New consensus definition on defining and measuring care for children with paediatric feeding disorder

AIM

This study addresses the absence of a definition of care for children with feeding disorders, limited agreement on key performance indicators (KPIs), and the lack of data linked to those KPIs.

METHODS

Clinicians, consumers and researchers involved in outpatient feeding care in New South Wales (NSW), Australia were invited to participate in a two-Phase study. In Phase 1, a modified Delphi method was used. Two rounds of voting resulted in a new consensus definition of a multidisciplinary paediatric feeding clinic. Three further rounds voting determined relevant KPIs. In Phase 2, the KPIs were piloted prospectively in 10 clinics.

RESULTS

Twenty-six clinicians, consumers and researchers participated in Phase 1. Participation across five voting rounds declined from 92% to 60% and a valid definition and KPI set were created. In Phase 2, the definition and KPIs were piloted in 10 clinics over 6 weeks. Data for 110 patients were collected. The final KPI set of 28 measures proposed covers clinical features, patient demographics and medical issues, parent-child interaction and outcome measures.

CONCLUSIONS

A new definition of a multidisciplinary paediatric feeding clinic is now available, linked to a standardised KPI set covering relevant performance measures. These proved viable in baseline data collection for 10 clinics across NSW. This sets a foundation for further data collection, systematic measurement of care provision and outcomes, and research needed to deliver care improvement for children with paediatric feeding disorder.

8 Unexpected retinopathy in a patient presenting with bilateral optic disc swelling

A 12-year-old boy presented with 5 day history of blurry vision, 'wobbly eyes', tinnitus and difficulty seeing at night. Local ophthalmology noted bilateral optic disc swelling and referred him urgently for neurological investigations.Clinical Findings: At presentation VA was RE 0.00 and LE 0.2 with normal Ishihara colour vision. His extraocular movements were full without manifest strabismus. Fundoscopy showed bilateral optic disc swelling. Electrophysiology unexpectedly revealed a functionally cone isolated retina with markedly abnormal rod function. Pattern VEPs indicated bilateral macular pathway dysfunction affecting left eye more than right eye. Wide field imaging showed bilateral diffusely scattered yellow-white flecks in the midperiphery of each eye. His kinetic visual fields were moderately restricted bilaterally. MRI showed a Chiari 1 malformation with cerebellar tonsil herniation, but LP opening pressure was normal.Differential diagnosis included RDH5 retinopathy or vitamin A deficiency. On questioning he reported a diet restricted to only meat and biscuits. His vitamin A levels were subnormal at 0.14 umol/L (reference range 0.9-2.5umol/l) and he was started on high-dose Vitamin A supplements.Four months after supplementation retinal appearances had normalised, the rod ERGs recovered, nyctalopia and visual field restriction resolved. PVEPs had improved but an element of LE macular pathway dysfunction remained. Optic disc swelling settled leaving mild temporal pallor, particularly of the LE with some RNFL loss.It is important to recognise nutritional Vitamin A deficiency in children as prompt recognition and treatment can improve symptoms, reverse retinal pathology which we have demonstrated with electrophysiological findings.

Twelve-month outcomes of a father-child lifestyle intervention delivered by trained local facilitators in underserved communities: The Healthy Dads Healthy Kids dissemination trial

Healthy Dads Healthy Kids (HDHK) was the first program internationally to specifically target overweight and obese fathers to improve their children's health. In previous randomized controlled trials, HDHK generated meaningful short-term improvements in the adiposity, physical activity, and eating behaviors of both fathers and children. The aim of this dissemination trial was to evaluate the 12-month impact of HDHK when delivered by trained facilitators across four low socioeconomic and regional communities in the Hunter Region, Australia. The study was a nonrandomized, prospective trial with minimal eligibility criteria (i.e., father body mass index [BMI] ≥ 25 kg/m2 and children aged 4-12 years). HDHK included eight weekly practical and theoretical sessions. Assessments were baseline, 3 months (post-intervention), 6-months, and 12-months. The primary outcome was fathers' weight. Secondary outcomes included child BMI z-score and validated lifestyle behavior measures (e.g., physical activity, diet). Overall, 189 fathers (mean age: 40.2 years, BMI: 32.6 kg/m2) and 306 children (mean age: 8.1 years) participated in one of 10 HDHK programs in four areas. Intention-to-treat linear mixed models revealed a significant mean reduction in fathers' weight at post-intervention (-3.6 kg, 95% confidence interval: -4.3, -2.9), which was maintained at 12 months (71% retention). Corresponding improvements were also detected in children's BMI z-score and a range of lifestyle behaviors for both fathers and children. Attendance and satisfaction levels were high. Positive intervention effects observed in previous randomized controlled trials were largely replicated and sustained for 12 months when HDHK was delivered by trained local facilitators in underserved communities. Further investigation into the key systems, processes, and contextual factors required to deliver HDHK at scale appears warranted.

