Effects of a monetary incentive on primary care prescribing in Ireland: changes in prescribing patterns in one health board 1990-1995

BACKGROUND

In an attempt to curb the rapidly rising costs of primary care prescribing in Ireland, the government introduced a financial incentive scheme in 1993, to encourage general practitioners to restrain their prescribing.

PURPOSE

To investigate the effects of a financial incentive scheme on GP prescribing in Ireland on prescribing costs and volume, and on some specific therapeutic areas.

METHODS

Prescribing for 3 years before (1990-1992) and 3 years (1993-1995) after the introduction of incentives, based on a defined cohort of 233 general practitioners in the area of one health board. GPs were divided into tertiles based on their performance against their prescribing budgets into 'savers' (generally underspent and received incentive payments), modest overspenders and large overspenders.

RESULTS

Savers were always lower cost prescribers than the other groups. They contained their rate and costs of prescribing in contrast to the other groups, e.g. percentage rise in prescribing costs in the year after the introduction of the scheme -7.9%, +1.2% and +7.3% respectively, (P < 0.05) for savers, modest overspenders and large overspenders respectively. This effect was short lived however and was gone by the third year of the study.

CONCLUSIONS

The financial incentives had a marked effect on prescribing volume and cost on some practices who could achieve targets and hence incentive payments. The incentives had little effect on high spending practices. Such incentive schemes need careful evaluation if they are not to become perverse to the good health of patients.

Transdermal drug delivery systems and skin sensitivity reactions. Incidence and management

Transdermal devices are now marketed for the delivery of systemic medication through the skin. Advantages associated with transdermal drug delivery include avoidance of first-pass metabolism and variable absorption as well as improved patient compliance. Drugs currently available by this route include scopolamine, nitroglycerin (glyceryl trinitrate), estradiol, nicotine, clonidine, fentanyl, and testosterone. This novel development has brought about a specific constellation of skin problems which vary widely in incidence between drugs. It is important to vary the site of drug administration to minimize these reactions. Any eczematous reaction can be treated with a moderately potent topical corticosteroid. Patients with topical sensitivity are usually tolerant of oral challenge but systemic sensitization has been reported and caution is still advocated before proceeding to this step. The increasing use of transdermal drug delivery systems across many specialities means that problems of skin sensitivity are of growing relevance to the dermatologist, the hospital specialist, and the primary care physician.

Reproductive factors, subfertility, and risk of neural tube defects: a case-control study based on the Oxford Record Linkage Study Register

Periconceptual exposure to subfertility treatments is increasingly common, raising concerns about the possibility of malformations in the offspring. The authors conducted a case-control study to determine whether subfertility or its treatment was associated with increased risk of neural tube defects (NTDs). Cases were 694 women diagnosed with an NTD-affected pregnancy in Oxfordshire or West Berkshire, England, between 1970 and 1987. Cases were individually matched on maternal year of birth and year of index pregnancy to controls randomly selected from a computerized database. Data on demographic, reproductive, and obstetric factors were abstracted from patient hospital records. Overall, the period prevalences of subfertility and of subfertility treatment were 7% and 3%, respectively, No evidence was found that the risk of NTD-affected pregnancies was increased by either subfertility (odds ratio (OR) = 1.2, 95% confidence interval (CI): 0.7, 2.1) or its treatment (OR = 0.9, 95% CI: 0.4, 2.0). After adjustment, NTD-affected pregnancies were associated with female offspring (OR = 2.3, 95% CI: 1.8, 3.1), multiple birth (OR = 4.8, 95% CI: 1.2, 18.8), and higher numbers of pregnancies (p for trend = 0.005). The findings from this large, population-based study were wholly consistent with those from smaller studies that found no increased risk of NTD associated with exposure to fertility treatments but reported associations with various pregnancy outcomes.

Health-related quality of life in type 2 diabetes (TARDIS-2)

BACKGROUND

Type 2 diabetes is now recognized as a major public health concern but its burden on society is under-researched.

