-coital contraception', 42% of respondents agreed while 31.6% disagreed. This indicates that pharmacists do not have a consensus view regarding nurse prescribing of HEC. Arrangements for pharmacists prescribing under protocol received the support of 60.2% of respondents, whereas 41% expressed support for nurse prescribing under protocol. There was also relatively little support for 'specifically trained' nurses prescribing HEC. The findings are considered in relation to the development of a coherent and accessible provision of HEC and the wider implications for interprofessional relationships concerning prescribing.

Comparative effectiveness of general practitioner versus pharmacist dosing of patients requiring anticoagulation in the community

OBJECTIVE

To compare pharmacist- with general practitioner-managed anticoagulation in the community.

DESIGN

Included in the study were all patients who had been managed by general practitioners (GPs) and subsequently referred to the pharmacist-led outreach service within Gateshead & South Tyneside Health Authority. A retrospective analysis was carried out recording individual international normalized ratio (INR) estimations, the time interval between successive tests and whether the result resided within the prescribed therapeutic range. These values were derived for both the GP- and pharmacist-managed elements of care.

SUBJECTS

Fifty-one patients who met the inclusion criteria identified from eight practices had been successively treated by GPs and then by pharmacists. Eighteen patients (35.3%) had a diagnosis of non-rheumatic atrial fibrillation, 10 (19.6%) had thromboembolic disease and 13 (25.5%) had valvular disease.

RESULTS

In total, 1782 INR results were analysed. GPs were responsible for 1075 (60.3%) of these estimations and pharmacists for the remaining 707 (39.7%). Of the GP-monitored results the patient-mean proportion of estimates that resided within the prescribed therapeutic range was 0.6 (SD = 0. 21, n = 51) compared with pharmacist management where patients showed a mean in range proportion of 0.7 (SD = 0.18, n = 51, P = 0. 03). The mean inter-test interval was 28.6 days (SD = 8.65, n = 51) for GPs compared with 34.1 days (SD = 12.3, n = 51, P = 0.01) for pharmacists. The weighted INR index for GPs was 17.2 (SD = 7.93, n = 51) compared with 24.7 (SD = 13.15, n = 51, P < 0.001) for pharmacists.

CONCLUSION

There is no apparent detriment to INR control when pharmacist management is compared with that of GPs. The overall proportion of INR estimations within the prescribed range is greater for pharmacists than for GPs and the interval between tests is longer for pharmacists compared with GPs.

Pharmacists' concerns and perceived benefits from the deregulation of hormonal emergency contraception (HEC)

OBJECTIVE

To ascertain pharmacists' views, assess willingness for involvement and delineate individual perceived competence in the supply of deregulated hormonal emergency contraception (HEC).

DESIGN

Cross-sectional postal questionnaire utilising closed, open and Likert-scale questions.

SUBJECTS

Three thousand nine hundred and ninety-nine registered pharmacists abstracted from the mailing list of the Royal Pharmaceutical Society of Great Britain.

RESULTS

In total 1543 (38.6%) questionnaires were returned and analysed. Overall 1165 (75.5%) of pharmacists stated their willingness to be involved in the deregulated supply of HEC. However, pharmacists identified the need for specific training before effective deregulation should take place. Overall, 616 (39.9%) of respondents felt individually competent to supply deregulated HEC with a positive association between perceived competence and willingness to supply deregulated HEC (p < 0.05). Pharmacists perceive the major benefits of deregulation to be a reduced unwanted pregnancy rate and a subsequent reduced abortion rate. They perceive that deregulation would allow quicker and less restricted access to HEC by clients, facilitating an increased overall supply of HEC. Pharmacists express a number of concerns, tempering their collective desire to see HEC deregulation. The majority of these concerns related to safeguarding clients and the possible adverse public health effects associated with the possible reduced use of barrier methods of contraception.

