A survey of off-label prescribing for inpatients with mild intellectual disability and mental illness

BACKGROUND

The term 'off-label prescribing' refers to the use of a drug outside the terms of its Marketing Authorisation, including prescribing for an unlicensed indication. There have been few reports about off-label prescribing in psychiatry. The aims of the study were to determine the frequency of off-label prescribing of psychotropics for inpatients with mild intellectual disability (ID) and mental illness resident in a large psychiatric hospital, the nature of the off-label clinical indications and details about patient consent and case note documentation of the off-label usage.

METHODS

Cross-sectional survey of inpatients of the ID division of a charitable hospital was carried out. Interviews with consultant psychiatrists about off-label use of psychotropics were also made.

RESULTS

Of the 56 patients studied, 38 (67.9%) were receiving one or more psychotropic drugs and 26 (46.4%) were receiving at least one off-label psychotropic. The most frequently cited off-label indications were: reduction of aggression, arousal and behavioural disturbance (14 cases) and mood stabilization of affective disturbance (13). The principle psychotropics involved were atypical antipsychotics (17 cases) and mood stabilizers (13). Although in most instances the psychiatrist was aware the drug was being used off-label and had consulted other professionals, in only two (6%) instances had the patient been informed of the off-label usage, largely because the psychiatrist felt they lacked the capacity to understand the off-label concept. In most cases the off-label usage had not been documented in the case notes.

CONCLUSIONS

Off-label prescribing is common in patients with comorbid ID and mental disorder. When prescribing off-label, psychiatrists need to consider the evidence that the drug is likely to be effective for the unlicensed indication and any risks involved. Where there is limited evidence of benefit a trial of the drug, with clinical monitoring may be indicated. Patients should be fully informed about their medication. However, many patients with ID cannot understand the off-label concept. In some circumstances psychiatrists may find it helpful to consult other professionals before prescribing off-label. Good case note documentation of the process is important and supports the prescriber.

Risk factors for coronary heart disease among inpatients who have mild intellectual disability and mental illness

BACKGROUND

Coronary heart disease (CHD) is a major cause of morbidity and mortality in the UK. The aim of this study was to screen inpatients with mild or borderline intellectual disability, many of whom also have mental illness, for risk factors for CHD.

METHODS

Cross sectional survey. Participants were interviewed, measured and had blood samples taken.

RESULTS

Of the 53 participants, 20 (37.7%) were overweight and 18 (34.0%) obese. The mean body mass index (BMI) of those participants prescribed regular antipsychotics was higher than those who were not. Nine (20.9%) had waist circumference measurements placing them at increased risk of CHD and 21 (48.8%) were at substantially increased risk. Twenty-eight (52.8%) were current smokers. Of the 49 participants who had their blood pressure measured, 3 (6.1%) had readings above the reference range. Of the 19 participants who had random blood tests, one (5.3%) had an elevated cholesterol level.

CONCLUSIONS

In this population there was a high prevalence of two risk factors for CHD (obesity and smoking), requiring ongoing monitoring and long-term measures to reduce risk.

Predicting basal metabolic rate in the obese is difficult

OBJECTIVE

To reassess the validity of the Schofield equations for predicting basal metabolic rate (BMR) in the obese.

DATA

The data collection compiled from many studies by Schofield in 1985.

METHODS

Nonparametric curve fitting and comparison of groups.

RESULTS

BMR increases more slowly at heavier weights in men (above about 75 kg) and women (above about 65 kg), and to ignore this is to predict overestimates of BMR. Data obtained from studies of different populations show substantial differences, which are influential when data are combined.

CONCLUSIONS

The Schofield equations are unsuitable for obese populations. Given that current Western populations exhibit prevalences of obesity many times greater than those in the Schofield database, this indicates the need for further study of suitable predictors for these individuals.

