Advancing the social return on investment framework to capture the social value of public health interventions: semistructured interviews and a review of scoping reviews

OBJECTIVES

Investment in public health has far-reaching impacts, not only on physical health but also on communities, economies and the environment. There is increasing demand to account for the wider impact of public health and the social value that can be created, which can be captured through the use of the social return on investment (SROI) framework. This study aims to explore the application of SROI and identify areas of advancement for its use in public health.

STUDY DESIGN AND METHODS

Publically available SROI studies of public health interventions previously identified through published systematic scoping reviews were examined through a methodological lens. This was complemented by semistructured interviews with key public health academic experts with experience in the field of SROI. The results were thematically analysed and triangulated.

RESULTS

In total, 53 studies and nine interviews were included in the analysis. All interviewees agreed that SROI is a suitable framework to demonstrate the social value of public health interventions. Developmental aspects were also identified through the analysis. This included a more systematic use of SROI principles and methodological developments. Lastly, it was identified that further advancements were needed to promote awareness of SROI and how it can be used to generate investment.

CONCLUSION

By identifying key areas for advancement, the results from this study can be used to further refine the SROI framework for use within the speciality to promote investment in services and interventions that demonstrate maximum value to people, communities, economies and the environment.

Presenting a Social Value Database and Simulator for Public Health

Background

There is increasing recognition that Public Health Institutes need to build on the traditional value for money approach, to find ways to capture, measure and show the full range of their outcomes, impacts and related value. As part of a drive to measure value and impact in public health and demonstrate how investment in health can contribute to an Economy of Well-being, Public Health Wales has developed an interactive database to capture and illustrate the social value of public health services and interventions.

Methods

Scoping reviews of both academic and grey literature were undertaken to populate a database of health economics evaluations of public health interventions, focusing on Social Return on Investment (SROI). In addition, a simulated methodology was developed which allows the evidence to be manipulated and made relevant to individual contexts to help inform investment decisions at a local level.

Results

To date, the database has accumulated an excess of 50 SROI evaluations of various public health interventions, across areas including mental health, behaviour change, physical activity, nutrition, employment and primary care. The evaluations are based on European and International contexts, are published in both grey and academic sources, and are of varying quality.

Conclusions

SROI is a credible method for measuring the value of wider social, economic and environment outcomes achieved from public health interventions. The Social Value Database and Simulator presents a collation of studies and analysis utilising innovative health economics methods.

Key messages

• Public Health Wales’ Social Value Database and Simulator collates economic evaluations of public health interventions, to be used by policy makers to enable improved investment in health and well-being.

• Social Return on Investment is a credible method for measuring the wider impact created by public health interventions.

P-203 Searching for the optimal timing of intracytoplasmic sperm injection post oocyte retrieval: a systematic review and meta-analysis

Study question

What is the optimal time post oocyte retrieval (POR) to undertake intracytoplasmic sperm injection (ICSI) in order to maximise subsequent pregnancy and live birth outcomes?

Summary answer

Delaying ICSI for 5 hours or more POR may compromise subsequent clinical pregnancy and live birth rates.

What is known already

It is often challenging to perform ICSI at a set timing POR, especially in ART clinics with a heavy workload. However, the degree of flexibility in ICSI timing remains unclear in the literature. Some articles have reported detrimental impacts by delaying ICSI on the subsequent treatment outcomes (Pujol et al 2018), while others reported no evidence of adverse effects caused by different ICSI timings (Vandenberghe et al 2021). Therefore, we aimed to explore a “safety time window” for ICSI procedures to enable flexibility in workflow arrangement without compromising pregnancy outcomes.

Study design, size, duration

A systematic review and meta-analysis were performed according to PRISMA guidelines, with protocol registered with PROSPERO (ID: CRD42022296838). The studies were searched for in PubMed, MEDLINE, EMBASE and the Cochrane Library on 16 December 2021, using (“subfertile” OR “sub-fertile” OR “infert*” OR “fertility treatment” OR “women” OR “female” OR “couple”) AND (“ICSI” OR “intracytoplasmic sperm injection” OR “intra-cytoplasmic sperm injection”) AND (“timing” OR “time interval”) AND (“pregnancy” OR “fertili*” OR “birth”) NOT (Review [Publication Type]).

