Medication safety incidents associated with the remote delivery of primary care: a rapid review

OBJECTIVES

The COVID-19 pandemic triggered rapid, fundamental changes, notably increased remote delivery of primary care. While the impact of these changes on medication safety is not yet fully understood, research conducted before the pandemic may provide evidence for possible consequences. To examine the published literature on medication safety incidents associated with the remote delivery of primary care, with a focus on telemedicine and electronic prescribing.

METHODS

A rapid review was conducted according to the Cochrane Rapid Reviews Methods Group guidance. An electronic search was carried out on Embase and Medline (via PubMed) using key search terms 'medication error', 'electronic prescribing', 'telemedicine' and 'primary care'. Identified studies were synthesised narratively; reported medication safety incidents were categorised according to the WHO Conceptual Framework for the International Classification for Patient Safety.

KEY FINDINGS

Fifteen studies were deemed eligible for inclusion. All 15 studies reported medication incidents associated with electronic prescribing; no studies were identified that reported medication safety incidents associated with telemedicine. The most commonly reported medication safety incidents were 'wrong label/instruction' and 'wrong dose/strength/frequency'. The frequency of medication safety incidents ranged from 0.89 to 81.98 incidents per 100 electronic prescriptions analysed.

SUMMARY

This review of medication safety incidents associated with the remote delivery of primary care identified common incident types associated with electronic prescriptions. There was a wide variation in reported frequencies of medication safety incidents associated with electronic prescriptions. Further research is required to determine the impact of the COVID-19 pandemic on medication safety in primary care, particularly the increased use of telemedicine.

Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: A survey study

Introduction

The COVID-19 pandemic has had a profound impact on the delivery of primary care around the world. In Ireland, the use of technologies such as virtual consultations and the electronic transfer of prescriptions became widespread in order to deliver care to patients while minimising infection risk. The impact of these changes on medication safety is not yet known.

Objectives

The aims of this survey study were to investigate 1) the changes that have occurred in Irish primary care since the start of the COVID-19 pandemic and 2) the impact of these changes on medication safety.

Methods

Anonymous, online surveys were distributed to general practitioners (GPs) and pharmacists from August–September 2021. Surveys contained quantitative (multiple-choice, Likert scale) and qualitative (free-text) questions concerning workflow changes, medication safety incidents and near misses, and GP/pharmacist perspectives on medication safety and COVID-19. Reported medication safety incidents and near misses were categorised according to the WHO Conceptual Framework for the International Classification for Patient Safety.

Results

In total, there were 251 responses to the survey, comprising of 211 pharmacists and 40 GPs. The most significant workflow changes during the pandemic were the widespread use of a secure clinical email service (Healthmail) that facilitates electronic prescription transfer and communication (75.3% of respondents) and the increased use of telephone consultations (49%). Overall, Healthmail was widely perceived to have had a positive impact on medication safety. Most GPs did not perceive a change in the frequency of medication safety incidents during the pandemic, while most pharmacists reported a slight increase in incidents. Survey participants highlighted pressure, patient expectations, and patient monitoring as significant challenges encountered during the pandemic.

Conclusions

During the pandemic, a number of significant changes occurred in primary care in Ireland, particularly involving communication of healthcare information, with varying impacts on workflow and medication safety. Future research should focus on the optimisation of electronic prescribing and telemedicine services in Ireland, patient perspectives on the changes in primary care, and interventions to improve medication safety in primary care.

Prevalence of potentially serious alcohol-medication interactions in older adults in a community pharmacy setting: a cross-sectional study

OBJECTIVE

Previous prevalence estimates of POtentially Serious Alcohol-Medication INteractions in Older adults (POSAMINO) are based on in-home inventories of medications; however, this method is associated with under-reporting of medications when compared with dispensing records. This study aims to estimate the prevalence of POSAMINO among community-dwelling older adults using drug dispensing data from the community pharmacy setting.

DESIGN

Cross-sectional study.

SETTING

Irish Community Pharmacy.

PARTICIPANTS

1599 consecutive older adults presenting with a prescription to 1 of 120 community pharmacies nationwide; community-dwelling, aged ≥65 years, able to speak and understand English, with no evidence of cognitive impairment. The mean age of sample was 75.5 years (SD 6.5); 55% (n=884) female.

MEASURES

38 POSAMINO criteria were identified using participants' pharmacy dispensing records linked to self-reported alcohol consumption (beverage-specific quantity and frequency measures) over the last 12 months.

