Interacting with patients at risk of self-harm or suicide - A qualitative study of community pharmacists and pharmacy staff

Background

Suicide and self-harm are significant public health concerns. Community pharmacies are accessible and frequented regularly by the public, making them well positioned to identify and intervene with those at risk. The aims of this research project are to evaluate pharmacy staff experiences of dealing with people at risk of suicide/self-harm, and explore how best to support staff during these interactions.

Methods

Semi-structured online and telephone interviews were conducted with a sample of community pharmacists and community pharmacy staff (CPS) in the south west of Ireland. Interviews were audio recorded and transcribed verbatim. The Braun and Clarke approach to inductive thematic analysis was used to analyse the data.

Results

Thirteen semi-structured qualitative interviews were conducted in November-December 2021. Most participants had encountered a person at risk of suicide/self-harm in their practice, however participants described a lack of training and guidelines around how to navigate these scenarios. Three major themes emerged: (i) Interacting with patients at risk of suicide/self-harm- facilitators and barriers; (ii) Referrals and signposting; (iii) Addressing uncertainty. Positive relationships between the person and pharmacy staff facilitated interactions, while privacy, time constraints and uncertainty among staff were seen as barriers. Participants felt it was necessary to refer at-risk people to other supports, and made suggestions for increasing staff confidence through the implementation of support tools within the pharmacy setting.

Conclusions

This study highlights that at present, community pharmacy staff feel uncertain regarding how to handle interactions with people at risk of suicide/self-harm, due to lack of training and supports. Future research should focus on building upon existing resources and obtaining specialist and stakeholder input to produce the most effective support tool(s), tailored to the pharmacy setting.

The efficacy of interventions in reducing belief in conspiracy theories: A systematic review

Conspiracy beliefs have become a topic of increasing interest among behavioural researchers. While holding conspiracy beliefs has been associated with several detrimental social, personal, and health consequences, little research has been dedicated to systematically reviewing the methods that could reduce conspiracy beliefs. We conducted a systematic review to identify and assess interventions that have sought to counter conspiracy beliefs. Out of 25 studies (total N = 7179), we found that while the majority of interventions were ineffective in terms of changing conspiracy beliefs, several interventions were particularly effective. Interventions that fostered an analytical mindset or taught critical thinking skills were found to be the most effective in terms of changing conspiracy beliefs. Our findings are important as we develop future research to combat conspiracy beliefs.

Influence of novel risk markers on defibrillator implantation in hypertrophic cardiomyopathy

Background/Introduction

To guide implantable defibrillator (ICD) use in hypertrophic cardiomyopathy (HCM), European Society of Cardiology (ESC) guidelines recommend using individualised sudden death (SCD) risk scores based on quantitative clinical data. Newly published American guidelines are based on the accumulation of binary risk markers, which include imaging-based novel risk markers (NRMs) that were absent from the development of the ESC's algorithm. These NRMs are ejection fraction <50%, apical aneurysm, and extensive late gadolinium enhancement on cardiac magnetic resonance (CMR) imaging.

Purpose

To assess how NRMs may have altered ICD prescription across ESC-based SCD risk status prior to publication of current American guidance.

Methods

We examined electronic records (2013–2020) of a subset of HCM patients with contemporaneous (within 12 months) CMR and echocardiography data for NRMs, ESC risk status, and ICD prescription. Differences in categorical data were assessed by Fisher's exact test.

Results

We studied 334 HCM patients (74% male; age: 58±14 years), of whom 83 (25%) were referred for ICD. ESC risk status was considered low, medium (4–6% 5-year SCD risk), or high in 264, 26, and 20 patients, for whom ICDs were recommended in 40 (15%), 20 (77%), and 18 (90%) patients, respectively. In patients with low SCD risk status, rate of ICD recommendation was significantly higher when ≥1 NRMs were present (34/126 – 27% vs. 0 NRMs: 6/138 – 4%; p<0.0001). NRMs did not appear to influence ICD recommendation in patients with medium (≥1 NRMs: 14/17 – 82% vs. 0 NRMs: 6/9 – 67%; p=0.6) or high (≥1 NRMs: 14/15 – 93% vs. 0 NRMs: 4/5 – 80%; p=0.4) SCD risk status (Figure 1). NRMs were less frequent in low risk patients than in high risk patients (126/264 – 48% vs. 15/20 – 75%; p<0.05), suggesting interaction between ESC status and NRMs (Figure 2).