METHODS

T(2)ARDIS was a postal survey of 1578 people with type 2 diabetes across four UK centres, incorporating measures of resource use, treatment satisfaction and health-related quality of life (HrQoL). The findings included data on the EQ-5D that enabled the HrQoL burden of the disease to be established by comparison with equivalent data for the general population and the diabetic population as a whole from the 1996 Health Survey of England.

RESULTS

The results indicate a significant deficit experienced by people with type 2 diabetes vs. their age group peers in the general population. The proportion of T(2)ARDIS respondents reporting problems increases in relation to the presence of complications, and microvascular complications appear to have more impact than macrovascular complications.

CONCLUSIONS

This confirms the need for treatment policies to focus on reducing the risk of such complications and hence improve patients' HrQoL.

Personality traits of the relatives of autistic probands

BACKGROUND

There is substantial evidence that the genetic liability to autism confers a risk for a range of more subtle social and communication impairments, as well as stereotyped and repetitive behaviours. Recent research suggests that increased expression of particular personality traits may be a manifestation of the liability to autism.

METHODS

To investigate this we examined the personality traits of the adult relatives of 99 autistic and 36 Down's syndrome probands, using the informant version of the Modified Personality Assessment Schedule.

RESULTS

There was significantly increased expression of the traits anxious, impulsive, aloof, shy, over-sensitive, irritable and eccentric among the autism relatives with evidence of different profiles for male and female relatives and for parents and adult children. Factor analysis revealed three broad groups of traits, two of which ('withdrawn' and 'difficult') appeared to reflect impairments in social functioning and a third group of anxiety related traits ('tense'). Each of these factors differed in their pattern of associations with the factor we termed 'withdrawn' showing a similar pattern of association to that found for other autism related conditions. The 'tense' factor appeared in part to be related to the burden of caring for an autistic child.

CONCLUSIONS

This study confirms the finding that particular personality traits may aggregate in the family members of autistic individuals and furthermore that some of these traits may be a manifestation of the liability to autism.

Development and implementation of a geriatric care/case management program in a military community-based family medicine residency

This article discusses how the development of a longitudinal geriatric assessment form facilitated a case management program in identifying high-risk frail elders within a military family practice clinic. A careful review of geriatric assessment tools was performed. From this review, a model geriatric assessment form was developed. A "SWOT" (strengths, weaknesses, opportunities, and threats) analysis of the family medicine department was completed to determine if the environment was ready for case management. Analysis of the SWOT data revealed that the environment was favorable for a population-based approach to case management. Results of this initial study are encouraging. The new longitudinal geriatric assessment form has assisted family practice residents in organizing problems and data while seeing elderly patients. As a direct result, higher-risk frail elders have been identified for closer evaluation and follow-up. Future goals are to measure outcomes-based data and to refine the geriatric assessment process.

Molecular cloning of an Atlantic salmon nucleoside diphosphate kinase cDNA and its pattern of expression during embryogenesis

To gain insight into the process of development in Atlantic salmon (Salmo salar), we sought to identify genes that were differentially expressed at gastrulation. A polymerase chain reaction-based differential screening strategy allowed for the isolation of an Atlantic salmon nucleoside diphosphate kinase cDNA (nm23). Structural characterisation showed a high degree of homology with a large number of previously isolated nucleoside diphosphate kinases (NM23s), both prokaryote and eukaryote, though it represents the first teleost nucleoside diphosphate kinase identified. Highest similarities were found with the type 1 and type 2 NM23 isoforms of mammals. Phylogenetic analysis indicates that the duplication event that gave rise to these isoforms occurred after the splitting of tetrapods and fish, suggesting that the salmon NM23 represents a more ancestral isoform. The position of the salmon sequence on the phylogenetic tree indicates that the salmon genome is expected to have at least three copies of genes from the nm23 gene family. Northern blot analysis showed a single transcript of approximately 0.7 kb in both embryonic and adult tissues. Examination of the temporal pattern of expression of salmon nucleoside diphosphate kinase during embryonic development revealed that this gene is first expressed at the time of gastrulation. Nucleoside diphosphate kinases are thought to have a vital role in regulatory processes such as signal transduction, proliferation and differentiation. Taken together, these results suggest that nucleoside diphosphate kinases have an important role to play in early embryogenic development in vertebrates.

