Pain management interventions of the non-communicating patient in intensive care: What works for whom and why? A rapid realist review

AIM

The utility and uptake of pain management interventions across intensive care settings is inconsistent. A rapid realist review was conducted to synthesise the evidence for the purpose of theory building and refinement.

DESIGN

A five-step iterative process was employed to develop project scope/ research questions, collate evidence, appraise literature, synthesise evidence and interpret information from data sources.

METHODS

Realist synthesis method was employed to systematically review literature for developing a programme theory.

DATA SOURCES

Initial searches were undertaken in three electronic databases: MEDLINE, CINHAL and OVID. The review was supplemented with key articles from bibliographic search of identified articles. The first 200 hits from Google Scholar were screened.

RESULTS

Three action-oriented themes emerged as integral to successful implementation of pain management interventions. These included health facility actions, unit/team leader actions and individual nurses' actions.

CONCLUSION

Pain assessment interventions are influenced by a constellation of factors which trigger mechanisms yielding effective implementation outcomes.

IMPLICATIONS

The results have implications on policy makers, health organisations, nursing teams and nurses concerned with optimising the successful implementation of pain management interventions.

IMPACT

The review enabled formation of a programme theory concerned with explaining how to effectively implement pain management interventions in intensive care.

REPORTING METHOD

This review was informed by RAMESES publication standards for realist synthesis.

PUBLIC CONTRIBUTION

No patient or public contribution. The study protocol was registered in Open Science Framework. 10.17605/OSF.IO/J7AEZ.

Perspectives of mental health clinicians on physical health of young people with early psychosis

The aim of this study is to explore the views and understanding of youth mental health clinicians with regard to the physical health of young people with early psychosis and their perspectives on lifestyle interventions improving the health and well-being of young people with early psychosis. Physical health disparities leading to premature mortality among people with mental illness are well evident in the literature. Mental health and physical health are directly correlated. The risk of poor physical health often begins before the onset of mental ill health. Young people with early psychosis are highly susceptible to poor physical health. A co-designed integrated approach focusing on early prevention and intervention in overall well-being and health is imminent for this targeted population to prevent poor physical health trajectory across the lifespan. Ten clinicians were recruited and participated in this study through semi-structured interviews. Five themes were identified: (i) Impact of early psychosis, (ii) Focus of care, (iii) Conversations around physical health, (iv) Co-location of specialist roles and (v) Health literacy. The findings of this study confirm the dimensional impact of early psychosis on the well-being and health of young people through the vicious cycle of early psychosis. Promotion of health literacy along with social connectedness and elements of self-determination, as well as having a prime focus on the individuals' experience in the journey of health promotion through participation in lifestyle interventions, has been identified as critically prominent.

Modifying the clinical reasoning cycle to enhance forensic mental health nursing utility

Forensic mental health nursing is a specialty area of practice requiring specific knowledge and skills to work collaboratively with consumers. The Clinical Reasoning Cycle has been recognised as a potential framework to support nursing practice; however, it has been identified that adaptations are required to enhance utility in a forensic mental health services. The aim of this study was to explore and finalise a version of the cycle for forensic mental health nursing practice. Focus groups and interviews were used to explore adaptations with staff from a state-wide forensic service and forensic mental health nursing academics. Data were thematically analysed. Four main themes were interpreted: (1) allegiance to the Nursing Process, (2) moving the cycle from page to practice, (3) working as a team, or not, and (4) implementation will be a marathon and not a sprint. While nursing academics were more in favour of updating the Nursing Process to ensure contemporary practice is captured, staff from the service were supportive of the adapted cycle but emphasised the need to ensure collaboration with the consumer and their supporters. The adapted cycle was seen to articulate the contribution of forensic mental health nursing care, and support for a nursing-specific cycle was embraced by other disciplines, despite some hesitation from nurses. Prior to implementation there is a need to ensure the merits of the cycle are clearly articulated, along with a range of resources and specific contextual information to ensure the cycle can be successfully applied to enhance nursing practice and consumer care.

Nurses' perspectives on medication errors and prevention strategies in residential aged care facilities through a national survey

BACKGROUND

Medication errors are common in residential aged care facilities (RACFs) due to several factors. Effective medication management is essential to prevent medication errors among older people particularly due to the complexity of co-morbidities they can experience.

OBJECTIVES

This study aimed to examine and quantify the contributing factors of medication errors from nurses' perspectives and the prevention strategies to reduce medication errors among older adults living in RACFs.

METHODS

A survey with 140 completed responses from registered nurses (RNs) and endorsed enrolled nurses (EENs) working in RACFs across Australia were included in the study. The survey had 24 items, related to contributing factors of medication errors, and the prevention strategies. Descriptive statistics and exploratory factor analysis were used in the data analysis process.