Antipsychotic-related fatal poisoning, England and Wales, 1993-2013: impact of the withdrawal of thioridazine

CONTEXT

Use of second generation antipsychotics in England and Wales has increased in recent years whilst prescription of first generation antipsychotics has decreased.

METHODS

To evaluate the impact of this change and of the withdrawal of thioridazine in 2000 on antipsychotic-related fatal poisoning, we reviewed all such deaths in England and Wales 1993-2013 recorded on the Office for National Statistics drug poisoning deaths database. We also reviewed antipsychotic prescribing in the community, England and Wales, 2001-2013. Use of routine mortality data: When an antipsychotic was recorded with other drug(s), the death certificate does not normally say if the antipsychotic caused the death rather than the other substance(s). A second consideration concerns intent. A record of "undetermined intent" is likely to have been intentional self-poisoning, the evidence being insufficient to be certain that the individual intended to kill. A record of drug abuse/dependence, on the other hand, is likely to have been associated with an unintentional death. Accuracy of the diagnosis of poisoning: When investigating a death in someone prescribed antipsychotics, toxicological analysis of biological samples collected post-mortem is usually performed. However, prolonged attempts at resuscitation, or diffusion from tissues into blood as autolysis proceeds, may serve to alter the composition of blood sampled after death from that circulating at death. With chlorpromazine and with olanzapine a further factor is that these compounds are notoriously unstable in post-mortem blood. Deaths from antipsychotics: There were 1544 antipsychotic-related poisoning deaths. Deaths in males (N = 948) were almost twice those in females. For most antipsychotics, the proportion of deaths in which a specific antipsychotic featured either alone, or only with alcohol was 30-40%, but for clozapine (193 deaths) such mentions totalled 66%. For clozapine, the proportion of deaths attributed to either intentional self-harm, or undetermined intent was 44%, but for all other drugs except haloperidol (20 deaths) the proportion was 56% or more. The annual number of antipsychotic-related deaths increased from some 55 per year (1.0 per million population) between 1993 and 1998 to 74 (1.5 per million population) in 2000, and then after falling slightly in 2002 increased steadily to reach 109 (1.9 per million population) in 2013. Intent: The annual number of intentional and unascertained intent poisoning deaths remained relatively constant throughout the study period (1993: 35 deaths, 2013: 38 deaths) hence the increase in antipsychotic-related deaths since 2002 was almost entirely in unintentional poisoning involving second generation antipsychotics. Clozapine, olanzapine, and quetiapine were the second generation antipsychotics mentioned most frequently in unintentional poisonings (99, 136, and 99 deaths, respectively). Mentions of diamorphine/morphine and methadone (67 and 99 deaths, respectively) together with an antipsychotic were mainly (84 and 90%, respectively) in either unintentional or drug abuse-related deaths. Deaths and community prescriptions: Deaths involving antipsychotics (10 or more deaths) were in the range 11.3-17.1 deaths per million community prescriptions in England and Wales, 2001-2013. Almost all (96%) such deaths now involve second generation antipsychotics. This is keeping with the increase in annual numbers of prescriptions of these drugs overall (<1 million in 2000, 7 million in 2013), largely driven by increases in prescriptions for olanzapine and quetiapine. In contrast, deaths involving thioridazine declined markedly (from 40 in 2000 to 10 in 2003-2013) in line with the fall in prescriptions for thioridazine from 2001.

CONCLUSIONS

The removal of thioridazine has had no apparent effect on the incidence of antipsychotic-related fatal poisoning in England and Wales. That such deaths have increased steadily since 2001 is in large part attributable to an increase in unintentional deaths related to (i) clozapine, and (ii) co-exposure to opioids, principally diamorphine and methadone.

