Prevalence and risk factors for long COVID among adults in Scotland using electronic health records: a national, retrospective, observational cohort study

Background

Long COVID is a debilitating multisystem condition. The objective of this study was to estimate the prevalence of long COVID in the adult population of Scotland, and to identify risk factors associated with its development.

Methods

In this national, retrospective, observational cohort study, we analysed electronic health records (EHRs) for all adults (≥18 years) registered with a general medical practice and resident in Scotland between March 1, 2020, and October 26, 2022 (98-99% of the population). We linked data from primary care, secondary care, laboratory testing and prescribing. Four outcome measures were used to identify long COVID: clinical codes, free text in primary care records, free text on sick notes, and a novel operational definition. The operational definition was developed using Poisson regression to identify clinical encounters indicative of long COVID from a sample of negative and positive COVID-19 cases matched on time-varying propensity to test positive for SARS-CoV-2. Possible risk factors for long COVID were identified by stratifying descriptive statistics by long COVID status.

Findings

Of 4,676,390 participants, 81,219 (1.7%) were identified as having long COVID. Clinical codes identified the fewest cases (n = 1,092, 0.02%), followed by free text (n = 8,368, 0.2%), sick notes (n = 14,469, 0.3%), and the operational definition (n = 64,193, 1.4%). There was limited overlap in cases identified by the measures; however, temporal trends and patient characteristics were consistent across measures. Compared with the general population, a higher proportion of people with long COVID were female (65.1% versus 50.4%), aged 38-67 (63.7% versus 48.9%), overweight or obese (45.7% versus 29.4%), had one or more comorbidities (52.7% versus 36.0%), were immunosuppressed (6.9% versus 3.2%), shielding (7.9% versus 3.4%), or hospitalised within 28 days of testing positive (8.8% versus 3.3%%), and had tested positive before Omicron became the dominant variant (44.9% versus 35.9%). The operational definition identified long COVID cases with combinations of clinical encounters (from four symptoms, six investigation types, and seven management strategies) recorded in EHRs within 4-26 weeks of a positive SARS-CoV-2 test. These combinations were significantly (p < 0.0001) more prevalent in positive COVID-19 patients than in matched negative controls. In a case-crossover analysis, 16.4% of those identified by the operational definition had similar healthcare patterns recorded before testing positive.

Interpretation

The prevalence of long COVID presenting in general practice was estimated to be 0.02-1.7%, depending on the measure used. Due to challenges in diagnosing long COVID and inconsistent recording of information in EHRs, the true prevalence of long COVID is likely to be higher. The operational definition provided a novel approach but relied on a restricted set of symptoms and may misclassify individuals with pre-existing health conditions. Further research is needed to refine and validate this approach.

Funding

Chief Scientist Office (Scotland), Medical Research Council, and BREATHE.

A proposal for further developing fatigue-related post COVID-19 health states for burden of disease studies

Previous efforts to estimate the burden of fatigue-related symptoms due to long COVID have a very high threshold for inclusion of cases, relative to the proposed definition from the World Health Organization. In practice this means that milder cases, that may be occurring very frequently, are not included in estimates of the burden of long COVID which will result in underestimation. A more comprehensive approach to modelling the disease burden from long COVID, in relation to fatigue, can ensure that we do not only focus on what is easiest to measure; which risks losing focus of less severe health states that may be more difficult to measure but are occurring very frequently. Our proposed approach provides a means to better understand the scale of challenge from long COVID, for consideration when preventative and mitigative action is being planned.

What Happens When Donors Pull Out? Examining Differences in Motivation Between Health Workers Who Recently Had Performance-Based Financing (PBF) Withdrawn With Workers Who Never Received PBF in the Democratic Republic of Congo

Background: A motivated workforce is necessary to ensure the delivery of high quality health services. In developing countries, performance-based financing (PBF) is often employed to increase motivation by providing financial incentives linked to performance. However, given PBF schemes are usually funded by donors, their long-term financing is not always assured, and the effects of withdrawing PBF on motivation are largely unknown. This cross-sectional study aimed to identify differences in motivation between workers who recently had donor-funded PBF withdrawn, with workers who had not received PBF.

Methods: Quantitative data were collected from 485 health workers in 5 provinces using a structured survey containing questions on motivation which were based on an established motivation framework. Confirmatory factor analysis was used to verify dimensions of motivation, and multiple regression to assess differences in motivation scores between workers who had previously received PBF and those who never had. Qualitative interviews were also carried out in Kasai Occidental province with 16 nurses who had previously or never received PBF.

Results: The results indicated that workers in facilities where PBF had been removed scored significantly lower on most dimensions of motivation compared to workers who had never received PBF. The removal of the PBF scheme was blamed for an exodus of staff due to the dramatic reduction in income, and negatively impacted on relationships between staff and the local community.

