The costs incurred by the NHS in England due to the unnecessary prescribing of dependency-forming medications

This cross-sectional study estimates the costs incurred by the National Health Service (NHS) in England as a consequence of the unnecessary prescribing (i.e. non-indicated or dispensable) of dependency-forming medicines (antidepressants, opioids, gabapentinoids, benzodiazepines, Z-drugs). It assesses prescribing in primary care from April 2015-March 2018. Analyses were based upon the following data sets: the number of adults continuously prescribed dependency forming medications and the duration of prescriptions (obtained from Public Health England); the Net Ingredient Cost (NIC) and the dispensing costs for each medicine (obtained from the NHS Business Service Authority [NHSBSA]). Consultation costs were calculated based on guideline recommendations and the number of consultations evidenced in prior research for long-term medication monitoring. Across opioids, gabapentinoids, benzodiazepines, Z-drugs the total estimated unnecessary cost over three years (April 2015-March 2018) was £1,367,661,104 to £1,555,234,627. For antidepressants the total estimated unnecessary cost for one year was £37,321,783 to £45,765,504. The data indicate that the NHS in England may incur a significant estimated mean annual loss of £455,887,035 to £518,411,542 for opioids, gabapentinoids, benzodiazepines, Z-drugs and an estimated annual loss of £37,321,783 to £45,765,504 for antidepressants. Combined, this gives an estimated annual loss of £493,208,818 to £564,177,046 as a result of non-indicated or dispensable prescribing of dependency-forming medicines. Estimates are conservative and figures could be higher.

Sustaining global partnerships for simulation integration: lessons from the field

AIM

A reciprocal partnership between two World Health Organization Collaborating Centers in the Americas region aimed to strengthen nursing and midwifery education through innovative integration of high-fidelity simulation.

METHODS/IMPLEMENTATION

Immersion of a visiting scholar in six-week training within a North American nursing school (host) solidified simulation champion designation, upon return at the home institution. Next, two expert nursing faculty implemented a train-the-trainer simulation course on-site. Following evaluation and virtual debriefing, a midwifery faculty visited the host institution for second-round training.

CONCLUSION

This ongoing program targets faculty development needs through a strong academic partnership, built upon global awareness and sustainable engagement.

Structure-function analyses of the ATX1 metallochaperone

Saccharomyces cerevisiae Atx1p represents a member of the family of metallochaperone molecules that escort copper to distinct intracellular targets. Atx1p specifically delivers copper to the Ccc2p copper transporter in the Golgi. Additionally, when overproduced, Atx1p substitutes for superoxide dismutase 1 in preventing oxidative damage; however the mechanistic overlap between these functions is unresolved. The crystal structure of Atx1p has been solved recently. By examining a surface electrostatic potential distribution, multiple conserved lysines are revealed on one face of Atx1p. An additional conserved lysine (Lys65) lies in close proximity to the metal binding site. Through site-directed mutagenesis, residues in the metal binding region including Lys65 were found to be necessary for both copper delivery to Ccc2p and for Atx1p antioxidant activity. Copper trafficking to Ccc2p also relied on the lysine-rich face of Atx1p. Surprisingly however, elimination of these lysines did not inhibit the antioxidant activity of Atx1p. We provide evidence that Atx1p does not suppress oxidative damage by a metallochaperone mechanism but may directly consume superoxide. Purified Cu-Atx1p reacts noncatalytically with superoxide anion in vitro. We conclude that the copper-trafficking and antioxidant functions of Atx1p arise from chemically and structurally distinct attributes of this metallochaperone.

Chronic pelvic pain caused by residual ovaries and ovarian remnants

OBJECTIVE

To determine the diagnostic effectiveness and treatment of women with chronic lower abdominal pain due to residual ovaries or ovarian remnants.

DESIGN

A prospective observational study.

SETTING

Tertiary referral pelvic pain clinic.

SUBJECTS

Seventeen women complaining of chronic pelvic pain of up to 25 years' duration, of whom seven had residual ovaries and 10 ovarian remnant(s).

MAIN OUTCOME MEASURES

Persistent lower abdominal pain, pelvic tenderness and quality of life one year post-operatively.