RESULTS

The study identified medication errors are caused by contributing factors such as use of agency staffing (70.4%) and delays in receipt of laboratory results (94.3%). However, it also identified suggestions to reduce medication errors in RACFs, for example use of electronic alerts (88.3%), and efficient laboratory communication (91.8%). Our results revealed three key factors for causes (workload, interprofessional involvement and interruptions) and suggestions (medication safety alerts, medication process improvement and effective reporting).

CONCLUSION

Medication errors in RACFs are a global problem being one of the leading causes of morbidity and mortality. The knowledge and awareness of the factors associated with medication errors and the prevention strategies can guide potential quality improvement plans and contribute to minimisation of risk associated with medication safety in RACFs.

IMPLICATIONS FOR PRACTICE

The study recommends strategies for best practices in medication management such as interprofessional collaboration, implementing standardised policies and electronic alerts to reduce medication errors in RACFs.

Developing entrustable professional activities to enhance application of an aggression prevention protocol

AIM

The research aim of this study was to seek feedback from prevention of aggression training experts about the suitability of Entrustable Professional Activities (EPAs) as an assessment tool for an Aggression Prevention Protocol. The protocol was designed to structure intervention to prevent aggression and reduce the use of restrictive practices following risk assessment using a validated instrument (the Dynamic Appraisal of Situational Aggression).

BACKGROUND

Preventing aggression and limiting the use of restrictive practices are key priorities for inpatient mental health services. Assessing clinical activities using a competence framework has limitations, particularly when determining complex interventions. EPAs could provide a suitable method for assessing complex clinical activities like de-escalation and limit setting, which comprise some of the interventions in the Aggression Prevention Protocol. EPAs are new to forensic mental health nursing; therefore, feedback was sought regarding the utility of EPAs to assess aggression prevention interventions.

METHODS

Data were collected via focus groups including 11 aggression prevention experts from Australia and New Zealand. A thematic analysis, comparative analysis and a Strength, Weakness, Opportunity and Threats analysis was conducted.

RESULTS

Three themes were interpreted from the data: 1) Frameworks such as the APP are needed to work towards elimination of restrictive practices; 2) APP-EPAs afford an opportunity to set the standard for practice; and 3) 'who watches the watchers', were identified by the experts as well as areas to enhance EPAs prior to introduction into practice.

CONCLUSIONS

EPAs address a practice-gap and offer a framework to assist movement towards elimination of restrictive practices, while prompting best-practice, self-reflection and practice improvement guidance.

Exploring adaptations to the clinical reasoning cycle for forensic mental health nursing: A qualitative enquiry

Forensic mental health nurses (FMHN) provide care to address the needs of people who have mental illnesses across a range of diverse settings. The Clinical Reasoning Cycle (CRC) has been identified as a potential framework to assist FMHNs; however, adaptations were required to reflect the unique nature of the clinical setting. This study aimed to explore adaptations made to determine suitability prior to implementation in practice. Nominal Group Technique was used to explore suggested adaptations determined from a previous study and reach a consensus on the changes. Fourteen senior nurses from a state-wide Forensic mental Health (FMH) service participated. A consensus was reached for two proposed changes. Data were analysed using thematic analysis. Three main themes were interpreted from the data; FMH adaptations are warranted, the focus of the CRC, and who owns the cycle? Nurses in this study considered the need to include offence and risk issues due to the impact these factors have on the therapeutic relationship and cognitive bias; however, they also identified the need to focus on recovery-oriented care while engaging in clinical reasoning. Nurses in this study also expressed some reluctance for nursing to 'own' the model, due to concern that ownership may cause division among the team or result in inconsistency in care. However, some participant's suggested the CRC with adaptations assisted FMH nurses to articulate their specialist skills and knowledge to others and highlight the nursing contribution to care. Further work is needed to finalize adaptations with a focus on engaging the consumer carer workforce and interdisciplinary team.

The perceptions of mental health clinicians integrating exercise as an adjunct to routine treatment of depression and anxiety

Individuals with depressive symptoms often experience changes in physical activity and lifestyle factors. Despite the benefits of exercise, mental health clinicians often do not refer for or prescribe exercise as part of traditionally accepted models of care for consumers with depression and anxiety. The aims were to investigate: (i) mental health clinicians' understanding of the relationship between exercise and mental health, (ii) if and how exercise is used by mental health clinicians in treatment for depression and anxiety, and (iii) the barriers to prescription of exercise. A descriptive qualitative method was used, and data were collected via individual semi-structured interviews. Ten mental health clinicians with varying backgrounds participated in this study. The data driven inductive analysis of participants views identified three themes: (i) knowing and not knowing, (ii) consumer comorbidities - the risk and benefit dilemma, and (iii) protecting vulnerable consumers. Enhancing clinicians' knowledge of the beneficial role of exercise in treatment for consumers' experiencing depression and anxiety is an important step. Mental health services can support integration of exercise by implementing policies and training for staff to support exercise prescription, and the role and referral of exercise and physical activity specialists, as part of routine care to improve clinical outcomes for consumers. Additional considerations should be given to fiscal support to access exercise as an adjunct therapy.