Influence of lipoxin A(4) and other lipoxygenase-derived eicosanoids on tissue factor expression

Lipoxins (LX) are eicosanoids generated via transcellular biosynthetic routes during inflammation, hypersensitivity reaction, and after angioplasty. LXs are modulators of leukocyte trafficking and vascular tone. Their influence on the coagulation cascade has not been determined. In this study, we evaluated the influence of LXs on the expression of tissue factor (TF), a key regulator of coagulation. TF activity was measured in lysates of monocytes, human umbilical vein endothelial cells, and ECV304 cells using a one-stage clotting assay. LXA(4) stimulated TF activity in each cell type. The influence of LXA(4) on TF activity by ECV304 cells was studied further to explore the mechanism of induction of TF expression. LXA(4)-induced TF activity was dose dependent, cycloheximide sensitive, and associated with increased TF mRNA levels. Induction of TF activity was specific for LXA(4) and was not observed with LXB(4), the other major lipoxin generated by mammalian cells. Furthermore, ECV304 cell TF expression was not influenced by 15(R/S)-methyl-LXA(4) or 16-phenoxy-LXA(4), synthetic analogs of LXA(4) that activate the myeloid LXA(4) receptor, and was not modulated by SKF-104353, which blocks LXA(4) bioactivities transduced through the putative shared LXA(4)/LTD(4) receptor. LXA(4)-stimulated TF expression was blunted by pertussis toxin and by GF-109203X, an inhibitor of protein kinase C, and was not associated with degradation of IkappaBalpha. Our results establish that LXA(4) induces TF activity via cell signaling pathways with different structural and receptor requirements from those described for inhibition of leukocyte-endothelial cell interactions. They suggest a role for LXA(4) as a modulator of TF-related vascular events during inflammation and thrombosis.

Effects of 7 years of growth hormone replacement therapy in hypopituitary adults

Short-term studies of GH replacement in adult hypopituitarism have usually demonstrated beneficial effects on body composition and circulating lipids, with neutral or occasionally adverse effects on glucose tolerance. Fasting hyperinsulinemia has been reported. GH effects on cardiac function have been variable. The effects of long-term GH therapy, taking into account the consequences of increasing age, are not fully known. Thirty-three hypopituitary, initially middle-aged adults were studied over a 7-yr period; 12 patients took GH therapy (mean, 0.7 mg daily) continuously (group A); 11 took GH for only 6-18 months, a minimum of 5 yr previously (group B); and 10 patients never received GH therapy (group C). Other pituitary replacement was maintained. Effects on anthropometry, body composition (by bioimpedance analysis, total body potassium, and dual energy x-ray absorptiometry), circulating lipids, glucose and insulin concentrations, cardiac 2-dimensional and Doppler echocardiography, and exercise tolerance were assessed before and after the treatment period. Continuous GH therapy had no significant effect on body weight, but it prevented the increase in waist circumference and waist to hip ratio that occurred in the patients without GH substitution (waist to hip ratio, group A, 0.87+/-0.08 at baseline, 0.85+/-0.09 at 7 yr; group B, 0.89+/-0.11 at baseline, 0.94+/-0.11 at 7 yr; P < 0.005 for GH effect; group C, 0.87+/-0.10 at baseline, 0.92+/-0.10 at 7 yr; P < 0.005 for GH effect). A GH-induced decrease in subscapular skinfold thickness was also observed. By bioimpedance analysis, GH therapy caused an increase in total body water and fat-free mass, and a decrease in the percent body fat. Although changes occurred with time in all groups, no significant additional GH therapy effects were observed on glucose tolerance, insulin concentrations, lipid levels, cardiac dimensions, echocardiographic diastolic function, or exercise tolerance. In conclusion, prolonged GH substitution in middle-aged hypopituitary adults causes a sustained improvement in body composition. Other benefits, e.g. on lipid levels and exercise tolerance, were not apparent at 7 yr when comparisons were made with GH-untreated hypopituitary controls. Potentially adverse effects on glucose tolerance and insulinemia did not develop with prolonged GH therapy.