Moderate hemolytic disease of the newborn (HDN) due to anti-Rh17 produced by a black female with an e variant phenotype

The Rh blood group antigen e is of high incidence and has many epitopes. Partial expression may occur, more commonly in black persons. Individuals with e variant phenotypes can make antibodies to epitopes they lack. While some of these antibodies may be specific for an antigen, e.g., hrB, others, like anti-Rh17 (anti-Hro), show broader specificity, compatible only with D-- and Rhnull red blood cells (RBCs). Anti-Rh17 in persons of the D-- phenotype has been reported to cause mild to fatal HDN. We report an example of anti-Rh17 produced by a black female with an e variant RBC phenotype that caused moderate HDN. A panel of seven monoclonal anti-e demonstrated her RBCs carried a variant e antigen, and her genotype was RHD, RHce by PCR-RFLP analysis. Amniotic fluid with.OD450 values from 30 to 35 weeks' gestation predicted moderate HDN probability by the Liley method. At 38+ weeks, a viable 3165 g female infant was delivered. The infant's direct antiglobulin test was 2+ with anti-IgG. Total bilirubin rose to 14.2 mg/dL within 48 hours. Indirect bilirubin peaked at 14.7 mg/dL. The bilirubin responded to triple phototherapy. The infant was discharged on day 6. Potential for infant morbidity due to anti-Rh17- mediated HDN and the importance of specifying risks to women with this antibody if they contemplate pregnancy are discussed.

Genetic mapping with SNP markers in Drosophila

Map-based positional cloning of Drosophila melanogaster genes is hampered by both the time-consuming, error-prone nature of traditional methods for genetic mapping and the difficulties in aligning the genetic and cytological maps with the genome sequence. The identification of sequence polymorphisms in the Drosophila genome will make it possible to map mutations directly to the genome sequence with high accuracy and resolution. Here we report the identification of 7,223 single-nucleotide polymorphisms (SNPs) and 1,392 insertions/deletions (InDels) in common laboratory strains of Drosophila. These sequence polymorphisms define a map of 787 autosomal marker loci with a resolution of 114 kb. We have established PCR product-length polymorphism (PLP) or restriction fragment-length polymorphism (RFLP) assays for 215 of these markers. We demonstrate the use of this map by delimiting two mutations to intervals of 169 kb and 307 kb, respectively. Using a local high-density SNP map, we also mapped a third mutation to a resolution of approximately 2 kb, sufficient to localize the mutation within a single gene. These methods should accelerate the rate of positional cloning in Drosophila.

Methodological considerations when conducting direct observation in an outdoor environment: our experience in local parks

OBJECTIVE

This paper discusses some of the inherent methodological limitations of gathering data via direct observation using local parks as a case study.

METHODS

Direct observation was carried out in five parks on seven non-consecutive days in 1998 and on matched days in 1999. Information recorded for each person included the time of park entry and exit, gender, age group, and activity/ies undertaken while in the park. METHODOLOGICAL CONSIDERATIONS: The location of the observation point, observer reliability, recording and accuracy of data, and specific issues related to outdoor observation areas should all be considered when designing a study incorporating direct observation as a data collection method.

CONCLUSIONS

Direct observation can provide valuable information. However, pilot testing is essential for minimising potential problems associated with this method and optimising data quality.

IMPLICATIONS

The issues discussed in this paper provide a useful guide for other researchers undertaking direct observation in outdoor environments.

Energy density of foods: effects on energy intake

This article examines the importance of dietary energy density (ED) as a major factor that may influence human appetite and energy intake (EI). The article examines whether the effects of diet composition on appetite and EI can be explained in terms of ED. There is clear evidence that dietary macronutrients exert differential effects on energy intake (EI), both in the laboratory and in real life. Under normal conditions where fat contributes disproportionately to ED, protein, carbohydrate, and fat exert hierarchical effects on satiety in the order protein >carbohydrate > fat. Alcohol appears to stimulate EI. In human appetite studies the main effect of controlling ED is to diminish the impact of differences in the satiating effects of fat and carbohydrate. ED exerts profound effects in constraining EI in short-to-medium term studies. Subjects behave differently in longer term interventions. In short-to-medium term laboratory studies, increases in ED are more effective at increasing EI than at decreasing food intake. In longer term and cross-sectional studies conducted in naturalistic environments, increased ED appears more effective at decreasing food intake and less effective at elevating EI. The available evidence suggests that we should be evolving more complex, multifactor models to account for the observations that both macronutrients and ED affect EI rather than substituting one simplistic model with another.

