We have had a gutful: The need for deprescribing proton pump inhibitors

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue.

METHODS

Australian Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review.

RESULTS AND DISCUSSION

Proton pump inhibitor use in Australia increased between 2002 and 2010 and then gradually decreased. Estimates of the extent of inappropriate use in the international literature had a wide variation (11-84%). There appeared to be little change in the extent of appropriate PPI use reported through 34 international studies from 2000 to 2016. Interventions to address inappropriate use included patient-centred deprescribing, academic detailing, educational programmes and drug safety notifications.

WHAT IS NEW AND CONCLUSION

Proton pump inhibitors continue to be overused worldwide and should be a focus for deprescribing programmes. Ongoing education and awareness campaigns for health professionals and patients, including electronic reminders at the point of prescribing, are strategies that have potential to reduce PPI use in individuals who do not have an evidence-based clinical indication for their long-term use.

'New to me': changing patient understanding of psoriasis and identifying mechanisms of change. The Pso Well® patient materials mixed-methods feasibility study

Background

Psoriasis is an inflammatory long‐term condition involving comorbidities, unhealthy lifestyle and significant life impact. Patients’ understanding of psoriasis is limited and support lacking. The Common‐Sense Model of Self‐Regulation of Health and Illness emphasizes the role of illness and treatment beliefs on coping and self‐management. New ‘Pso Well^®’ patient materials informed by the model, addressed psoriasis as a long‐term condition, medication management and lifestyle behaviours.

Objectives

To investigate whether Pso Well^® materials (i) broaden understanding of psoriasis without increasing anxiety; (ii) are acceptable; and (iii) comprise features that appear to effect change.

Methods

The Revised Illness Perceptions Questionnaire (IPQ‐R modified) and the Hospital Anxiety and Depression Scale (HADS) were administered in patients before and after intervention. Numerical rating scales assessed perceptions of change in understanding and anxiety resulting from engagement with the materials. Qualitative interviews explored acceptability and perceived ‘active ingredients’.

Results

Fifty‐five patients completed pre‐ and postintervention questionnaires (56% female; median age 59 years). Postintervention, a large effect size was indicated in two IPQ‐R domains – illness coherence [t(55) = −3·48, P = 0·001 (two‐tailed), η² = 0·19] and personal control [t(55) = −2·98, P = 0·004 (two‐tailed), η² = 0·14] – and a medium effect in one, treatment control [t(55) = −2·08, P = 0·042 (two‐tailed), η² = 0·08]. HADS scores did not change. For numerical rating scales, 80% of participants reported increased understanding of psoriasis and none reported increased anxiety. Interviews with 19 patients indicated the materials were acceptable and usable. Factors reported to broaden understanding and promote engagement with self‐management included linking of related disease aspects, personally relevant content and high‐quality design.

Conclusions

High‐quality, theory‐based psoriasis materials are acceptable to patients and can improve understanding and sense of control without increasing anxiety.

What's already known about this topic?

Psoriasis is associated with comorbidities, unhealthy lifestyle and significant life impact.

Patients’ understanding of psoriasis is limited, self‐management support is lacking and disengagement from healthcare services is common.

What does this study add?

The new, theory‐informed Pso Well^® patient materials address psoriasis as a long‐term condition; medications management and lifestyle behaviour.

The Pso Well^® patient materials can increase understanding of psoriasis, promote feelings of self‐worth and encourage a desire to engage in self‐management and behaviour change, without increasing anxiety or depression.

What are the clinical implications of this work?

The Pso Well^® patient materials could support clinical consultations by helping patients recognize the remitting–relapsing nature of psoriasis.

This will help to improve understanding of the disease, as well as providing a clearer rationale for treatment adherence and lifestyle behaviour change.

Linked Comment: Prinsen. Br J Dermatol 2017; 177:616–617

Biosimilars for psoriasis: clinical studies to determine similarity

Biosimilars are drugs that are similar, but not identical, to originator biologics. Preclinical analytical studies are required to show similarity on a molecular and structural level, but efficacy and safety studies in humans are essential to determining biosimilarity. In this review, written by members of the International Psoriasis Council, we discuss how biosimilars are evaluated in a clinical setting, with emphasis on extrapolation of indication, interchangeability and optimal clinical trial design.

Concurrent gonococcal and chlamydial infections among men attending a sexually transmitted diseases clinic

The aim of this retrospective study was to determine the prevalence of Chlamydia trachomatis co-infection in men with gonorrhoea attending a sexually transmitted diseases clinic in Edinburgh, Scotland. During the study period, there were 660 cases of culture-proven gonorrhoea. Chlamydial DNA was detected in the urethra in 79 (31%; 95% confidence interval [CI], 25–37%) heterosexual men who have sex with women (MSW); the median age was significantly lower than those with gonorrhoea alone (24.0 versus 30.0; P < 0.0005). The prevalence of urethral chlamydial infection among MSW was significantly higher than among men who have sex with men (MSM) (32 [12%; 95% CI, 8–16%] of 268 MSM) (χ2 = 27.21; P < 0.001). Sixteen (24%; 95% CI, 14–34%) of 68 MSM with rectal gonorrhoea had concurrent rectal chlamydial infection. The high prevalence of concurrent gonorrhoea and chlamydiae therefore warrants empirical treatment and/or testing for chlamydia in all men with urethral gonorrhoea.