Conclusion

NRMs have disproportionate influence on ICD prescription in low ESC risk HCM patients. However, NRMs are not independent of ESC risk status, suggesting iterative development of the ESC's algorithmic approach will be the most effective way of predicting SCD.

Funding Acknowledgement

Type of funding sources: None.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

A mixed methods analysis of the monitoring of oral anti-cancer therapies

PURPOSE

Oral anti-cancer therapies offer advantages over parenteral therapies in terms of their non-invasive nature and reduced intrusiveness. However, the shift from directly observed administration of these therapies to home administration means that continuous monitoring is needed. The oral anti-cancer therapy market is rapidly growing, with an ever-increasing number of new medicines available for the patients presenting with cancer illnesses. This study aims to (i) evaluate both the cost of providing monitoring consultations of oral anti-cancer therapies, and (ii) to assess the experience of cancer therapy nurses responsible for the monitoring and their opinions of the quality of the service.

METHODS

This study provides a mixed methods evaluation of the monitoring of oral anti-cancer therapies. Nurses were asked to record the time taken for them to perform their monitoring duties, and staff related costs were calculated using publicly available salary data. Patient-related costs were calculated using the Human Capital method. Nurses were asked to discuss their experience of monitoring oral anti-cancer therapies in semi-structured interviews. These interviews were subsequently analysed using thematic analysis.

RESULTS

201 recordings and their associated costs were documented. The median consultation time was 33 min, costing €22.10 using Clinical Nurse Specialist salary figures and €26.51 using Advanced Nurse Practitioner salary figures. The associated patient cost was €14.06. Themes of the effect of Covid-19 on the service, expanding and complicated care package requirements, the need for dedicated oral clinics and the future of the service emerged from the interview data.

CONCLUSION

The monitoring service provided by nurses may be undervalued. The commitment to fully dedicated oral anti-cancer therapy clinics and an increase in staff to align with the ongoing increase in service demand is seen as vital for the continued safe and effective delivery of this specialist cancer service.

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial

OBJECTIVE

To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital.

DESIGN

Cluster randomised controlled trial.

SETTING

110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors.

PARTICIPANTS

2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term).

INTERVENTION

Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person's prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing.

MAIN OUTCOME MEASURE

Primary outcome was first drug related hospital admission within 12 months.

RESULTS

2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths).

CONCLUSIONS

Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02986425.

The relationship between left ventricular outflow tract gradient and sudden cardiac death in childhood hypertrophic cardiomyopathy

Background

The most common mode of death in childhood hypertrophic cardiomyopathy (HCM) is sudden cardiac death (SCD). Left ventricular outflow tract obstruction (LVOTO) is an established risk factor for SCD in adults with the disease. In contrast, the prognostic implications of LVOTO in childhood disease is unclear, with recent studies suggesting that it may have an inverse relationship with the risk of SCD.

Purpose

The aim of this study was to explore the role of LVOTO and the risk of SCD in childhood HCM.

Methods

A multi-centre, retrospective, longitudinal cohort of 871 children (diagnosed with HCM &lt;16 years of age) was used to explore the relationship between SCD and LVOTO (LVOT gradient ≥30mmHg).

Results

189 patients (23%) had LVOTO, which was mild (30–50mmHg), moderate (50–100mmHg) or severe (&gt;100mmHg) in 58 (6.7%), 98 (11.3%) and 33 (3.8%), respectively. The risk of SCD showed an inverse relation to LVOT gradient severity compared to those with no obstruction: mild HR 1.75 (95% CI 0.89–3.44), moderate HR 1.04 (95% 0.55–1.98), and severe HR 0.7 (0.36–1.35) [figure].On univariable analysis [table] LVOTO was associated with heart failure symptoms (NYHA&gt;1) [p &lt;0.001], maximal wall thickness (MWT) [p &lt;0.001], left atrial (LA) diameter [p &lt;0.001], and future myectomy occurring during follow up [p &lt;0.001]. The inverse relationship observed was not altered by the presence or absence of other traditional risk factors.

