The direct costs to the NHS of discontinuing and switching prescriptions for hypertension

There is much evidence to suggest that the treatment of hypertension reduces the risk of cardiovascular diseases and that it is cost-effective in most patients. However, the effectiveness of treatment relies on compliance and maintenance of treatment. Each pharmacological agent differs in terms of side effects. The existence of side effects can result in poor compliance and switching between treatments. A number of studies have reported high discontinuation rates for anti-hypertensive therapies. This potentially imposes costs on the health service. The aim of this study is to use the MEDIPLUS data set to consider the cost arising from switching and discontinuation of therapy. The analysis will assess the resource costs in terms of extra GP visits and hospitalisations arising from individuals switching and discontinuing treatments. The total costs of hypertension were estimated to be around 76.5 m pound sterling per annum, of which 26.9 m pound sterling can be attributed to patients who switch or discontinue therapy.

In-vitro activity of piperacillin/tazobactam relative to other antibiotics against blood culture isolates

Resistance of bacteria to antibiotics is an increasing problem in many countries. Accurate locally relevant information is essential for detection and control of emerging resistance and to facilitate choice of empirical antibiotic therapy in the immediate management of seriously ill patients. We have determined the minimum inhibitory concentration of piperacillin/tazobactam for 97 strains of bacteria (55 Enterobacteriaceae, 13 non-fermentative Gram-negative bacilli, 22 Staphylococcus aureus, 6 Enterococcus faecalis and 1 Bacillus cereus) isolated from blood cultures and compared its activity to that of amoxycillin, co-amoxiclav, cephalothin, cefotaxime, ceftazidime, ciprofloxacin, gentamicin, piperacillin, cefotaxime. The strains were consecutive non-fastidious isolates with the following qualifications: coagulase negative staphylococci and diphtheroids were excluded and the number of Staphylococcus aureus isolates was limited to 12 methicillin-resistant and 10 methicillin-sensitive strains. Multiple isolates of the same species from individual patients were not included. The minimum inhibition concentrations of methicillin, penicillin, teichoplanin and vancomycin were also determined for specific groups of organisms. MICs were determined by the Etest method (AB Biodisk, Solna, Sweden) on Mueller Hinton agar. The MICs of appropriate American Type Culture Collection control strains were determined. Based on the interpretative criteria of the National Committee for Clinical Laboratory Standards (USA), 87 per cent of Gram-negative bacilli were susceptible to piperacillin/tazobactam compared with amoxycillin 26 per cent, cephalothin 35 per cent, co-amoxiclav 54 per cent, piperacillin 56 per cent, cefotaxime 69 per cent, ceftazidime 84 per cent, gentamicin 85 per cent and ciprofloxacin 91 per cent. Of all isolates 75 per cent were sensitive to piperacillin/tazobactam, compared with amoxycillin 22 per cent, cephalothin 35 per cent, piperacillin 41 per cent, co-amoxiclav 52 per cent, cefotaxime 59 per cent, ceftazidime 60 per cent, gentamicin 74 per cent and ciprofloxacin 77 per cent. Two isolates (1 E. coli and 1 Klebsiella pneumoniae) with antibiograms consistent with the relatively new resistance phenomenon of extended spectrum beta-lactamase production were identified. The spectrum of activity of piperacillin-tazobactam for empirical antibiotic therapy is significantly greater than that of piperacillin alone and is similar to that of ciprofloxacin and gentamicin.

Community health monitoring: taking the pulse of America's children

OBJECTIVE

To describe the development, content, enablers/barriers, and impact of child health reports in nine communities participating in the Robert Wood Johnson Foundation funded Child Health Initiative (1991-1996).

METHODS

A qualitative, prospective, multiyear, longitudinal evaluation using a multiple case-study methodology. Three waves of structured in-person and telephone interviews of the project staff, community leaders, and key participants tracked the development of child health reports in all nine communities. A mailed survey of project directors was administered to assess accomplishments at the completion of the project. Content analysis of each community health report was conducted using different conceptual frameworks for health measurement and reporting.

RESULTS

All communities succeeded in creating a report that contained a broad set of outcome indicators reflecting children's health and well-being. The process of creating these reports, their content, level of analysis, presentation formats, and dissemination varied across sites based on available resources, data and analysis capacity, and other political considerations. While commonly accepted outcome measures were used in most reports (e.g., infant mortality, teen births, immunization rates), process indicators, important for quality monitoring and community health improvement, were notably lacking. In each community the reports were credited with providing a more comprehensive and integrated view of the health needs of children.