Mesenchymal stem cells as vehicles for gene delivery

Mesenchymal stem cells contribute to the regeneration of mesenchymal tissues such as bone, cartilage, muscle, ligament, tendon, adipose, and marrow stroma. Transduction of mesenchymal stem cells from species other than humans is required for the development of disease models in which mesenchymal stem cells-based gene delivery is evaluated. Attempts to transduce mesenchymal stem cells from some species with amphotropic retroviral vectors were unsuccessful, leading to comparative mesenchymal stem cells transductions with xenotropic and gibbon-ape leukemia virus envelope-pseudotyped retroviral vectors. Human, baboon, canine, and rat mesenchymal stem cells were transduced optimally with amphotropic vector supernatants. In contrast, sheep, goat, and pig mesenchymal stem cells showed highest transduction levels with xenotropic retroviral vector supernatant, and rabbit mesenchymal stem cells were transduced optimally with gibbon-ape-enveloped vectors. Using a myeloablative canine transplantation model and gene-marked canine mesenchymal stem cells, the biodistribution of infused and ex vivo expanded mesenchymal stem cells were examined. The majority of transduced canine mesenchymal stem cells were found in the bone marrow samples. The current study shows the use of mesenchymal stem cells as a delivery vehicle for gene transfer studies, and validates the feasibility of delivering mesenchymal stem cells to the marrow compartment for stromal regeneration after cancer-associated cytotoxic therapies.

Your patient may be at risk for isolated systolic hypertension!

Isolated systolic hypertension is a risk factor for the development of stroke, heart attack, and left ventricular hypertrophy, which can result in eventual congestive heart failure. Recent studies have validated the benefits of treatment of isolated systolic hypertension in the elderly and have shown that treatment can reduce the risk for cardiovascular complications. An update on isolated systolic hypertension and the importance of detecting and treating are presented.

Galactorrhoea and hyperprolactinaemia associated with protease-inhibitors

We describe four patients with galactorrhoea as an isolated endocrine abnormality after use of protease inhibitors (PIs) as part of both highly active antiretroviral therapy (HAART) and postexposure prophylaxis (PEP). This reaction may be a direct effect of PIs or may be indirectly mediated by the effect of PIs on the cytochrome P450 system, thus potentiating the dopamine antagonist effects of other drugs.

Functional heterogeneity and high frequencies of cytomegalovirus-specific CD8(+) T lymphocytes in healthy seropositive donors

Human cytomegalovirus (HCMV) infection is largely asymptomatic in the immunocompetent host, but remains a major cause of morbidity in immunosuppressed individuals. Using the recently described technique of staining antigen-specific CD8(+) T cells with peptide-HLA tetrameric complexes, we have demonstrated high levels of antigen-specific cells specific for HCMV peptides and show that this may exceed 4% of CD8(+) T cells in immunocompetent donors. Moreover, by staining with tetramers in combination with antibodies to cell surface markers and intracellular cytokines, we demonstrate functional heterogeneity of HCMV-specific populations. A substantial proportion of these are effector cytotoxic T lymphocytes, as demonstrated by their ability to lyse peptide-pulsed targets in "fresh" killing assays. These data suggest that the immune response to HCMV is periodically boosted by a low level of HCMV replication and that sustained immunological surveillance contributes to the maintenance of host-pathogen homeostasis. These observations should improve our understanding of the immunobiology of persistent viral infection.

Extensive soft tissue uptake of 99Tcm methylene diphosphonate in a patient with multiple myeloma

Bone scintigraphy is not usually performed in multiple myeloma (MM), as marrow deposits characteristically show no tracer uptake. However, metastatic bone disease often mimics MM both clinically and biochemically, resulting in a substantial number of MM patients undergoing bone scintigraphy. Variable appearances in these cases have been reported, ranging from normal to a superscan, the latter a result of massive tracer uptake within bone. Soft tissue uptake has been documented, often when MM is complicated by secondary amyloidosis. This usually results in mainly solid organ uptake of tracer. We report a case of MM where massive soft tissue uptake occurred, primarily within muscles, with very little isotope elsewhere.

