825 DEVELOPMENT OF THE ANTICHOLINERGIC MEDICATION INDEX (ACMI)

Introduction

Medications with Anticholinergic (AC) properties, are prescribed to treat a range of conditions. Older people are increasingly likely to be prescribed multiple AC medications, but are also more likely to experience unwanted adverse effects, such as falls and delirium. The risks of adverse outcomes increase with the number and potency of AC medications prescribed. The aim of this study was to use a prognostic modelling approach to develop an AC Medication Index (ACMI) that identifies patients at high risk of AC medication side effects.

Methods

The prognostic model was developed using data on patients aged 65–95 years, registered with a general practice contributing data to ‘Connected Bradford’ in 2019. A Time-dependent Cox model was fitted, with hospital admission for delirium or falls as the composite outcome and AC medications, age, sex and important clinical factors (e.g. dementia, arthritis, urinary incontinence) as predictors. Concordance and Negalkerke’s R2 derived from five-fold cross-validation were used to assess model performance.

Results

There were 151,604 patients included in the study, of whom 47,035 (31.0%) were prescribed ≥1 AC medication during 2019. Codeine, Prednisolone, Furosemide and Amitriptyline were most commonly prescribed with 7.4%, 4.0%, 3.8% and 3.1% of patients prescribed these medications at least once in 2019, respectively. During 2019, 6,078 (4.0%) patients experienced a hospital admission with delirium or a fall, with the rate being increased in those prescribed ≥1 AC medication during 2019 (4.8% vs 3.7%; p < 0.001). The prognostic model yielded a discrimination statistic of 0.86 with an R2 of 0.1.

Conclusion

The model used to develop the ACMI shows good discrimination. External validation will soon be performed using data from the SAIL databank and the ACMI will be further developed as a tool for use in primary care.

Agreement and Intraobserver Variability in Detection of Helicobacter pylori Infection Using Routine Histology, H. pylori Immunohistochemical Stain, and Warthin-Starry Special Stain on Gastric Tissue Biopsy Samples

Introduction/Objective

Helicobacter pylori (HP) is a prevalent cause of gastritis in the US and worldwide. Accurate detection of the organism is important for appropriate treatment. Diagnosis is made using immunohistochemistry and special stains including Warthin-Starry stain (WS) which is low cost, technically easy to perform on tissue sections, and can be automated. We aimed to assess interobserver variability, reproducibility and validity of hematoxylin and eosin stain (H&E), WS and anti-Helicobacter pylori immunohistochemical staining (HP-IHC) for the histopathological identification and evaluation of HP organisms on gastric mucosa biopsies.

Methods/Case Report

We prospectively evaluated gastric biopsies from ten adult patients. These patients underwent upper gastrointestinal endoscopy with subsequent biopsy for various abdominal complaints. Seven of the ten biopsies (7/10) were HP infection positive, and three cases (3/10) were HP negative by H&E stain and HP-IHC (determined by GI Pathologist). The presence or absence and density of HP, were assessed on H&E, HP-IHC and WS in blinded fashion by five general surgical (GS) pathologists. The GS pathologists assessed the cases for presence and density of HP using the semi-quantitative modified Sydney classification (none, mild, moderate, and severe). Percentage agreement and interobserver variablilty using Cohen-Kappas statistics (KS) were calculated.

Results (if a Case Study enter NA)

The percentage agreement for presence or absence of HP in the biopsies with H&E, HP-IHC and WS stains were 91%, 98% and 99%, respectively. The interobserver agreement for evaluation of presence of HP was excellent with WS staining method (Overall KS = 0.737 95%, Confidence Interval (CI) = 0.501- 0.973) and HP-IHC (Overall KS = 0.783, 95% CI = 0.585-0.980). Agreement for H&E was moderate (Overall KS = 0.532, 95% CI= 0.392-0.672). HP density agreement was excellent using WS and HP-IHC and H&E was in the moderate range.

Conclusion

This study found excellent interobserver agreement using IHC and WS. While IHC is the most specific stain, WS is more sensitive in identifying the shape and morphology of HP organisms and is an efficient and low-cost alternative with excellent morphology in general surgical practice.