The sensitivity of syphilis assays in detecting different stages of early syphilis

Our aim was to determine the sensitivity of the Murex ICE enzyme immunoassay (EIA) as a screening test for early syphilis and to determine how many additional cases of infection were detected by performing additional tests when requested on clinical grounds.

This was an observational study on consecutive patients diagnosed with syphilis in the Department of Genitourinary Medicine, Edinburgh between January 1st 2004 and April 1st 2005. Additional tests were performed on sera that gave a positive or equivocal EIA on screening as well as by clinical request on sera from contacts of syphilis, and those with clinical signs of syphilis. Additional tests included a Venereal Diseases Research Laboratory (VDRL) carbon antigen test, a Treponema pallidum particle agglutination (TPPA) test, INNO-LIA line immunoblot assay, and an EIA specific for anti-treponemal IgM.

A total of 105 patients were diagnosed with syphilis: primary (50), secondary (26), early latent (8), and of unknown duration (21). The TPPA was the most sensitive test in primary syphilis and had a sensitivity of 96% (48/50), which was significantly higher ( P <0.05) than the sensitivity of 84% (42/50) for the screening EIA: seven of the EIA negatives were detected by EIA–IgM, six by TPPA, five by immunoblot, and two by VDRL. EIA–IgM was negative in six primaries; all were positive by TPPA and immunoblot.

We conclude that, in order to maximize the serological detection of primary syphilis a specific EIA–IgM test and a TPPA test should be performed whenever there is a clinical suspicion of primary infection. This is particularly important when an EIA such as Murex ICE is used as a single screening test as it is less sensitive than the TPPA in primary infection.

Evaluation of the Serodia Treponema pallidum particle agglutination, the Murex Syphilis ICE and the Enzywell TP tests for serodiagnosis of syphilis

We evaluated the Treponema pallidum haemagglutination assay (TPHA), a treponemal test, with three other treponemal tests, the Serodia T. pallidum particle agglutination assay, the Murex Syphilis ICE IgG + IgM enzyme immunoassay (EIA) and the Enzywell TP IgG + M EIA (a new rapid EIA) for use in conjunction with the rapid plasma reagin test (RPR), a non-treponemal test, for serodiagnosis of syphilis. In all, 124 serum samples were found reactive with RPR and/or TPHA after testing by the routine laboratory protocol. Twenty-three (18.5%) of them were positive only by RPR test and were evaluated as biologically false-positive, 16 were positive only by the TPHA and 84 by both the RPR and TPHA tests; one sample was non-specific (heterophile reaction) in the TPHA.

Agreements of the TPHA with the Serodia TPPA, the Murex Syphilis ICE and the Enzywell TP tests were 96.7%, 100% and 99.1%, respectively.

We conclude that each one of the tests, the Serodia TPPA, the Murex Syphilis ICE and the Enzywell TP, is an appropriate substitute for screening for serodiagnosis of syphilis.

Non-chlamydial non-gonococcal urethritis or undiagnosed chlamydial urethritis?

The aim of this study is to investigate the prevalence of sexually transmitted infections (STI) in the partners of men with non-chlamydial, non-gonococcal urethritis (NCNGU).

Observational study of the sexual partners of men with NCNGU diagnosed in the Department of Genitourinary Medicine, Edinburgh between 1 June 2002 and 31 December 2003. The diagnosis of chlamydial infection was based on ligase chain reaction (LCx) between June 2002 and March 2003, and on polymerase chain reaction (PCR) thereafter. Gonococcal infection was diagnosed with culture method.

Sexual partners of 99 (25%) of the 403 heterosexual men diagnosed with NCNGU were screened. Chlamydial infection was detected in 19 (19%) of the female sexual partners. Higher proportion of female partners of symptomatic men (15/51) had chlamydial infection compared with that of partners of asymptomatic men (4/48) ( P < 0.005).

NCNGU may be related to false-negative results of chlamydial diagnostic tests. Screening and treatment of sexual partners of men with NCNGU is therefore necessary.