Conclusion: Donors and governments unable to sustain PBF or other donor-payments should have clear exit strategies and institute measures to mitigate any adverse effects on motivation following withdrawal.

Knowing What We Know - Reflections on the Development of Technical Guidance for Loss Data for the Sendai Framework for Disaster Risk Reduction

INTRODUCTION

To report on activities aligned with the Sendai Framework for Disaster Risk Reduction 2015-2030, national governments will use the Sendai Monitor platform to track progress using a series of indicators that inform seven Global Targets originally agreed in 2015. In February 2017, the UN General Assembly adopted a set of 38 agreed indicators based on work led by an open-ended intergovernmental expert working group (OIEWG) on indicators and terminology relating to disaster risk reduction. In January 2018 the United Nations Office for Disaster Risk Reduction released technical guidance documents in advance of the launch of the Sendai Monitor in March 2018.

METHODS

This paper discusses several challenges to recording and reporting on loss data under the Sendai Framework. Additional insights to elaborate on discussion build upon commentary and examples raised during a workshop held on developing loss data that was hosted by the United Nations Office of Disaster Risk Reduction (UNISDR), the Integrated Research on Disaster Risk (IRDR) programme, and Public Health England (PHE) from February 15-17 2017 at the Royal Society in London, United Kingdom. The meeting's purpose was to refine technical guidance notes concerning Global Targets A, B, C, and D, which had been drafted in coordination with the work of the OIEWG. The workshop was attended by representatives from UN Agencies, UN Member States, international scientific bodies, academic bodies, the government of the United Kingdom and the private sector.

RESULTS

Global Targets A, B, C and D of the Sendai Framework have common and specific complexities which require acknowledgement and support in recording, reporting and using disaster loss data. Discussions during the February 2017 loss data workshop highlighted a number of complexities and the need for common standards and principles for loss data. Individual target complexities include attribution of health impacts, assessing impacts, consistently calculating economic losses and measuring disruption to critical infrastructure.

DISCUSSION

Transparent monitoring is critical to ensure political will, financial efforts and effective evidence support the global shift towards more sustainable development. Data involves common challenges which can undermine accuracy and understanding of reporting across the frameworks that outline the United Nations' 2030 Agenda. Disaster loss data adds further challenges which require support and innovation to ensure stakeholders across sectors in all sectors have appropriate technical guidance that can support useful loss data management processes. The February 2017 workshop highlighted systemic challenges with working with loss data and highlighted several pertinent pathways to progress on the breadth and reliability of disaster loss data across different settings.

Haemoperfusion over Ion Exchange Resins and Polymeric Adsorbents

A review of the development and application of haemoperfusion over ion exchange resins and polymeric adsorbents is presented. Aspects of biocompatibility and ion balance are discussed.

How to and how not to develop a theory of change to evaluate a complex intervention: reflections on an experience in the Democratic Republic of Congo

Theories of change (ToCs) describe how interventions can bring about long-term outcomes through a logical sequence of intermediate outcomes and have been used to design and measure the impact of public health programmes in several countries. In recognition of their capacity to provide a framework for monitoring and evaluation, they are being increasingly employed in the development sector. The construction of a ToC typically occurs through a consultative process, requiring stakeholders to reflect on how their programmes can bring about change. ToCs help make explicit any underlying assumptions, acknowledge the role of context and provide evidence to justify the chain of causal pathways. However, while much literature exists on how to develop a ToC with respect to interventions in theory, there is comparatively little reflection on applying it in practice to complex interventions in the health sector. This paper describes the initial process of developing a ToC to inform the design of an evaluation of a complex intervention aiming to improve government payments to health workers in the Democratic Republic of Congo. Lessons learnt include: the need for the ToC to understand how the intervention produces effects on the wider system and having broad stakeholder engagement at the outset to maximise chances of the intervention’s success and ensure ownership. Power relationships between stakeholders may also affect the ToC discourse but can be minimised by having an independent facilitator. We hope these insights are of use to other global public health practitioners using this approach to evaluate complex interventions.

A cross-sectional study of the income sources of primary care health workers in the Democratic Republic of Congo

BACKGROUND

In the Democratic Republic of Congo (DRC), the state system to remunerate health workers is poorly functional, encouraging diversification of income sources and corruption. Given the central role that health workers play in health systems, policy-makers need to ensure health workers are remunerated in a way which best incentivises them to provide effective and good quality services. This study describes the different sources and quantities of income paid to primary care health workers in Equateur, Maniema, Kasai Occidental, Province Orientale and Kasai Oriental provinces. It also explores characteristics associated with the receipt of different sources of income.

METHODS

Quantitative data on the income received by health workers were collected through baseline surveys. Descriptive statistics explored the demographic characteristics of health workers surveyed, and types and amounts of incomes received. A series of regression models were estimated to examine the health worker and facility-level determinants of receiving each income source and of levels received. Qualitative data collection was carried out in Kasai Occidental province to explore perceptions of each income source and reasons for receiving each.