Axillary response rates to neoadjuvant chemotherapy in breast cancer patients with advanced nodal disease

PURPOSE

Utilization of sentinel lymph node biopsy (SLNB) in breast cancer patients with positive nodes after neoadjuvant chemotherapy (NAC) has increased. We examine axillary response rates after NAC in patients with clinical N2-3 disease to determine whether SLNB should be considered.

METHODS

Breast cancer patients with clinical N2-3 (AJCC 7th Edition) disease who received NAC followed by surgery were selected from our institutional tumor registry (2009-2018). Axillary response rates were assessed.

RESULTS

Ninety-nine patients with 100 breast cancers were identified: 59 N2 (59.0%) and 41 (41.0%) N3 disease; 82 (82.0%) treated with axillary lymph node dissection (ALND) and 18 (18.0%) SLNB. The majority (99.0%) received multiagent NAC. In patients undergoing ALND, cCR was observed in 20/82 patients (24.4%), pathologic complete response (pCR) in 15 patients (18.3%), and axillary pCR in 17 patients (20.7%). In patients with a cCR, pCR was identified in 60.0% and was most common in HER2+ patients (34.6%).

CONCLUSION

In this analysis of patients with clinical N2-3 disease receiving NAC, 79.3% of patients had residual nodal disease at surgery. However, 60.0% of patients with a cCR also had a pCR. This provides the foundation to consider evaluating SLNB and less extensive axillary surgery in this select group.

Childhood adversity in association with personality disorder dimensions: New findings in an old debate

Background

Various studies have reported a positive relationship between child maltreatment and personality disorders (PDs). However, few studies included all DSM-IV PDs and even fewer adjusted for other forms of childhood adversity, e.g. bullying or family problems.

Method

We analyzed questionnaires completed by 512 participants of the ZInEP epidemiology survey, a comprehensive psychiatric survey of the general population in Zurich, Switzerland. Associations between childhood adversity and PDs were analyzed bivariately via simple regression analyses and multivariately via multiple path analysis.

Results

The bivariate analyses revealed that all PD dimensions were significantly related to various forms of family and school problems as well as child abuse. In contrast, according to the multivariate analysis only school problems and emotional abuse were associated with various PDs. Poverty was uniquely associated with schizotypal PD, conflicts with parents with obsessive-compulsive PD, physical abuse with antisocial PD, and physical neglect with narcissistic PD. Sexual abuse was statistically significantly associated with schizotypal and borderline PD, but corresponding effect sizes were small.

Conclusion

Childhood adversity has a serious impact on PDs. Bullying and violence in schools and emotional abuse appear to be more salient markers of general personality pathology than other forms of childhood adversity. Associations with sexual abuse were negligible when adjusted for other forms of adversity.

Enhanced Recovery After Surgery (ERAS) Reduces Hospital Costs and Improve Clinical Outcomes in Liver Surgery: a Systematic Review and Meta-Analysis

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols are evidence-based, multimodal and patient-centred approach to optimize patient care and experience during their perioperative pathway. It has been shown to be effective in reducing length of hospital stay and improving clinical outcomes. However, evidence on its effective in liver surgery remains weak. The aim of this review is to investigate clinical benefits, cost-effectiveness and compliance to ERAS protocols in liver surgery.

METHODS

A systematic literature search was conducted using CINAHL Plus, EMBASE, MEDLINE, PubMed and Cochrane for randomized control trials (RCTs) and cohort studies published between 2008 and 2019, comparing effect of ERAS protocols and standard care on hospital cost, LOS, complications, readmission, mortality and compliance.

RESULTS

The search resulted in 6 RCTs and 21 cohort studies of 3739 patients (1777 in ERAS and 1962 in standard care group). LOS was reduced by 2.22 days in ERAS group (MD = -2.22; CI, -2.77 to -1.68; p < 0.00001) compared to the standard care group. Fewer patients in ERAS group experienced complications (RR, 0.71; 95% CI, 0.65-0.77; p = < 0.00001). Hospital cost was significantly lower in the ERAS group (SMD = -0.98; CI, -1.37 to - 0.58; p < 0.0001).

CONCLUSION

Our review concluded that the introduction of ERAS protocols is safe and feasible in hepatectomies, without increasing mortality and readmission rates, whilst reducing LOS and risk of complications, and with a significant hospital cost savings. Laparoscopic approach may be necessary to reduce complication rates in liver surgery. However, further studies are needed to investigate overall compliance to ERAS protocols and its impact on clinical outcomes.

