Exploring the views of infection consultants in England on a novel delinked funding model for antimicrobials: the SMASH study

Objectives

A novel 'subscription-type' funding model was launched in England in July 2022 for ceftazidime/avibactam and cefiderocol. We explored the views of infection consultants on important aspects of the delinked antimicrobial funding model.

Methods

An online survey was sent to all infection consultants in NHS acute hospitals in England.

Results

The response rate was 31.2% (235/753). Most consultants agreed the model is a welcome development (69.8%, 164/235), will improve treatment of drug-resistant infections (68.5%, 161/235) and will stimulate research and development of new antimicrobials (57.9%, 136/235). Consultants disagreed that the model would lead to reduced carbapenem use and reported increased use of cefiderocol post-implementation. The presence of an antimicrobial pharmacy team, requirement for preauthorization by infection specialists, antimicrobial stewardship ward rounds and education of infection specialists were considered the most effective antimicrobial stewardship interventions. Under the new model, 42.1% (99/235) of consultants would use these antimicrobials empirically, if risk factors for antimicrobial resistance were present (previous infection, colonization, treatment failure with carbapenems, ward outbreak, recent admission to a high-prevalence setting).Significantly higher insurance and diversity values were given to model antimicrobials compared with established treatments for carbapenem-resistant infections, while meropenem recorded the highest enablement value. Use of both 'subscription-type' model drugs for a wide range of infection sites was reported. Respondents prioritized ceftazidime/avibactam for infections by bacteria producing OXA-48 and KPC and cefiderocol for those producing MBLs and infections with Stenotrophomonas maltophilia, Acinetobacter spp. and Burkholderia cepacia.

Conclusions

The 'subscription-type' model was viewed favourably by infection consultants in England.

P3521Predicting 30-day mortality and 30-day re-hospitalization risks in patients with heart failure

Background

Heart failure (HF) is the leading cause of hospitalization among persons aged ≥65 years. In the USA, nearly one-quarter of these patients are discharged to skilled nursing facilities (SNFs). These patients are typically older, and have greater mortality and re-hospitalization risks compared with those discharged home. Despite the importance of SNFs as a post-acute care setting for patients with HF, little is known about factors that predict short-term mortality and re-hospitalization in these high risk patients.

Purpose

To develop and validate separate predictive models for 30-day all-cause mortality and 30-day all-cause re-hospitalization among HF patients discharged from acute care hospitals to SNF.

Methods

Using a nationwide dataset including Medicare claims data cross-linked with Minimum Data Set 3.0 (2011–2013), we identified 77,670 hospitalized patients with HF discharged to 11,529 SNFs; we randomly split the patients into development (2/3 of the sample) and validation (1/3 of the sample) cohorts. Using data on patient sociodemographic and clinical characteristics, health service use, functional status, and facility-level factors, we developed separate prediction models for 30-day mortality and 30-day re-hospitalization using logistic regression models in the development cohort.

Results

In the development cohort, the median age of patients was 84 years, 39.6% were men, 83.4% were Caucasian whites. The median Charlson index was 4 and the median length of hospital stay was 6 days. Functional disabilities were prevalent: 80.0% had moderate-to-severe physical limitations and 35.9% moderate or severe cognitive impairment. After admission to SNF, 6.8% died and 24.2% were re-hospitalized within 30 days in the development cohort. Of those who died, 56.1% were re-hospitalized and 13.6% were discharged to home or self-care before their death. Of those who were re-hospitalized, 18.5% were discharged to home or self-care before their readmission. Of 48 potential predictors, 13 patient-level factors remained in the final model for 30-day mortality and 10 patient-level factors for re-hospitalization with good calibration. Among the selected predictors, developing symptoms of dyspnea, having physical limitations, depression severity, BMI, Charlson index, number of hospitalizations in past 6 months and length of hospital stay contributed most. The area under receiver operating characteristic curves were 0.71 for 30-day mortality and 0.63 for re-hospitalization in the validation cohort.

Conclusions

Among HF patients discharged to SNFs, our predictive model based on administrative data may be used to identify those at risk for death within 30 days, which could aid clinicians in improving care during this vulnerable period. Further work identifying factors for re-hospitalization remains needed.