CONCLUSIONS

Additional conceptual and technical work is needed to improve the ability of community health reports to capture key indicators of interest. Community reports can serve an important role in building the consensus needed to create program and policy changes. Community reports may have additional utility in monitoring the impact of health systems change on population health. Community reports can also facilitate a shared learning process for the participants and the community, and can be a useful tool to advance a children's health policy agenda.

Using bioscience knowledge in nursing: actions, interactions and reactions

This paper draws on empirical data from a study undertaken to explore the outcomes of the applied physiology component of a post-registration diploma in nursing (DN). Most students completing the DN were utilizing their new bioscience knowledge in clinical practice, and reported increased participation in interprofessional discussions and team decisions. Respondents found themselves better able to monitor and evaluate doctors' decisions and this led to friction with some medical colleagues. However, the strongest resistance came from senior nurses, very few of whom had completed advanced nursing courses in bioscience and who were generally unwilling to allow respondents to develop new roles. General managers were also perceived as a major barrier to change. There is little evidence of tangible benefits to the nurses themselves: most saw the DN qualification as a way of protecting their status as professional nurses in the face of managerially driven organizational change, rather than as a route to occupational advancement.

Virulence of antibiotic-resistant Salmonella typhimurium

We show that most Salmonella typhimurium mutants resistant to streptomycin, rifampicin, and nalidixic acid are avirulent in mice. Of seven resistant mutants examined, six were avirulent and one was similar to the wild type in competition experiments in mice. The avirulent-resistant mutants rapidly accumulated various types of compensatory mutations that restored virulence without concomitant loss of resistance. Such second-site compensatory mutations were more common then reversion to the sensitive wild type. We infer from these results that a reduction in the use of antibiotics might not result in the disappearance of the resistant bacteria already present in human and environmental reservoirs. Thus, second-site compensatory mutations could increase the fitness of resistant bacteria and allow them to persist and compete successfully with sensitive strains even in an antibiotic-free environment.

Concentration of ionized calcium in plasma from cats with urethral obstruction

OBJECTIVE

To measure ionized calcium concentration in plasma from cats with urethral obstruction and to correlate these values with results of clinical biochemical analyses and physical examinations.

DESIGN

Prospective study.

ANIMALS

24 male cats.

PROCEDURE

Blood samples were obtained from each cat on admission, and PCV, pH, and concentrations of ionized calcium, total calcium, glucose, total solids, sodium, potassium, BUN, creatinine, chloride, magnesium, albumin, and phosphorus were determined. Mentation, tissue perfusion, and ECG recordings were also assessed.

RESULTS

18 (75%) cats had low ionized calcium concentrations (reference range, 2.4 to 2.8 mEq/L). Hypocalcemia was considered mild (2.0 to 2.36 mEq/L) in 9 (37.5%) cats, moderate (1.6 to 1.98 mEq/L) in 6 (25%), and severe (< 1.6 mEq/L) in 3 (12.5%). Significant positive correlations were found between ionized calcium concentration and heart rate, pH, and concentrations of sodium, chloride, and total calcium. Significant negative correlations were found between ionized calcium concentration and concentrations of potassium, BUN, creatinine, and phosphorus.

CLINICAL IMPLICATIONS

Most cats with urethral obstruction had a low concentration of ionized calcium. This may contribute to cardiac electrical and mechanical dysfunction in some severely affected cats. Although effects of i.v. administration of calcium were not evaluated, results of this study strengthen the rationale for its use in cats with urethral obstruction.

Late-onset preemptive analgesia associated with preincisional large-dose alfentanil

Few studies using systemic opioids have been adequately designed to demonstrate a preemptive effect. We investigated the preemptive effect of intraoperative large-dose intravenous (I.V.) opioids over a 72-h period after lower abdominal surgery. Thirty-eight ASA physical status I or II patients undergoing abdominal hysterectomy were studied in a prospective, randomized, double-blind design. Group PRE received alfentanil 70 microg/kg over 10 min before surgical incision; Group POST received alfentanil 70 microg/kg over 10 min after incision. Patients received no other intraoperative opioid. Pain was treated in the recovery room with 2-mg I.V. boluses of morphine and was subsequently managed via patient-controlled analgesia (PCA) using morphine sulfate. Visual analog scale pain scores at rest (VAS-R) and on movement (VAS-M) and PCA morphine consumption were recorded for 72 hours. VAS-M and VAS-R scores did not differ at any point, and morphine consumption was similar in both groups over the initial 48 h. Group PRE used significantly less morphine from 48 to 72 h postoperatively (P < 0.02). We conclude that presurgical incisional (i.e., compared with postincisional) large-dose opioid exposure results in a modest, late decrease in postoperative morphine consumption, with no clinical impact on early postoperative pain. Timing of the observed reduction coincides with maximal output of substances implicated in experimental hyperalgesia.