Conclusions

LVOTO appears to have a complex relationship with the risk of SCD in childhood HCM, with multiple contributing factors. The pathophysiological mechanisms behind this observation need further exploration, which may be limited by low patient numbers

Cummulative incidence of SCD by LVOTO

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): British Heart Foundation

A cost comparison study to review community versus acute hospital models of nursing care delivered to oncology patients

PURPOSE

Ireland's Sláintecare health plan is placing an increased focus on primary care. A community oncology nursing programme was developed to train community nurses to deliver care in the community. While the initial pilot was proven to be clinically safe, no cost evaluation was carried out. This study aims to compare the costs of providing cancer support services in a day-ward versus in the community.

METHODS

183 interventions (40 in day-ward and 143 in community) were timed and costed using healthcare professional salaries and the Human Capital method.

RESULTS

From the healthcare provider perspective, the day-ward was a significantly cheaper option by an average of €17.13 (95% CI €13.72 - €20.54, p < 0.001). From the societal perspective, the community option was cheaper by an average of €2.77 (95% CI -€3.02 - €8.55), although this was a non-significant finding. Sensitivity analyses indicate that the community service may be significantly cheaper from the societal perspective.

CONCLUSIONS

Given the demand for cost-viable options for primary care services, this programme may represent a national option for cancer care in Ireland when viewed from the societal perspective.

Exposure to selected preservatives in personal care products: case study comparison of exposure models and observational biomonitoring data

Exposure models provide critical information for risk assessment of personal care product ingredients, but there have been limited opportunities to compare exposure model predictions to observational exposure data. Urinary excretion data from a biomonitoring study in eight individuals were used to estimate minimum absorbed doses for triclosan and methyl-, ethyl-, and n-propyl- parabens (TCS, MP, EP, PP). Three screening exposure models (European Commission Scientific Commission on Consumer Safety [SCCS] algorithms, ConsExpo in deterministic mode, and RAIDAR-ICE) and two higher-tier probabilistic models (SHEDS-HT, and Creme Care & Cosmetics) were used to model participant exposures. Average urinary excretion rates of TCS, MP, EP, and PP for participants using products with those ingredients were 16.9, 3.32, 1.9, and 0.91 μg/kg-d, respectively. The SCCS default aggregate and RAIDAR-ICE screening models generally resulted in the highest predictions compared to other models. Approximately 60-90% of the model predictions for most of the models were within a factor of 10 of the observed exposures; ~30-40% of the predictions were within a factor of 3. Estimated exposures from urinary data tended to fall in the upper range of predictions from the probabilistic models. This analysis indicates that currently available exposure models provide estimates that are generally realistic. Uncertainties in preservative product concentrations and dermal absorption parameters as well as degree of metabolism following dermal absorption influence interpretation of the modeled vs. measured exposures. Use of multiple models may help characterize potential exposures more fully than reliance on a single model.

Position statement for the diagnosis and management of anogenital warts

BACKGROUND

Anogenital warts (AGW) can cause economic burden on healthcare systems and are associated with emotional, psychological and physical issues.

OBJECTIVE

To provide guidance to physicians on the diagnosis and management of AGW.

METHODS

Fourteen global experts on AGW developed guidance on the diagnosis and management of AGW in an effort to unify international recommendations. Guidance was developed based on published international and national AGW guidelines and an evaluation of relevant literature published up to August 2016. Authors provided expert opinion based on their clinical experiences.

RESULTS

A checklist for a patient's initial consultation is provided to help physicians when diagnosing AGW to get the relevant information from the patient in order to manage and treat the AGW effectively. A number of frequently asked questions are also provided to aid physicians when communicating with patients about AGW. Treatment of AGW should be individualized and selected based on the number, size, morphology, location, and keratinization of warts, and whether they are new or recurrent. Different techniques can be used to treat AGW including ablation, immunotherapy and other topical therapies. Combinations of these techniques are thought to be more effective at reducing AGW recurrence than monotherapy. A simplified algorithm was created suggesting patients with 1-5 warts should be treated with ablation followed by immunotherapy. Patients with >5 warts should use immunotherapy for 2 months followed by ablation and a second 2-month course of immunotherapy. Guidance for daily practice situations and the subsequent action that can be taken, as well as an algorithm for treatment of large warts, were also created.