Acknowledgement/Funding

None

Lipophilic activated ester prodrug approach for drug delivery to the intestinal lymphatic system

The intestinal lymphatic system plays an important role in the pathophysiology of multiple diseases including lymphomas, cancer metastasis, autoimmune diseases, and human immunodeficiency virus (HIV) infection. It is thus an important compartment for delivery of drugs in order to treat diseases associated with the lymphatic system. Lipophilic prodrug approaches have been used in the past to take advantage of the intestinal lymphatic transport processes to deliver drugs to the intestinal lymphatics. Most of the approaches previously adopted were based on very bulky prodrug moieties such as those mimicking triglycerides (TG). We now report a study in which a lipophilic prodrug approach was used to efficiently deliver bexarotene (BEX) and retinoic acid (RA) to the intestinal lymphatic system using activated ester prodrugs. A range of carboxylic ester prodrugs of BEX were designed and synthesised and all of the esters showed improved association with chylomicrons, which indicated an improved potential for delivery to the intestinal lymphatic system. The conversion rate of the prodrugs to BEX was the main determinant in delivery of BEX to the intestinal lymphatics, and activated ester prodrugs were prepared to enhance the conversion rate. As a result, an 4-(hydroxymethyl)-1,3-dioxol-2-one ester prodrug of BEX was able to increase the exposure of the mesenteric lymph nodes (MLNs) to BEX 17-fold compared to when BEX itself was administered. The activated ester prodrug approach was also applied to another drug, RA, where the exposure of the MLNs was increased 2.4-fold through the application of a similar cyclic activated prodrug. Synergism between BEX and RA was also demonstrated in vitro by cell growth inhibition assays using lymphoma cell lines. In conclusion, the activated ester prodrug approach results in efficient delivery of drugs to the intestinal lymphatic system, which could benefit patients affected by a large number of pathological conditions.

Structural alterations of phospholipid film domain morphology induced by cholesterol

Structures of the monolayer films of dipalmitoylphosphatidylcholine (DPPC) mixed with different amounts of cholesterol were studied at air-water interface using surface pressure-area measurements, epifluorescence microscopy and atomic force microscopy (AFM). Pure DPPC, cholesterol or DPPC-cholesterol mixtures were dissolved in organic solvents with a small amount of fluorescently labeled phospholipid probe (NBD-PC) and spread onto the air-water interface. Surface pressure-area isotherms and epifluorescence microscopy of such films at the air-water interface suggested that DPPC undergoes a gas to fluid to condensed phase transition, while cholesterol undergoes a gas to solid-like transition. A shift of the surface pressure-area curve to lower area per molecule was observed when cholesterol was mixed with DPPC. Epifluorescence microscopy showed the formation of spiral shaped domains for mixed monolayers. Increase in cholesterol content abolished domain characteristics possibly due to fluidizing property of cholesterol. AFM measurements of monolayers, transferred onto freshly cleaved mica by Langmuir-Blodgett technique, revealed the alterations caused by cholesterol on the gel and fluid domains of such films. AFM measurements re-established similar trend in domain characteristics as evidenced in epifluorescence microscopy.

White paper on herbal products. American College of Clinical Pharmacy

Individuals increasingly are taking a more active role in their health care, and herbal products have emerged as a common choice among self-care therapies. Pharmacists are active participants in the care of patients who are taking herbal products. Currently, most pharmacists are not educated adequately about herbal products and other types of alternative medicine. Furthermore, good information about many of these products is not available. These combined factors present a challenge for pharmacists as they seek to provide optimal care and counseling to patients who use herbs or supplements. We recommend the following actions to place pharmacists in better positions as effective agents protecting public safety: Regulations should be implemented at a federal level to require basic levels of standardization and quality control in the manufacture of herbal products. Indexing terms in medical bibliographic systems should be expanded to target herbal products. Funding should be increased for scientific research evaluating herbal products. Pharmacy schools should include a competency statement in their curricula regarding herbal medicines. Continuing education in herbal products should be available and encouraged for all pharmacists. Pharmacists should approach the use of all therapeutic interventions with scientific rigor, whether they are traditional or complementary in nature. Patients will benefit as more information is known and widely disseminated. By actively embracing the responsibility for counseling individuals on the appropriate use of herbal products, pharmacists will become a recognized source of expert information in this rapidly growing area, yielding important improvements in the quality of care.