Low emotion-oriented coping and informal help-seeking behaviour as major predictive factors for improvement in major depression at 5-year follow-up in the adult community

PURPOSE

Given the broad range of biopsychosocial difficulties resulting from major depressive disorder (MDD), reliable evidence for predictors of improved mental health is essential, particularly from unbiased prospective community samples. Consequently, a broad spectrum of potential clinical and non-clinical predictors of improved mental health, defined as an absence of current major depressive episode (MDE) at follow-up, were examined over a 5-year period in an adult community sample.

METHODS

The longitudinal population-based PsyCoLaus study from the city of Lausanne, Switzerland, was used. Subjects having a lifetime MDD with a current MDE at baseline assessment were selected, resulting in a subsample of 210 subjects. Logistic regressions were applied to the data.

RESULTS

Coping styles were the most important predictive factors in the present study. More specifically, low emotion-oriented coping and informal help-seeking behaviour at baseline were associated with the absence of an MDD diagnosis at follow-up. Surprisingly, neither formal help-seeking behaviour, nor psychopharmacological treatment, nor childhood adversities, nor depression subtypes turned out to be relevant predictors in the current study.

CONCLUSIONS

The paramount role of coping styles as predictors of improvement in depression found in the present study might be a valuable target for resource-oriented therapeutic models. On the one hand, the positive impact of low emotion-oriented coping highlights the utility of clinical interventions interrupting excessive mental ruminations during MDE. On the other hand, the importance of informal social networks raises questions regarding how to enlarge the personal network of affected subjects and on how to best support informal caregivers.

Evaluation of the information needs of patients with chronic obstructive pulmonary disease following pulmonary rehabilitation: a focus group study

Aims: This study aimed to understand patient information needs and how best to meet them in order to improve rehabilitation provision and aid disease self-management by exploring experiences of people who had recently completed a pulmonary rehabilitation programme in a community hospital setting.

Methods: Qualitative research using focus groups was undertaken with 23 patients who had completed pulmonary rehabilitation within the previous four months. The focus groups were tape-recorded and contemporaneous notes made. The tapes were transcribed verbatim and template analysis was used to develop themes.

Findings: The key information needs were for a full understanding of the disease to be generated for patients, their families and the wider public much earlier in the disease process and preferably at the point of diagnosis. Patients perceived that they needed to come to terms with the condition. In order to improve disease self-management feelings of anxiety and frustration should to be addressed with the suggestion that individual counselling might be made available through the rehabilitation programme. The need for continued support was highlighted with an emphasis on peer group support activities.

Conclusions: The findings have implications for primary care in terms of unmet needs in the early stages of the condition and pulmonary rehabilitation programmes in terms of providing individual counselling and ongoing peer group support to aid disease self-management. Chronic Respiratory Disease 2007; 4: 195—203

Comparison of von Willebrand factor (VWF) activity levels determined by HemosIL AcuStar assay and HemosIL LIA assay with ristocetin cofactor assay by aggregometry

INTRODUCTION

Diagnosis of von Willebrand disease (VWD) requires quantitative as well as qualitative determination of von Willebrand factor (VWF) levels. For functional assessment of VWF, ristocetin cofactor assay by aggregometry is considered to be the gold standard. However, need for technical expertise, labour intensiveness, difficult standardization and high intra- and inter- assay variabilities are some of the limitations of this methodology. Various assays for determination of VWF adhesive function using different methodologies have been developed in recent years.

AIM

To evaluate the HemosIL AcuStar chemiluminescence assay (VWF:RCo[Acu]) and the HemosIL latex immunoassay (VWF:act) as diagnostic tests for VWD and identification of type 2 VWD in comparison with the ristocetin cofactor assay performed by aggregometry (VWF:RCo[Agg]).

METHODS

Results from 96 samples analysed by VWF:RCo[Acu] and 128 samples by VWF:act were compared with VWF:RCo[Agg]. Sixty of these samples (25 normal, 17 type 1 and 18 type 2) were analysed by all three assays.

RESULTS

VWF:RCo[Acu] showed excellent agreement with VWF:RCo[Agg], and readily identified all type 2 VWD samples tested. VWF:act showed reasonable agreement with VWF:RCo[Agg] for most patients, but had a slightly lower sensitivity for detection of type 2 VWD.