Participants/materials, setting, methods

Two independent reviewers systematically evaluated each study on patient, intervention, comparison, and outcome (PICO). The Newcastle-Ottawa scale was used for risk of bias assessment in non-randomised trials and observational studies. Further screening was performed separately by the two independent reviewers, with differences mediated by the third reviewer. Data extraction was performed according to Cochrane methods. Clinical pregnancy or live birth data were synthesised from eligible studies depending on availability of raw data in corresponding subgroups.

Main results and the role of chance

A total of 605 records were hit in the search. After initial exclusion according to PICO, 30 articles were included for further screening for eligibility. For meta-analysis, 4 retrospective cohort studies were eventually included for clinical pregnancy rate assessment while 2 for live birth rate analysis. Due to different groupings in ICSI timing amongst these studies, a series of comparisons on ICSI timings with a cut-off at an hourly increment were set up to pool data from the 4 included studies where applicable. Clinical pregnancy rates were comparable when ICSI was performed (a) 2+ hours (n = 6448, Relative Risk or RR = 1.031, 95% CI 0.964-1.102) in reference to < 2 hours POR (n = 2336), (b) 3+ hours (n = 5101, RR = 1.005, 95% CI 0.945-1.069) in reference to < 3 hours POR (n = 3465), and (c) 4+ hours (n = 3192, RR = 1.017, 95% CI 0.956-1.082) in reference to < 4 hours POR (n = 5374). However, clinical pregnancy rates were significantly compromised when ICSI was performed at 5+ hours (n = 2335, RR = 1.103, 95% CI 1.036-1.175) in reference to < 5 hours POR (n = 7169). Similarly, live birth rate was also significantly reduced when ICSI was performed 5+ hours (n = 2335, RR = 1.155, 95% CI 1.070-1.246) in reference to < 5 hours POR (n = 7169).

Limitations, reasons for caution

All studies included for meta-analysis were retrospective with heterogeneity. There were various groupings amongst studies due to the wide range of ICSI timings POR, which limits data pooling and subsequent comparisons. A future well designed randomised controlled trial is warranted for further analysis based on better quality evidence.

Wider implications of the findings

Our results indicate 5 hours POR should be considered the maximum time limit to perform ICSI. This finding, supported by statistics with improved power through meta-analysis, offers valuable guidance to busy clinics. This information could both improve pregnancy outcomes and allow better workflow arrangements without compromising them.

Trial registration number

not applicable

Maximising Social Value and Health Impact – what is the role of PHIs?

Issue

Public health Institutes (PHIs) need to build on traditional approaches to capture and measure their value and impact. As we transfer into the COVID-19 recovery phase, it is important to maximise the value of the health impact but also the social, economic and environmental impact of PHIs. Exploration is required to understand how the social value and impact of PHIs is, or can be, captured and measured. Existing research has illustrated the potential link between Health Impact Assessment (HIA) which assesses health and well-being through the lens of the determinants of health, and economic methods such as Social Return on Investment (SROI). This research aims to understand the current role which PHIs have, in order to strengthen advocacy for investment in public health and prevention in order to protect and improve population health.

Description of the problem

A scoping survey was designed and distributed digitally to national and regional PHIs via international networks. Semi-structured interviews were also used to add a qualitative value to the research to allow for triangulation of results. The survey data was analysed descriptively and interview data analysed thematically and coded.

Results

The results of the research present an understanding of the meaning of investment, social value and health impact within PHIs including how it is measured using SROI and HIA. It also highlights whether PHIs have considered how capturing social value and health impact can contribute to the recovery from COVID-19, and whether they believe that SROI and HIA have a role in achieving this.

Lessons

This innovative work aims to develop a picture of how PHIs are capturing and measuring the wider social, economic and environmental value of their programmes and services. Survey results will be used to help develop a framework for capturing the wider impact and value of public health at an international level, with an aim to achieving sustainable investment in future public health.

Key messages

Making the case for investing in public health by illustrating its social, economic and environmental value is vital.

Understanding how to capture and measure the wider value of public health is imperative to aid the recovery from COVID-19.