Prevalence, clinical correlates, and treatment of hypertension in elderly nursing home residents. SAGE (Systematic Assessment of Geriatric Drug Use via Epidemiology) Study Group

BACKGROUND

Hypertension is prevalent in the elderly, but an information gap remains regarding the old, frail, individuals with complex conditions living in long-term care.

OBJECTIVE

To analyze the patterns of antihypertensive drug therapy among elderly patients living in nursing homes to elucidate their conformity with consensus guidelines.

SUBJECTS AND METHODS

We used a long-term care database that merged sociodemographic, functional, clinical, and treatment information on nearly 300000 patients admitted to the facilities of 5 US states between 1992 and 1994.

RESULTS

Hypertension was diagnosed in 80206 patients (mean age, 82.7+/-7.8 years). The prevalence was higher among women and among blacks. About one fourth of patients had 6 or more comorbid conditions; 26%, 22%, and 29% had concomitant diagnoses of coronary heart disease, congestive heart failure, and cerebrovascular disease, respectively. Seventy percent of patients were treated pharmacologically. Calcium channel blockers were the most common agents (26%), followed by diuretics (25%), angiotensin-converting enzyme inhibitors (22%), and beta-blockers (8%). The relative use of these drugs changed according to the presence of other cardiovascular conditions. Adjusting for potential confounders, the relative odds of receiving antihypertensive therapy were significantly decreased for the oldest subjects (> or =85 years old: odds ratio, 0.85; 95% confidence interval, 0.81-0.89) and those with marked impairment of physical (odds ratio, 0.77; 95% confidence interval, 0.73-0.81) and cognitive (odds ratio, 0.67; 95% confidence interval, 0.64-0.70) function.

CONCLUSIONS

Among very old, frail hypertensive patients living in nursing homes, the pattern of treatment seems not to follow recommended guidelines; age, functional status, and comorbidity appear to be important determinants of treatment choice.

Ablation of ventricular tachycardia associated with tetralogy of Fallot: demonstration of bidirectional block

INTRODUCTION

Ventricular tachycardia is commonly seen in patients following surgical repair for tetralogy of Fallot. The technique of ablation for this arrhythmia is not well defined.

METHODS AND RESULTS

In two patients with ventricular tachycardia following surgical repair of tetralogy of Fallot, the traditional indicators for a site for ventricular tachycardia ablation did not yield cure. Based on careful mapping, the circuit was found to involve the isthmus between the outflow tract patch and the tricuspid annulus; linear radiofrequency lesions across this isthmus resulted in cure of ventricular tachycardia. Not only was the tachycardia no longer inducible, but bidirectional block at the line of ablation confirmed interruption of the reentrant circuit.

CONCLUSION

A linear radiofrequency lesion was effective in eliminating ventricular tachycardia in both patients. The demonstration of bidirectional block confirms a cure independent of inducibility of ventricular tachycardia.

Family history and premature coronary heart disease

BACKGROUND

We were interested in studying whether a family history of coronary heart disease (CHD) persisted as a significant risk factor for premature coronary heart disease after adjusting for traditional and nontraditional risk factors.

METHODS

Ninety-five case patients with documented premature CHD (occurring in a person less than 60 years old and with greater than 50 percent occlusion of a major epicardial vessel or a documented myocardial infarction) and 95 community-based control patients were examined for risk factors including family history, hypertension, diabetes mellitus, sedentary lifestyle, smoking, body mass index, total cholesterol, high-density lipoprotein cholesterol, triglycerides, low-density lipoprotein cholesterol, lipoprotein(a), homocysteine, and fibrinogen.

RESULTS

The risk of premature CHD for a positive family history ranged from an odds ratio (OR) of 3.25 for a standard family history of CHD in a first-degree relative, 5.9 for family history of early CHD in a first-degree relative before the age of 45 years, and 6.1 for a strong family history of CHD defined as CHD in at least two first-degree relatives. Family history persisted as a significant risk factor for premature CHD (OR = 3.9, 95 percent confidence interval [CI] 1.8-8.7) in multiple variable models that included traditional and nontraditional risk factors. It was rare, however, for a person with a positive family history not to have at least two other traditional or nontraditional risk factors.