CONCLUSION

VWF:RCo[Acu] assay has the potential to replace VWF:RCo[Agg] for the diagnosis of VWD.

Sex-related and non-sex-related comorbidity subtypes of tic disorders: a latent class approach

BACKGROUND AND PURPOSE

Recent evidence suggests that there may be more than one Gilles de la Tourette syndrome (GTS)/tic disorder phenotype. However, little is known about the common patterns of these GTS/tic disorder-related comorbidities. In addition, sex-specific phenomenological data of GTS/tic disorder-affected adults are rare. Therefore, this community-based study used latent class analyses (LCA) to investigate sex-related and non-sex-related subtypes of GTS/tic disorders and their most common comorbidities.

METHODS

The data were drawn from the PsyCoLaus study (n = 3691), a population-based survey conducted in Lausanne, Switzerland. LCA were performed on the data of 80 subjects manifesting motor/vocal tics during their childhood/adolescence. Comorbid attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, depressive, phobia and panic symptoms/syndromes comprised the selected indicators. The resultant classes were characterized by psychosocial correlates.

RESULTS

In LCA, four latent classes provided the best fit to the data. We identified two male-related classes. The first class exhibited both ADHD and depression. The second class comprised males with only depression. Class three was a female-related class depicting obsessive thoughts/compulsive acts, phobias and panic attacks. This class manifested high psychosocial impairment. Class four had a balanced sex proportion and comorbid symptoms/syndromes such as phobias and panic attacks. The complementary occurrence of comorbid obsessive thoughts/compulsive acts and ADHD impulsivity was remarkable.

CONCLUSIONS

To the best of our knowledge, this is the first study applying LCA to community data of GTS symptoms/tic disorder-affected persons. Our findings support the utility of differentiating GTS/tic disorder subphenotypes on the basis of comorbid syndromes.

Challenges in implementing the new BASHH guidelines for the management of gonorrhoea

Neisseria gonorrhoeae has progressively developed reduced sensitivity to different classes of antibiotics. The British Association for Sexual Health and HIV (BASHH) updated guidelines for the diagnosis and management of gonorrhoea in 2011. New recommendations include an increased dose of ceftriaxone with adjuvant use of azithromycin, as well as test of cure (TOC) in all cases. We present an audit of adherence to new antibiotic prescribing guidelines as well as TOC uptake in an inner city genitourinary medicine clinic. Among the 271 (242 male, 29 female) patients included, 96% ( n = 260) received the new first-line treatment. Test of cure uptake was found to be suboptimal at 55% ( n = 149) with the majority (67%) of these taking place within 20 days of treatment. The new first-line treatment for gonorrhoea is feasible and generally accepted by patients. However the TOC uptake is low, emphasising the need for robust follow-up and recall policies. Further study is required into the optimal timing for TOC.

The hepatitis B e antigen suppresses IL-1β-mediated NF-κB activation in hepatocytes

Previous clinical studies have demonstrated an association between the hepatitis B e antigen and Toll-like receptor (TLR) expression and signalling. Therefore, the aim of this study was to develop an in vitro assay to measure the effect of hepatitis B virus proteins, including the precore protein, on signalling mediated by members of the Toll-like/interleukin 1 (TIR) superfamily, by measuring NF-κB promoter activity. The basal level of NF-κB reporter activity was measured in three hepatocyte cell lines (Huh7, HepG2 and PH5CH8) and one kidney cell line (HEK293) using a luciferase assay. All cell lines were virtually refractory to stimulation with lipopolysaccharide; however, PH5CH8 cells had a robust activation of NF-κB in response to IL-1β stimulation, with ∼ 40-fold higher activation than the unstimulated control, a higher degree of activation than that observed in either Huh7 and HepG2, or HEK293 and HEK293-TLR2 cells. In PH5CH8 cells transfected with pCI expression constructs and stimulated with IL-1β, we showed that the precursor form of the precore protein, p25, inhibits NF-κB activation by up to 30% and the cytosolic form, p22, inhibits NF-κB activation by 70%. The core protein, p21, which shares significant homology with the precore protein except for a 10-amino acid extension at the N-terminus, had no effect on NF-κB activation. We hypothesize that the inhibition of IL-1β-mediated NF-κB activation by the precore protein may be a mechanism that allows the virus to persist, suggesting a role for the pool of precore protein that remains intracellular.