RESULTS

Nurses made up the majority of workers in primary care. Only 31% received a government salary, while 75% reported compensation from user fees. Almost half of all nurses engaged in supplemental non-clinical activities. Receipt of government payments was associated with income from private practice and non-clinical activities. Male nurses were more likely to receive per diems, performance payments, and higher total remuneration compared to females. Contextual factors such as provincial location, presence of externally financed health programmes and local user fee policy also influenced the extent to which nurses received many income sources.

CONCLUSIONS

The receipt of government payments was unreliable and had implications for receipt of other income sources. A mixture of individual, facility and geographical factors were associated with the receipt of various income sources. Greater co-ordination is needed between partners involved in health worker remuneration to design more effective financial incentive packages, reduce the fragmentation of incomes and improve transparency in the payment of workers in the DRC.

Clinical features of patients isolated for suspected Ebola virus disease at Connaught Hospital, Freetown, Sierra Leone: a retrospective cohort study

BACKGROUND

The size of the west African Ebola virus disease outbreak led to the urgent establishment of Ebola holding unit facilities for isolation and diagnostic testing of patients with suspected Ebola virus disease. Following the onset of the outbreak in Sierra Leone, patients presenting to Connaught Hospital in Freetown were screened for suspected Ebola virus disease on arrival and, if necessary, were admitted to the on-site Ebola holding unit. Since demand for beds in this unit greatly exceeded capacity, we aimed to improve the selection of patients with suspected Ebola virus disease for admission by identifying presenting clinical characteristics that were predictive of a confirmed diagnosis.

METHODS

In this retrospective cohort study, we recorded the presenting clinical characteristics of suspected Ebola virus disease cases admitted to Connaught Hospital's Ebola holding unit. Patients were subsequently classified as confirmed Ebola virus disease cases or non-cases according to the result of Ebola virus reverse-transcriptase PCR (EBOV RT-PCR) testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of every clinical characteristic were calculated, to estimate the diagnostic accuracy and predictive value of each clinical characteristic for confirmed Ebola virus disease.

RESULTS

Between May 29, 2014, and Dec 8, 2014, 850 patients with suspected Ebola virus disease were admitted to the holding unit, of whom 724 had an EBOV RT-PCR result recorded and were included in the analysis. In 464 (64%) of these patients, a diagnosis of Ebola virus disease was confirmed. Fever or history of fever (n=599, 83%), intense fatigue or weakness (n=495, 68%), vomiting or nausea (n=365, 50%), and diarrhoea (n=294, 41%) were the most common presenting symptoms in suspected cases. Presentation with intense fatigue, confusion, conjunctivitis, hiccups, diarrhea, or vomiting was associated with increased likelihood of confirmed Ebola virus disease. Three or more of these symptoms in combination increased the probability of Ebola virus disease by 3·2-fold (95% CI 2·3-4·4), but the sensitivity of this strategy for Ebola virus disease diagnosis was low. In a subgroup analysis, 15 (9%) of 161 confirmed Ebola virus disease cases reported neither a history of fever nor a risk factor for Ebola virus disease exposure.

INTERPRETATION

Discrimination of Ebola virus disease cases from patients without the disease is a major challenge in an outbreak and needs rapid diagnostic testing. Suspected Ebola virus disease case definitions that rely on history of fever and risk factors for Ebola virus disease exposure do not have sufficient sensitivity to identify all cases of the disease.

FUNDING

None.

Picking up the bill - improving health-care utilisation in the Democratic Republic of Congo through user fee subsidisation: a before and after study

BACKGROUND

User fees have been shown to constitute a major barrier to the utilisation of health-care, particularly in low-income countries such as the Democratic Republic of Congo (DRC). Importantly, such barriers can lead to the exclusion of vulnerable individuals from health-care. In 2008, a donor-funded primary health-care programme began implementing user fee subsidisation in 20 health zones of the DRC. In this study, we quantified the short and long-term effects of this policy on health-care utilisation.

METHODS

Sixteen health zones were included for analysis. Using routinely collected health-care utilisation data before and after policy implementation, interrupted time series regression was applied to quantify the temporal impact of the user fee policy in the studied health zones. Payment of salary supplements to health-care workers and provision of free drugs - the other components of the programme - were controlled for where possible.

RESULTS

Fourteen (88%) health zones showed an immediate positive effect in health-care utilisation rates (overall median increase of 19%, interquartile range 11 to 43) one month after the policy was introduced, and the effect was significant in seven zones (P <0.05). This initial effect was sustained or increased at 24 months in five health zones but was only significant in one health zone at P <0.05. Utilisation reduced over time in the remaining health zones (overall median increase of 4%, interquartile range -10 to 33). The modelled mean health-care utilisation rate initially increased significantly from 43 consultations/1000 population to 51 consultations/1000 population during the first month following implementation (P <0.01). However, the on-going effect was not significant (P =0.69).