RESULTS

Six of the seven women with residual ovaries, and nine of the 10 women with presumed ovarian remnants experienced relief of the original pain, loss of pelvic tenderness and an improved quality of life.

CONCLUSIONS

Residual ovaries after hysterectomy and ovarian remnants are established causes of chronic pelvic pain. Diagnosis and surgical removal is frequently difficult. Management strategies are proposed for both conditions.

An alternative to hysterectomy? GnRH analogue combined with hormone replacement therapy

OBJECTIVE

To assess whether GnRH analogues are effective in relieving pelvic pain and congestion and whether menopausal symptoms caused by GnRH analogues can be minimised by supplementation with low dose continuous combined hormone replacement therapy (HRT).

DESIGN

Open prospective study.

SETTING

Tertiary referral clinic at a teaching hospital.

PATIENTS

Twenty-one women with chronic pelvic pain.

INTERVENTION

Four months' therapy with goserelin 3.6 mg/month combined with continuous oestradiol valerate 1 mg daily and medroxyprogesterone acetate 5 mg daily.

MAIN OUTCOME MEASURES

Visual analogue scale for pain, menopausal symptoms, bleeding patterns, uterine area, endometrial status, oestradiol concentrations and venogram scores.

RESULTS

Amenorrhoea was maintained in all but two women. Endometrial atrophy was maintained despite HRT supplementation. Two women had moderate menopausal symptoms but none had severe symptoms. Significant reduction of uterine cross sectional area was maintained throughout the study. There was no significant relief of pain.

CONCLUSIONS

HRT supplementation of GnRH analogues abolishes menopausal symptoms and thus may improve patient acceptability. Potentially beneficial effects such as endometrial atrophy, reduction of uterine volume and amenorrhoea were not negated by HRT. This combination is not effective in the treatment of chronic pelvic pain and congestion.

Pelvic congestion in women: evaluation with transvaginal ultrasound and observation of venous pharmacology

Fourteen women with chronic pelvic pain due to congestion underwent transvaginal ultrasound scanning to observe changes in the diameters of dilated pelvic veins. Spontaneous fluctuations were observed, and intravenous dihydroergotamine resulted in a consistent venoconstrictor response (p = 0.0021) during 20 min observation. Transvaginal ultrasound is useful for imaging dilated pelvic veins and for the study of venous pharmacology.

Accuracy of ultrasound measurements of female pelvic organs

Uterine size, endometrial thickness and ovarian volume were measured ultrasonically and the results compared with caliper measurements made shortly afterwards at the time of total hysterectomy and bilateral salpingo-oophorectomy. The results establish the validity of ultrasound measurements. Histological studies also confirmed the diagnosis made with ultrasound of polycystic ovaries in women complaining of pain due to pelvic congestion.

Carbon fibre composite bone plates. Development, evaluation and early clinical experience

We compared the mechanical properties of carbon fibre composite bone plates with those of stainless steel and titanium. The composite plates have less stiffness with good fatigue properties. Tissue culture and small animal implantation confirmed the biocompatibility of the material. We also present a preliminary report on the use of the carbon fibre composite plates in 40 forearm fractures. All fractures united, 67% of them showing radiological remodelling within six months. There were no refractures or mechanical failures, but five fractures showed an unexpected reaction; this is discussed.

The effect of starch glove powder on joint and other tissues

The purpose of this research was to establish the possible role of starch glove powder in complications following orthopaedic surgery using in vivo and in vitro techniques. Exposure of primary mouse peritoneal macrophages to starch glove powder caused 10% release of prostaglandin E2 (0.1 mg/ml, 16 h) but no increased release of lactate dehydrogenase, demonstrating that cell integrity had not been compromised. Long-term tissue reaction to starch glove powder was investigated in vivo by injection into mouse knee joints. Over a period of 52 weeks no inflammatory response was elicited, no starch was observed in the regional lymph nodes and none was found in joints after the 8th week. Starch glove powder appeared to be innocuous in the joint and although prostaglandin E2 release was stimulated in vitro, this had no apparent effect on joints in vivo.