Disinsertion of the inferior oblique muscle for treatment of superior oblique paresis

PURPOSE

To examine the safety and efficacy of disinsertion of the inferior oblique muscle in the treatment of long-standing ipsilateral superior oblique paresis.

METHODS

This retrospective study included 52 patients who underwent disinsertion of the inferior oblique muscle over a 5-year period. Mean age at presentation was 30.8 years (range: 1-70 years). All patients had long-standing unilateral superior oblique paresis and overaction of the ipsilateral inferior oblique muscle. Information recorded included pre- and postoperative vertical deviation, pre- and postoperative Hess chart error scores, reoperation rate, and symptom relief.

RESULTS

Following surgery, mean vertical deviation was reduced from 12.9 to 4 prism diopters, while mean Hess chart error score decreased from 596 to 258. This procedure alone resulted in satisfactory symptom relief in 84.6% of patients. The only complication was significant undercorrection requiring further surgery in 13.6% of patients and prisms in 1.8%. When further surgery was needed, the procedure of choice was tucking of the affected superior oblique. Recession of the contralateral inferior rectus was carried out when superior oblique tucking was believed to be unsuitable.

CONCLUSIONS

Disinsertion of the inferior oblique muscle is a safe and effective treatment for the majority of long-standing idiopathic unilateral superior oblique pareses.

Large-scale purification of antisense oligonucleotides by high-performance membrane adsorber chromatography

Very high flux ion-exchange membranes were utilized for a novel purification of antisense oligonucleotides (20-mer). Strong anion-exchange membranes were produced by attaching polymeric ligands onto a microporous cellulosic matrix. The oligonucleotides purified were therapeutic single-stranded phosphorothioates deoxyribonucleotides. Although small-scale membrane devices (15 cm2) had similar resolution to traditional chromatographic columns; their throughputs were superior. Greater than a 1300-fold scale-up produced very similar purity and yields of the phosphorothionate product. Scale-up experiments were conducted with a 2 m2 surface area membrane module. These modules were easily capable of very high throughputs of 0.5 to 2 l/min. High purity and yields were achieved by both step and linear gradient elution.

Association between polymorphisms in dopamine metabolic enzymes and tobacco consumption in smokers

Central dopaminergic reward pathways give rise to dependence and are activated by nicotine. Allelic variants in genes involved in dopamine metabolism may therefore influence the amount of tobacco consumed by smokers. We developed assays for polymorphisms in dopamine beta-hydroxylase (DBH), monoamine oxidase (MAO) and catechol O-methyl transferase (COMT) using the polymerase chain reaction with sequence specific primers (PCR-SSP). We then typed 225 cigarette smokers to assess whether genotype was related to the number of cigarettes smoked a day. Smokers with DBH 1368 GG genotype smoked fewer cigarettes than those with GA/AA [mean difference -2.9 cigarettes, 95% confidence interval (CI) -5.5, -0.4; P = 0.022]. The effect reached statistical significance in women (-3.8, 95% CI -6.4, -1.0, P = 0.007) but not in men (-1.5, 95% CI -6.0, 3.0, P = 0.498). Overall, the effect was greater when analysis was confined to Caucasians (-3.8, 95% CI -6.6, -1.1, P = 0.007). Smokers with MAO-A 1460 TT/TO smoked more cigarettes than those with CC/CT/CO (2.9, 95% CI 0.6, 5.1, P = 0.013). Within each sex group, the trend was similar but not statistically significant (difference for men 2.9, 95% CI -1.0, 6.7; for women 2.0, 95% CI -0.7, 4.8). The effect of the allele was greater in smokers with a high body mass index (> 26) (difference 5.1, 95% CI 1.4, 8.8, P = 0.008). More heavy smokers (> 20 a day) had the DBH 1368A allele when compared to light smokers (< 10 a day). (Relative risk 2.3, 95% CI 1.1, 5.0, P = 0.024.) The trend for increasing prevalence of the DBH A allele in heavy smokers was greater when analysis was restricted to Caucasians (relative risk 3.2, 95% CI 1.3, 8.2, P = 0.004). Conversely, heavy smokers were less likely to have the MAO-A 1460C allele (relative risk 0.3, 95% CI 0.1, 0.7, P = 0.012). Variations in DBH and MAO predict whether a person is a heavy smoker and how many cigarettes they consume. Our results support the view that these enzymes help to determine a smoker's requirement for nicotine and may explain why some people are predisposed to tobacco addiction and why some find it very difficult to stop smoking. This finding has important implications for smoking prevention and offers potential for developing patient-specific therapy for smoking cessation.