CONCLUSIONS

Our research brings mixed findings on the effectiveness of user fee subsidisation as a strategy to increase the utilisation of services. Future work should focus on feasibility issues associated with the removal or reduction of user fees and how to sustain its effects on utilisation in the longer term.

Increasing Pneumocystis pneumonia, England, UK, 2000-2010

After an increase in the number of reported cases of Pneumocystis jirovecii pneumonia in England, we investigated data from 2000-2010 to verify the increase. We analyzed national databases for microbiological and clinical diagnoses of P. jirovecii pneumonia and associated deaths. We found that laboratory-confirmed cases in England had increased an average of 7% per year and that death certifications and hospital admissions also increased. Hospital admissions indicated increased P. jirovecii pneumonia diagnoses among patients not infected with HIV, particularly among those who had received a transplant or had a hematologic malignancy. A new risk was identified: preexisting lung disease. Infection rates among HIV-positive adults decreased. The results confirm that diagnoses of potentially preventable P. jirovecii pneumonia among persons outside the known risk group of persons with HIV infection have increased. This finding warrants further characterization of risk groups and a review of P. jirovecii pneumonia prevention strategies.

Travel-associated Legionnaires’ disease in residents from England and Wales travelling to Corfu, Greece, August to October 2011

Binary file ES_Abstracts_Final_ECDC.txt matches

Fatal Cerebral Toxoplasmosis in a Heavily Immune Suppressed Patient with Waldentrom's Disease

A 57 year-old gentleman with Waldenstrom's disease developed ecthyma gangrenosum, molluscum contagiosum and fatal cerebral toxoplasmosis. The emergence of these infections is discussed in the light of drug-induced immune-suppression.

Effect of axial length on retinal vascular network geometry

PURPOSE

To explore the association between axial length and retinal vascular network geometry (arteriovenous diameter ratio [AVR], arteriolar branching angles, and junctional exponents).

DESIGN

Prospective, cross-sectional study.

METHODS

Patients were recruited from a pseudophakic population that had preexisting axial length measurements. Mean arterial blood pressure and previous medical history were recorded. Fundal photographs were taken. Digital image analysis was used to determine the AVR, mean arteriolar bifurcation angle, and junctional exponent for each subject.

RESULTS

In total, 52 subjects were analyzed. Axial length had no association with AVR (R = -0.01, P = .941), mean angles at arteriolar bifurcations (R = -.134, P = .342), or junctional exponents (R = .003, P = .982). However, increased axial length was associated with a trend for lower measured retinal venular and arteriolar diameters (R = -.28, P = .04 and R = -.23, P = .10, respectively). Junctional exponents correlated with both the AVR (R = .32, P = .019) and vascular bifurcation angles (omega) (R = .317, P = .022).

CONCLUSIONS

Increased axial length is associated with narrowing of both arteriolar and venular diameters, but not on the AVR, or vessel junctions. Future studies exploring the influence of systemic disease on retinal vascular topography do not need to consider axial length as a potential confounding variable when utilizing measures such as AVR or vessel junctions. Vascular arteriolar junctional exponents may serve as a good measure of overall altered retinal vascular geometry in cardiovascular disease.

The use of porous polyethylene (Medpor) lower eyelid spacers in lid heightening and stabilisation

BACKGROUND/AIMS

The management of lower eyelid retraction can be challenging, and established techniques to correct it are not always successful. Previous reports have suggested a role for the ultrathin high density porous polyethylene lower eyelid spacer (Medpor LES) in such patients. The authors report the experience of three surgeons implanting Medpor LES over 1 year, and ascertain whether such implants are a safe and effective alternative to autogenous spacers.

METHODS

A prospective, interventional, non-comparative case series of consecutive patients. Surgical indications for Medpor LES were noted. Preoperative and postoperative lower marginal reflex distance (L-MRD), vertical palpebral aperture (PA), lagophthalmos, and scleral show inferior to the limbus (LSS) were recorded, together with major and minor complications.

RESULTS

32 patients (35 eyelids) had a Medpor LES inserted, 22/32 under local anaesthetic, and nine with adjunctive procedures. Mean follow up was 22 months (range 15-28 months). The Medpor LES was effective in reducing the palpebral aperture (p<0.001) and lagophthalmos (p = 0.04) and raising the lower eyelid height by reducing both L-MRD (p = 0.006) and LSS (p<0.001). However there were major complications in 7/32 patients and minor complications in 8/32, most requiring further surgery. Final outcome was good in 24/35 eyelids and satisfactory in 5/35.

CONCLUSIONS

Despite a good or satisfactory final outcome in the majority of patients, the value of this technique is limited by complications, and should be reserved for those unsuitable for safer techniques.