A multi-layered approach to developing academic written communication skills for nursing students

OBJECTIVES

Academic literacy in nursing students has historically been poor this research therefore aimed to investigate the effectiveness of an embedded multidisciplinary approach to academic written communication skills for first year Bachelor of Nursing students in Australia.

METHODS

This initiative consisted of (1) collaboratively embedding academic skills with nursing staff and Learning and Academic Skills Advisors using scaffolded tasks, curriculum/material development, workshops/tutorials on writing skills; and (2) individual support sessions. Data was obtained via questionnaire.

RESULTS

Responses were received from 92 (74% local and 26% international) students. Key findings showed the collaborative approach to embedding skills with added follow up, was beneficial for students' skills development, including improved academic writing, increased confidence, and recognition of the importance of academic writing.

CONCLUSIONS

It is important to equip student to develop academic literacy and an embedded academic literacy program has been determined to assist and may contribute to future professionalisation in nursing.

Using the Nominal Group Technique to determine a nursing framework for a forensic mental health service: A discussion paper

The Nominal Group Technique is a method used to explore issues, generate ideas, and reach consensus on a topic. The Nominal Group Technique includes individual and group work and is designed to ensure participants have the same opportunity to engage and provide their opinions. While the technique has been used for around six decades to assist groups, in industry, and government organizations to examine issues and make decisions, this technique has received limited attention in nursing research, particularly in mental health. This discussion paper describes the use of a modified Nominal Group Technique for a study designed to determine a nursing decision-making framework for a state-wide forensic mental health service. Modifications were made to the traditional technique, to enable participants to make an informed and collective decision about a suitable framework for the novice to expert nurses, across secure inpatient, prison, and community forensic mental health settings. The Nominal Group Technique generated rich data and offered a structured approach to the process. We argue that the Nominal Group Technique offers an exciting and interactive method for nursing research and can increase opportunity for minority group members to participate. This technique also offers a time efficient way to engage busy clinical nurses to participate in research, with the advantage of members knowing the decision on the day of the group. Consideration, however, needs to be given to the duration and effect on participant concentration, and if not actively managed by facilitators, the possible emergence of group dynamics affecting individuals' decisions.

Exploration of the utility of the Nursing Process and the Clinical Reasoning Cycle as a framework for forensic mental health nurses: A qualitative study

Forensic mental health nursing (FMHN) is a specialized field, designed to meet the needs of people who have a serious mental illness across the criminal justice system, inpatient services and community. Frameworks can assist assessment, planning, intervention, documentation and evaluation of nursing care. However, there is no prior research investigating frameworks in FMHN. This study aimed to explore the Nursing Process (NP) and the Clinical Reasoning Cycle (CRC), with nurses, to determine a suitable framework for use service-wide. A Nominal Group Technique was used to facilitate exploration of the two frameworks, where open-ended verbal and written responses collected from a Nominal Group were thematically analysed, and the participants voted on their preferred framework. Seventeen nurses from a state-wide forensic mental health (FMH) service participated. The four main themes were as follows: challenges to current practice, limitations of the NP, perceived benefits of the CRC and addressing implementation. Consensus was reached with the nurses selecting the CRC as the framework of choice. This is the first study to explore frameworks to guide practice in FMHN. Nurses in this study considered the CRC to be a suitable framework for novice through to expert, offering a contemporary framework to guide nursing care in complex FMH settings. Some adjustments to the existing cycle were suggested to emphasize recovery-oriented practice, and inclusion of family and carers. Any changes to the cycle warrant exploration with the interdisciplinary team and consumer carer workforce.

The lived experience of adherence to asthma medication in young adults (18-34 years)

BACKGROUND

Adherence to asthma medications is commonly poor and is the primary cause for anticipated worsening health outcomes for patients with asthma. Worldwide, qualitative investigations that examine the adherence of young adults (18-34 years) to their asthma medication are limited.

METHOD

This study used a phenomenological research approach to explicate the experience of asthma medication adherence as described by young adults. Data were collected using semi-structured in-depth video interviews conducted with participants aged between 18 and 34 years to elicit their lived experience with adherence to asthma medication. Data from the interviews were transcribed and analyzed using the Edward and Welch (1) extension of Colaizzi's approach to phenomenology.

RESULTS

Results yielded four main themes related to the phenomenon of adherence that emerged from the analysis. The themes were: Having a plan; Having knowledge about your medication and asthma triggers; Being responsible with asthma medication; and Health belief.

CONCLUSION

According to the findings, for young people adhering to asthma medication is a process that depends on four vital aspects: (A) plan, (B) knowledge, (C) responsibility, and (D) belief. If young adults with asthma received individualized written asthma plans and have adequate knowledge about this plan, developing the correct health belief is likely to result. Hence, this can lead to a greater responsibility to manage their asthma to the recommended adherence level.