Simple methodology for the therapeutic drug monitoring of the tyrosine kinase inhibitors dasatinib and imatinib

A simple HPLC method has been developed to measure imatinib and N-desmethylimatinib (norimatinib) in plasma or serum at concentrations attained during therapy. Adaptation of this method to LC-MS/MS also allows dasatinib assay. A small sample volume (100 μL HPLC-UV, 50 μL LC-MS/MS) is required and analysis time is <5 min in each case. Detection was by UV (270 nm) or selective reaction monitoring (two transitions per analyte) tandem mass spectrometry. Assay calibration was linear (0.05-10 mg/L imatinib, 0.01-2.0 mg/L norimatinib and 1-200 µg/L dasatinib), with acceptable accuracy (86-114%) and precision (<14% RSD) for both methods. A comparison between whole blood and plasma confirmed that plasma is the preferred sample for imatinib and norimatinib assay. For dasatinib, although whole blood concentrations were slightly higher, plasma is still the preferred sample. Despite considerable variation in the (median, range) plasma imatinib and norimatinib concentrations in patient samples [1.66 (0.02-4.96) and 0.32 (0.01-0.99) mg/L, respectively, N = 104], plasma imatinib was >1 mg/L (suggested target for response) in all but one sample from patients achieving complete molecular response. As to dasatinib, the median (range) plasma dasatinib concentration was 13 (2-143) µg/L (N = 33). More observations are needed to properly assess the potential role of therapeutic drug monitoring in guiding treatment with dasatinib.

Motivation, attitudes and experience of donation: a follow-up of women donating eggs in assisted conception treatment

This paper reports a follow-up of 39 women who had donated eggs to an assisted conception unit. Their experience of donation and their motivation and attitudes were assessed. Comparisons were made with a group of semen donors who were attending a second unit. Female and male donors donated for altruistic reasons and neither group wished to have contact with recipients or donor offspring or have their identity revealed. Female donors were more involved in the donation process and more interested in the outcome of donation. They also appeared to be more motivated by 'helping' than male donors. The sample of female donors contained a small group of women who were donating to sisters and friends. In comparison with anonymous donors, these women reported more effects upon the family and issues of secrecy and openness were more apparent. The results are discussed in the light of previous studies and the legal framework for donation in the UK. Attention is drawn to the lack of social psychological analyses in this controversial medical area.

Developing educational programmes for nurses that meet today's addiction challenges

Since undergraduate curricula have in the past offered little substance abuse content, bold and innovative educational programmes are necessary to prepare nurses for the addiction challenges of the 1990s. The University of Kansas and the American Nurses' Foundation (ANF) recently addressed the problem when they were jointly funded by the John W. and Effie E. Speas Memorial Trust to present an alcohol and other drug education project targeted to nurses practicing in the local community. 60 nurses in key clinical settings were given an opportunity to receive general information about substance abuse through two, 2-day workshops. The purposes of the project were; (1) to plan and develop materials for an alcohol and other drug abuse (AODA) curriculum for practicing nurses in a variety of clinical areas; (2) to assess the effectiveness of the programme through on-site and post-workshop participant evaluations; (3) and to refine the curriculum and materials according to evaluation data. Results indicated that participants' knowledge of AODA was significantly increased by the workshop. Attitudes also changed in two areas, permissiveness and belief in treatment interventions. Decreased permissiveness toward substance abuse persisted 3 months after the workshop indicating this may be a lasting change. The conclusion is that education can lead to a change in knowledge and attitudes toward substance abuse.

Effects of alpha-adrenoceptor agonists and antagonists and of antidepressant drugs on pre- and postsynaptic alpha-adrenoceptors

The effects of alpha-adrenoceptor agonists and antagonists and of antidepressant drugs were studied on pre- and postsynaptic alpha-adrenoceptors. The rat vas deferens, stimulated at low frequency (0.1 Hz) was used for presynaptic studies. The rat anococcygeus muscle was used in postsynaptic studies. In the agonist studies clonidine and guanfacine were selective for presynaptic alpha-adrenoceptors, methoxamine and phenylephrine were selective for postsynaptic alpha-adrenoceptors and noradrenaline and alpha-methylnoradrenaline were equipotent at pre- and post-synaptic alpha-adrenoceptors. In the antagonist studies piperoxane and yohimbine were selective for presynaptic alpha-adrenoceptors, phentolamine was equipotent at pre- and postsynaptic alpha-adrenoceptors and prazosin was a selective postsynaptic alpha-adrenoceptor antagonist. In the series of antidepressants studied, mianserin was the most potent antagonist at presynaptic alpha-adrenoceptors, followed by trazodone, amitriptyline and nortriptyline in descending order of potency. Mianserin was approximately two hundred times less potent than piperoxane as a presynaptic alpha-adrenoceptor antagonist. Viloxazine and desipramine were inactive. With the exception of viloxazine all of the antidepressants examined possessed postsynaptic alpha-adrenoceptor antagonist properties.

A Discussion on the Operative Treatment of Cancer of the Rectum

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