CONCLUSIONS

Family history of CHD should not be considered a simple binary risk factor for premature CHD, and a positive family history of CHD indicates that a person is at high risk for premature CHD independent of traditional and nontraditional risk factors.

Expectations, experiences and satisfaction with labour

Emotional, medical and control aspects of labour were explored in 81 primiparous women. Expectations were assessed antenatally and compared with postnatal reports of experiences. Expectations of positive emotions were significantly greater than experience while negative emotional expectations were paralleled by experience. There was a major discrepancy between expectations and experiences of the occurrence of interventions, with the proportion of women expecting interventions being greatly exceeded by those actually undergoing such experiences. In addition, expectations concerning personal control together with the use and efficacy of breathing and relaxation exercises in labour were elevated in relation to experience. Positive emotional expectations were strong predictors of positive emotional experiences and unrelated to negative emotional expectations. Expectations in general were positively related to experience but the strength of the association was weak. Personal satisfaction (i.e. satisfaction with self) in labour was strongly associated with the ability to control panic and other aspects of personal control. The ability to control panic was mainly influenced by the use of exercises. Attenders and non-attenders at antenatal preparation classes showed no significant differences in their experiences or personal satisfaction levels. Possible explanations for this absence of impact are discussed together with issues concerning the relevance of psychological theory to midwifery practice and the need for greater integration.

Behavioral and neurochemical effects of continuous infusion of cocaine in rats

The ability of continuous intravenous infusion of cocaine (60 mg/kg per day for 11 or 12 days; by osmotic minipump) to alter responses to acute injection of cocaine (20 mg/kg, i.p.; given 24 hr after termination of the infusion by minipump) was tested in conscious, tethered Sprague-Dawley rats. Extracellular levels of cocaine, dopamine and metabolites of dopamine in the striatum were determined by in vivo microdialysis. Locomotor activity and stereotyped behavior were evaluated simultaneously during dialysis sampling. Prior infusion of cocaine blunted the ability of acute challenge with cocaine to increase the efflux of dopamine in the striatum, locomotor activity and stereotypy. Increases in extracellular levels of homovanillic acid in the striatum were significantly greater in cocaine-infused rats than vehicle-infused controls, both prior to and after acute injections of cocaine. However, no differences between these two groups were observed in levels of cocaine in the striatum after acute challenge. Extracellular levels of dopamine in the striatum correlated significantly (P less than 0.05) with stereotypy in both groups but with locomotor activity only in cocaine-infused rats. The results indicate that behavioral tolerance occurred after continuous intravenous infusions of cocaine, that this was correlated with neurochemical tolerance to acute cocaine challenge and that alterations in the metabolism of cocaine did not account for the observed behavioral responses.

MCMI differences between alcoholics and cocaine abusers: effect of age, sex, and race

Samples of alcohol-dependent-only subjects (n = 164), cocaine-dependent-only subjects (n = 63), and subjects dependent on multiple substances, including alcohol and cocaine (n = 103), were administered the Millon Clinical Multiaxial Inventory (MCMI) as part of a routine clinical evaluation. The alcohol-only group was older (M = 38.7 years) and had a higher percentage of White subjects than other groups. The multiple-use (60%) group also had a higher percentage of White subjects than the cocaine only group (38%) and a higher percentage of male subjects (81%) than the alcohol-only group (67%). Although the MCMI characteristics of each diagnostic group paralleled previous findings, few MCMI differences were found after controlling for age, sex, and race effects. The implications of these results for treatment development are discussed.

Cocaine elevates striatal dopamine efflux in spontaneously hypertensive and Wistar-Kyoto rats

The effects of acute cocaine administration on central dopaminergic systems were examined in the striata of spontaneously hypertensive (SHR) and Wistar-Kyoto (WKY) rats with the use of an in vivo microdialysis technique. Increased extracellular levels of dopamine were observed for 45 to 75 minutes following acute cocaine administration in both halothane-anesthetized and conscious SHR and WKY. However, no significant differences were noted between anesthetized and conscious SHR and WKY in either baseline levels or cocaine-induced changes in extracellular levels of dopamine and its metabolites. A positive, linear correlation between extracellular levels of dopamine and cocaine was demonstrated for the 60-min period following acute cocaine administration in both SHR and WKY. The slopes of the linear regression plots obtained from the data of each 15-min sample was slightly, but significantly, higher in conscious SHR than in conscious WKY. The present results suggest a transient and dose-related stimulation of striatal dopamine release following acute cocaine administration and a linear relationship between striatal extracellular levels of dopamine and cocaine in both SHR and WKY.