CONCLUSION

The guidance provided will help physicians with the diagnosis and management of AGW in order to improve the health and quality of life of patients with AGW.

ExpoQual: Evaluating measured and modeled human exposure data

Recent rapid technological advances are producing exposure data sets for which there are no available data quality assessment tools. At the same time, regulatory agencies are moving in the direction of data quality assessment for environmental risk assessment and decision-making. A transparent and systematic approach to evaluating exposure data will aid in those efforts. Any approach to assessing data quality must consider the level of quality needed for the ultimate use of the data. While various fields have developed approaches to assess data quality, there is as yet no general, user-friendly approach to assess both measured and modeled data in the context of a fit-for-purpose risk assessment. Here we describe ExpoQual, an instrument developed for this purpose which applies recognized parameters and exposure data quality elements from existing approaches for assessing exposure data quality. Broad data streams such as quantitative measured and modeled human exposure data as well as newer and developing approaches can be evaluated. The key strength of ExpoQual is that it facilitates a structured, reproducible and transparent approach to exposure data quality evaluation and provides for an explicit fit-for-purpose determination. ExpoQual was designed to minimize subjectivity and to include transparency in aspects based on professional judgment. ExpoQual is freely available on-line for testing and user feedback (exposurequality.com).

Cost Minimization Analysis of Intravenous or Subcutaneous Trastuzumab Treatment in Patients With HER2-Positive Breast Cancer in Ireland

BACKGROUND

Two large acute Irish University teaching hospitals changed the manner in which they treated human epidermal growth factor receptor (HER)2-positive breast cancer patients by implementing the administration of trastuzumab via the subcutaneous (SC) route into their clinical practice. The study objective is to compare the trastuzumab SC and trastuzuamb intravenous (IV) treatment pathways in both hospitals and assess which route is more cost-effective and time saving in relation to active health care professional (HCP) time.

MATERIALS AND METHODS

A prospective observational study in the form of cost minimization analysis constituted the study design. Active HCP time for trastuzumab SC- and IV-related tasks were recorded. Staff costs were calculated using fully loaded salary costs. Loss of productivity costs for patients were calculated using the human capital method.

RESULTS

On average, the total HCP time saved per trastuzumab SC treatment cycle relative to trastuzumab IV treatment cycle was 59.21 minutes. Time savings in favor of trastuzumab SC resulted from quicker drug reconstitution, no IV catheter installation/removal, and less HCP monitoring. Over a full treatment course of 17 cycles, average HCP time saved accumulates to 16.78 hours, with an estimated direct cost saving of €1609.99. Loss of productivity for patients receiving trastuzumab IV (2.15 days) was greater than that of trastuzumab SC (0.60 days) for a full treatment course.

CONCLUSION

Trastuzumab SC treatment has proven to be a more cost-effective option than trastuzumab IV treatment that generated greater HCP time savings in both study sites. Healthcare policymakers should consider replacing trastuzumab IV with trastuzumab SC treatment in all eligible patients.

Investigation of the potential for a simplified exposure tool in medical nutrition (SETIM) to minimise exposures to sweeteners in young patients aged 1-3 years with PKU and CMPA