RESULTS

The overall prevalence of POSAMINO in the study population was 28%, with 10% at risk of at least one POSAMINO criteria and 18% at risk of two or more. Exposure to POSAMINO most commonly involved cardiovascular agents (19%) and central nervous system agents (15%). Exposure to a higher number of POSAMINO criteria was associated with younger age (adjusted incident rate ratio (AIRR): 0.97; 95% CI: 0.95 to 0.98), male sex (AIRR: 0.55; 95% CI: 0.45 to 0.67) and a higher number of comorbidities (AIRR: 1.05; 95% CI: 1.01 to 1.13).

CONCLUSION

This study adds to the growing body of evidence, which suggests that older adults are vulnerable to potentially serious alcohol-medication interactions, particularly those involving cardiovascular and central nervous system agents, increasing their risk of orthostatic hypotension, gastrointestinal bleeds and increased sedation. Application of the POSAMINO criteria at the point of prescribing may facilitate the risk stratification of older adults and prioritise alcohol screening and brief alcohol interventions in those at greatest risk of harm.

Infliximab Induced Cardiac Tamponade

Aim To report the first case of cardiac tamponade related to Infliximab induction therapy in an Ulcerative Colitis patient. Methods Review of published case reports. Results This complication was likely due to a type 3 hypersensitivity immune-complex reaction resulting in a reactive pericardial effusion Discussion Though rare, this case demonstrates how autoimmune reaction to anti-TNF𝛼 therapy can initially mimic infection, as our patient presented with tachycardia, hypotension, raised inflammatory and infective markers and fever.

Pharmacokinetics of once-daily darunavir/ritonavir in HIV-1-infected pregnant women

OBJECTIVES

HIV antiretroviral therapy during pregnancy is recommended to reduce the risk of mother-to-child transmission and for maternal care. Physiological changes during pregnancy can affect pharmacokinetics. The impact of pregnancy was evaluated for once-daily (qd) darunavir/ritonavir.

METHODS

HIV-1-infected pregnant women on an antiretroviral regimen that includes darunavir were enrolled in the study and further treated with darunavir/ritonavir 800/100 mg qd. Plasma concentrations were assessed over 24 h during the second and third trimesters and postpartum using a validated high-performance liquid chromatography tandem mass spectrometry assay for total darunavir and ritonavir, and using (14) C-darunavir-fortified plasma for unbound darunavir. Pharmacokinetic parameters were derived using noncompartmental analysis. Safety and antiviral response were assessed at all visits.

RESULTS

Data were available for 16 women. The area under the plasma concentration-time curve from 0 to 24 h (AUC24h ) for total darunavir was 34-35% lower during pregnancy vs. postpartum. Unbound darunavir AUC24h was 20-24% lower during pregnancy vs. postpartum. The minimum plasma concentration of total and unbound darunavir was 32-50% and 13-38% lower, respectively, during pregnancy vs. postpartum. The antiviral response (< 50 HIV-1 RNA copies/mL) was 59% at baseline and increased to 87-100% during the trial; the CD4 count increased over time. One serious adverse event (gestational diabetes) was judged as possibly related to study medication. All 16 infants born to women remaining in the study at delivery were HIV-1 negative (two were premature).

CONCLUSIONS

Total darunavir exposure decreased during pregnancy, but the decrease was less for unbound (active) darunavir. These changes are not considered clinically relevant. Darunavir/ritonavir 800/100 mg qd may therefore be a treatment option for HIV-1-infected pregnant women.

Predicting exposure of wildlife in radionuclide contaminated wetland ecosystems

Many wetlands support high biodiversity and are protected sites, but some are contaminated with radionuclides from routine or accidental releases from nuclear facilities. This radiation exposure needs to be assessed to demonstrate radiological protection of the environment. Existing biota dose models cover generic terrestrial, freshwater, and marine ecosystems, not wetlands specifically. This paper, which was produced under IAEA's Environmental Modelling for Radiation Safety (EMRAS) II programme, describes an evaluation of how models can be applied to radionuclide contaminated wetlands. Participants used combinations of aquatic and terrestrial model parameters to assess exposure. Results show the importance of occupancy factor and food source (aquatic or terrestrial) included. The influence of soil saturation conditions on external dose rates is also apparent. In general, terrestrial parameters provided acceptable predictions for wetland organisms. However, occasionally predictions varied by three orders of magnitude between assessors. Possible further developments for biota dose models and research needs are identified.