Abstract P1-11-05: Phase 2 Study of Neoadjuvant Treatment with Cellular Redox Modulator NOV-002 in Combination with Doxorubicin and Cyclophosphamide Followed by Docetaxel (AC→T) in Patients with Stage II-III HER-2 (-) Breast Cancer

Background: NOV-002 (a formulation of disodium glutathione disulfide) modulates signaling pathways involved in tumor cell proliferation and metastasis and enhances anti-tumor immune responsiveness in tumor models. The addition of NOV-002 to a range of cytotoxic chemotherapeutic regimens has been shown to increase their anti-tumor efficacy in several early phase oncology trials and in animal models. Pathological complete response (pCR) has been demonstrated to be associated with favorable overall survival in primary breast cancer, and neoadjuvant treatment of early breast cancer aims at achieving high rates of pCR. In patients with HER-2 (-) breast cancer pCR rates with anthracycline and taxane combinations have been reported to be approximately 10-20% depending on hormone receptor status. We conducted a clinical trial in HER-2 negative patients (pts) combining daily N0V-002 with AC→T. Methods: Women with newly diagnosed stages II-III HER-2 (-) breast cancer received AC x 4 [60/600 mg/m2] followed by T [100 mg/m2] x 4 every 3 weeks in conjunction with daily N0V-002 [60mg IV day 1 and subcutaneously days 2-21 of each cycle]. The primary endpoint is pCR, defined as: (i) ypN0, and (ii) ypT0 or presence of invasive tumor &lt;10mm.

Sample size (n=46 total patients) was calculated using a Simon 2-stage optimal design assuming a doubling of the historical pCR rate with the addition of NOV-002 to AC→T from a p0 of 0.16 to a p1 of 0.32. If a total of 12 or more patients experience a pCR by the end of the trial, then the treatment regimen will be declared active. The calculation assumes an alpha of 0.05 and 80% power.

Results: A total of 39 pts have been enrolled to date across three study sites, with 31 patients having completed chemotherapy and undergone surgery. One patient dropped out during cycle 1 and was not assessable for response; 5 are currently receiving chemotherapy; and 2 patients have completed all chemotherapy, but have not yet undergone surgery. A total of 292 chemotherapy cycles have been administered, with 92% of all patients being able to complete all 8 cycles of planned chemotherapy. Of the 31 evaluable patients, 12 achieved a pCR (39%), meeting the primary endpoint of the trial. In patients with residual invasive primary breast tumor &lt;10mm and ypN0 (19%) mean residual tumor size was 4.4 mm. Interestingly, of the 17 patients with biopsy-proven axillary involvement, 4 (23%) had no residual invasive tumor in axillary nodes at time of surgery. In 26 patients with estrogen positive breast cancer, which is least sensitive to chemotherapy, 42% achieved a pCR. The most common toxicities included: nausea, sensory neuropathy, emesis, fatigue, and hand-foot syndrome. Conclusions: The addition of NOV-002 has to date resulted in a doubling of previously published pCR rates with AC→T in HER-2 (-) breast cancer patients. Subsequent investigation of NOV-002 in conjunction with neoadjuvant chemotherapy in breast cancer is warranted. Updated clinical data on all 39 patients as well as immunologic correlative markers will be presented.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-11-05.

Pediatric health-related quality of life: Feasibility, reliability and validity of the PedsQL transplant module

The measurement properties of the newly developed Pediatric Quality of Life Inventory (PedsQL) 3.0 Transplant Module in pediatric solid organ transplant recipients were evaluated. Participants included pediatric recipients of liver, kidney, heart and small bowel transplantation who were cared for at seven medical centers across the United States and their parents. Three hundred and thirty-eight parents of children ages 2-18 and 274 children ages 5-18 completed both the PedsQL 4.0 Generic Core Scales and the Transplant Module. Findings suggest that child self-report and parent proxy-report scales on the Transplant Module demonstrated excellent reliability (total scale score for child self-report alpha= 0.93; total scale score for parent proxy-report alpha= 0.94). Transplant-specific symptoms or problems were significantly correlated with lower generic HRQOL, supporting construct validity. Children with solid organ transplants and their parents reported statistically significant lower generic HRQOL than healthy children. Parent and child reports showed moderate to good agreement across the scales. In conclusion, the PedsQL Transplant Module demonstrated excellent initial feasibility, reliability and construct validity in pediatric patients with solid organ transplants.