Personality characteristics of alcohol dependent inpatients: relationship of MCMI subtypes to self-reported drinking behavior

Recent cluster analytic research with alcoholic inpatients has demonstrated the existence of several Millon Clinical Multiaxial Inventory (MCMI) clusters that appear to be consistent across different subject samples. The validity of these data would be strengthened by a statistical demonstration of the similarity of attained clusters across studies--a demonstration of concordance of subject classification across different clustering techniques on the same data set- and the inclusion of external, independent measures against which to evaluate the predictive validity of the cluster typology. We found a high level of concordance in subject classification across different clustering methods on the same data set and a high level of agreement with cluster typologies attained in previous studies. Subsequent multivariate analyses employing independent scales measuring various aspects of alcohol use confirmed differences among cluster members on perceived benefits of alcohol use and deleterious effects of alcohol use. The prominent differences in alcohol use along with a rationale for their development are discussed.

C4a anaphylatoxin levels as an indicator of disease activity in systemic lupus erythematosus

The use of a synthetic protease inhibitor, nafamstat mesilate, has enabled reliable estimations of in vivo complement activation to be made in systemic lupus erythematosus (SLE). Elevation of C3a anaphylatoxins was found in two out of 24 patients and elevation of C4a anaphylatoxins was found in 20 out of 24 patients, confirming that complement activation, predominantly by the classical pathway, is a common occurrence in the disease. Significantly higher levels of C4a anaphylatoxin were found in 16 patients, with more aggressive disease requiring supplementary treatment with azathioprine, while the remaining eight patients, with less severe disease, required purely steroid therapy. Very strong associations between elevated C4a anaphylatoxins and raised DNA antibody titres, C1q binding activity and low complement C4 levels were also observed, suggesting that anaphylatoxin measurement may be a sensitive additional method for monitoring disease activity in SLE.

The acute effects of cigarette smoking on cutaneous blood flow in smoking and non-smoking subjects with and without Raynaud's phenomenon

The acute effects of smoking a single cigarette on peripheral blood flow were investigated by laser-Doppler flowmetry in nine patients with Raynaud's phenomenon and 12 normal controls. In regular smokers, a marked fall in finger blood flow was demonstrated, but this was not present in non- or irregular smokers. In addition, no effect on capillary blood flow was found. There was no difference between subjects with and without Raynaud's phenomenon. In five normal, non-smoking volunteers, 2.4 g of aspirin for 3 days resulted in a similar fall in blood flow due to a single cigarette. These results suggest that regular smoking sensitizes the peripheral vasculature to the vasoconstricting effects of the next cigarette, and that at least part of this sensitization is mediated by the inhibition of endothelial prostacyclin synthesis. Patients with Raynaud's phenomenon, either primary or secondary, are no more sensitive than normal subjects, but should nevertheless avoid cigarette smoking.

Complement activation in systemic sclerosis

The use of a synthetic protease inhibitor, nafamstat mesilate, has enabled reliable estimations of in vivo complement activation to be made in patients with systemic sclerosis. Elevations of C3a and C4a anaphylatoxins were found in 2 and 24 out of 30 patients respectively, indicating that complement activation, predominantly by the classical pathway, is a common occurrence in the disease, even though complement C3 and C4 levels were within the reference range.

Antibody-dependent cellular cytotoxicity of vascular endothelium: characterization and pathogenic associations in systemic sclerosis

Ten sera from 48 patients with systemic sclerosis were found to be capable of producing cytotoxicity of human umbilical venous and arterial endothelium when co-cultured with peripheral blood mononuclear cells. Fractionation of sera on Ultrogel and the preparation of monomeric IgG by ion exchange and affinity chromatography suggested that the cytotoxicity was mediated by anti-endothelial antibodies capable of pre-sensitizing target cells in a mechanism that resembled antibody-dependent cellular cytotoxicity. These anti-endothelial antibodies together with C1q-binding immune complexes and anti-cardiolipin antibodies were found in 18 of 28 patients so investigated, suggesting that multiple immunological mechanisms may be involved in the pathogenesis of the vascular lesion of systemic sclerosis.