Physical and structural stability of the monoclonal antibody, trastuzumab (Herceptin®), intravenous solutions

A major limitation of biological therapeutics is their propensity for degradation particularly in aqueous solutions hence resulting in their short shelf-life. In this study, the stability of trastuzumab (Herceptin®) intravenous (i.v.) solutions, an IgG1 monoclonal antibody (mAb), indicated for the treatment of HER2 positive breast cancer, stored under refrigerated conditions, was evaluated over 28 days. No change in visual appearance or average particle size was observed. The pH values of the trastuzumab i.v. solutions remained stable over time. Interestingly, no change in trastuzumab monomer concentration was observed throughout the 28-day study, as determined by SEC-HPLC. SDSPAGE showed only a monomer band corresponding to the molecular weight of trastuzumab. Circular dichroism spectra obtained following 28-day storage demonstrated integrity of the secondary structural conformation of trastuzumab. Results from this study show that trastuzumab i.v. solutions remain physically and structurally stable on storage at 2-8°C for 28 days. These findings suggest that trastuzumab in solution may not be as sensitive to degradation as expected for a mAb and therefore may have important implications in extending trastuzumab shelf life for clinical use and reducing associated healthcare cost.

Helicobacter pylori resistance rates for levofloxacin, tetracycline and rifabutin among Irish isolates at a reference centre

INTRODUCTION

Helicobacter pylori eradication rates using conventional triple therapies are falling, making viable second-line and rescue regimens necessary. Levofloxacin, tetracycline and rifabutin are three efficacious antibiotics for rescue therapy.

AIM

We aimed to assess the resistance rates for H. pylori against these antibiotics in an Irish cohort.

METHODS

Gastric biopsies were collected from 85 patients infected with H. pylori (mean age 46 years) in the Adelaide and Meath Hospital, Dublin in 2008 and 2009. Susceptibility to antibiotics was tested using the Etest. Clinical information was obtained from endoscopy reports and chart review.

RESULTS

50.6 % of patients were females. Mean age was 47 years. Ten had prior attempts at eradication therapy with amoxicillin-clarithromycin-PPI, two had levofloxacin-based second-line therapy. 11.7 % [95 % CI (6.5-20.3 %)] (N = 10) had strains resistant to levofloxacin. There were no strains resistant to rifabutin or tetracycline. Levofloxacin resistance in the under 45 age group was 2.6 % (1/38) compared to 19.1 % (9/47) of above 45 age group (p = 0.02).

DISCUSSION

The levofloxacin rates illustrated in this study are relatively low by European standards and in line with other studies from the United Kingdom and Germany, with younger patients having very low levels of resistance. Levofloxacin, tetracycline and rifabutin are all valid options for H. pylori eradication in Irish patients but the importance of compliance cannot be underestimated.

The pitfalls of treating anorectal conditions after radiotherapy for prostate cancer

We present a salutary lesson learned from three cases with significant complications that followed anorectal intervention in the presence of radiation proctitis due to prior radiotherapy for adenocarcinoma of the prostate. After apparent routine rubber band ligation for painful haemorrhoids, one patient developed a colo-cutaneous fistula. Following laser coagulation for radiation proctitis, one patient required a pelvic exenteration for a fistula, while another developed a rectal stenosis. Those diagnosing and treating colonic conditions should be mindful of the increased prevalence of patients who have had radiotherapy for prostate cancer and the potential for complications in treating these patients.

Inappropriate colonoscopic surveillance of hyperplastic polyps

Colonoscopic surveillance of hyperplastic polyps alone is controversial and may be inappropriate. The colonoscopy surveillance register at a university teaching hospital was audited to determine the extent of such hyperplastic polyp surveillance. The surveillance endoscopy records were reviewed, those patients with hyperplastic polyps were identified, their clinical records were examined and contact was made with each patient. Of the 483 patients undergoing surveillance for colonic polyps 113 (23%) had hyperplastic polyps alone on last colonoscopy. 104 patients remained after exclusion of those under appropriate surveillance. 87 of the 104 patients (84%) were successfully contacted. 37 patients (8%) were under appropriate colonoscopic surveillance for a significant family history of colorectal carcinoma. 50 (10%) patients with hyperplastic polyps alone and no other clinical indication for colonoscopic surveillance were booked for follow up colonoscopy. This represents not only a budgetary but more importantly a clinical opportunity cost the removal of which could liberate valuable colonoscopy time for more appropriate indications.