The influence of the surface energy and roughness of implants on bone resorption

We investigated the possibility that the macrophages which are seen around implants may stimulate bone resorption and cause loosening. We found that macrophages release mediators that stimulate bone resorption, and that the amount of resorption increased by between 2.5 and 10 times when the macrophages adhered to a foreign surface. This bone resorption depended on the surface energy and roughness of the foreign surface, varying with these physical properties rather than with the chemical nature of the material. It is concluded that loosening of orthopaedic implants is likely to be influenced by the surface energy and roughness of the implant.

The biological response to titanium and titanium-aluminium-vanadium alloy particles. I. Tissue culture studies

One aspect of the biological response to titanium and titanium-aluminium-vanadium alloy was investigated by exposing primary cultures of human synovial fibroblasts and mouse peritoneal macrophages to particulate preparations of these materials. Both cell types appeared to be unaffected by either material as judged by microscopical examination. A small but significant release of lactate dehydrogenase was detected from both cell types in response to their exposure to the particulate material indicating that some cell damage occurred. Macrophages also exhibited a small release of the two lysosomal enzyme markers beta-glucuronidase and N-acetyl-beta-D-glucosaminidase. This indicates that these materials may have a mild inflammatory potential. No soluble metal could be shown to have dissolved from the particulate alloy or from pure titanium.

The biological response to titanium and titanium-aluminium-vanadium alloy particles. II. Long-term animal studies

The long-term tissue reactions to particulate titanium and titanium-aluminium-vanadium alloy were investigated by the intra-articular injection of material into the knee joints of mice. The tissue response was studied over a period of 2 to 52 weeks. In general, both materials were well tolerated, there was no evidence of necrosis and only a slight thickening of the synovium occurred around particles. Multinucleated giant cells were only rarely seen and no palpable tumours formed in any animal at any site.

The intra-articular response to particulate carbon fibre reinforced high density polyethylene and its constituents: an experimental study in mice

Carbon fibre reinforced high density polyethylene (CFRHDP) Meuller acetabular cups are available for total hip replacement. Despite the improved mechanical properties of CFRHDP over high density polyethylene (HDP) the wear characteristics of CFRHDP are a contentious issue. The biocompatibility of CFRHDP wear debris was investigated by intra-articular injection into mice and compared with that induced by HDP and carbon fibres. The response to CFRHDP was identical to that seen with HDP: the carbon fibre component did not appear to modify the response. From the biological point of view, therefore, the wear properties of CFRHDP must be better than those of HDP to offer a significant advantage.

The action of cobalt, nickel and chromium on phagocytosis and bacterial killing by human polymorphonuclear leucocytes; its relevance to infection after total joint arthroplasty

Infection after total joint arthroplasty is a serious clinical complication. The accumulation of metallic wear and corrosion products may cause a localized reduction in the defense process, which may be particularly relevant in the cause of late infections. This hypothesis has been tested by exposing human polymorphonuclear leucocytes (PMN) in vitro to cobalt, nickel and chromium at various concentrations. The ability of PMNs to phagocytose and kill Staphylococcus epidermidis was measured. Nickel and cobalt reduced the number of bacteria phagocytosed by about 50% at a concentration of 0.05 and 0.01 mumol ml-1 respectively over an 18 h incubation period. Neither metal affected the rate at which S. epidermidis was killed. Chromium had no effect. All metals were used at sub-toxic levels.

The toxicity of metals used in orthopaedic prostheses. An experimental study using cultured human synovial fibroblasts