The Health and wellbeing impacts of Home and agile working in Wales: A HIA Approach

The SARS-COV-02 pandemic has globally resulted in a number of policies and interventions to address and reduce the transmission of the disease throughout the population. Mitigation measures have ranged from ‘Staying at Home' or ‘Lockdowns' to social distancing policies and requirements to work from home when you can. Whilst there are a number of papers which discuss the effects of home or remote working on employees and their families the large scale shift, accelerated pace and wider impacts of such a shift has not been well explored in the literature or has been focussed on specific topics, for example, productivity. HIA is promoted as a beneficial tool to identify the wider impacts of a policy, plan or intervention across a population and as such is well placed to examine and articulate who in a population may be affected and how, and the inequalities that may be created by an intervention such as home working. Using the lens of social determinants and equity focussed-HIA, this work examines the wider impact of home working in Wales during the COVID-19 pandemic. It provides a coherent overview of the major impacts on health and the particular populations affected. It articulates the process followed, the key evidence based findings, discusses the gaps in the evidence base that require further exploration and the impact and influence it has had to date. Finally, it shares the transferable learning, which will be of use to researchers, policy and decision makers, organisations and public health agencies.

Adding value to the use of Health Impact Assessment and social return on investment technologies

Health Impact Assessment (HIA) and Social Return on Investment (SROI) are beneficial public health methodologies that assess potential effects on health including social, economic and environmental factors and have synergies in their approaches. This paper explores how HIA and SROI can complement each other to capture and account for the impact and social value of an assessed intervention or policy.

A scoping review of academic and grey literature was undertaken to identify case studies published between January 1996 and April 2019 where HIA and SROI methods have been used to complement each other. Semi-structured interviews were carried out with nine international experts from a range of regulatory/legislative contexts to gain a better understanding of past experiences and expertise of both HIA and SROI. A thematic analysis was undertaken on the data collected. The review identified two published reports which outline when HIA and SROI have both been used to assess the same intervention. Interview results suggest that both methods have strengths as standalone processes i.e. HIAs are well-structured in their approach, assessing health in its broadest context and SROI can add value by monetizing social value as well as capturing social/environmental impact. Similarities of the two methods were identified i.e. a strong emphasis on stakeholder engagement and common shared principles. When questioned how the two methods could complement each other in practice, the results indicate the benefits of using HIA to explore initial impact, and as a platform on which to build SROI to monetarize social value.

HIA and SROI methodologies have cross-over. The research suggests potential benefits when used in tandem or combining the methods to assess impact and account for health and social value. Innovative work is now being carried out in Wales to understand the implications of this in practice and to understand how the results of the two methods could be used by decision-makers.

Key messages

HIA and SROI methods can be used in tandem to capture both the health impact and social value of policies and proposed interventions. HIA and SROI when used together can provide valuable information to inform decision makers around the health impact and social value of proposed policies and interventions.

A practical guide to make the case for sustainable investment in well-being and health

Key messages

Investing in well-being and health equity drives and enables sustainable development. Making the case for investment in health equity requires a well-planned, evidence-informed approach.

Capturing the social value and return on investment of public health services and interventions

Key messages

Making the case for investing in public health by illustrating its social, economic and environmental value is vital. Social Return on Investment is an innovative and useful method to estimate the wider value of public health interventions.

The social and economic benefit of health literacy interventions in the WHO EURO region

Background

Health literacy (HL) allows people to make informed decisions regarding their health, enabling them to understand health promotion activities and to self-manage their disease or complication without requiring support from healthcare services. HL has the potential to support sustainability in health systems by decreasing healthcare spendings stemming from lowered disease occurrence and progression, it can also impact on the rest of peoples’ lives and their surroundings by allowing them to be more independent. This study researched the evidence for return on investment and the social return on investment for health literacy interventions within the WHO EURO region.

Methods

A narrative literature review on published peer-reviewed reviews and grey literature was conducted by use of keywords and MeSH terms. Google, Google Scholar and PubMed were used find literature. The search on PubMed was restricted to reviews, published within the last 10 years (2009-2019), in English.

Results

In total, 450 publications were screened 12 publications that analysed the economic or social aspect of HL interventions were identified. Five discussed the cost-effectiveness of health literacy, three the return on investment (ROI) and the remaining three the social return on investment (SROI) of HL. Types of HL interventions ranged from health promotion campaigns, web-based HL programs, prevention systems to education-based interventions. Cost-effectiveness differed between studies and fields. Evidence for ROI was found, the return ratios ranged from 0.62 to 27.4. Findings show SROI between 4.41 and 7.25, indicating additional value of social benefit next to improved health.

Conclusions

A link between cost-effectiveness and HL interventions was established and ROI and SROI showed positive ratios. Further research is required in order to investigate whether HL interventions consistently achieve a positive returns.