Improving the physical health of young people with early psychosis with lifestyle interventions: Scoping review

People with mental illness experience a shorter life expectancy compared to the general population. Poor physical health trajectory emerges following the onset of psychosis and is further compounded by the initiation of antipsychotic treatment. Young people are particularly at risk as the onset of mental illness mostly occurs between the age of 12 and 25 years. This represents a crucial period for early intervention to prevent a physical ill health trajectory. Furthermore, those who are at ultra-high risk for psychosis should also be targeted for early intervention. Lifestyle interventions have been identified as the first-line physical health promotion practice for improving the physical health of people with severe mental illness. The aim of this study was to conduct a scoping review following the JBI methodological guidance on scoping reviews to explore the current literature on lifestyle intervention trialled for early psychosis, including first-episode psychosis and those who are at ultra-high risk for psychosis. This review also explores the extent of literature examining physical health literacy in this specific population. The literature search was conducted on Medline, Embase, PsycINFO and Scopus. Twenty-two studies were included for the purpose of this scoping review, 21 of which examined the effects of lifestyle interventions and one of which reported on physical health literacy. This scoping review indicates the need for co-designed lifestyle interventions with the involvement of service users, families and carers and a focus on promoting physical health literacy, social support, and an incorporation of a health behaviour change model focus on promoting autonomous motivation. The findings of this study can inform future development of a novel co-designed lifestyle intervention for the targeted population.

Undergraduate nursing students' resilience, challenges, and supports during corona virus pandemic

The coronavirus global pandemic interrupted teaching at Australian universities. Face-to-face teaching was replaced by online delivery. This presented challenges for nursing programmes due to the hands-on teaching requirements and clinical placements. Questions were raised around students' resilience and stress in the face of adversity. This study explored undergraduate nursing students' resilience, challenges experienced, and supports utilized during the pandemic. Convenience sampling recruited students from one nursing programme (n = 340). Quantitative and qualitative data were collected. The Connor-Davidson Resilience Scale (CD-RISC-25) examined resilience scores through non-parametric analysis. Narrative responses were analysed using inductive thematic analysis. 121 surveys (40.3%) were completed. Most participants were from second year (n = 77, 63.6%). The difference in median resilience scores among employed participants was statistically significant (P = 0.029) and higher than the unemployed. The median scores of students working in nursing-related roles were higher than others. Median resilience score across all year levels was 70 (IQR = 62-80), in the lowest score range. Major themes identified were fear of the virus, isolation, and mental health problems. The coping strategies identified were developing daily routines, staying connected, and establishing self-help techniques. This research has implications to optimize students' learning experience, enhance resilience, and promote mental health and well-being.

Pain assessment of the adult sedated and ventilated patients in the intensive care setting: A scoping review

BACKGROUND

Pain is frequently encountered in the intensive care setting. Given the impact of pain assessment on patient outcomes and length of hospital stay, studies have been conducted to validate tools, establish guidelines and cast light on practices relating to pain assessment.

OBJECTIVE

To examine the extent, range and nature of the evidence around pain assessment practices in adult patients who cannot self-report pain in the intensive care setting and summarise the findings from a heterogenous body of evidence to aid in the planning and the conduct of future research and management of patient care. The specific patient cohort studied was the sedated/ ventilated patient within the intensive care setting.

DESIGN

A scoping review protocol utilised the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping review checklist (PRISMA-ScR).

METHODS

The review comprised of five phases: identifying the research question, identifying relevant studies, study selection, charting the data and collating, summarizing, and reporting the results. Databases were systematically searched from January to April 2020. Databases included were Scopus, Web of Science, Medline via Ovid, CINAHL COMPLETE via EBSCO host, Health Source and PUBMED. Limits were applied on dates (2000 to current), language (English), subject (human) and age (adult). Key words used were "pain", "assessment", "measurement", "tools", "instruments", "practices", "sedated", "ventilated", "adult". A hand search technique was used to search citations within articles. Database alerts were set to apprise the availability of research articles pertaining to pain assessment practices in the intensive care setting.

RESULTS

The review uncovered literature categorised under five general themes: behaviour pain assessment tools, pain assessment guidelines, position statements and quality improvement projects, enablers and barriers to pain assessment, and evidence appertaining to actual practices. Behaviour pain assessment tools are the benchmark for pain assessment of sedated and ventilated patients. The reliability and validity of physiologic parameters to assess pain is yet to be determined. Issues of compliance with pain assessment guidelines and tools exist and impact on practices. In some countries like Australia, there is a dearth of information regarding the prevalence and characteristics of patients receiving analgesia, type of analgesia used, pain assessment practices and the process of recording pain management. In general, pain assessment varies across different intensive care settings and lacks consistency.