Graded expression of EphA3 in the retina and ephrin-A2 in the superior colliculus during initial development of coarse topography in the wallaby retinocollicular projection

We describe the expression of EphA3 and EphA7 receptors and ephrin-A2 ligand in the retina and the superior colliculus during the development of the retinocollicular projection in the marsupial wallaby (Macropus eugenii), using immunoblotting and immunohistochemistry. EphA3 in the retina was in a striking, low central to high peripheral gradient, superimposed on which was a high temporal to low nasal level of expression. This distribution was evident from postnatal day 30, when axons are growing into the colliculus and forming a coarsely organized topographic projection, to postnatal day 65, when axons have arborized in their correct retinotopic positions. EphA7 showed a shallow centroperipheral gradient with no nasotemporal differences in expression. In the superior colliculus no rostrocaudal differences in distribution were detected for either of these receptors. Ephrin-A2 was distributed in a gradient increasing from the rostral to the caudal pole in the superficial layers of the superior colliculus only up to postnatal day 30. Ephrin-A2 was evenly distributed in the retina throughout development of the projection. Expression of EphA3 in the retina increased, while the expression of ephrin-A2 in the colliculus was downregulated over time. The graded expression of EphA3 and ephrin-A2 early in the development of the projection suggests that they play a role in establishment of coarse topography of retinal axons along the rostrocaudal axis of the superior colliculus. However, the gradients were not complementary, meaning that EphA3 alone cannot mediate the repulsive interactions with ephrin-A2 that have been postulated to underlie formation of the topographic map.

Gender in development: a long haul -- but we're getting there!

While women's movements in Latin America and elsewhere have succeeded in putting many issues that are relevant to women and to gender relations onto the political agenda, and although most international aid agencies have made efforts to incorporate gender analysis into their work, this progress has been neither comprehensive nor unproblematic. This article focuses on ways in which the development cooperation agenda, and the priorities and working methods of development agencies and nongovernmental organizations, have served to distort the vision and practice of the women's organizations whose work they seek to support.

Evaluation of linked cancer registry and hospital records of breast cancer

BACKGROUND

Information on the treatment of women with breast cancer in Australia is generally available only from special surveys. Analysis of routinely collected datasets may be more timely and cost effective, if the data are sufficiently accurate and complete.

OBJECTIVE

To evaluate the accuracy and completeness of data on treatment in linked records of breast cancer from two routinely collected datasets.

METHODS

The NSW Department of Health linked NSW Central Cancer Registry (CCR) records for 2,636 women diagnosed with breast cancer in NSW in 1992 to all hospital admission records in the NSW In-patient Statistics Collection (ISC) from January 1991 to June 1994. We queried the original paper records of subsets of women to identify missing or miscoded information and cases not notified to the CCR. We also compared the treatment data with data collected independently from the medical records of 19% of the women.

RESULTS

ISC records linked to 89% of the CCR records. The CCR had identified 94.9% of women with breast cancer treated as hospital in-patients and 83% of these women had surgical treatment recorded in the ISC. The linked dataset under-estimated the percentage of women having breast-conserving therapy (-4%) and slightly over-estimated the percentage having mastectomy (+1%). We estimated that 42% of women treated surgically for breast cancer had actually had breast-conserving surgery, compared with 39% in the original dataset. There was no evident bias by age or by urban or rural residence in the under-recording of breast conservation. There was 94% agreement on the type of surgery between the linked dataset and the independent dataset.