Key messages

A link between health literacy interventions and positive investment returns has been established. Health literacy interventions show potential for sustainable development of health systems.

Step-by-step process of making the case for sustainable investment in wellbeing and health equity

Issue

Urgent action is needed to address the growing health, inequity, economic and planetary challenges that threaten the wellbeing of present and future generations. Business as usual has proven unsustainable with high human, social, economic and environmental costs. Coordinated policy action on the determinants of health combined with well-designed and implemented governance and innovative investment approaches can have a dual effect: a) reducing the health gap; and b) improving overall population health.

Description

The WHO Collaborating Centre on Investment for Health and Wellbeing has developed a practical step-by-step guide, outlining the process of how to synthesise, translate and communicate public health and economics evidence into policy and practice, in order to make the case for investment in wellbeing and health equity. It aims to: 1) prevent disinvestment in health; 2) increase investment in prevention / public health; and 3) mainstream cross-sector investment to address the wider determinants of health and equity, driving prosperity for all.

Building on the Knowledge-to-Action framework and an extensive international multi-disciplinary consultation, four key phases are described: 1) Project scoping and planning; 2) Evidence gathering, synthesis and design; 3) Dissemination and communication; and 4) Monitoring and evaluation. Key messages, different products and a number of practical tools and tips are highlighted. An essential element is using health economics approaches and tools to build the case, showing the burden of inaction in parallel with available sustainable solutions, which can bring ‘social return on investment’.

Results/Lessons

The result of the above-described process is the development of evidence-informed, context-tailored advocacy documents and tools, enabling healthy policy- and decision-making across different sectors, levels of government and country settings.

Abstract P2-03-04: Application of digital-PCR technology to determine c-MET copy number variation in paired primary breast cancer and brain metastases

INTRODUCTION:

c-MET amplification/overexpression has been associated with treatment failure and progression in many cancers, including breast cancer (BC). c-MET showed amplification by fluorescent in situ hybridization (FISH) in 27% of trastuzumab-treated HER2-positive patients. These patients had a high trastuzumab failure rate and a shorter time to progression. Up to 50% of patients with metastatic HER2-positive disease will develop brain metastases (BM) during their disease course and in approximately one third, brain is the first site of progression. Amplification/copy number variations (CNVs) are mainly assessed by FISH whereas overexpression is assessed by immunohistochemistry (IHC). We present a PCR-based assay (digital-PCR) able to determine CNV in c-MET and HER2 in a cohort of patients with metastatic BC to the brain and demonstrate the correlation of CNV to protein expression.

METHODS:

DNA was isolated from paraffin-embedded tissues of 23 paired primary BC-BM cases. CNV was analysed by the QuantStudioTM 3D-Digital-PCR (QS3D) and real-time qPCR (both from ThermoFisher Scientific). The breast MCF7, T47D, BT474, AU565, SKBR3 and the gastric MKN45 cell lines were used as controls for the HER2 and c-MET CNV assays. Copy number per diploid genome was calculated using the absolute quantification number of FAM-labelled target and VIC-labelled RNaseP reference multiplied by 2. Cases with ≤2 copies are classified as normal whereas cases with >2 were classified as amplified. The HER2 positivity of the primary BC cases was routinely assessed by IHC. The c-MET protein expression was assessed by IHC using the c-MET(3D4) monoclonal antibody (ThermoFisher Scientific).

RESULTS:

CNV in c-MET by QS3D digital-PCR was detected in 69.6% of primary BC (ER-/HER2+:2, ER+/HER2+:5, ER+/HER2-:8, Triple-negatives:5, unknown:3) as well as 69.6% of BM, whereas HER2 CNV was observed in 39.1% primary BC and 52.2% BM. In the HER2-positive cases, the prevalence of HER2 CNV was 100% in both primary BC and BM. Within these cases, c-MET CNV was 85.7% in the primary BC and 71.43% in BM. CNVs in both genes were observed in 30.4 % of all primary and 39.1% of BM. The CNV data are presented in Table 1.

CNV data for c-MET and HER2 between primary breast cancer (BC) and corresponding brain metastatic (BM) casesc-MET CNVHER2 CNVBCBMBCBM>2: 16>2: 12≤2: 4>2: 9>2: 8≤2: 1≤2: 7>2: 4≤2: 3≤2: 14>2: 4≤2: 10

There was a high concordance between the QS3D and qPCR data with Pearson's R=0.74 (p<0.00001).