CONCLUSION

Research on pain assessment practices requires further investigation to explore the causative mechanisms that contribute to poor compliance with established pain management guidelines. The protocol of this review was registered with Open Science Framework (https://osf.io/25a6) Tweetable abstract: Pain assessment in intensive care settings lacks consistency. New information is needed to understand the causative mechanisms underpinning poor compliance with guidelines.

Undergraduate nursing students' experience of mental health simulation post-clinical placement: A Qualitative study

In nursing, it is vital that educational techniques are developed to improve students' capabilities to communicate with and assess mental health consumers while on placement. Simulation is a valid learning technique used to prepare students to encounter consumers with mental illness before exposure in the clinical environment. The aim of this study was to explore undergraduate nursing students' experience mental health simulation following their mental health clinical placement. An explorative descriptive qualitative study. Participants were recruited from a metropolitan Melbourne university using purposive convenience sampling. The participants were interviewed after their mental health clinical placement using semi-structured interview format. A total of n = 14 participants were interviewed. Overall, the participants expressed the fact that the mental health simulation enhanced their clinical placement experience. Two themes were identified: 'The things I might see' and 'Felt better prepared'. There was a total of five subthemes: 'The link between…', 'Having the know how', 'Like an 8-hour shift', 'Took away the fear factor' and 'Feeling more confident'. It is important that nursing students entering mental health settings receive adequate preparation prior to the commencement of their placements. Students need to be prepared in the areas of building therapeutic relationships, communication, assessment and how to work within a mental health clinical setting. The mental health simulation enhanced students' confidence and better prepared them to undertake their clinical placement which can ultimately affect the care provided to consumers.

Undergraduate student nurses' experience of mental health simulation pre-clinical placement: A pre/post-test survey

Undertaking a mental health clinical placement can be anxiety-provoking for nursing students at times. There is a need to adequately prepare undergraduate nursing students for clinical placement in a mental health setting in relation to their skills and confidence. This study aimed to evaluate the effect of a mental health simulation workshop on the skills and confidence of nursing students in providing care to consumers living with a mental illness. The study also evaluated the design of the mental health simulation workshop from an educational perspective. A pre/post-test survey was administered to a cohort of N = 89 Australian pre-registration nursing students. Exploratory factor analysis identified three factors: Mental health therapeutic engagement, mental health assessment skills, and mental health placement preparedness. Analyses of pre-post differences indicated that all three factors were significantly different between the initial and follow-up responses, with follow-up responses being more favourable. The findings of this study demonstrate that there is value in including mental health simulated patient exercise as part of the learning strategies in the curriculum of pre-registration nurses. This has implications for the quality of care in the clinical environment and level of preparedness of these students' nurses for mental health clinical placement where they will be providing care to consumers living with a mental illness under direct supervision.

Anxiety, flipped approach and self-efficacy: Exploring nursing student outcomes

BACKGROUND

Self-efficacy is crucial for student success. Studies have demonstrated a positive relationship between flipped learning approach and self-efficacy. Anxiety, however, can reduce self-efficacy.

OBJECTIVE

Testing the relationship between the flipped approach and self-efficacy by flipping a nursing module within an externally-imposed and once-off anxiety-inducing context.

METHOD

Students completed a self-efficacy survey before (n = 71) and after (n = 91) a compressed semester, which provided the anxiety-inducing context.

RESULTS

Pre-semester self-efficacy was 2.93/4, and post-semester was 2.98/4. The results demonstrated no significant change in students' self-efficacy.

CONCLUSION

We argue the flipped approach counters anxiety-inducing effects to maintain self-efficacy. In less anxiety-inducing contexts, we argue the flipped approach would develop students' confidence, capability, persistence and strength beliefs, collectively enhancing self-efficacy perceptions.

Constructing nurses' professional identity through group performance

AIMS

The aim of this study was to examine professional identity through the group performances of nurses within a specific work environment.

BACKGROUND

Professional identity and social identity are closely linked. Nurses undertake clinical practice usually within a social group environment. The literature is limited on the development of professional identity within the context of nurses' daily work.

DESIGN

An integrated ethnographic case context design was adopted, consisting of two clinical wards in one acute health-care facility in Australia. The application of the social identity theory (SIT) was used to study two specific professional activities to describe the group performance of nurses within this organizational cultural context and how this influenced nurses' professional identity.

METHOD

The research was undertaken between 2012 and 2014. Data collection included observation, interviews and fieldnotes of a convenience sample of nurses and allied health-care professionals who undertook two professional activities in their normal work environment.

FINDINGS

The development of group efficacy contributed to the development of the professional identity in the homogenous handover activity. Self-efficacy was demonstrated in the heterogenous multidisciplinary activity.

CONCLUSION

The results indicated the importance of recognizing core identity-building activities and understanding the value of these activities to professional identity development.