The relationship between physical activity and low back pain outcomes: a systematic review of observational studies

Although clinical guidelines advocate exercise and activity in the management of non-specific low back pain (NSLBP), the link between levels of physical activity and outcomes is unclear. This systematic review investigated the relationships between free living activity levels after onset of low back pain (LBP) and measures of pain, and disability in patients with NSLBP. Cohort and cross-sectional studies were located using OVID, CINAHL, Medline, AMED, Embase, Biomed, PubMed-National Library of Medicine, Proquest and Cochrane Databases, and hand searches of reference lists. Studies were included if a statistical relationship was investigated between measures of free living physical activity (PA) in subjects with LBP and LBP outcome measures. Twelve studies (seven cohort and five cross-sectional) were included. One prospective study reported a statistically significant relationship between increased leisure time activity and improved LBP outcomes, and one cross-sectional study found that lower levels of sporting activity were associated with higher levels of pain and disability. All other studies (n = 10) found no relationship between measures of activity levels and either pain or disability. Heterogeneity of study designs, particularly in terms of activity measurement, made comparisons between studies difficult. These data suggest that the activity levels of patients with NSLBP are neither associated with, nor predictive of, disability or pain levels. Validated activity measurement in prospective research is required to better evaluate the relationships between PA and LBP.

How effective is the new community-based Welsh low vision service?

AIMS

To determine if there was a significant difference between user-centred and clinical outcomes in people with low vision who attended a new community-based low vision service (CLVS) or the hospital-based low vision service (HBLV).

METHODS

A prospective controlled before and after study. Participants were recruited from the CLVS (n=343; 96 male, 247 female; median age 82 years) and from the HLVS (n=145; 55 male, 90 female; median age 80 years). The primary outcome measure was change (baseline to 3&emsp14;months) in visual disability as evaluated by the seven-item National Eye Institute-Visual Function Questionnaire (NEI-VFQ). Secondary outcome measures included: use of low vision aids, satisfaction with the service provided and change in near visual acuity before and after the provision of low vision aids.

RESULTS

There were no significant differences in user-centred and clinical outcome measures between the CLVS and HLVS. Self-reported visual disability was significantly reduced after low vision service intervention for participants in both groups by 0.46 and 0.57 logits in the HLVS and CLVS, respectively.

CONCLUSION

This study provides strong evidence that CLVS and HLVS are effective methods of service provision in Wales.

Thrombolytic therapy guided by a decision analysis model: are there potential benefits for patient management?

BACKGROUND

Although thrombolytic therapy improves the outcome of myocardial infarction, it is associated with increased risks of stroke and bleeding; these risks may outweigh the benefits of therapy. The risks and benefits of thrombolysis, for any individual clinical situation, can be explicitly estimated by means of decision analysis.

HYPOTHESIS

The aim of this study was to compare the actual use of thrombolytic agents for suspected acute myocardial infarction (AMI) with the management preferred by a decision analysis model.

METHODS

Admission data prospectively obtained in 262 consecutive patients admitted to a rural community hospital's coronary care unit with suspected AMI, as well as clinical decisions and outcomes, were reviewed and analyzed.

RESULTS

Seventeen deaths from AMI and no major strokes were observed, compared with 18.30 deaths and 0.85 major strokes predicted by a decision analysis model. Forty-seven of 84 patients with confirmed AMI and 3 of 178 without AMI were given a thrombolytic agent, compared with 65 patients with and 7 without AMI who had decision analysis-guided therapy. Decision analysis-guided therapy could have saved 3.7 additional lives and gained 29.6 life years, but produced 0.4 extra strokes. Changing the quality adjustment for stroke or heart failure would not have altered the treatment preferred by decision analysis in any of the 262 cases studied. Some patients were predicted to benefit considerably from thrombolysis with little extra risk of stroke and vice versa: all cases must, therefore, be assessed individually.

CONCLUSIONS

A decision analysis model can guide thrombolytic therapy by promptly defining its risks and benefits.