Characterization of the innate immune signalling pathways in hepatocyte cell lines

Hepatitis B virus (HBV) infection is a major cause of liver-related morbidity and mortality. Toll-like receptors (TLRs) have recently been recognized to play an important role in the pathogenesis of chronic hepatitis B (CH-B). Furthermore, manipulation of TLR signalling pathways shows potential as an antiviral therapeutic strategy. Whether hepatocytes themselves possess intact TLR signalling pathways remains controversial. It is critical that cell culture models be developed to allow investigation of the interaction between HBV and the TLR signalling pathways. We have screened three hepatocyte cell lines for the integrity of pro-inflammatory responses and antiviral cytokines following stimulation with interleukin-1 (IL-1) and different TLR ligands. We observed that Huh-7, HepG2 and PH5CH8 cells selectively responded to IL-1 and TLR2 ligands, leading to the activation of NF-kappaB. In addition, the PH5CH8 cell lines were able to induce type 1 interferon (IFN) via both TLR3 and RIG-I following stimulation with poly I:C, HepG2 cells mounted an IFN response via RIG-I only, whereas Huh-7 cells were unresponsive. We conclude that the hepatocyte cell lines investigated display a repertoire of TLR signalling, albeit limited, suggesting that hepatocytes may themselves play an active role in innate immune responses to viruses such as HBV. Furthermore, particular hepatoma cell lines are suitable for investigating the interaction between HBV and hepatocyte-expressed pattern recognition receptors.

Drugs to support smoking cessation in UK general practice: are evidence based guidelines being followed?

BACKGROUND

Prescribing drugs to support smoking cessation is one of the most cost effective interventions in primary care, but there is evidence they are underused. Little is known about how far guidelines have been adopted.

AIMS

To examine the context in which nicotine replacement therapy (NRT) and bupropion are prescribed in UK general practice and whether guidelines are being followed.

DESIGN

Patient questionnaire survey.

SETTING

Twenty five general practices from the Trent Focus Collaborative Research Network in South Yorkshire and East Midlands, UK.

METHODS

Participating practices posted a questionnaire to up to 40 patients prescribed NRT and bupropion respectively in the previous 3-9 months.

RESULTS

The response rate for people prescribed NRT was 44.7% (323/723) and for bupropion 42.5% (77/181). Patients reported initiating the prescription request in 258 cases (65%), whereas GPs were reported as suggesting it in 49 (12%), smoking cessation services (SCS) in 38 (10%), and practice nurses in 36 (9%). Of those who could recall the content of the consultation in which NRT or bupropion was prescribed, 191 (79%) reported receiving advice on treatment use and 209 (68%) were encouraged to set a quit date. Follow up by SCS was recommended to 186 (64%) and practice follow up was offered to 212 (63%), but 41 (15%) reported no offer of follow up support.

CONCLUSIONS

The majority of patients reported receiving advice and follow up in line with guidelines. However, relatively few prescriptions were suggested by GPs or practice nurses and, in a significant minority of cases, neither follow up by the practice nor additional support from SCS was recommended. More active implementation of guidelines could increase the impact of general practice on the prevalence of smoking.

To freeze or not to freeze: a cost-effectiveness analysis of wart treatment

BACKGROUND

Several general practitioner (GP)-prescribed and over-the-counter therapies for warts and verrucae are available. However, the cost-effectiveness of these treatments is unknown.

OBJECTIVES

To compare the cost-effectiveness of different treatments for cutaneous warts.

METHODS

We designed a decision-analytic Markov simulation model based on systematic review evidence to estimate the cost-effectiveness of various treatments. The outcome measures studied are percentage of patients cured, cost of treatment and incremental cost-effectiveness ratio for each treatment, compared with no treatment, after 18 weeks.

RESULTS

Duct tape was most cost-effective but published evidence of its effectiveness is sparse. Salicylic acid was the most cost-effective over-the-counter treatment commonly used. Cryotherapy administered by a GP was less cost-effective than GP-prescribed salicylic acid and less cost-effective than cryotherapy administered by a nurse.

CONCLUSIONS

Duct tape could be adopted as the primary treatment for cutaneous warts if its effectiveness is verified by further rigorous trials. Nurse-administered cryotherapy is likely to be more cost-effective than GP-administered cryotherapy.

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.