The risk of complications of uveitis in a district hospital cohort

AIMS

To establish the frequency and risk factors for visual loss in a primary referral cohort of hospital patients with uveitis.

METHODS

561 consecutive uveitis patients attending three district hospitals were recruited and the acuity at the end of the study period recorded. A retrospective case-control study of risk factors for visual loss (permanent loss of acuity <6/9) was performed. Risk factors examined included type of uveitis, age at onset of uveitis, race, type of systemic inflammatory disease, length of follow up, and treatment variables.

RESULTS

Visual loss of at least 6/12 in one eye was found in 111 patients (19.9%). Only four patients (0.7%) suffered severe bilateral visual loss (6/36 or less). Visual loss was associated with age at onset >60 years (odds ratio 3.9, 95% confidence interval (CI) 2.2 to 7.0, long follow up 2.0 (1.2 to 3.3) and a history of cataract surgery 3.9 (2.1 to 7.2). It was less likely in patients with acute anterior uveitis 0.2 (0.1 to 0.3).

CONCLUSION

The frequency of visual loss associated with uveitis in a district hospital cohort is less than that found in referral centres and levels of legal blindness are low. Although acute anterior uveitis has a low frequency of visual loss it contributes significantly to the total burden. The ocular co-morbidity of the elderly may contribute to the increased visual loss of late onset uveitis.

Phototherapeutic keratectomy re-treatment for recurrent corneal erosion syndrome

AIMS

Phototherapeutic keratectomy with an excimer laser is commonly used to treat recurrent corneal erosion syndrome. The aim of this study was to determine the success of a repeat phototherapeutic keratectomy for patients with persistent macroerosions following initial treatment with phototherapeutic keratectomy.

METHODS

Eight patients who failed primary phototherapeutic keratectomy for recurrent corneal erosion syndrome were treated with repeat phototherapeutic keratectomy. All patients were treated with a superficial therapeutic ablation profile with a Visx, Nidek, or Summit 193 nm excimer laser. All patients were treated for both their primary treatment and re-treatment by the same surgeon. Retrospective analysis of case records of all patients requiring re-treatment was supplemented with a telephone interview.

RESULTS

Over a 5 year period (October 1995 to October 2000) 76 eyes were treated for recurrent erosion syndrome with phototherapeutic keratectomy. All patients had documented macroerosions and had failed previous treatment with a lubricant at night. Eight eyes (11%) continued to have macroerosions after this initial treatment; all opted for re-treatment with phototherapeutic keratectomy. Following re-treatment none reported symptoms consistent with a macroerosion. Six of eight patients (75%) are now symptom free; 2/8 (25%) have an occasional foreign body sensation relieved by lubricants. Follow up ranged from 9-60 months with a mean of 25.5 months.

CONCLUSION

Re-treatment with phototherapeutic keratectomy appears to be successful for patients with macroerosions complicating recurrent corneal erosion syndrome who have failed conservative management with ocular lubricants and a primary phototherapeutic keratectomy.

Correction of refractive error in the Victorian population: the feasibility of "off the shelf" spectacles

AIMS

To assess the feasibility of providing a stock of ready made spectacles for correction of refractive error in the general population.

METHODS

Data were collected in the Visual Impairment Project, a population based survey of Victorian residents aged 40 years or older in randomly selected urban and rural sample areas. This included a refractive eye examination and the proportion of subjects with hypermetropia, emmetropia (defined as -1.0 to +1.0D spherical equivalent), and myopia documented in the 40-60 year age group.

RESULTS

2595 (54.8%) participants were aged between 40 and 60 years. Those with a best corrected visual acuity of less than 6/12, astigmatism of more than 1.25D, and anisometropia of more than 0.5D were excluded. 516 participants had refractive error which was deemed suitable for correction by "off the shelf" spectacles. This represents 19.9% of all participants between 40 and 60 years of age. Provision of spectacles in 0.5D increments would provide suitable stock spectacles for 85.5% of a -3.0 to +3.0D range or 89.2% of a -3.50 to +3.50D range.

CONCLUSIONS

Ready made "off the shelf" spectacles could significantly alleviate visual morbidity due to refractive error in up to 20% of an urban population in Australia. This approach may also be useful in developing countries with poor access to optometric services.

A comparison of different depth ablations in the treatment of painful bullous keratopathy with phototherapeutic keratectomy

AIM

To study the efficacy of phototherapeutic keratectomy (PTK) for pain relief for patients with painful bullous keratopathy and poor visual potential.

METHODS

Patients with painful bullous keratopathy and poor visual potential were treated with superficial PTK (8-25 microm), intermediate (50-100 microm) or deep PTK (25% stromal thickness) using the Nidek EC5000 excimer laser after manual epithelial debridement. Follow up ranged from 1 to 24 months (mean 6.5 months). Outcome measures included symptomatic relief and need for further treatment.