IMPLICATIONS

When given before surgical incision, alfentanil, a short-acting narcotic, was associated with a reduction in morphine requirements 48-72 h after surgery. Brief interventions may have a delayed and sustained impact on pain perception, possibly by reducing mechanisms of sensitization.

The macrophage scavenger receptor type A is expressed by activated macrophages and protects the host against lethal endotoxic shock

During gram-negative bacterial infections, lipopolysaccharide (LPS) stimulates primed macrophages (Mphi) to release inflammatory mediators such as tumor necrosis factor (TNF)-alpha, which can cause hypotension, organ failure, and often death. Several different receptors on Mphi have been shown to bind LPS, including the type A scavenger receptor (SR-A). This receptor is able to bind a broad range of polyanionic ligands such as modified lipoproteins and lipoteichoic acid of gram-positive bacteria, which suggests that SR-A plays a role in host defense. In this study, we used mice lacking the SR-A (SRKO) to investigate the role of SR-A in acquired immunity using a viable bacillus Calmette Guérin (BCG) infection model. We show that activated Mphi express SR-A and that this molecule is functional in assays of adhesion and endocytic uptake. After BCG infection, SRKO mice are able to recruit Mphi to sites of granuloma formation where they become activated and restrict BCG replication. However, infected mice lacking the SR-A are more susceptible to endotoxic shock and produce more TNF-alpha and interleukin-6 in response to LPS. In addition, we show that an antibody which blocks TNF-alpha activity reduces LPS-induced mortality in these mice. Thus SR-A, expressed by activated Mphi, plays a protective role in host defense by scavenging LPS as well as by reducing the release by activated Mphi of proinflammatory cytokines. Modulation of SR-A may provide a novel therapeutic approach to control endotoxic shock.

Carbon starvation of Salmonella typhimurium does not cause a general increase of mutation rates

Mutation rates in bacteria can vary depending on the genetic target studied and the specific growth conditions of the cells. Here, two different methods were used to determine how rates of mutation to antibiotic resistance, auxotrophy, and prototrophy were influenced by carbon starvation on agar plates. The rate of mutation to rifampin resistance was increased by starvation as measured by fluctuation tests, similar to what has been reported previously for Escherichia coli. In contrast, the rates of mutation to various types of auxotrophy were unaffected or decreased as measured by both fluctuation tests and a repeated-streaking procedure. Similarly, the rates of reversion to prototrophy of his and lac nonsense and missense mutations were unaffected by starvation. Thus, mutation rates of different genetic targets can be affected differently by starvation and we conclude that carbon starvation is not generally mutagenic in Salmonella typhimurium.

The effect of injection speed on the pain of lidocaine infiltration

OBJECTIVE

To determine whether reducing the speed of injection is effective in reducing injection pain for buffered and unbuffered lidocaine solutions.

METHODS

A prospective, single-blind, randomized, crossover, laboratory study was performed. Adult volunteers were recruited from ED staff at an urban teaching hospital to serve as subjects. Twenty-nine subjects each received 4 1-mL injections into the dorsum of the hands. Each subject received fast and slow injections of buffered and unbuffered lidocaine. Subjects rated the pain of each injection on a 100-mm visual analog scale (VAS). Mean pain scores for each intervention were compared using analysis of variance.

RESULTS

The mean pain VAS score for fast injection of buffered lidocaine was 14.1 mm. For slow buffered injection, the mean pain score was 11.4 mm (p = 0.98). For unbuffered lidocaine, the means were 28.7 mm for fast injection and 22.2 mm for slow injection (p = 0.40).

CONCLUSIONS

Reducing injection speed did not produce a statistically significant change in injection pain for either buffered or unbuffered solutions.