Drug hypersensitivity in clonal mast cell disorders: ENDA/EAACI position paper

Mastocytosis is a clonal disorder characterized by the proliferation and accumulation of mast cells (MC) in different tissues, with a preferential localization in skin and bone marrow (BM). The excess of MC in mastocytosis as well as the increased releasability of MC may lead to a higher frequency and severity of immediate hypersensitivity reactions. Mastocytosis in adults is associated with a history of anaphylaxis in 22-49%. Fatal anaphylaxis has been described particularly following hymenoptera stings, but also occasionally after the intake of drugs such as nonsteroidal anti-inflammatory drugs, opioids and drugs in the perioperative setting. However, data on the frequency of drug hypersensitivity in mastocytosis and vice versa are scarce and evidence for an association appears to be limited. Nevertheless, clonal MC disorders should be ruled out in cases of severe anaphylaxis: basal serum tryptase determination, physical examination for cutaneous mastocytosis lesions, and clinical characteristics of anaphylactic reaction might be useful for differential diagnosis. In this position paper, the ENDA group performed a literature search on immediate drug hypersensitivity reactions in clonal MC disorders using MEDLINE, EMBASE, and Cochrane Library, reviewed and evaluated the literature in five languages using the GRADE system for quality of evidence and strength of recommendation.

Antiretroviral therapy CNS penetration and HIV-1-associated CNS disease

OBJECTIVE

The impact of different antiretroviral agents on the risk of developing or surviving CNS disease remains unknown. The aim of this study was to investigate whether using antiretroviral regimens with higher CNS penetration effectiveness (CPE) scores was associated with reduced incidence of CNS disease and improved survival in the UK Collaborative HIV Cohort (CHIC) Study.

METHODS

Adults without previous CNS disease, who commenced combination antiretroviral therapy (cART) between 1996 and 2008, were included (n = 22,356). Initial and most recent cART CPE scores were calculated. CNS diseases were HIV encephalopathy (HIVe), progressive multifocal leukoencephalopathy (PML), cerebral toxoplasmosis (TOXO), and cryptococcal meningitis (CRYPTO). Incidence rates and overall survival were stratified by CPE score. A multivariable Poisson regression model was used to identify independent associations.

RESULTS

The median (interquartile range) CPE score for initial cART regimen increased from 7 (5-8) in 1996-1997 to 9 (8-10) in 2000-2001 and subsequently declined to 6 (7-8) in 2006-2008. Differences in gender, HIV acquisition risk group, and ethnicity existed between CPE score strata. A total of 251 subjects were diagnosed with a CNS disease (HIVe 80; TOXO 59; CRYPTO 56; PML 54). CNS diseases occurred more frequently in subjects prescribed regimens with CPE scores ≤ 4, and less frequently in those with scores ≥ 10; however, these differences were nonsignificant. Initial and most recent cART CPE scores ≤ 4 were independently associated with increased risk of death.

CONCLUSION

Clinical status at time of commencing cART influences antiretroviral selection and CPE score. This information should be considered when utilizing CPE scores for retrospective analyses.

Pharmacokinetic and safety profile of raltegravir and ribavirin, when dosed separately and together, in healthy volunteers

BACKGROUND

Treatment of chronic hepatitis C virus (HCV) infection in HIV-1-co-infected individuals remains challenging due to numerous factors, including drug-drug interactions. The aim of this study was to assess the safety and pharmacokinetic (PK) profile of raltegravir and ribavirin when dosed separately and together.

METHODS

Fourteen healthy volunteers [mean (standard deviation) age 35 (10) years, 71% male] entered this phase 1 PK study and received single-dose ribavirin (800 mg) on day 1 (phase 1). Following a washout period, subjects received raltegravir (400 mg twice daily) on days 15-19 (phase 2) and single-dose ribavirin (800 mg) with raltegravir (400 mg) on day 20 (phase 3). Intensive PK sampling was undertaken on days 1, 19 and 20 and differences in geometric mean ratios (GMRs) for PK parameters between study periods were assessed.

RESULTS

No statistically significant differences in PK parameters were observed for raltegravir between phases 2 and 3. A statistically significant decrease in maximum plasma concentration (C(max)) and an increase in time to maximum plasma concentration (T(max)) were observed for ribavirin in phase 3 compared with phase 1 [GMR (95% confidence interval) 0.79 (0.62-1.00) and 1.39 (1.08-1.78), respectively], whereas no significant differences in other ribavirin PK parameters were observed between study phases. No clinically significant safety concerns were reported.

CONCLUSIONS

The PK profile of ribavirin is altered when administered with raltegravir (reduced C(max) and increased T(max)), with no safety concerns identified. This is unlikely to be of clinical significance or have an impact on the antiviral effects of ribavirin in HIV-1- and HCV-co-infected subjects.