Children with phenylketonuria (PKU) and severe cow's milk protein allergy (CMPA) consume prescribed, specially formulated, foods for special medical purposes (FSMPs) in addition to having restricted intake of normal foods. These vulnerable patients are exposed to artificial sweeteners from the consumption of a combination of both free and prescribed foods. Young patients with PKU and CMPA aged from 1 to 3 years have a higher risk of exceeding the acceptable daily intake (ADI) for sweeteners than age-matched healthy children. A probabilistic modelling approach has been adapted successfully to assess the exposure of young patients with PKU and CMPA to low-calorie sweeteners. To assist professionals in the screening and formulation of foods containing food additives for such patients, a simplified exposure method/tool has been developed. The tool is intended to ensure that total dietary exposure can be considered. The simplified tool is not intended to replace the probabilistic model but may be used as a screening tool to determine if further investigation on exposure is warranted. The aim of this study was to develop and validate this simplified exposure tool to support those currently used by healthcare professionals (HCPs) using data available from the probabilistic modelling of exposure in young children with PKU and CMPA. The probabilistic model does not allow for swift screening of exposure scenarios nor is the present EFSA Food Additive Intake Assessment Model (FAIM) fully suitable for application to medical foods. The simplified exposure tool in medical nutrition (SETIM) reported here is both reliable and consistent and provides additive usage levels which minimise regular exposure above the ADI in patients. In addition to the usefulness of SETIM for the medical nutrition industry, the tool has the potential to enhance the practice of evidence-based medical nutrition by official risk assessment bodies, registration authorities and healthcare professionals.

A probabilistic intake model to estimate the impact of reformulation by the food industry among Irish consumers

This project quantified the impact that voluntary reformulation efforts of the food industry had on the Irish population's nutrient intake. Nutrient composition data on reformulated products were collected from 14 major food companies for two years, 2005 and 2012. Probabilistic intake assessments were performed using the Irish national food consumption surveys as dietary intake data. The nutrient data were weighted by market shares replacing existing food composition data for these products. The reformulation efforts assessed, significantly reduced mean energy intakes by up to 12 kcal/d (adults), 15 kcal/d (teens), 19 kcal/d (children) and 9 kcal/d (pre-schoolers). Mean daily fat intakes were reduced by up to 1.3 g/d, 1.3 g/d, 0.9 g/d and 0.6 g/d, saturated fat intakes by up to 1.7 g/d, 2.3 g/d, 1.8 g/d and 1 g/d, sugar intakes by up to 1 g/d, 2 g/d, 3.5 g/d and 1 g/d and sodium intakes by up to 0.6 g/d, 0.5 g/d, 0.2 g/d, 0.3 g/d for adults, teenagers, children and pre-school children, respectively. This model enables to assess the impact of industry reformulation amongst Irish consumers' nutrient intakes, using consumption, food composition and market share data.

Critical and systematic evaluation of data for estimating human exposures to 2,4-dichlorophenoxyacetic acid (2,4-D) - quality and generalizability

The herbicide 2,4-dichlorophenoxyacetic acid (2,4-D) has been commercially available since the 1940's. Despite decades of data on 2,4-D in food, air, soil, and water, as well as in humans, the quality the quality of these data has not been comprehensively evaluated. Using selected elements of the Biomonitoring, Environmental Epidemiology, and Short-lived Chemicals (BEES-C) instrument (temporal variability, avoidance of sample contamination, analyte stability, and urinary methods of matrix adjustment), the quality of 156 publications of environmental- and biomonitoring-based 2,4-D data was examined. Few publications documented steps were taken to avoid sample contamination. Similarly, most studies did not demonstrate the stability of the analyte from sample collection to analysis. Less than half of the biomonitoring publications reported both creatinine-adjusted and unadjusted urine concentrations. The scope and detail of data needed to assess temporal variability and sources of 2,4-D varied widely across the reviewed studies. Exposures to short-lived chemicals such as 2,4-D are impacted by numerous and changing external factors including application practices and formulations. At a minimum, greater transparency in reporting of quality control measures is needed. Perhaps the greatest challenge for the exposure community is the ability to reach consensus on how to address problems specific to short-lived chemical exposures in observational epidemiology investigations. More extensive conversations are needed to advance our understanding of human exposures and enable interpretation of these data to catch up to analytical capabilities. The problems defined in this review remain exquisitely difficult to address for chemicals like 2,4-D, with short and variable environmental and physiological half-lives and with exposures impacted by numerous and changing external factors.