CONCLUSIONS

Most pharmacists would be willing to supply HEC if it were deregulated to 'pharmacy only' from 'prescription only' medicine status. Although concerns were raised, these were mainly related to safety issues, with few pharmacists identifying moral and ethical barriers to deregulation. For effective deregulation to occur issues of professional competence need to be addressed.

Expectations of nursing home use in the Health and Retirement Study: the role of gender, health, and family characteristics

Economic models of life cycle behavior suggest that expectations about future events may affect savings, insurance, and retirement planning. This article uses data from the first wave of the Health and Retirement Survey (HRS) to examine how personal characteristics and health conditions influence expectations of nursing home use. Subjective expectations of nursing home use are quite close to known probabilities of lifetime use. There are marked differences in the determinants of expectations for women and men that also conform to actual behavior. There is strong evidence that women and men incorporate what is known about nursing home risk into their own expectations, even many years prior to the time when they are most likely to need long-term care.

Hemolytic jaundice due to G6PD deficiency causing kernicterus in a female newborn

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an inherited deficiency of an enzyme necessary to protect the erythrocyte from oxidative stress and hemolysis. Without this enzyme, affected neonates are at risk for acute onset of hemolytic jaundice and severe sequelae, from hearing loss and mild retardation to kernicterus. In some populations, especially in blacks and those of Mediterranean ancestry, the incidence of G6PD deficiency has been reported to be as high as 10% to 14%. We describe a female newborn who had acute onset of hyperbilirubinemia leading to kernicterus in the first week of life. Investigation proved G6PD deficiency. This case suggests a need to screen for this disease or to follow serial bilirubin levels in populations at risk.

Quantitative and temporal relationships between DNA adduct formation in target and surrogate tissues: implications for biomonitoring

DNA-carcinogen adducts offer a potential dosimeter for environmental genotoxicants reaching the exposed individual. Because the target tissues for many chemical carcinogens are not readily accessible for monitoring adducts in humans, peripheral blood lymphocytes (PBLs) have served as surrogate sources of exposed DNA. Both benzo[a]pyrene (BaP) and benzo[b]fluoranthene (BbF) are widely distributed in the environment as components of complex mixtures, such as automobile exhaust, cigarette smoke, foods, water, and urban air. Thus, human exposure to these chemicals is widespread, and they probably contribute to overall human lung cancer risk. The interpretation of the results of such studies would be enhanced by an understanding of the pharmacokinetics of specific DNA adduct formation and persistence in both target and surrogate tissues. Polycyclic aromatic hydrocarbons (PAHs) were administered to male Sprague-Dawley rats IP at 100 mg PAH/kg body weight. Lung, liver, and PBL tissues were harvested 1, 3, 7, 14, 28, and 56 days after treatment. DNA was extracted from each tissue and 32P-postlabeling analysis of DNA adducts with nuclease P1 enhancement was conducted. In all three tissues, BaP-DNA adducts exhibit a similar pattern, reaching a maximum at 3-4 days, followed by a decrease to 56 days. For BbF, the maximum DNA adduct levels in each tissue were between 5 and 14 days after injection. By 56 days after administration, the total adducts remaining in all tissues were measurable. Correlation analyses of the amount of DNA adducts in lung or liver compared to those found in the PBL of the same animals suggest a range of correlations (R2 = 0.67-0.83).(ABSTRACT TRUNCATED AT 250 WORDS)

How should Fitts' Law be applied to human-computer interaction?

The paper challenges the notion that any Fitts' Law model can be applied generally to human-computer interaction, and proposes instead that applying Fitts' Law requires knowledge of the users' sequence of movements, direction of movement, and typical movement amplitudes as well as target sizes. Two experiments examined a text selection task with sequences of controlled movements (point-click and point-drag). For the point-click sequence, a Fitts' Law model that used the diagonal across the text object in the direction of pointing (rather than the horizontal extent of the text object) as the target size provided the best fit for the pointing time data, whereas for the point-drag sequence, a Fitts' Law model that used the vertical size of the text object as the target size gave the best fit. Dragging times were fitted well by Fitts' Law models that used either the vertical or horizontal size of the terminal character in the text object. Additional results of note were that pointing in the point-click sequence was consistently faster than in the point-drag sequence, and that pointing in either sequence was consistently faster than dragging. The discussion centres around the need to define task characteristics before applying Fitts' Law to an interface design or analysis, analyses of pointing and of dragging, and implications for interface design.