The British HIV Association national audit on the management of subjects co-infected with HIV and hepatitis B/C

The aim of this work was to survey current service provision and adherence to the British HIV Association (BHIVA) guidelines for the management of HIV and hepatitis B/C co-infected patients in the UK. Sites were invited to complete a survey of local care arrangements for co-infected patients. A case-note audit of all co-infected attendees during a six-month period in 2009 was performed. Data including demographics, clinical parameters, hepatitis disease status, antiretroviral and hepatitis B/C therapy were collected. Using BHIVA guidelines as audit standards, the proportion of sites and subjects meeting each standard was calculated. One-hundred and forty sites (75%) responded and data from 973 eligible co-infected patients were submitted. Approximately a third of sites reported not re-checking hepatitis serology or vaccination titres annually. Of all co-infected patients, 122 (13%) were neither vaccinated nor immune to hepatitis A and 26 (5%) of patients with hepatitis C were neither vaccinated nor naturally immune to hepatitis B. Of HBsAg-positive subjects, 25 (6%) were receiving lamivudine as the sole drug with antihepatitis B activity. In the UK, the management of HIV and hepatitis B/C co-infection remains highly variable. Optimizing the care of this high-risk patient group is a priority.

Increased level of arginase activity correlates with disease severity in HIV-seropositive patients

Infection with human immunodeficiency virus (HIV) results in a chronic infection that progressively impairs the immune system. Although depletion of CD4(+) T cells is frequently used to explain immunosuppression, chronicity of infection and progressive loss of CD4(+) T cells are not sufficient to fully account for immune dysregulation. Arginase-induced l-arginine deprivation is emerging as a key mechanism for the down-regulation of immune responses. Here, we hypothesized that the level of arginase activity increases with disease severity in HIV-seropositive patients. We determined the levels of arginase activity in peripheral blood mononuclear cells from HIV-seropositive patients and uninfected control participants. Our results show that peripheral blood mononuclear cells from HIV-seropositive patients with low CD4(+) T cell counts expressed statistically significantly higher levels of arginase activity, compared with patients with high CD4(+) T cell counts or uninfected control participants. Furthermore, we found a statistically significant correlation between high level of arginase activity and high viral load in HIV-seropositive patients.

Does acute hepatitis C infection affect the central nervous system in HIV-1 infected individuals?

Central nervous system (CNS) manifestations of chronic hepatitis C virus (HCV) and chronic human immune deficiency virus-1 (HIV-1) infections have been reported, but the impact of acute HCV infection on the CNS is unknown. A total of 10 individuals with chronic stable HIV-1 with documented acute HCV (HCV-RNA polymerase chain reaction positive and HCV antibody negative, group 1) underwent cerebral proton magnetic resonance spectroscopy (MRS) using acquisition parameters to quantify myo-inositol/creatine (mI/Cr) ratio in the right basal ganglia (RBG). Two matched control groups also underwent MRS; group 2: ten with chronic HIV-1 and no evidence of HCV, and group 3: ten with no evidence of HIV or HCV. Subjects also underwent computerized neurocognitive assessments (CogState). RBG mI/Cr ratio in group 1 (acute HCV in a background of HIV) was significantly lower than that in groups 2 and 3 [2.90 (+/-0.7) vs 3.34 (+/-0.4) and 3.43 (+/-0.4), mean (SD) for group 1 vs 2 and 3 respectively, P = 0.049], with 50% of subjects in group 1 having a mI/Cr ratio below the lowest observed ratio in either of the other groups. On neurocognitive testing, significant defects in the monitoring domain were observed in group-1, compared with matched controls (P = 0.021). Acute HCV in HIV-1 infected subjects is associated with CNS involvement. Clinicians should be vigilant of early CNS involvement when assessing subjects with acute HCV.

Cocaine, ethanol, and cocaethylene cardiotoxity in an animal model of cocaine and ethanol abuse

OBJECTIVES

Simultaneous abuse of cocaine and ethanol affects 12 million Americans annually. In combination, these substances are substantially more toxic than either drug alone. Their combined cardiac toxicity may be due to independent effects of each drug; however, they may also be due to cocaethylene (CE), a cocaine metabolite formed only in the presence of ethanol. The purpose of this study was to delineate the role of CE in the combined cardiotoxicity of cocaine and ethanol in a model simulating their abuse.

METHODS

Twenty-three dogs were randomized to receive either 1) three intravenous (IV) boluses of cocaine 7.5 mg/kg with ethanol (1 g/kg) as an IV infusion (C+E, n = 8), 2) three cocaine boluses only (C, n = 6), 3) ethanol infusion only (E, n = 5), or 4) placebo boluses and infusion (n = 4). Hemodynamic measurements, electrocardiograms, and serum drug concentrations were obtained at baseline, and then at fixed time intervals after each drug was administered.

RESULTS

Two of eight dogs in the C+E group experienced cardiovascular collapse. The most dramatic hemodynamic changes occurred after each cocaine bolus in the C+E and C only groups; however, persistent hemodynamic changes occurred in the C+E group. Peak CE levels were associated with a 45% (SD +/- 22%, 95% CI = 22% to 69%) decrease in cardiac output (p < 0.05), a 56% (SD +/- 23%, 95% CI = 32% to 80%) decrease in dP/dt(max) (p <.006), and a 23% (SD +/- 15%, 95% CI = 7% to 49%) decrease in SVO(2) (p < 0.025). Ventricular arrhythmias were primarily observed in the C+E group, in which four of eight dogs experienced ventricular tachycardia.