How to obtain excellent response rates when surveying physicians

This paper outlines ways to maximize response rates to surveys by summarizing the most relevant literature to date and demonstrating how these techniques have resulted in consistently high rates of return in family practice research. We describe the methodology used in recent surveys of physicians conducted by the Centre for Studies in Family Medicine through its Thames Valley Family Practice Research Unit, located in London, Ontario, Canada and funded by the Ontario Ministry of Health and Long-Term Care. The identification and implementation of these techniques to maximize response rates is critical, as primary health care researchers often rely on information gathered through questionnaires to study physicians' practice profiles, experiences and attitudes. Four separate and distinct mailed surveys of physicians using a modified Dillman approach were conducted from 2001 to 2004. The sampling strategies, topics, types of questions and response formats of these surveys varied. The first survey did not use any incentives or recorded delivery/registered mail and received a response rate of 48%. In sharp contrast, the other three surveys obtained responses rates of 76%, 74%, 74%, respectively, achieved through the use of gift certificates and recorded delivery/registered mail. Sending a survey by recorded delivery/registered mail tends to result in the survey package being given priority in the physicians' incoming mail at the practice. Gift certificates partially compensate physicians for time spent completing the survey and recognition of the time required is appreciated. The response rates achieved provide strong evidence to support the use of monetary incentives and recorded delivery/registered mail (along with the Dillman approach) in survey research. It is anticipated that this evidence will be used by other researchers to justify requests for funding to cover the costs associated with incentives and recorded delivery/registered mail. We recommend the use of these strategies to maximize response rates and improve the quality of this type of primary health care research.

Airborne gamma survey of the historic Sleisbeck mine area in the Northern Territory, Australia, and its use for site rehabilitation planning

An airborne gamma-survey provided information about the extent of radioactive contamination around the historic Sleisbeck mine. Quickbird satellite data were acquired to relate airborne measurements to land cover features. Enhanced equivalent uranium (eU) levels were found to be confined to the mine and low grade waste rock dumps. The average terrestrial background radiation dose rate estimated from the airborne gamma survey data was 0.10-0.14 microGy h(-1) while the area around the mine exhibited a maximum of approximately 2.3 microGy h(-1), but measurements on the ground indicate that this maximum is exceeded in some localized areas. Rehabilitation of the site is likely to result in a threefold reduction in radiation doses to people accessing the area.

Rail signallers' assessments of their satisfaction with different shift work systems

This paper describes rail employee views on shift-work systems obtained from administration of the Rail Ergonomics Questionnaire (REQUEST) to a large sample of rail professionals in Great Britain, achieving a response rate of 83%. Results from signallers, the largest occupational grouping in the survey (n = 3230), are presented. ANOVA has been used to investigate the effects of different aspects of the shift patterns (the length of shift and the speed and direction of rotation of shifts) and the effects of age on the ratings of satisfaction with the shift system. The findings from the analyses indicate preferences for the 12-h shift system over the 7-9-h rotating shift system. There were no main effects of the direction of rotation of shifts, though there were significant interactions between the direction of rotation of shifts, the numbers of consecutive shifts and the age of respondents. There is a need for clear data addressing the impact on workers of key shift-related parameters such as shift length, direction of rotation of shifts, numbers of consecutive shifts and personal factors such as age. This paper presents findings of the effects of these key shift and personal parameters and their interactions on respondents' ratings of satisfaction with the shift system, using data collected with REQUEST in a national survey of rail signallers.

Colonoscopy completion rates--are we prepared for a national screening programme?

Colonoscopy is a difficult technique to learn. There are international standards regarding its completion rates. An audit of colonoscopy completion rates was carried out using computerized data in which the compliance with international standards was assessed. Of 909 patients overall crude and adjusted (excluding incompletion due to poor preparation and disease) caecal intubation rates were 88% and 94.1% respectively. Of those who were considered eligible for terminal ileal intubation, the crude and terminal ileal intubation rates were 47.3% and 50.3% respectively. The results indicated completion rated as per recommendations and were adequate for any colon screening programme to be successful.