The transposable element Tan1 of Aspergillus niger var. awamori, a new member of the Fot1 family

Aspergillus niger var. awamori has transposable elements that we refer to as Vader and Tan1 (transposon A. niger). Vader was identified by screening unstable nitrate reductase (niaD) mutants for insertions. Four of the isolated niaD mutants were shown to contain a small insertion element. This 437 bp insertion element, Vader, is flanked by 44 bp inverted repeats (IR) and is present in approximately 15 copies in the genomes of two A. niger strains examined. A synthetic 44 bp oligomer of the inverted repeat of Vader has now been used to clone, via the polymerase chain reaction, a 2.3 kb Tan1 element. The Tan1 element has also been isolated from a partial genomic library. Tan1 is present as a single copy in A. niger var. awamori. The Tan1 element has a unique organization: IR-ORF-IR-IR-Vader-IR. The single open reading frame (ORF) (1668 bp) encodes a putative transposase homologous to Fusarium oxysporum Fot1 and Magnaporthe grisea Pot2. Immediately 3' to the second inverted repeat, which bounds the transposase, is a copy of the AT-rich Vader element. We hypothesize that at some stage the independent Vader element, although inactive by itself, arose from Tan1, resulting in current strains with only one copy of Tan1 providing transposase activity and numerous mobile copies of Vader dispersed in the genome.

Identification and cloning of a mobile transposon from Aspergillus niger var. awamori

Aspergillus niger var. awamori contains multiple copies of a transposable element, Vader. This element was detected as a 437-bp insertion in four independently isolated spontaneous mutants of the niaD (nitrate reductase) gene. The Vader element is present in approximately 15 copies in both A. niger var. awamori and A. niger. A single copy of Vader was detected from only one of the two laboratory strains of A. nidulans which were also examined. Insertion of the Vader element into the niaD gene of A. niger var. awamori caused a 2-bp duplication (TA) of the target sequence. The Vader element is flanked by a 44-bp inverted repeat. The genetic stabilities of the inserted Vader elements at niaD were examined by studying reversion frequencies resulting in colonies able to grow on nitrate as a sole nitrogen source. Mutants niaD392 and niaD436 reverted at a frequency of 9x10(-3) and 4x10(-2), respectively. Two of the mutants, niaD587 and niaD410, reverted at a lower frequency of 6x10(-4).

Anti-Holley detected in a primary immune response

Anti-Holley (Hy) has been reported as an IgG antibody occurring in previously transfused or multiparous black patients. In this case anti- Hy was identified in a 16-year-old black, primigravida female admitted at 32 weeks gestation because of premature rupture of the membranes. On admission, her blood type was determined to be A2B, D-positive and an antibody screen was negative. A second antibody screen, performed 4 days later, was positive in all three cells. Anti-Hy was subsequently identified. The antibody was reactive at room temperature, 37 degrees C, and in the antiglobulin phase. IgG and IgM components of anti-Hy were demonstrated in the maternal serum, documenting a primary immune response. This resulted in serologic findings not previously described for anti-Hy. A direct antiglobulin test on the newborn red cells was negative and there was no clinical evidence of hemolytic disease of the newborn (HDN). A monocyte monolayer assay performed with maternal serum yielded negative results. Recent scientific information has resulted in the placement of Hy in the Dombrock blood group system. Alloantibodies to Dombrock system antigens have not been associated with severe HDN.

Analysis of the routine use of polyethylene glycol (PEG) as an enhancement medium

This study compared the performance of polyethylene glycol (PEG) and low-ionic saline solutions (LISS) as enhancement media for routine use in a large transfusion service. A PEG additive solution (PEG plus LISS) was compared to a LISS additive (LISS plus polymers) and to an albumin-indirect antiglobulin test (A-IAT). Fifty serum samples containing clinically significant alloantibodies and fifty samples without alloantibodies were tested. Following an acute hemolytic transfusion reaction (HTR) involving an anti-K that was not detected with LISS but was retrospectively found to be reactive with PEG, an additional 151 samples received for antibody screening were prospectively evaluated in parallel using PEG and LISS. PEG detected all clinically significant antibodies in the 50 previously tested samples, with mean reactivity scores greater than LISS or A-IAT. In the prospective study, PEG detected 35 clinically significant antibodies and 10 clinically insignificant antibodies, while LISS detected only 15 clinically significant antibodies and 33 clinically insignificant antibodies. PEG appears to increase detection of significant antibodies while decreasing detection of insignificant antibodies. PEG was therefore substituted for LISS as an enhancement medium and has been in routine use for 12 months, with no reported acute or anamnestic HTRs in 6,353 transfusions.