RESULTS

In the superficial PTK group five of eight (62%) patients improved symptomatically after treatment. The three (38%) who did not improve went on to have penetrating keratoplasty for pain relief. In the intermediate depth group only two of five (40%) patients had symptom alleviation. The three others (60%) required further procedures. 20 of 24 (83%) patients treated with deep PTK had significant or total alleviation of symptoms. Of these, one developed acute anterior uveitis 9 months after PTK and two required botulinum ptosis for persistent corneal epithelial defects, one of whom had three consecutive episodes of microbial keratitis. Three of 24 suffered occasional discomfort and one patient required a penetrating keratoplasty for continued pain.

CONCLUSION

PTK can be a useful therapeutic measure in painful bullous keratopathy with poor visual potential. Deep PTK appears to be more successful in pain management than superficial treatment.

Patterns of prescription and drug use in ophthalmology in a tertiary hospital in Delhi

AIMS

The present study was carried out to describe the patterns of prescription and drug use in Ophthalmology in out-patients at Dr Rajendra Prasad (R.P.) Centre for Ophthalmic Sciences of All India Institute of Medical Sciences (A.I.I.M.S.), New Delhi.

METHODS

Prescriptions of 1017 out-patients were audited through a specially designed form and analysed for the following: average number of drugs per prescription, duration of treatment (recorded or not), dosage forms prescribed, frequency of administration (recorded or not), number of encounters with antibiotics and percentage of drugs prescribed by generic name.

RESULTS

Prescription analysis showed that the average number of drugs per prescription was 3.03. Duration of treatment was recorded for only 26.4% of the drugs prescribed. The maximum number of drugs prescribed were in the form of eye drops (76%), followed by tablets (10.9%), ointments (6.4%), syrups (1%), capsules (0.7%), lotions (0.3%) and injections (0.1%). No dosage form was recorded for 4.6% of the drugs prescribed. The frequency of administration was recorded for only 77.9% of the drugs prescribed. The number of antibiotics prescribed was 1059 which constitutes 34.2% of the total number of drugs prescribed. The percentage of drugs prescribed by generic name was only 35%.

CONCLUSIONS

The results obtained in this study indicated an awareness of polypharmacy but a high incidence of common prescription writing errors such as not recording the duration of therapy, frequency of administration and dosage form. Moreover prescribing by generic name was also low.

Infliximab (chimeric anti-tumour necrosis factor alpha monoclonal antibody) versus placebo in rheumatoid arthritis patients receiving concomitant methotrexate: a randomised phase III trial. ATTRACT Study Group

BACKGROUND

Not all patients with rheumatoid arthritis can tolerate or respond to methotrexate, a standard treatment for this disease. There is evidence that antitumour necrosis factor alpha (TNFalpha) is efficacious in relief of signs and symptoms. We therefore investigated whether infliximab, a chimeric human-mouse anti-TNFalpha monoclonal antibody would provide additional clinical benefit to patients who had active rheumatoid arthritis despite receiving methotrexate.

METHODS

In an international double-blind placebo-controlled phase III clinical trial, 428 patients who had active rheumatoid arthritis, who had received continuous methotrexate for at least 3 months and at a stable dose for at least 4 weeks, were randomised to placebo (n=88) or one of four regimens of infliximab at weeks 0, 2, and 6. Additional infusions of the same dose were given every 4 or 8 weeks thereafter on a background of a stable dose of methotrexate (median 15 mg/week for > or =6 months, range 10-35 mg/wk). Patients were assessed every 4 weeks for 30 weeks.

FINDINGS

At 30 weeks, the American College of Rheumatology (20) response criteria, representing a 20% improvement from baseline, were achieved in 53, 50, 58, and 52% of patients receiving 3 mg/kg every 4 or 8 weeks or 10 mg/kg every 4 or 8 weeks, respectively, compared with 20% of patients receiving placebo plus methotrexate (p<0.001 for each of the four infliximab regimens vs placebo). A 50% improvement was achieved in 29, 27, 26, and 31% of infliximab plus methotrexate in the same treatment groups, compared with 5% of patients on placebo plus methotrexate (p<0.001). Infliximab was well-tolerated; withdrawals for adverse events as well as the occurrence of serious adverse events or serious infections did not exceed those in the placebo group.

INTERPRETATION

During 30 weeks, treatment with infliximab plus methotrexate was more efficacious than methotrexate alone in patients with active rheumatoid arthritis not previously responding to methotrexate.