Oral developmental toxicity study of methylsulfonylmethane in rats

Methylsulfonylmethane (MSM) is a metabolite of dimethyl sulfoxide, and occurs naturally at low levels in many foods. MSM has received wide attention as a dietary supplement to promote joint health. The objective of these studies was to determine the developmental toxicity potential of MSM when administered orally to pregnant rats during the period of major organogenesis and histogenesis. In a preliminary dose-finding study, distilled MSM microprill (i.e., microspherical pellets of MSM) was administered by oral gavage at dose levels of 0 (vehicle control), 50, 250, 500, and 1000 mg/kg/day to 8-9 sperm-positive female Sprague-Dawley rats/group/day on gestation days 6-20. No evidence of maternal or fetal toxicity was observed. For the definitive developmental study, four groups of 24-25 timed-bred primiparous female rats were administered 0, 50, 500, or 1000 mg MSM/kg/day via gavage on gestation days 6-20. Maternal feed consumption, body weight, body weight gain, uterus weight and corrected body weight/body weight gain were unaffected by treatment. No evidence of maternal toxicity, and no significant differences in litter viability, litter size, or litter body weight were detected. Fetal evaluations failed to show any biologically significant increase in the incidence of anomalies in the MSM treated groups, and no malformations were seen in any of the fetuses. No evidence of fetal mortality, alterations to growth, or structural alterations were observed in the fetuses of dams administered 50-1000 mg/kg/day. Therefore, under the conditions of this study, the no-observed-adverse-effect level (NOAEL) for maternal and developmental toxicity was 1000 mg/kg/day.

Expression of survivin and its splice variants survivin-2B and survivin-DeltaEx3 in breast cancer

Alternative splicing of survivin mRNA gives rise to multiple isoforms, that is, survivin and 3 splice variants, survivin-2B, survivin-3B and survivin-ΔEx3. The aim of this study was to compare the expression of survivin, survivin-2B and survivin-ΔEx3 in normal breast tissue, fibroadenomas, primary breast cancer and axillary nodal metastases. Survivin, survivin-2B and survivin-ΔEx3 mRNA were measured using semiquantitative RT–PCR. In the primary carcinomas, we related mRNA for each form of survivin to both survivin protein and apoptosis. For each type of breast tissue, survivin was the predominant form detected, being present in 146 out of 156 (93.6%) primary breast carcinomas, 11 out of 11 (100%) axillary nodal metastases, 21 out of 31 (67.7%) fibroadenomas and five out of 22 (22.7%) specimens of normal breast tissue. Levels of the three forms of survivin were significantly higher in the carcinomas compared to normal breast tissue (P<0.0001). Levels of both survivin-2B and survivin-ΔEx3 but not survivin were significantly higher in nodal metastases than primary carcinomas. Survivin mRNA levels correlated significantly with survivin protein. Finally, both survivin and survivin-ΔEx3 but not survivin-2B correlated positively with apoptosis. Although survivin, survivin-2B and survivin-ΔEx3 were all detected in both malignant and nonmalignant breast tissue, the predominant form was survivin. Our results suggest that the different forms of survivin may have different roles in apoptosis in breast cancer.

Increased Risk of Hemorrhagic Complications in Renal Allograft Recipients Receiving Systemic Heparin Early Posttransplantation

The aim of this paper is to document the risk of hemorrhagic complications in renal allograft recipients requiring systemic heparinisation within the first 2 weeks posttransplantation.

METHODS

A retrospective chart review of 326 RA recipients from January 1998 to July 2003 was subjected to statistics by SPIDA with P values <.05 considered significant.

RESULTS

16/326 (4.9%) recipients were initiated on intravenous (IV) heparin within the study period. Enoxaparin was subsequently used in 10/16 (62.5%) of these recipients. Intravenous heparin was instituted at a median 8 (1-14) days posttransplantation. Hemorrhagic complications occurred in 10/16 (62.5%) recipients on IV heparin versus 11/310 (3.5%) nonanticoagulated RA recipients (P = .0001). Hemorrhage occurred at a mean 9.75 (2-43) days into the course of IV heparin. The median peak APTT 24 hours prior to hemorrhage in RA recipients on heparin was 68.5 (58-180) versus a median peak APTT of 70 (50-140) among recipients on heparin who did not sustain a hemorrhagic complication (P = .30). A major intervention (predominantly surgery) was required in 6/16 (37%) recipients on IV heparin versus 7/310 (2.2%) nonheparinised RA recipients (P < .0001). Enoxaparin was instituted at a mean 22.5 (4-55) days posttransplantation. Delayed hemorrhage subsequently occurred in 4/10 (40%) recipients on enoxaparin. In conclusion, major and minor hemorrhagic complications occur more commonly among recipients requiring early post transplant IV heparin. Hemorrhage occurred despite APTT monitoring with APTT levels tending to be similar in RA recipients with versus without complications. Delayed hemorrhage was also seen with the subsequent use of enoxaparin.