Predictive modelling of the exposure to steviol glycosides in Irish patients aged 1-3 years with phenylketonuria and cow's milk protein allergy

Children with Phenylketonuria (PKU) and severe cow's milk protein allergy (CMPA) consume prescribed, specially formulated, foods for special medical purposes (FSMPs) as well as restricted amounts of normal foods. These patients are exposed to artificial sweeteners from the consumption of a combination of free and prescribed foods. Young patients with PKU and CMPA have a higher risk of exceeding acceptable daily intakes (ADI) for additives than age-matched healthy children. A predictive modelling approach has been adapted successfully to assess the additive exposure of young patients with PKU and CMPA to artificial sweeteners. Steviol glycosides (E960) are at various stages of regulatory approval for the various food categories in the EU but are not as yet permitted for use in products intended for young children. The aim of this study was to predict potential steviol glycoside exposure in young children with PKU and CMPA considering the potential for future provisions for the use of this sweetener. The recent introduction of steviol glycosides means that no exposure data are available for children with CMPA and PKU. Food consumption data were derived from the food consumption survey data of healthy young children in Ireland from the National Preschool and Nutrition Survey (NPNS, 2010-11). Specially formulated amino acid-based FSMPs are used to replace whole or milk protein foods and were included in the exposure model to replace restricted foods. The recommendations to ensure adequate protein intake in these patients were used to determine FSMP intake. Exposure assessment results indicated that the maximum permitted level (MPL) for FSMPs would warrant careful consideration to avoid exposures above the ADI. These data can be used to inform recommendations for the medical nutrition industry.

Longitudinal modelling of the exposure of young UK patients with PKU to acesulfame K and sucralose

Artificial sweeteners are used in protein substitutes intended for the dietary management of inborn errors of metabolism (phenylketonuria, PKU) to improve the variety of medical foods available to patients and ensure dietary adherence to the prescribed course of dietary management. These patients can be exposed to artificial sweeteners from the combination of free and prescribed foods. Young children have a higher risk of exceeding acceptable daily intakes (ADI) for additives than adults, due to higher food intakes per kg body weight. Young patients with PKU aged 1-3 years can be exposed to higher levels of artificial sweeteners from these dual sources than normal healthy children and are at a higher risk of exceeding the ADI. Standard intake assessment methods are not adequate to assess the additive exposure of young patients with PKU. The aim of this study was to estimate the combination effect on the intake of artificial sweeteners and the impact of the introduction of new provisions for an artificial sweetener (sucralose, E955) on exposure of PKU patients using a validated probabilistic model. Food consumption data were derived from the food consumption survey data of healthy young children in the United Kingdom from the National Diet and Nutrition Survey (NDNS, 1992-2012). Specially formulated protein substitutes as foods for special medical purposes (FSMPs) were included in the exposure model to replace restricted foods. Inclusion of these protein substitutes is based on recommendations to ensure adequate protein intake in these patients. Exposure assessment results indicated the availability of sucralose for use in FSMPs for PKU leads to changes in intakes in young patients. These data further support the viability of probabilistic modelling as a means to estimate food additive exposure in patients consuming medical nutrition products.

Probabilistic modelling to assess exposure to three artificial sweeteners of young Irish patients aged 1-3 years with PKU and CMPA

The choice of suitable normal foods is limited for individuals with particular medical conditions, e.g., inborn errors of metabolism (phenylketonuria - PKU) or severe cow's milk protein allergy (CMPA). Patients may have dietary restrictions and exclusive or partial replacement of specific food groups with specially formulated products to meet particular nutrition requirements. Artificial sweeteners are used to improve the appearance and palatability of such food products to avoid food refusal and ensure dietary adherence. Young children have a higher risk of exceeding acceptable daily intakes for additives than adults due to higher food intakes kg^-1 body weight. The Budget Method and EFSA's Food Additives Intake Model (FAIM) are not equipped to assess partial dietary replacement with special formulations as they are built on data from dietary surveys of consumers without special medical requirements impacting the diet. The aim of this study was to explore dietary exposure modelling as a means of estimating the intake of artificial sweeteners by young PKU and CMPA patients aged 1-3 years. An adapted validated probabilistic model (FACET) was used to assess patients' exposure to artificial sweeteners. Food consumption data were derived from the food consumption survey data of healthy young children in Ireland from the National Preschool and Nutrition Survey (NPNS, 2010-11). Specially formulated foods for special medical purposes were included in the exposure model to replace restricted foods. Inclusion was based on recommendations for adequate protein intake and dietary adherence data. Exposure assessment results indicated that young children with PKU and CMPA have higher relative average intakes of artificial sweeteners than healthy young children. The reliability and robustness of the model in the estimation of patient additive exposures was further investigated and provides the first exposure estimates for these special populations.