Intravenous fluid bolus therapy: a bi-national survey of critical care nurses' self-reported practice

Knowledge of critical care nurses' intravenous fluid bolus therapy (FBT) practice remains underexplored. Using a multi-choice online survey conducted between September and October 2014, we sought to describe the self-reported practice of critical care nurses located in Australia and New Zealand. Two hundred and ninety-five critical care nurses responded to the survey with most practising in adult ICUs. Overall, 0.9% saline solution was the preferred solution for FBT. However, more Australian than New Zealand respondents preferred 'albumin 4%' (31% versus 3.6%, P <0.01) for FBT. In contrast, more New Zealand respondents preferred 'Plasma-Lyte®' (33.3% versus 6.4%, P <0.01). Half of the respondents defined FBT as 250 ml administered as quickly as possible. However, FBT volumes ranged from 100 ml to >1000 ml and administration duration from as quickly as possible to 60 minutes. In response to FBT, almost half of the respondents expected an increase in mean arterial pressure of between 11 to 20 mmHg. Similarly, >40% expected a central venous pressure increase >3 mmHg, >70% expected a urinary output increase of 0.5 to 1.0 ml/kg/hr, and >60% expected a decrease in heart rate of >11 /min. Overall, 0.9% saline remains the most common solution for FBT, but there are significant national differences in the preference for albumin and Plasma-Lyte. A volume of 250 ml defines a fluid bolus, with a range from 100 ml to >1000 ml, and speed of delivery from stat to 60 minutes. Most nurses expect substantial physiological effects with FBT.

Urinary neutrophil gelatinase-associated lipocalin to hepcidin ratio as a biomarker of acute kidney injury in intensive care unit patients

BACKGROUND

Labile iron is important in the pathogenesis of acute kidney injury (AKI). Neutrophil gelatinase-associated lipocalin (NGAL) and hepcidin control iron metabolism and are upregulated during renal stress. However, higher levels of urinary NGAL are associated with AKI severity whereas higher urinary hepcidin levels are associated with absence of AKI. We aimed to investigate the value of combining both biomarkers to estimate the severity and progression of AKI in intensive care unit (ICU) patients.

METHODS

Urinary NGAL and hepcidin were quantified within 48 hours of ICU admission in patients with the systemic inflammatory response syndrome and early kidney dysfunction (oliguria for ≥ 2 hours and/or a 25 µmol/L creatinine rise from baseline). Diagnostic and prognostic characteristics were assessed by logistic regression and receiver operating characteristics (ROC) analysis.

RESULTS

Of 102 patients, 26 had mild AKI and 28 patients had severe AKI on admission. Sepsis (21%), cardiac surgery (17%) and liver failure (9%) were primary admission diagnoses. NGAL increased (P=0.03) whereas hepcidin decreased (P=0.01) with increasing AKI severity. The value of NGAL/hepcidin ratio to detect severe AKI was higher than when NGAL and hepcidin were used individually and persisted after adjusting for potential confounders (adjusted OR 2.40, 95% CI 1.20-4.78). The ROC areas for predicting worsening AKI were 0.50, 0.52 and 0.48 for NGAL, 1/hepcidin and the NGAL/hepcidin ratio.

CONCLUSION

The NGAL/hepcidin ratio is more strongly associated with severe AKI than the single biomarkers alone. NGAL and hepcidin, alone or combined as a ratio, were unable to predict progressive AKI in this selected ICU cohort.

Can daytime measures of lung function predict respiratory failure in children with neuromuscular disease?

Neuromuscular disorders in children are a heterogeneous group of conditions with a variable age of presentation and overlapping clinical manifestations, many of which have progressive respiratory morbidity. Respiratory insufficiency occurs as a consequence of an imbalance between demands on the respiratory system and respiratory muscle capacity. Daytime measures of pulmonary function are used routinely in these children to assess respiratory status and monitor the consequences of the progression of muscle weakness. This review describes the current evidence for daytime pulmonary function tests and their ability to predict imminent respiratory morbidity.

Patient-reported outcome measures in psoriasis: the good, the bad and the missing!

As a long-term condition, psoriasis demands significant personal and professional input for optimal self-management. Low levels of well-being and high levels of psychological distress in patients with psoriasis are associated with reduced resources for self-care. Patient-reported outcome (PRO) measures can be used to assess physical, social and psychological functioning in order to guide treatment. In this article, we systematically reviewed the development and validation of existing PRO measures. PubMed (Medline), PsycINFO and CINAHL were searched systematically using predefined search terms. The search was limited to articles in the English language relating to human subjects. Articles were selected for full review through explicit inclusion/exclusion criteria. PRO measures were critically reviewed in accordance with the published guidelines and theory on the development and validation of PROs. The search identified 967 abstracts; 71 of these articles met the criteria for full review. In these 71 articles, 45 PRO measures were found: 16 were specific to psoriasis, 21 assessed other dermatological conditions and eight were developed for generic nondermatological health conditions. The review revealed several limitations of the existing measures, including: (i) a composite structure assessing multiple, poorly-defined concepts; (ii) a lack of evidence for face and content validity; (iii) a failure to include both patient and clinician perspectives and requirements and (iv) a lack of evidence regarding the feasibility and acceptability for patients and physicians. No single PRO measure with adequate evidence of validity, reliability and sensitivity to change captures patient well-being in psoriasis. A valid, sensitive, specific and acceptable PRO that assesses the full impact of psoriasis on well-being is needed for the comprehensive clinical management of psoriasis.