A significant correlation between HER2 protein expression and CNV was observed (Fisher's exact test p=0.0005). Data will be presented on c-MET protein expression in the pair samples.

CONCLUSIONS:

The prevalence of CNV is much higher than that reported by immunohistochemistry and FISH in the literature to date, possibly due to the sensitivity of the digital-PCR technology. The high level of c-MET CNV in primary and metastatic BC, and the concurrent CNV in both genes warrants further investigation. It also highlights the potential to use c-MET directed therapy particularly in HER2+ BC and reinforces the potential importance of precise detection methods in both the primary and metastatic setting. Analysis of a larger series is currently on-going.

Citation Format: Giannoudis A, Zakaria R, Platt-Higgins A, Syed KAR, Ashton K, Dawson T, Rudland PS, Holcombe C, Jenkinson MD, Palmieri C. Application of digital-PCR technology to determine c-MET copy number variation in paired primary breast cancer and brain metastases [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-03-04.

Relative contribution of modifiable versus non-modifiable factors as predictors of racial variance in roux-en-Y gastric bypass weight loss outcomes

African-Americans have been shown to have poorer weight loss outcomes after bariatric surgery, and many reasons for such outcomes have been postulated, including metabolic and genetic differences, socioeconomic factors, and differences in culture. African-Americans have also been noted to have differences from the majority population in other psychosocial correlates to weight loss outcomes. However, the relative contribution of targetable factors in relation to non-modifiable factors to such outcomes remains unclear. African-American and Caucasian patients who had received a Roux-en-Y gastric bypass and returned for a 12-month follow up appointment (n = 415) were selected for retrospective analysis. A stepwise hierarchical regression of 12 month percent excess weight loss (% EWL) was conducted that included race after controlling for psychosocial and demographic factors previously linked to postsurgical outcomes. These variables were then compared between racial groups using independent t tests and chi-square analyses. Race remained a significant predictor of % EWL after controlling for pertinent psychosocial and demographic variables. Age and preoperative BMI were significant negative predictors, whereas presurgical BMI loss and Caucasian race were positive (p < 0.05). Percentage of follow-up appointment attendance was borderline significant. No significant racial differences were noted in these variables. Non-modifiable factors inherent to race such as metabolism play small but significant roles in the postoperative weight loss in African-American patients. Further research is needed to better elucidate the roles of targetable factors in outcomes, particularly adherence and pay status as their evaluation in this study was limited.

Axillary meristems and the development of epicormic buds in wollemi pine (Wollemia nobilis)

Intact trees of Wollemia nobilis Jones, Hill and Allen (Araucariaceae) routinely develop multiple coppice shoots as well as orthotropic epicormic shoots that become replacement or additional leaders. As these are unusual architectural features for the Araucariaceae, an investigation was made of the axillary meristems of the main stem and their role in the production of epicormic and possibly coppice shoots. Leaf axils, excised from the apex to the base of 2-m-high W. nobilis plants (seedling origin, ex situ grown), were examined anatomically. Small, endogenous, undifferentiated (no leaf primordia, no vascular or provascular connections) meristems were found in the axils from near the shoot apex. In the more proximal positions about half the meristems sampled did not differentiate further, but became tangentially elongated to compensate for increases in stem diameter. In the remaining axils the meristems slowly developed into bud primordia, although these buds usually developed few leaf primordia and their apical 'domes' were wide and flat. Associated vascular development was generally restricted to provascular dedifferentiation of the cortical parenchyma, with the procambium usually forming a 'closed loop' that did not extend back to the secondary vascular tissues. Development of the meristems was very uneven with adjacent axils often at widely differing stages of development into buds. The study shows that, unlike most conifers, W. nobilis possesses long-lived meristematic potential in most, if not all, leaf axils. Unlike other araucarias that have been investigated, many of the meristems in the orthotropic main stem will slowly develop into bud primordia beneath the bark in intact plants. It appears likely that this slow but continued development provides a ready source of additional or replacement leaders and thus new branches and leaves.