Adenoviral non-gonococcal urethritis

Adenoviruses infect mucous membranes, including – on rare occasions – the urethra. Adenoviruses should therefore be considered as yet another cause of chlamydia-negative non-gonococcal urethritis. The following case illustrates the dilemma posed in a patient with conjunctivitis and urethritis.

Lichen sclerosus

Lichen sclerosus (LS) is a chronic inflammatory disorder of the skin and mucosa, presenting to genitourinary physicians and dermatologists. It affects both sexes and all age groups. Although the exact aetiology is uncertain, genetic predisposition, infections and autoimmune factors have been implicated in its pathogenesis. Symptoms include pruritis and soreness, but asymptomatic presentations are not uncommon. The classical clinical picture is of atrophic white plaques in the anogenital region. Histopathology is specific with basal cell degeneration, upper dermal oedema, homogenization of collagen and a chronic inflammatory infiltrate. Short courses of potent topical corticosteroids form the mainstay of treatment. The condition tends to be remitting and relapsing, with spontaneous regressions reported in a few. In men, the term balanitis xerotica obliterans is sometimes used to describe late and severe LS of the penis. Scarring and progression to squamous cell carcinomas can occur in chronic LS, resulting in significant morbidity. A multi-disciplinary approach to care and the need for long-term monitoring cannot be over-emphasized.

Difficult wart cases - use of imiquimod cream 5%

Treatment of genital warts is a significant part of genitourinary medicine work load. Home therapies are the sensible way forward. Even problem cases can be managed successfully. Four difficult cases with successful outcomes are discussed.

Behçet's disease

Behçet's disease (BD) is a chronic, relapsing multisystem vasculitis with predominant involvement of the oral and genital mucosa. It has a worldwide distribution, but the prevalence is highest in Central Asia and the Far East (along the ancient 'Silk Route'). Genetic, environmental, immunological and haemostatic factors play a role in the aetiopathogenesis. The International Study Group for BD proposed criteria for the diagnosis of this condition, the essential feature being recurrent oral ulceration. Genital ulcers and skin manifestations are common, while ocular changes are the most important cause of morbidity. Almost any organ in the body can be involved, and systemic involvement may portend a poorer prognosis. There is no pathognomonic test for BD and the diagnosis is made on clinical findings. Treatment of BD would require multidisciplinary cooperation, and early referral to an ophthalmologist is advisable to prevent ocular morbidity. Topical and systemic agents (colchicine, dapsone and thalidomide) are useful in controlling exacerbation of the oral and genital ulcers. Severe disease may require immunosuppressive agents and, more recently, biological agents have been used successfully. It tends to follow an unpredictable course, and the eventual prognosis depends on the systemic involvement.

Use of an aggregate exposure model to estimate consumer exposure to fragrance ingredients in personal care and cosmetic products

Ensuring the toxicological safety of fragrance ingredients used in personal care and cosmetic products is essential in product development and design, as well as in the regulatory compliance of the products. This requires an accurate estimation of consumer exposure which, in turn, requires an understanding of consumer habits and use of products. Where ingredients are used in multiple product types, it is important to take account of aggregate exposure in consumers using these products. This publication investigates the use of a newly developed probabilistic model, the Creme RIFM model, to estimate aggregate exposure to fragrance ingredients using the example of 2-phenylethanol (PEA). The output shown demonstrates the utility of the model in determining systemic and dermal exposure to fragrances from individual products, and aggregate exposure. The model provides valuable information not only for risk assessment, but also for risk management. It should be noted that data on the concentrations of PEA in products used in this article were obtained from limited sources and not the standard, industry wide surveys typically employed by the fragrance industry and are thus presented here to illustrate the output and utility of the newly developed model. They should not be considered an accurate representation of actual exposure to PEA.