CONCLUSIONS

Cocaine and ethanol in combination were more toxic than either substance alone. Co-administration resulted in prolonged cardiac toxicity and was dysrhythmogenic. Peak serum cocaethylene concentrations were associated with prolonged myocardial depression.

Etiologic factors in progression of carotid stenosis: a 10-year study in 905 patients

PURPOSE

The purpose of this study was to determine the etiologic factors in the progression of carotid stenosis.

METHODS

We performed prospective serial duplex scan surveillance of 1470 carotid arteries in 905 asymptomatic patients during a 10-year period, with an average follow-up interval of 29 months and an average of 3.0 scans per carotid artery. Vascular laboratory and hospital records were used to collect risk factor information. The data were analyzed with proportional hazards modeling.

RESULTS

We examined several demographic, clinical, and laboratory risk factors that were chosen because of their potential relevance to atherosclerotic disease. These factors were analyzed with univariate proportional hazards modeling, in which time to progression of stenosis was the outcome variable. The six significant predictors (P <.05) were age, sex, systolic pressure, pulse pressure (systolic pressure - diastolic pressure), total cholesterol, and high-density lipoprotein (HDL). All, except HDL, were positive predictors of time to disease progression. With multivariate modeling, only pulse pressure and HDL remained as significant independent predictors of stenosis progression. The risk ratio for a 10-mm Hg rise in pulse pressure was 1.12, and the risk ratio for a 10-mg/dL decrease in HDL was 1.20.

CONCLUSION

In this large cohort of patients who were followed prospectively for carotid stenosis, pulse pressure and HDL were found to be the key risk factors for carotid stenosis progression. The fact that pulse pressure superseded systolic pressure in multivariate modeling may shed light on the biology of carotid plaque progression. Further, our identification of these modifiable risk factors may help in the design of therapeutic trials for the prevention of progression of carotid atherosclerosis.

Cocaine-induced wide complex dysrhythmia

Cocaine is a local anesthetic with the potential to induce dysrhythmia due to direct myocardial sodium channel antagonism similar to class I antidysrhythmic drugs. The hallmark of myocardial sodium channel poisoning is wide complex dysrhythmia, and the current accepted treatment is intravenous bicarbonate. Wide complex dysrhythmio due to cocaine in the absence of myocardial infarction is rare, and optimum management is undefined. We report three cases of acute cocaine intoxicating during which patients developed wide complex dysrhythmia consistent with sodium channel poisoning. In one case, wide complex tachycardia resolved without direct treatment. In the other cases, wide complex dysrhythmia resolved following intravenous bicarbonate therapy directed at reversing sodium channel blockade.

Adjuvant hormonal treatment with peptide YY or its analog decreases human pancreatic carcinoma growth

BACKGROUND

Recent studies have revealed decreased pancreatic cancer cell growth upon administration of peptide YY (PYY). We examined whether adjuvant treatment with PYY or its synthetic analog, BIM-43004, would decrease human pancreatic adenocarcinoma growth.

MATERIALS AND METHODS

Human pancreatic ductal adenocarcinomas, MiaPaCa-2 and BxPC-3, were cultured and assessed for growth by MTT assay. Pancreatic cancer cells received 500 pmol of PYY or BIM-43004 for 24 hours prior to 5-fluorouracil (5-FU; 10 micrograms/mL) and leucovorin (40 micrograms/mL) administration. Cell membrane epidermal growth factor (EGF) receptors were analyzed by Western blotting after exposure to peptides and chemotherapy.

RESULTS

Cancer cell growth was reduced in all groups receiving hormonal pretreatment (23% PYY/5-FU/leucovorin versus control; 27% BIM-43004/5-FU/leucovorin versus control) as compared with groups receiving 5-FU and leucovorin only (16% versus control). The EGF receptor expression was reduced by 30% in cells treated with PYY/5-FU/leucovorin and by 45% in cells treated with BIM/5-FU/leucovorin as compared with control cells without treatment.

CONCLUSION

Human pancreatic cancer cell growth is further decreased when pretreated with PYY or its synthetic analog prior to chemotherapy.

Assay of apolipoproteins A-1 and B by immunoturbidimetry: detection of individuals at risk for atherosclerotic artery disease

Recent evidence has suggested that the levels of Apolipoprotein A-1 and B in plasma are better indicators of the risk of atherosclerotic artery disease than plasma lipids. This study describes the measurement of plasma Apolipoprotein A-1 and B by immunoturbidimetry in patients with atherosclerotic artery disease and in normal controls. Apoprotein B and the ratio of Apoprotein A-1/Apoprotein B were found to be the best discriminators between the two groups.