Quantitative trait loci for the monoamine-related traits heart rate and headless behavior in Drosophila melanogaster

Drosophila melanogaster appears to be well suited as a model organism for quantitative pharmacogenetic analysis. A genome-wide deficiency screen for haploinsufficient effects on prepupal heart rate identified nine regions of the genome that significantly reduce (five deficiencies) or increase (four deficiencies) heart rate across a range of genetic backgrounds. Candidate genes include several neurotransmitter receptor loci, particularly monoamine receptors, consistent with results of prior pharmacological manipulations of heart rate, as well as genes associated with paralytic phenotypes. Significant genetic variation is also shown to exist for a suite of four autonomic behaviors that are exhibited spontaneously upon decapitation, namely, grooming, grasping, righting, and quivering. Overall activity levels are increased by application of particular concentrations of the drugs octopamine and nicotine, but due to high environmental variance both within and among replicate vials, the significance of genetic variation among wild-type lines for response to the drugs is difficult to establish. An interval mapping design was also used to map two or three QTL for each behavioral trait in a set of recombinant inbred lines derived from the laboratory stocks Oregon-R and 2b.

Time-dependent disposition of tacrolimus and its effect on endothelin-1 in liver allograft recipients

STUDY OBJECTIVE

To characterize a time-dependent disposition of oral tacrolimus and its relationship with plasma endothelin-1 concentrations.

DESIGN

Randomized, crossover study.

SETTING

Clinical research center of a university-affiliated hospital.

PATIENTS

Twelve stable liver transplant recipients.

INTERVENTIONS

In the steady state, 23 blood samples were taken from each patient before and after tacrolimus administration over 24 hours.

MEASUREMENTS AND MAIN RESULTS

Whole blood samples for tacrolimus and plasma endothelin-1 were analyzed by enzyme immunoassay. The relationship of their concentrations and their pharmacokinetic parameters between morning and evening doses were compared. The area under the curve (AUC) of tacrolimus in the morning dose was significantly larger than that in the evening dose (219 +/- 54 ng.hr/ml and 188 +/- 57 ng.hr/ml, respectively, p = 0.004). The mean time to peak concentration (Tmax) was significantly shorter for the morning dose than for the evening dose (1.6 +/- 0.7 hrs and 3.5 +/- 2.9 hrs, respectively, p = 0.01). The mean peak concentration (Cmax) was significantly higher in the morning dose than in the evening dose (32.2 +/- 9.1 ng/ml and 21.6 +/- 8.3 ng/ml, respectively, p = 0.008). However, the mean through concentration (Cmin) was not significantly different between doses. Endothelin-1 concentrations followed the same pattern as tacrolimus, with AUC and Cmax for the morning significantly higher than those for the evening dose of tacrolimus (AUC 13.8 +/- 3.7 pg.hr/ml, morning, and 11.0 +/- 3.5 pg.hr/ml, evening, p = 0.005; Cmax 2.4 +/- 1.1 pg/ml morning, and 1.5 +/- 0.6 pg/ml evening, p = 0.02). Tacrolimus levels did not correlate with endothelin-1 levels (r2 = 0.06, p = 0.001).

CONCLUSIONS

Tacrolimus disposition in liver transplant patients is determined by time of administration. Plasma endothelin-1 concentrations follow the same pattern as blood tacrolimus concentrations.

Effect of grapefruit juice on cyclosporine pharmacokinetics in renal transplant patients

This study investigated the effect of grapefruit juice on cyclosporine A (CsA) bioavailability in 10 renal transplant patients. Under CsA steady state conditions, patients were randomly administered their usual dose of CsA with either 8 ounces of grapefruit juice or 8 ounces of water. Using a crossover design, a 12-hr pharmacokinetic study was then conducted. Grapefruit juice increased the area under the concentration versus time curve (4218+/-1497 ng x hr/ml [grapefruit juice] vs. 3415+/-1288 ng x hr/ml [water], P=0.029) and 12-hr trough (244+/-214 ng x ml [grapefruit juice] vs. 132+/-56 ng x ml [water], P=0.09), but it did not change peak concentration (734+/-290 ng x ml [grapefruit juice] vs. 708+/-305 ng x ml [water], P=0.76). In addition, grapefruit juice delayed the time to peak concentration compared with water (5.4+/-3.0 hr [grapefruit juice] vs. 2.8+/-0.8 hr [water], P=0.025). These data suggest that concurrent administration of grapefruit juice with CsA will delay the absorption of CsA and increase the drug exposure of CsA without changing peak concentration.

Kenneth Ashton links reports of spiralling nurse turnover rates with the continuing clinical grading debacle

I am responding to your news article (Nursing Standard October 9) concerning the 'huge cost of replacing NHS nurses'.