2015 UK National Guideline on the management of non-gonococcal urethritis

We present the updated British Association for Sexual Health and HIV guideline for the management of non-gonococcal urethritis in men. This document includes a review of the current literature on its aetiology, diagnosis and management. In particular it highlights the emerging evidence that azithromycin 1 g may result in the development of antimicrobial resistance in Mycoplasma genitalium and that neither azithromycin 1 g nor doxycycline 100 mg twice daily for seven days achieves a cure rate of >90% for this micro-organism. Evidence-based diagnostic and management strategies for men presenting with symptoms suggestive of urethritis, those confirmed to have non-gonococcal urethritis and those with persistent symptoms following first-line treatment are detailed.

Estimates of dietary exposure to bisphenol A (BPA) from light metal packaging using food consumption and packaging usage data: a refined deterministic approach and a fully probabilistic (FACET) approach

The FACET tool is a probabilistic model to estimate exposure to chemicals in foodstuffs, originating from flavours, additives and food contact materials. This paper demonstrates the use of the FACET tool to estimate exposure to BPA (bisphenol A) from light metal packaging. For exposure to migrants from food packaging, FACET uses industry-supplied data on the occurrence of substances in the packaging, their concentrations and construction of the packaging, which were combined with data from a market research organisation and food consumption data supplied by national database managers. To illustrate the principles, UK packaging data were used together with consumption data from the UK National Diet and Nutrition Survey (NDNS) dietary survey for 19-64 year olds for a refined deterministic verification. The UK data were chosen mainly because the consumption surveys are detailed, data for UK packaging at a detailed level were available and, arguably, the UK population is composed of high consumers of packaged foodstuffs. Exposures were run for each food category that could give rise to BPA from light metal packaging. Consumer loyalty to a particular type of packaging, commonly referred to as packaging loyalty, was set. The BPA extraction levels used for the 15 types of coating chemistries that could release BPA were in the range of 0.00005-0.012 mg dm(-2). The estimates of exposure to BPA using FACET for the total diet were 0.0098 (mean) and 0.0466 (97.5th percentile) mg/person/day, corresponding to 0.00013 (mean) and 0.00059 (97.5th percentile) mg kg(-1) body weight day(-1) for consumers of foods packed in light metal packaging. This is well below the current EFSA (and other recognised bodies) TDI of 0.05 mg kg(-1) body weight day(-1). These probabilistic estimates were compared with estimates using a refined deterministic approach drawing on the same input data. The results from FACET for the mean, 95th and 97.5th percentile exposures to BPA lay between the lowest and the highest estimates from the refined deterministic calculations. Since this should be the case, for a fully probabilistic compared with a deterministic approach, it is concluded that the FACET tool has been verified in this example. A recent EFSA draft opinion on exposure to BPA from different sources showed that canned foods were a major contributor and compared results from various models, including those from FACET. The results from FACET were overall conservative.

The cost of managing genital warts in the UK

The national cost of managing genital warts (GWs) in the UK has not been fully estimated, yet is required to inform decisions on vaccination against human papillomavirus. This study estimated the 2010 UK costs based on secondary genitourinary (GU) medicine clinic data from the Health Protection Agency (HPA) and primary care data from the Health Improvement Network database. Extrapolating data to 2010 resulted in 173,077 GU medicine clinic and 16,782 primary care GW episodes. Using treatment patterns obtained from key opinion leaders and tariffs from National Health Service Payment by Results (NHS PbR), the national costs were estimated at £52.4 million: £276 per treated GW episode.

Imiquimod use in adolescents: off-label but effective

Genital warts are very common in the under-18 years old population, yet treatment with imiquimod is currently off-label. We looked at 50 cases of genital warts in patients aged under 18 years who had been treated with Imiquimod to see if this treatment was effective, and it was.

Use of Telephonetics RESULTS computer-facilitated telephone system with automatic results upload

Our genitourinary medicine service implemented an automated telephone results system in 2010. This system is used in other services but few are able to upload negative results automatically from laboratory software. The use of this system reduced unanswered calls to a telephone results line and also the number of calls that had to be connected to clinical staff. Patients have better access to their results in a timely manner, as per the requirements of the recent Standards for the Management of Sexually Transmitted Infections document.