A Digitally Enabled, Pharmacist service to detecT medicine harms in residential aged care (nursing home) (ADEPT): protocol for a feasibility study

INTRODUCTION

This feasibility study aims to develop and test a new model of practice in Australia using digital technologies to enable pharmacists to monitor early signs and symptoms of medicine-induced harms in residential aged care.

METHODS AND ANALYSIS

Thirty residents will be recruited from an aged care facility in South Australia. The study will be conducted in two phases. In phase I, the study team will work with aged care software providers and developers of digital technologies (a wearable activity tracker and a sleep tracking sensor) to gather physical activity and sleep data, as well as medication and clinical data from the electronic medication management system and aged care clinical software. Data will be centralised into a cloud-based monitoring platform (TeleClinical Care (TCC)). The TCC will be used to create dashboards that will include longitudinal visualisations of changes in residents' health, function and medicine use over time. In phase II, the on-site pharmacist will use the centralised TCC platform to monitor each resident's medicine, clinical, physical activity and sleep data to identify signs of medicine-induced harms over a 12-week period.A mixed methods process evaluation applying the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework will be used to assess the feasibility of the service. Outcome measures include service reach, changes in resident symptom scores (measured using the Edmonton Symptom Assessment System), number of medication adverse events detected, changes in physical activity and sleep, number of pharmacist recommendations provided, cost analysis and proportion of all pharmacists' recommendations implemented at 4-week, 8-week and 12-week postbaseline period.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the University of South Australia's Human Research Ethics Committee (205098). Findings will be disseminated through published manuscripts, conference presentations and reporting to the study funder.

TRIAL REGISTRATION NUMBER

ACTRN12623000506695.

Chronic actinic dermatitis associated with human immunodeficiency virus infection

Chronic actinic dermatitis is a photodistributed, eczematous dermatitis that preferentially affects elderly men and persists for months to years. Its occurrence in individuals infected with human immunodeficiency virus (HIV) has been described in five patients. We report four additional cases of this uncommon, chronic photodermatosis associated with HIV infection. In two of the patients, photosensitivity was a presenting disorder leading to the diagnosis of HIV infection. All patients were men of skin type VI with a mean age of 50 years, all had decreased minimal erythema doses to ultraviolet B, three of the four patients had decreased minimal erythema doses to ultraviolet A and all had CD4 cell counts of < 200 x 10(6)/L.

UVB phototherapy is an effective treatment for pruritus in patients infected with HIV

BACKGROUND

Pruritus in patients positive for HIV may be debilitating.

OBJECTIVE

Our purpose was to evaluate the efficacy of UVB therapy in the treatment of pruritus in patients positive for HIV.

METHODS

Twenty-one male HIV-positive patients with intractable pruritus (14 with eosinophilic folliculitis and 7 with primary pruritus) were treated three times weekly with UVB phototherapy. Pruritus was quantified with use of a subjective score of 0 (none) to 10 (severe).

RESULTS

Mean CD4 counts at the initiation of therapy were 91.0 +/- 31.9 cells/microliter. Pruritus scores before and after treatment were 8.6 +/- 0.4 and 2.2 +/- 0.5, respectively (p < 0.001). The mean number of treatments to achieve maximal improvement was 20.7 +/- 2.3, with a cumulative UVB dose of 3399.1 +/- 597.4 mJ/cm2. No significant difference was found between the group with eosinophilic folliculitis and the group with primary pruritus.

CONCLUSION

UVB phototherapy can produce significant relief of pruritus and improvement in the quality of life in patients positive for HIV.

Chronic actinic dermatitis. An immunohistochemical study of its T-cell antigenic profile, with comparison to cutaneous T-cell lymphoma

Chronic actinic dermatitis (CAD) describes a persistent photosensitivity disorder in the absence of continued exposure to photosensitizers; it is characterized by a T-cell infiltrate within the epidermis and dermis. The purpose of this study was to characterize the T-cell infiltrate better immunohistochemically. Serial cryostat sections of fresh-frozen punch biopsy specimens of skin were analyzed in 11 patients with CAD and 3 patients with erythrodermic cutaneous T-cell lymphoma (CTCL). Monoclonal antibodies against the pan T-cell, pan B-cell, and T-cell subsets and the T cell-receptor (TCR) antigens were used. CD8-positive (T-suppressor-cytotoxic) cells were predominant in the epidermis of CAD, while CD4-positive (T-helper) cells were predominant in the epidermis and dermis of CTCL. CDw29-positive (T-memory) cells were predominant in all cases. The number of BF1 (beta-chain constant region of the TCR)-positive cells approximated the number of CD3-positive cells in all CAD cases but was significantly lower than the number of CD3-positive cells in two of three cases of CTCL. There was no clustering or preferential staining with any of the beta-chain variable-region antibodies in any of the specimens. These results indicate that CAD has a characteristic immunophenotype distinct from that of most cases of CTCL and that discordance between BF1 and CD3 expressions did not occur in the CAD cases.

The safety of UVB phototherapy in patients with HIV infection

BACKGROUND

In patients with psoriasis and human immunodeficiency virus type 1 (HIV-1) infection, therapeutic options may be limited by their potential immunosuppressive effects. UVB radiation can activate HIV-1 gene expression in transgenic mice and in vitro. It is not known whether this viral activation leads to a clinically significant effect or if these findings can be extrapolated to humans.