Dietary folate and the prevalence of neural tube defects in the British Isles: the past two decades

OBJECTIVES

To measure the changes in folate consumption and the prevalence of neural tube defects in the British and Irish populations during the past two decades.

DESIGN

Ecological study.

MAIN OUTCOME MEASURES

Average daily dietary folate consumption for Britain for the period 1980-1996 was estimated from the National Food Survey. Annual neural tube defect prevalences for the same period were obtained from the Oxford Record Linkage Study Neural Tube Defect register, the Glasgow EUROCAT register, and the three Irish EUROCAT registers (Belfast, Dublin and Galway).

RESULTS

Dietary folate consumption increased on average by 1.6% per annum in Scotland and 1.4% in England during the study period. The annual rate of decline of neural tube defect prevalence averaged 10.4% in the Irish population, 8.2% in Glasgow, and 5.2% in Oxfordshire and West Berkshire.

CONCLUSIONS

The decline in neural tube defect prevalence observed in all British and Irish populations since the early 1970s continued with the introduction of folate fortification of cereals, which produced measurable increases in average daily folate consumption. Further declines in neural tube defect prevalence may be achieved by targeted folate supplementation during the periconceptual period.

Computer support for interpreting family histories of breast and ovarian cancer in primary care: comparative study with simulated cases

OBJECTIVES

To evaluate the potential effect of computer support on general practitioners' management of familial breast and ovarian cancer, and to compare the effectiveness of two different types of computer program.

DESIGN

Crossover experiment with balanced block design.

PARTICIPANTS

Of a random sample of 100 general practitioners from Buckinghamshire who were invited, 41 agreed to participate. From these, 36 were selected for a fully balanced study.

INTERVENTIONS

Doctors managed 18 simulated cases: 6 with computerised decision support system Risk Assessment in Genetics (RAGs), 6 with Cyrillic (an established pedigree drawing program designed for clinical geneticists), and 6 with pen and paper.

MAIN OUTCOME MEASURES

Number of appropriate management decisions made (maximum 6), mean time taken to reach a decision, number of pedigrees accurately drawn (maximum 6). Secondary measures were method of support preferred for particular aspects of managing family histories of cancer; importance of specific information on cancer genetics that might be provided by an "ideal computer program."

RESULTS

RAGs resulted in significantly more appropriate management decisions (median 6) than either Cyrillic (median 3) or pen and paper (median 3); median difference between RAGs and Cyrillic 2.5 (95% confidence interval 2.0 to 3.0; P<0.0001). RAGs also resulted in significantly more accurate pedigrees (median 5) than both Cyrillic (median 3.5) and pen and paper (median 2); median difference between RAGs and Cyrillic 1.5 (1.0 to 2.0; P<0.0001). The time taken to use RAGs (median 178 seconds) was 51 seconds longer per case (95% confidence interval 36 to 65; P<0.0001) than pen and paper (median 124 seconds) but was less than Cyrillic (median 203 seconds; difference 23. (5 to 43; P=0.02)). 33 doctors (92% (78% to 98%)) preferred using RAGs overall. The most important elements of an "ideal computer program" for genetic advice in primary care were referral advice, the capacity to create pedigrees, and provision of evidence and explanations to support advice.

CONCLUSIONS

RAGs could enable general practitioners to be more effective gatekeepers to genetics services, empowering them to reassure the majority of patients with a family history of breast and ovarian cancer who are not at increased genetic risk.