Some of the component metals of the alloys used for total joint prostheses are toxic and dissolve in the body fluids. It is important to establish how toxic these metals are and to assess the risk of localised tissue necrosis around the prostheses. This has been investigated by incubating primary monolayer cultures of human synovial fibroblasts with various preparations of metals for periods up to 18 days. Morphological changes were evident after exposure to cobalt chloride at a concentration of 50 nanomoles per millilitre and to nickel chloride at 200 nanomoles per millilitre. Chromic chloride, ammonium molybdate and ferric chloride produced no changes up to 500 nanomoles per millilitre. Cultures exposed to particulate pure metals were poisoned by cobalt and vanadium but were not affected under the same conditions by nickel, chromium, molybdenum, titanium or aluminium. Particulate cobalt and vanadium were probably toxic due to their relatively high solubility (four and one micromoles per millilitre respectively after seven days incubation). Particulate nickel also dissolved (three nanomoles per millilitre after seven days) but not in sufficient quantities to be toxic. It appears, therefore, that potentially the most harmful components are cobalt from cobalt-chromium alloy, nickel from stainless steel, and vanadium from titanium alloy. As far as can be estimated, the only combination of materials which is likely to give rise to toxic levels of metal under clinical conditions, is cobalt-chromium alloy articulating against itself to produce relatively high levels of cobalt.

The haemolytic action of particulate metals (Cd, Cr, Co, Fe, Mo, Ni, Ta, Ti, Zn, Co-Cr alloy)

The haemolytic action of particulate cadmium, chromium, cobalt, iron, molybdenum, nickel, tantalum, titanium, zinc and cobalt-chromium alloy is described. Cobalt, nickel and cobalt-chromium alloy were found to be the most active and were also the most toxic for other cells in tissue culture. In contrast the other particulate metals produced only low levels of haemolysis and in general, were well tolerated by cells in culture. A dual effect of particulate metals is described due firstly to a direct interaction between the particle surface and cell membrane and secondly to the possible toxic effects of dissolved metal.

Tolerance of mouse macrophages in vitro to barium sulfate used in orthopedic bone cement

Barium sulfate, used as a radio-opaque marker in some orthopedic bone cements, has been shown to escape into the surrounding tissues. This may present a potential hazard. In particular, phagocytic cells may be exposed to relatively high internal levels of barium once the particles have been phagocytosed. Mouse peritoneal macrophages exposed to barium sulfate for periods up to 144 hr showed a marked cytoplasmic vacuolization from which they recovered only partially. Barium sulfate did not appear to damage the cell membrane as judged by lactice dehydrogenase release. In the relatively low doses and with the periods of exposure described here, barium sulfate does not appear to present a serious toxic hazard in the short term. It is possible, however, that longer exposures and larger doses may result in the death of phagocytic cells which have ingested barium sulfate.

A study on the effects of particulate metals of orthopaedic interest on murine macrophages in vitro

This is part of a larger study designed to investigate the action of particulate metals of orthopaedic interest on tissues. Damaging effects were determined by cytological examination and the assay of two enzymes. Lactic dehydrogenase (LDH) if released into the supernatant indicates a damaged cell membrane; decreased intracellular levels of glucose-6-phosphate dehydrogenase (G6PD) indicates a lowered phagocytic capacity of the cells. Soluble and wear products around implanted prostheses could facilitate late infections by impairing local reactions to bacteria. Particulate cobalt, nickel and cobalt-chromium alloy were found to damage the cells and to cause LDH release. G6PD was found to have a lower activity in the cells exposed to these materials. In contrast, titanium, chromium and molybdenum were well tolerated by macrophages and had no effect on the distribution and activity of either enzyme. The solubility of these metals in the culture medium was also measured.

A STUDY ON THE EFFECTS OF PARTICULATE METALS OF ORTHOPAEDIC INTEREST ON MURINE MACROPHAGES IN VITRO

This is part of a larger study designed to investigate the action of particulate metals of orthopaedic interest on tissues. Damaging effects were determined by cytological examination and the assay of two enzymes. Lactic dehydrogenase (LDH) if released into the supernatant indicates a damaged cell membrane; decreased intracellular levels of glucose-6-phosphate dehydrogenase (G6PD) indicates a lowered phagocytic capacity of the cells. Soluble and wear products around implanted prostheses could facilitate late infections by impairing local reactions to bacteria. Particulate cobalt, nickel and cobalt-chromium alloy were found to damage the cells and to cause LDH release. G6PD was found to have a lower activity in the cells exposed to these materials. In contrast, titanium, chromium and molybdenum were well tolerated by macrophages and had no effect on the distribution and activity of either enzyme. The solubility of these metals in the culture medium was also measured.