Cytokines in autoimmune disorders

Cytokines are important protein mediators of immunity, inflammation, cell proliferation, differentiation, fibrosis, etc. (Oppenheim and Saklatvala, 1993). As these are the major biological processes underlying autoimmunity, it is not surprising that there is now convincing evidence that cytokines have an important role in the pathogenesis of autoimmunity (Brennan and Feldmann, 1996; Feldmann et al., 1996). There has been much progress since we first highlighted the role of cytokines such as IFN gamma in autoimmunity in the early 1980s (Bottazzo et al., 1983). The number of cytokines molecularly cloned has increased greatly, and the biochemical and structural basis of their action are partly understood, as cytokine genes and that of their receptors have been cloned. Knowledge of cytokine signalling is rapidly expanding (see Chapter XIII). In medical terms, clear evidence of the importance of cytokines in autoimmunity is demonstrated by therapeutic advances. Thus it is possible to dramatically improve patients with rheumatoid arthritis and Crohn's disease by blocking TNF alpha, and a new target for therapy, TNF alpha, has thus been validated for both these diseases.

The natural history of epiphora in childhood

PURPOSE

To investigate the incidence and aetiology of epiphora in a population of 7-year-old children and determine whether a conservative management policy for congenital nasolacrimal duct obstruction (CNLDO) results in excess lacrimal dysfunction in later childhood.

METHODS

A postal questionnaire was sent to the parents of a large cohort of 7-year-old children previously investigated to determine the incidence and natural progression of CNLDO. They were asked about the presence of epiphora, and its relationship to atopic disease and the presence of upper respiratory tract infections (URTI). Information on epiphora had also been gathered from the same cohort at age 3 1/2 years at a routine examination. Data were compared with those for epiphora in infancy in the same cohort.

RESULTS

The incidence of epiphora at 3 1/2 years was 5.5%, and 7 years 7.7%. At age 7 years 70% of cases were related to atopic disease or URTI. CNLDO was not significantly related to epiphora in later childhood (p = 0.000032).

CONCLUSIONS

A policy of delaying nasolacrimal probing in CNLDO until after the age of 1 year does not result in a detectable excess of lacrimal dysfunction in later childhood, when epiphora is more likely to be related to atopic disease or upper respiratory tract infection.

Indocyanine green angiography in a case of punctate inner choroidopathy

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Choroidal ischaemic plaques in sarcoidosis

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T-cell-targeted immunotherapy

The pace of T-cell research is matched only by the speed with which fundamental advances are being developed as new therapies. This report from a recent meeting updates developments in a number of immunointervention strategies.

Detection of transforming growth factor-beta in rheumatoid arthritis synovial tissue: lack of effect on spontaneous cytokine production in joint cell cultures

The presence of transforming growth factor-beta (TGF-beta) in inflammatory joint disease was investigated. Synovial fluid from patients with rheumatoid arthritis (RA) and patients with other non-autoimmune inflammatory joint diseases contained high levels of both active and latent TGF-beta. Levels of active TGF-beta did not correlate with drug regimen in either patient group or with the recovery period in the individuals with non-RA joint disease. Freshly isolated synovial cells from individuals with RA were shown by Northern blotting to express the mRNA for TGF-beta 1 and to secrete latent TGF-beta protein which could be neutralized by antibodies to TGF-beta 1 and TGF-beta 2. Lipopolysaccharide-stimulated peripheral blood mononuclear cells from normal donors produced interleukin-1 (IL-1) and tumour necrosis factor-alpha (TNF-alpha) which was inhibited by pretreatment of these cells with recombinant TGF-beta. Cytokine production was not inhibited if the addition of TGF-beta was used after the inducing stimulus, suggesting that in activated cells cytokine production cannot be inhibited. This was confirmed by the observation that neither TGF-beta 1 or TGF-beta 2 inhibited spontaneous IL-1 or TNF-alpha production by rheumatoid synovial mononuclear cells in culture. These findings show that despite the presence of active TGF-beta in RA synovial joints and the spontaneous production of latent (potentially active) TGF-beta by RA cells in culture, additional TGF-beta did not inhibit ongoing cytokine synthesis in vitro. This suggests that TGF-beta may not inhibit cytokine production in the rheumatoid joint although it cannot be ruled out that in vivo TGF-beta already has an immunosuppressive effect which cannot be further increased in vitro by exogenous protein.

Inhibitory effect of TNF alpha antibodies on synovial cell interleukin-1 production in rheumatoid arthritis

The effect of tumour necrosis factor (TNF alpha) antibodies on synovial cell interleukin-1 (IL-1) production was investigated in 7 patients with rheumatoid arthritis and in 7 with osteoarthritis. Synovial cell IL-1 production was significantly reduced by anti-TNF alpha antibody in cultures from patients with rheumatoid arthritis, but antilymphotoxin antibody did not have this effect (except in 1 culture). In cultures from patients with osteoarthritis spontaneous IL-1 production was low, despite high concentrations of TNF alpha, and IL-1 production was not inhibited by anti-TNF alpha antibody. In rheumatoid arthritis, TNF alpha may be the main inducer of IL-1, and anti-TNF alpha agents may be useful in treatment.