High-level expression, purification, and characterization of recombinant human tumor necrosis factor synthesized in the methylotrophic yeast Pichia pastoris

Human tumor necrosis factor (TNF) alpha/cachectin was expressed in the methylotrophic yeast Pichia pastoris at high levels (greater than 30% of the soluble protein) by placing the TNF cDNA under the control of regulatory sequences derived from the alcohol oxidase gene. Batch fermentor cultures at cell densities of 50 and 85 g dry cell weight/L contained approximately 6 X 10(10) and 10(11) units/L TNF bioactivity (6 and 10 g/L TNF), respectively. TNF productivity of 0.108 g L-1 h-1 was obtained in the continuous mode on glycerol- and methanol-mixed feed at 25 g dry cell weight/L cell density. TNF contained in the yeast cell lysate was soluble, displayed full cytotoxic activity, and was recognized by antibodies prepared against TNF derived from Escherichia coli. TNF was purified to greater than 95% purity with greater than 75% recovery by using three sequential chromatographic steps with a coordinated effluent-affluent buffer scheme which allowed one eluate to also serve as the loading buffer for the succeeding column. The amino acid composition, NH2-terminal amino acid sequence, isoelectric point, and minimal molecular weight determined for TNF corroborated those properties predicted from the nucleotide sequence. Sedimentation data indicated that TNF in the native form is a compact trimer held by noncovalent interactions. Circular dichroic spectra of TNF resemble those of proteins with high beta structure. TNF exhibited cachectic activity on mouse 3T3-L1 cells at about the same equivalence as the cytotoxic activity toward mouse L929 cells. In the criteria examined, TNF derived from P. pastoris closely resembles TNF derived from recombinant E. coli and human HL-60 cells.

Sensitivity to sulfited foods among sulfite-sensitive subjects with asthma

Eight individuals with asthma who had been diagnosed as sulfite sensitive on the basis of double-blind capsule-beverage challenges were subjected to challenges with various sulfited foods, including lettuce, shrimp, dried apricots, white grape juice, dehydrated potatoes (as mashed potatoes), and mushrooms. Four of these patients failed to respond to challenges with any of the sulfited foods. The other four patients experienced a decrease in pulmonary function on double-blind challenges with sulfited lettuce. Two of three of these patients reacted to challenges with dried apricots and white grape juice; the fourth patient has not yet been challenged with these products. Only one of these four patients reacted to challenges with dehydrated potatoes and mushrooms, and, in this case, the response to double-blind challenges with dehydrated potatoes was not consistent. None of the sulfite-sensitive subjects with asthma responded to challenges with sulfited shrimp. It is concluded that sulfite-sensitive subjects with asthma will not necessarily react after ingestion of sulfited foods. The likelihood of a reaction is dependent on the nature of the food, the level of residual sulfite, the sensitivity of the patient, and perhaps on the form of residual sulfite and the mechanism of the sulfite-induced reaction.

Comparison of alprazolam and imipramine for treatment of outpatient depression

A 6-week double-blind comparison of the therapeutic efficacy of alprazolam and imipramine in 90 depressed psychiatric outpatients revealed a significantly superior response to alprazolam in the first 2 weeks of treatment as measured by total scores on the Hamilton Rating Scale for Depression and the Brief Psychiatric Rating Scale. Further analyses revealed that all significant differences could be accounted for by the superior effect of alprazolam on sleep disturbance. By the end of Weeks 4 and 6, no significant differences in therapeutic response between the two treatment groups were noted, with patients in both groups evidencing improvement on all measures. A differentially high dropout rate among patients in the imipramine treatment group posed a problem for interpretation of results in the latter weeks of treatment.