OBJECTIVE

This study was performed to evaluate the safety of UVB light treatment in HIV-infected persons.

METHODS

We prospectively studied the effect of UVB phototherapy on five HIV-infected patients with psoriasis and one with pruritus. A complete blood cell count with differential count, CD4+ and CD8+ T-lymphocyte counts, serum beta 2-microglobulin and HIV-1 p24 antigen were obtained before UVB phototherapy and after 21 and 42 treatments. After every five treatments patients were evaluated for opportunistic infections, and psoriatic involvement was quantified with the Psoriasis Area and Severity Index (PASI).

RESULTS

Cumulative UVB doses ranged from 3326 to 43,364 mJ/cm2. There were no statistically significant changes in laboratory findings after 21 and 42 treatments. Of three patients without detectable serum levels of HIV-1 p24 antigen before phototherapy, only one became positive after 42 treatments. None of the six subjects had an opportunistic infection or malignancy during phototherapy. The PASI improved in all five patients with psoriasis, and the other patient noticed decreased pruritus.

CONCLUSION

Our results suggest that UVB phototherapy is efficacious in HIV-1-infected patients with UVB-responsive dermatoses and is not associated with short-term changes in immune function.

The porphyrias

The vesiculobullous porphyrias are a group of blistering diseases with systemic as well as cutaneous manifestations ranging from mild to disabling, secondary to endogenous photosensitizing porphyrins. The characteristic patterns of porphyrin accumulation in erythrocytes, plasma, urine, and feces are invaluable for differentiating the vesiculobullous porphyrias from other blistering diseases and from one another. Most importantly, these porphyrin profiles are essential for distinguishing the acute vesiculobullous porphyrias, HCP and VP, from PCT, which is not associated with acute attacks. This distinction may prevent the potentially fatal administration of porphyrinogenic drugs to patients with HCP or VP. Histopathology is not helpful in differentiating the vesiculobullous porphyrias, as all typically show subepidermal bullae. Avoidance of sun exposure and precipitating factors are the initial steps in both the prevention and treatment of these entities. In addition, more specific therapy may be indicated, as discussed in the preceding pages.

Are topical corticosteroids useful adjunctive therapy for the treatment of psoriasis with ultraviolet radiation? A review of the literature

Adjunctive topical corticosteroids are often administered with UV-B phototherapy or oral psoralen plus UV-A (PUVA) photochemotherapy for the treatment of psoriasis. Five studies comparing PUVA alone with PUVA and topical corticosteroid preparations showed more rapid rates of clearing and a smaller total UV-A exposure with the latter regimen. However, one study demonstrated a higher relapse rate in association with corticosteroid use. Further studies to better define these risks are recommended. Six of seven reports evaluating the use of topical corticosteroid preparations with UV-B phototherapy failed to demonstrate an advantage to this regimen when compared with UV-B phototherapy alone. Therefore, the use of a topical corticosteroid preparation with UV-B phototherapy for the treatment of psoriasis is not recommended.

Papaverine hydrochloride in the treatment of atopic dermatitis: a double-blind, placebo-controlled crossover clinical trial to reassess safety and efficacy

In a double-blind crossover study, oral papaverine hydrochloride in doses of 150-300 mg t.i.d. was compared to placebo as an adjunctive treatment of atopic dermatitis. Twenty patients completed both 2-week phases of the crossover during which time the physician's weekly evaluation included an estimate of percentage skin involvement with disease, global evaluation and the grading of the erythema, scale and lichenification of a representative plaque. The patients' evaluation included their assessment of the degree of pruritus, and an estimate of the percentage of the day pruritus was present as well as a global evaluation of disease. Papaverine demonstrated no statistically significant advantage over placebo for any of the parameters measured and was noted to cause transient asymptomatic liver function test abnormalities in 3 of the study patients.

Hypersegmented neutrophils and vitamin B12 deficiency. Hypersegmentation in B12 deficiency

The sensitivities and specificities of the mean cell volume (MCV), the red cell distribution width (RDW), and blood smear hypersegmentation for B12 deficiency were reviewed in 515 patients whose B12 levels were determined. 61 patients had B12 levels less than 200 pg/ml. 43 patients were defined as B12 deficient (n = 13) or non-B12 deficient (n = 30). Hypersegmentation was more sensitive (91%) than MCV greater than 95 fl (62%) or RDW greater than 15% (54%) in detecting B12 deficiency. The MCV and the RDW should not be relied on when screening for B12 deficiency; examination of the blood smear for hypersegmentation is essential.

Red cell distribution width, mean corpuscular volume, and transferrin saturation in the diagnosis of iron deficiency

The usefulness of the red cell distribution width, mean corpuscular volume, and the transferrin saturation in diagnosing iron deficiency anemia were evaluated in a retrospective study of 247 anemic hospitalized patients, many of whom had chronic liver disease. A red cell distribution width greater than 15% had a sensitivity of 71% and a specificity of 54% for iron deficiency as diagnosed by a low serum ferritin or bone marrow examination. A mean corpuscular volume less than 80 femtoliters had a sensitivity of 53% and a specificity of 84%. Transferrin saturation less than 16% had a sensitivity of 61% and a specificity of 86%. Because the sensitivities and specificities of these tests are less than reported in studies of healthier populations, they cannot be relied on for screening for iron deficiency in sick hospitalized patients.