African American women in the workplace: relationships between job conditions, racial bias at work, and perceived job quality

Although studies have described work processes among employed African American women, few have examined the influence of these processes on job outcomes. This study examined relationships between African American women's exposure to a range of occupational stressors, including two types of racial bias--institutional discrimination and interpersonal prejudice--and their evaluations of job quality. Findings indicated that institutional discrimination and interpersonal prejudice were more important predictors of job quality among these women than were other occupational stressors such as low task variety and decision authority, heavy workloads, and poor supervision. Racial bias in the workplace was most likely to be reported by workers in predominantly white work settings. In addition, Black women who worked in service, semiskilled, and unskilled occupations reported significantly more institutional discrimination, but not more interpersonal prejudice, than did women in professional, managerial, and technical occupations or those in sales and clerical occupations.

Osteoporosis. Guidelines for general practitioners. Osteoporosis Australia

Osteoporosis and its associated problems are major health concerns in Australia, and are commonly encountered in general practice. As the population ages, the incidence of osteoporosis will continue to increase. Hence, it is important for general practitioners and healthcare professionals to remain up to date with the strategies involved in the prevention and treatment of osteoporosis. Over the last few years, there have been significant advances in our understanding and treatment of osteoporosis. It is now clear that osteoporosis is a problem for men as well as for women. Accurate and reliable measurements to diagnose osteoporosis, and effective medications to treat it, are now available. These guidelines have been prepared to help general practitioners identify people at risk of developing osteoporosis, and to inform general practitioners on the current diagnosis and treatment strategies of the condition. We commend these guidelines to you as a reference source for the treatment of people with osteoporosis.

Explaining oropharyngeal dysphagia after unilateral hemispheric stroke

BACKGROUND

Oropharyngeal dysphagia occurs in up to a third of patients presenting with a unilateral hemiplegic stroke, yet its neurophysiological basis remains unknown. To explore the relation between cortical motor function of swallowing and oropharyngeal dysphagia, mylohyoid, pharyngeal, and thenar electromyographic responses to stimulation of affected and unaffected hemispheres were recorded in dysphagic and non-dysphagic patients.

METHODS

The 20 patients studied had unilateral hemispheric stroke confirmed by computed tomography. Eight of them had associated swallowing difficulties. Electromyographic responses were recorded after suprathreshold transcranial magneto-electric stimulation of affected and unaffected hemispheres with a figure-of-eight coil.

FINDINGS

Stimulation of the unaffected hemisphere evoked smaller pharyngeal responses in dysphagic patients than in non-dysphagic patients (mean 64 microV, median 48, interquartile range 44-86 vs 118 microV, 81, 73-150) (p < 0.02). With stimulation of the affected hemisphere, the pharyngeal responses were smaller than for the unaffected hemisphere but similar between the two patient groups (26 microV, 0, 0-48 vs 54 microV, 0, 0-80). Dysphagic and non-dysphagic patients showed similar mylohyoid and thenar responses to stimulation of the unaffected hemisphere as well as to stimulation of the affected hemisphere-unaffected mylohyoid (269 microV, 239, 89-372 vs 239 microV, 163, 133-307), thenar (572 microV, 463, 175-638 vs 638 microV, 485, 381-764); affected mylohyoid (60 microV, 41, 0-129 vs 96 microV, 0, 0-195); thenar (259 microV, 258, 0-538 vs 451 microV, 206, 8-717).

INTERPRETATION

The findings indicate that dysphagia after unilateral hemispheric stroke is related to the magnitude of pharyngeal motor representation in the unaffected hemisphere.

Cost-effectiveness of different ACE inhibitor treatment scenarios post-myocardial infarction

AIMS

To assess the cost-effectiveness of three different treatment strategies for the use of ACE inhibitors after myocardial infarction. These were (a) a high risk (AIRE type) strategy, (b) an intermediate risk (SAVE type) strategy, and (c) initial, short-term treatment of all patients followed by long-term treatment according to (a) or (b).

METHODS AND RESULTS

Incremental costs per life year gained were calculated for each of the above scenarios. The most optimistic cost per life year gained over 10 years, for (a) was L1752 and for (b) was L2962. Strategy (c) increased the cost per life year gained of (a) to L2017 and (b) to L3110. The incremental cost-effectiveness ratio was found to be very sensitive to drug cost.

CONCLUSIONS

If a low cost ACE inhibitor is used, initial treatment of relatively unselected patients followed by long-term treatment of those at high and medium risk maximizes benefit at an acceptable cost. Use of an ACE inhibitor after myocardial infarction is very cost-effective by comparison with many other treatments.

Does the term carcinogen send the wrong message?