A radon and meteorological measurement network for the Alligator Rivers Region, Australia

The network described in this paper has been set up to provide detailed time-series data on concentrations of 222Rn in air at various locations within the Alligator Rivers Region, over a time frame of several years. These data will be important in assessing the effects of uranium mining operations on radon levels in the region, both in providing baseline and monitoring data and in calibrating and verifying predictive models. At present, three stations are operating in the region with a fourth being commissioned. Each station logs half hourly average radon concentrations and relevant meteorological data (wind speed, direction and variability, air pressure and temperature, relative humidity, soil temperature, rain and sunshine rates). It is intended to operate the four stations at selected locations for one- or two-year intervals, at the end of which three will be moved to new locations (one station at Mudginberri will be kept as a constant control station). Sites for which extensive datasets are currently available include: Jabiru Town, Jabiru East, Djarr Djarr, East Alligator Ranger Station and Nabarlek minesite. Illustrative data from these sites are presented.

Transvenous liver biopsy via the femoral vein

AIM

To study the safety, effectiveness and diagnostic value of transvenous forceps biopsy of the liver in 54 patients with coagulopathy, gross ascites or morbid obesity and suspected liver disease in whom percutaneous liver biopsy was contraindicated.

MATERIAL AND METHODS

Forceps biopsy of the liver via the femoral vein was attempted in 54 adult patients with advanced liver disease of unknown aetiology who had coagulation disorders (41 cases), gross ascites (11 cases) or morbid obesity (two cases). In each patient two to six biopsies (average four) were taken using a radial jaw forceps inserted via the right or left femoral vein.

RESULTS

The procedure was successful in 53 cases. Hepatic vein catheterization failed in one patient. Adequate liver tissue for diagnosis was obtained in 84% of cases. One patient developed delayed haemorrhage at 12 h from a capsular leak that was undetected during the biopsy procedure. This patient required blood transfusions and laparotomy to control bleeding. There were no deaths in the 53 patients studied. Transient minor chest and shoulder pain was encountered during sheath insertion into a hepatic vein in 23 patients. Three patients developed a femoral vein haematoma, which resolved with conservative treatment.

CONCLUSION

Transvenous liver biopsy via the femoral vein is another safe, effective, simple alternative technique of biopsy when the percutaneous route is contraindicated.

Long-term efficacy of a cognitive behavioural treatment from a randomized controlled trial for patients recently diagnosed with rheumatoid arthritis

OBJECTIVES

This study examined the long-term efficacy of a cognitive behavioural intervention for patients with recent-onset, seropositive rheumatoid arthritis (RA).

METHODS

Fifty-three consecutive patients with less than a 2-yr history of classic or definite RA were recruited into the trial. All participants received routine medical management during the study, and half were randomly allocated to receive an 8-week adjunctive psychological intervention. All assessments were conducted blind to the allocation. This paper reports intention-to-treat analyses of the 18-month follow-up.

RESULTS

Consistent with short-term results, significant differences were found between the groups in depressive symptoms. The intervention group maintained improvements in joint function, although those in routine care made similar improvements over the ensuing 18 months. At follow-up, group differences emerged for disability and anxiety.

CONCLUSIONS

These results indicate that cognitive behavioural intervention offered as an adjunct to standard clinical management early in the course of RA is efficacious in producing improvements in both psychological and physical indices. Furthermore, improvements appear to increase 18 months after a brief, time-limited psychological treatment.

Low vision services for vision rehabilitation in the United Kingdom

AIM

Little is known about the distribution and methods of delivery of low vision services across the United Kingdom. The purpose of this study was to determine the type and location of low vision services within the UK.

METHODS

Survey by means of a 29 point postal questionnaire, followed when necessary by a five point telephone questionnaire. All known potential providers of low vision services (n = 2539) including hospitals (n = 277), optician/optometry practices (n = 1683), social services (n = 177), voluntary groups (n = 190), specialist teachers (n = 205), and universities (n = 6) were surveyed. For each service provider, the type, magnitude, and geographical location were determined. The distribution of services across the United Kingdom and the ratio of providers to population density of people with a visual impairment were mapped using the Geographic Information System (GIS).