Prevalence of sensitivity to sulfiting agents in asthmatic patients

Ingestion of sulfiting agents can induce wheezing in some asthmatic patients. However, neither the prevalence of sulfite sensitivity nor the clinical characteristics of the affected asthmatic population are known. In a prospective single-blind screening study, 120 non-steroid-dependent and 83 steroid-dependent asthmatic patients underwent challenge with oral capsules of potassium metabisulfite. Five non-steroid-dependent and 16 steroid-dependent asthmatic patients experienced a greater than 20 percent reduction in their one-second forced expiratory volume within 30 minutes following the oral challenge. Twelve of these sulfite reactors were rechallenged with metabisulfite capsules in a double-blind protocol. Under these conditions, only three of seven steroid-dependent patients had a positive response. Moreover, only one of five non-steroid-dependent patients had a response to double-blind challenge. On the basis of this challenge study, the best estimate of the prevalence of sulfite sensitivity in the asthmatic patients studied is 3.9 percent. This population, however, contained a larger number of steroid-dependent asthmatic patients than would be found in the general asthmatic population. It is concluded, therefore, that the prevalence of sulfite sensitivity in the asthmatic population as a whole would be less than 3.9 percent and that steroid-dependent asthmatic patients are most at risk.

Discontinuing antiepileptic medication in children with epilepsy after two years without seizures. A prospective study

Antiepileptic medications were discontinued in 88 children with epilepsy of various causes who had been free of seizures for two to four years. The subjects were then followed for six months to five years (mean, 22 months). Sixty-six (75 per cent) remained free of seizures. Electroencephalographic characteristics, type of seizure, and age at onset were important in predicting outcome. Specific electroencephalographic features (such as the presence or absence of slowing or spikes) were more predictive than simple classification of an electroencephalogram as normal or abnormal. A history of complex partial seizures that had been controlled for two years carried a relatively favorable prognosis (P less than 0.05), whereas a history of atypical febrile seizures carried a poor prognosis (P less than 0.05). The variable of a younger age at onset was also associated with a better outcome (P less than 0.05), but only if accompanied by electroencephalographic slowing. Altogether, six variables (the interaction of age at onset with electroencephalographic slowing, electroencephalographic spikes, atypical febrile seizures, complex partial seizures, electroencephalographic slowing, and electroencephalographic change) were statistically significant (P less than 0.05) in predicting outcome. We conclude that in most children with epilepsy who have been free of seizures for two or more years, antiepileptic medications can safely be discontinued, and that it is possible to predict reasonably well which children will remain free of seizures.

Incomplete baroreceptor responses in newborn infants

Previous studies of the baroreceptor response to a 45 degree head-up tilt in preterm and mature infants during the first 3 days of life failed to demonstrate a significant tachycardia while eliciting a 25% reduction in limb blood flow. In order to determine if maturity or respiratory distress affected the presence of tachycardia after tilting, 34 infants between 28 and 40 weeks gestation, including 15 infants with RDS, were studied serially during their hospitalization in a neonatal intensive care unit. In the first 5 seconds after a rapid (1-second) tilt to 45 degrees, individual infants responded with changes in heart rate (HR) ranging from a fall of 8 beats/min to an increase of 13 beats/min. Individual responses were not predictable on the basis of maturity at birth, age after birth, or presence of clinical respiratory distress. The group as a whole demonstrated a statistically significant increase of 2 +/- 4 beats/min in the first 5 seconds immediately after tilting. This may be compared to a coefficient of variation of +/- 4-5% in the resting HR of the same group of infants. Because of the unpredictability of individual responses and the small magnitude of the response for the group as a whole, it can be concluded that the HR component of the baroreceptor response is poorly developed during the neonatal period.