The term carcinogen has been used by scientists and health regulatory officials for decades. During the last 20 years there have been attempts to redefine the term to make it more rigorous. But, as predicted two decades ago by a benchmark-setting subcommittee of the National Cancer Advisory Board, advances in scientific understanding have brought about dramatic changes in the way we are able to view the term carcinogen. These changes, their scientific bases and their effect on defining the term carcinogen are described. An alternative to the use of the term carcinogen is suggested by the recently proposed US Environmental Agency's guidelines for cancer risk assessment which appear to be in accord with current scientific understanding and the importance of considering the factors affecting the term carcinogen. The guidelines set forth four questions, the answers to which could, in our judgment, replace the need to define or use the term carcinogen which, in light of new scientific knowledge, has become more misleading than useful.

Relation between psychiatric disorder and abnormal illness behaviour in patients undergoing operations for cervical discectomy

OBJECTIVE

To test the hypothesis that depression in patients being considered for cervical disc surgery is associated with severe organic pathology. Secondly, to test whether depression and abnormal illness attitudes recorded preoperatively would predict poorer recovery.

METHODS

Seventy four patients with pain and disability from cervical arthrosis were examined during investigations before potential cervical surgery. The prevalence of psychiatric disorder was assessed using the SCAN, and attitude to illness using the illness attitude scale.

RESULTS

There was a rate of depressive disorder in the sample of 37%. The depressed patients did not have more severe organic pathology, more neurological symptoms or signs, or more disablement. They reported more pain and displayed more abnormal illness behaviour. Fifty patients went on to cervical surgery. Outcome four to eight months postoperatively was not related to the presence of psychiatric disorder or illness attitude recorded preoperatively.

CONCLUSION

Depressive disorder is not secondary to severe pathology; the outcome of surgery is predominantly determined by physical factors.

Prevention of normally occurring and deafferentation-induced neuronal death in chick brainstem auditory neurons by periodic blockade of AMPA/kainate receptors

The role of glutamate receptors in regulating programmed neuronal death and deafferentation-induced neuronal death in the brainstem auditory nuclei was studied by in ovo drug administration to chick embryos. The nucleus laminaris (NL) undergoes programmed developmental cell death of 19% between embryonic day 9 (E9) and E17. The AMPA/kainate receptor antagonist CNQX, when administered at doses of 200-300 microg/d from E8 to E15, prevented programmed neuronal death in NL through at least posthatching day 8, without producing anatomical or behavioral abnormalities. 3-((RS)-2-Carboxypiperazin-4-yl)-propyl-1-phos-phonic acid, an antagonist of NMDA receptors, had no effect on normal cell death in the NL. CNQX, given from E8 to E15 or only from E8 to E10, also blocked the 33% neuronal loss in the nucleus magnocellularis (NM) that follows surgical destruction of the otocyst on E3, a procedure that deafferents NM neurons by preventing formation of the cochlear nerve. Treatment either with CNQX or the more highly selective NBQX from E8 to E10, before the onset of synaptic transmission in NM and NL, was also effective in preventing normal neuronal death in NL. Analysis of the effects of CNQX or NBQX on spontaneous embryonic motility at E10 showed that the doses effective in preventing neuronal death suppressed motility for <8 hr. We conclude that periodic blockade of AMPA/kainate receptors can protect CNS neurons against subsequent programmed cell death or deafferentation-induced death.

"Ruling in" and "ruling out": two approaches to the micro-rationing of health care

Much of the implicit rationing said to characterise British health care occurs as doctors decide what resources to allocate to individual patients. This paper examines this process using data from case studies of selection of patients for cardiac surgery and admission to a specialist neurological rehabilitation centre. The analysis focuses on cardiac catheterisation conferences in which cardiologists present surgical candidates to a cardiac surgeon, and neuro-rehabilitation admissions conferences in which a multidisciplinary team assess the suitability of head injury and stroke patients referred by hospital doctors. For much of the time participants in both settings discuss patients within a clinical discourse that relies on technical assessments of coronary anatomy, ADL scores and the like. However, there are many examples where the discourse "frame" shifts to address patient characteristics of a social or moral nature. Information of this kind tends to be deployed in two ways: it can be used to signal the patient's unsuitability, usually on the basis that past behaviour implies poor prognosis ("ruling out"), or it can be used to suggest that a patient is especially deserving of help ("ruling in"). Analysis of the data suggests that "ruling out" is more salient within the cardiac catheterisation conferences, and "ruling in" within the neuro-rehabilitation admissions conferences. The authors suggest that this reflects differences in the work organisation of the two specialties, including the division of labour, the organisation of waiting lists as a queue or a pool, and the putative significance of patient agency in the genesis of disease and recovery.