RESULTS

Data were obtained on 1945 (77%) service providers: 1679 (66%) responded to the postal questionnaire and 266 (11%) to the telephone questionnaire. Of all respondents, 59% (n = 1135) offer some form of help to people with a visual disability, of which 26% (n = 497) only sell magnifiers and 33% (n = 638) provide low vision services. It is estimated that in total just under 155,000 low vision consultations are offered annually, the bulk of which are provided by hospital eye departments. The distribution was geographically uneven and there appears to be scarcity in some areas.

CONCLUSION

When compared to the probable number of people with a visual impairment in the UK there are apparent inadequacies in service provision in terms of distribution, magnitude, and coordination. The results highlight a need to review current services.

The breeding season diet of wedge-tailed eagles (Aquila audax) in western New South Wales and the influence of Rabbit Calicivirus Disease

A total of 2071 individual prey items were identified from 34 active and 55 inactive wedge-tailed eagle nests following the 1995, 1996 and 1997 breeding seasons. Overall, the eagle's diet was comparable to that reported in other studies within semi-arid regions, with rabbits, reptiles and macropods accounting for 47.8, 22.6 and 13.7% of prey items, respectively. In spring 1996 rabbit calicivirus moved into the study area, resulting in a 44-78% reduction in rabbit abundance (Sharp et al. 2001). An index was developed to enable the time since death for individual prey items to be approximated and a historical perspective of the eagle's diet to be constructed. Rabbits constituted 56-69% of dietary items collected during the pre-rabbit calicivirus disease (RCD) samples, but declined to 31% and 16% in the two post-RCD samples. A reciprocal trend was observed for the proportion of reptiles in the diet, which increased from 8-21% of pre-RCD dietary items to 49-54% after the advent of RCD. Similarly, the proportion of avian prey items was observed to increase in the post-RCD samples. These data suggested that prey switching may have occurred following the RCD epizootic. However, a lack of data on the relative abundances of reptiles and birds prevented an understanding of the eagle's functional responses to be developed and definitive conclusions to be drawn. Nevertheless, the eagles were observed to modify their diet to the change in rabbit densities by consuming larger quantities of native prey species.

Work in progress. Integrating physicians' services in the home

OBJECTIVE

While increasing acuity levels and the concomitant complexity of service demand that physicians be involved in in-home care, conflicting evidence and opinions do not show how this can best be achieved.

DESIGN

A phenomenologic research design was used to obtain insights into the challenges and opportunities of integrating physicians' services into the usual in-home services in London, Ont.

SETTING

Home care in London, Ont.

PARTICIPANTS

Twelve participants included three patients, two family caregivers, two family physicians, the program's nurse practitioner, two case managers, and two community nurses.

METHOD

In-depth interviews with a maximally varied purposeful sample of patients, caregivers, and providers were analyzed using immersion and crystallization techniques.

MAIN FINDINGS

Findings revealed the potential for enhanced continuity of care and interdisciplinary team functioning. Having a nurse practitioner, interdisciplinary team-building exercises and meetings, regular face-to-face contact among all providers, support for family caregivers, and 24-hour coverage for physicians were found to be essential for success.

CONCLUSION

Integration of services takes time, money, and sustained commitment, particularly when undertaken in geographically isolated communities. Informed choice and a fair remuneration system remain important considerations for family physicians.

A blind, randomized, controlled trial of cognitive-behavioural intervention for patients with recent onset rheumatoid arthritis: preventing psychological and physical morbidity

This study examined the efficacy of a cognitive and behavioural intervention (CBT) for patients with recent onset, seropositive rheumatoid arthritis. Fifty-three participants with a diagnosis of classical or definite rheumatoid arthritis, who were seropositive and had less than 2 years of disease history were recruited into the trial. All participants received routine medical management during the study, although half were randomly allocated to receive an adjunctive psychological intervention. All pre- and post-treatment assessments were conducted blind to the allocation. Analyses were conducted of treatment completers and also by intention-to-treat. Significant differences were found between the groups at both post-treatment and 6-month follow-up in depressive symptoms. While the CBT group showed a reduction in depressive symptoms, the same symptoms increased in the Standard group. At outcome but not follow-up, the CBT group also showed reduction in C-reactive protein levels. However, the CBT group did show significant improvement in joint involvement at 6-month follow-up compared with the Standard group, indicating physical improvements above those achieved with standard care. These results indicate that cognitive-behavioural intervention offered as an adjunct to standard clinical management early in the course of RA is efficacious in producing reductions in both psychological and physical morbidity