Reactive hyperemic responses in systemic sclerosis patients and healthy controls

Hyperemic responses after arterial occlusion were investigated in patients with Raynaud's phenomenon due to systemic sclerosis (SSc) and in healthy controls. The hyperemia due to arterial occlusion for 2 min was measured by laser-Doppler flowmetry. If the hyperemic response was absent, the measurements were repeated after vasodilatation was induced by hand warming in warm water. Reactive hyperemia was absent in 12 patients when investigations were performed on the unwarmed hand, and these patients had very low resting blood flows. After vasodilatation was induced in these patients, and also in those patients whose resting blood flow was normal, hyperemic responses were comparable in magnitude with those in the controls. The slope of the hyperemic response was significantly less in the patients (1.11 +/- 0.02 V/s) than in the controls (1.28 +/- 0.03 V/s), and therefore, the time course of the hyperemia was lengthened in the patients with SSc, with a delay to achieving maximum blood flow of 2 min. Peak blood flow was directly related to the level of the initial blood flow. These findings support the view that reactive hyperemia is principally a mechanical phenomenon, and also that vessel wall reactivity is abnormal in SSc, producing delayed hyperemic responses. The magnitude of the hyperemia depends on initial flow rates, and the apparent lack of these responses in SSc is a result of their low, but reversible, resting blood flow.

The effect of simple warming procedures on finger blood flow in systemic sclerosis

Finger blood flow was measured by laser Doppler flowmetry in 15 patients with Raynaud's phenomenon (RP) due to systemic sclerosis (SS), and 15 normal controls. Measurements were performed in a temperature controlled room at 28 degrees C. The blood flow in the patients was significantly lower than in the controls (P less than 0.001). After hand warming in water at 35 degrees C for 10 min, blood flow in the patients and controls did not differ significantly. Following this, the response to a standardized cold stress produced similar falls in both groups to levels that were not significantly different and these occurred over a similar time course. After cold stress ended, there was recovery of blood flow in both groups, and blood flow after 20 min was not significantly different between the two groups. The induced vasodilatation persisted, in those patients in whom it was remeasured, for at least 2 h. Repeating the experiments at a room temperature of 24 degrees C produced similar results. This indicates that considerable vasodilatation is possible in these patients, and can be produced by simple means. It also indicates that local and central thermoregulatory reflexes are intact. Cold induced symptoms in patients with SS are related to low resting blood flow, not to cold sensitivity, and simple warming may provide a useful treatment.

Penetration of moxalactam and cefazolin into bone following simultaneous bolus or infusion

The penetration of cefazolin and moxalactam into bone was studied in 20 adults scheduled for total hip arthroplasty. Patients randomly received both moxalactam and cefazolin (10 mg/kg of each) by either a rapid bolus or a 30-minute infusion. Serum and bone-extract concentrations were measured by HPLC. Serum concentrations of cefazolin were significantly greater than those of moxalactam at 15 minutes, 30 minutes, and at the time of bone removal for both rates of injection. Bone concentrations of cefazolin were significantly greater than those of moxalactam for both the bolus study (7.7 +/- 4.8 micrograms/g versus 5.4 +/- 3.4 micrograms/g) and the infusion study (5.6 +/- 3.4 micrograms/g versus 4.3 +/- 2.6 micrograms/g, respectively). There was no significant difference in the bone levels for the two drugs when penetration was expressed as a function of the simultaneous serum concentration (18% for each drug), and there were no significant differences in bone concentrations between the two rates of administration.

The value of embryo transfer to cattle breeding in Britain

An analysis is made of the maximum expenditure which could be justified in embryo transfer in cattle is used to: increase the rate of genetic improvement of dairy or beef cattle; increase the frequency of twin-pregnancies; and expedite a change of breed. Estimates of maximum justifiable expenditure have been compared with an estimate of the cost of non-surgical transfer. Embryo transfer should be used in elite beef herds to increase selection intensity, particularly if bulls from such herds can be used for artificial insemination. Other commercial applications will not be economically justifiable until the cost of transfer has fallen by 50 to 80 per cent.