Excessive production of interleukin 6/B cell stimulatory factor-2 in rheumatoid arthritis

High levels of interleukin 6 (IL 6/B cell stimulatory factor-2) were detected in synovial fluids from the joints of patients with active rheumatoid arthritis (RA). The cells found in freshly isolated synovial fluid constitutively expressed IL 6 mRNA. The synovial tissues obtained by joint biopsy were also found to produce IL 6 in vitro. Immunohistochemical analysis demonstrated that CD2+ T cells as well as CD20+ blastoid B cells in the synovial tissues produce IL 6. The data indicate that IL 6 is generated constitutively in RA and its overproduction may explain the local as well as the generalized symptoms of RA, since IL 6 can function as B cell growth and differentiation factor as well as hepatocyte-stimulating factor.

Detection of activated T cell products in the rheumatoid joint using cDNA probes to Interleukin-2 (IL-2) IL-2 receptor and IFN-gamma

Attempts to detect immune mediators in RA synovial fluids by bioassay or radioimmunoassay have yielded conflicting results, and so we have begun to analyse the complex immunological reactions occurring within the rheumatoid joint using recombinant DNA technology. High levels of Interleukin-2 (IL-2) and IL-2 receptor transcripts were found in the mononuclear cells of the rheumatoid lesions. Interferon gamma (IFN gamma) mRNA was also detected, although at lower level than IL-2. To investigate the possible relevance of IL-2 and IL-2 receptor mRNA expression to the chronicity of the disease, RA joint cells were cultured in the absence of any stimulus, and the duration of mRNA expression compared to that of blood mononuclear cells (PBM), optimally stimulated. IL-2 mRNA was found to persist in culture for many days, in contrast to its transient (less than 24 h) presence in stimulated PBM. IL-2 receptor expression was also prolonged. In contrast IFN gamma mRNA, present at biopsy in 10/12 RA samples, was found to increase significantly in vitro. These results suggest that persistent T cell activation is of importance in the pathogenesis of RA, and suggests that prolonged mediator production (IL-2 and IFN gamma) may be of importance. The elevation of IFN gamma mRNA in culture and its lower relative expression suggests that there are inhibitory immunoregulatory influences within the RA joint. To determine whether abnormal IL-2 mRNA expression may be due to a genetic defect in the region controlling IL-2 gene expression, Southern blotting analysis of genomic DNA was performed with a 5' flanking probe using normal, RA and systemic lupus erythematosis patients. No abnormalities were detected.

Experimental and clinical experience with a gelatin impregnated Dacron prosthesis

Laboratory and clinical evaluation of a knitted Dacron graft impregnated with gelatin to confer zero porosity is described. Graft performance was tested by standard methods for biodegradation of the sealant and in vitro thrombogenicity. The gelatin sealant was removed after seven to nine days and there was no platelet adhesion to Gelseal compared with unsealed Dacron. Animal experiments revealed normal macroscopic appearances in the graft and histological disappearance of the gelatin impregnate between five and ten days, allowing a cellular response similar to unsealed Dacron. The first 100 patients to have Gelseal aortic bifurcation graft implanted at Glasgow Royal Infirmary are described. The graft did not require preclotting. Blood transfusion was not necessary in 74% of patients. There is 100% patency at 21 months. A knitted Dacron graft sealed with gelatin is a safe, nonporous prosthesis at implantation.

New polyester arterial prostheses from Great Britain: an in vitro and in vivo evaluation

Two models of knitted velour polyester prostheses have been developed in Great Britain, i.e. the VP1200K and the VP50K Triaxial. The evaluation of these new devices in vitro and in vivo in dogs has demonstrated that, while the first model has similar surgical, mechanical and healing characteristics in the short term to other commercial knitted velour prostheses, the second model has lower water permeability and superior strength and dimensional stability. On the basis of these results, clinical investigations can be undertaken.

Repeated membrane plasma separation with on-line sorbent treatment of plasma in the conscious rat

Repeated membrane plasma separation with on-line sorbent treatment of plasma was performed in unrestrained and conscious rats, thus avoiding the possible effects of repeated stress and exposure to anesthetic agents. The procedure was well tolerated, even after four consecutive perfusions. Blood flow was 0.7 ml/min, with a transmembrane pressure of 18.6 mm Hg and plasma filtration rate of 0.21 ml/min. This allowed 12 ml of plasma (greater than 1 plasma volume) to be treated within 1 h. Levels of albumin, immunoglobulin G, and C3 remained constant during each perfusion and were not significantly different from those of animals subjected to control procedures. Results obtained from filtrate were comparable at 15 and 60 min with values obtained from whole blood, with sieving coefficients of approximately 1. Leukocyte, erythrocyte, and thrombocyte counts remained unchanged during each plasma perfusion. A progressive rise in leukocyte counts occurred following successive perfusions, but this was true also of animals subjected to control procedures.