Preventable suicides involving medicines: A systematic case series of coroners' reports in England and Wales

Background

In England and Wales coroners have a duty to write a report, called a Prevention of Future Deaths report or PFD, when they believe that actions should be taken to prevent future deaths. Coroners send PFDs to individuals and organisations who are required to respond within 56 days. Despite the increase in mental health concerns and growing use of medicines, deaths reported by coroners that have involved medicine-related suicides had not yet been explored. Therefore, this study aimed to systematically assess coroners' PFD reports involving suicides in which a medicine caused or contributed to the death to identify lessons for suicide prevention.

Methods

Using the Preventable Deaths Tracker database (https://preventabledeathstracker.net/), 3037 coroners' PFD reports in England and Wales were screened for eligibility between July 2013 and December 2019. Reports were included if they involved suicide or intentional self-harm and prescribed or over-the-counter medication; illicit drugs were excluded. Following data extraction, descriptive statistics, document and content analysis were performed to assess coroners' concerns and the recipients of reports.

Results

There were 734 suicide-related coroner reports, with 100 (14%) reporting a medicine. Opioids (40%) were the most common class involved, followed by antidepressants (30%). There was wide geographical variation in the writing of reports; coroners in Manchester wrote the most (18%). Coroners expressed 237 concerns; the most common were procedural inadequacies (14%, n = 32), inadequate documentation and communication (10%, n = 22), and inappropriate prescription access (9%, n = 21). 203 recipients received the PFDs, with most sent to NHS trusts (31%), clinical commissioning groups (10%), and general practices (10%), of which only 58% responded to the coroner.

Conclusions

One in four coroner reports in England and Wales involved suicides, with one in seven suicide-related deaths involving a medicine. Concerns raised by coroners highlighted gaps in care that require action from the Government, health services, and prescribers to aid suicide prevention. Coroner reports should be routinely used and monitored to inform public health policy, disseminated nationally, and responses to coroners should be transparently enforced so that actions are taken to prevent future suicides.

Abstract P5-15-12: Real-life activity of oral vinorelbine in metastatic breast cancer patients in the Unicancer ESME database

Background: In 2014, UNICANCER, composed of 18 French Comprehensive Cancer Centers, launched the Epidemiological Strategy and Medical Economics (ESME) program to investigate real-world data in oncology. Real-world data give the opportunity to assess the activity of specific products outside the framework of clinical trials. Oral vinorelbine (OV) is one of the therapeutic options available for metastatic breast cancer (mBC). Few data are available regarding its real clinical efficiency in current practice. We aimed at evaluating such activity within the ESME population.

Methods: The ESME-mBC database was built from information systems, treatment databases and patients' electronic files, with homogenous on-site collected information and high-level quality-control (Delaloge et al, Ann. Oncol 2016 (in press)). All patients having started a systemic treatment for mBC in a cancer center participating in the ESME program between 01-Jan-2008 and 31-Dec-2013 have been selected into the database.

For the purpose of the current analyses, data cut-off was July, 2015 and all patients who received OV at any time during the course of their disease were selected and analyzed. Primary end point was progression-free survival (PFS) from initiation of OV. Secondary end points were descriptive and prognostic analyses, and overall survival (OS).

Results: Among 13.853 patients recorded in the ESME-mBC database, 1402 received OV as a monotherapy or in combination (809 and 593 patients / 57.7% and 42.3% respectively). Most frequent combinations were with capecitabine (368 patients) and anti-HER2 therapy (165 patients). De-novo mBC was observed in 282 patients (20.1%) and 569 patients (40.6%) had only non-visceral metastases. At metastatic diagnosis, 221 patients (16.9%) had HER2-positive and 298 patients (22.9%) triple-negative tumors respectively. At OV initiation, median age was 59.0 [IC95%: 50-67] years. Endocrine therapy was given prior OV in 769 patients (54.9%). For PFS analysis, 1345 patients were evaluable. The following table summarizes PFS results according to the treatment patterns and the OV-line.

PFS results according to the treatment patterns and the OV-line  OV-line  1st line2nd line3rd line4th line and moreOverall populationN320414313270Overall populationPFS (months, [IC95%])4.7 [4.2-5.5]3.3 [3.0-3.5]2.9 [2.6-3.2]2.3 [2.1-2.4]OV monotherapyN118223207202OV monotherapyPFS (months, [IC95%])4.3 [3.1-5.3]3.2 [2.9-3.5]2.8 [2.5-3.2]2.2 [2.0-2.4]OV in combination with capecitabineN1531294925OV in combination with capecitabinePFS (months, [IC95%])5.1 [3.9-6.1]3.5 [2.8-4.6]3.0 [2.4-4.7]2.0 [1.4-5.2]OV in combination with anti-HER2N41503826OV in combination with anti-HER2PFS (months, [IC95%])6.0 [4.1-7.9]3.1 [2.4-3.8]3.3 [2.4-6.0]2.7 [1.9-3.7]

Following diagnosis of mBC, median OS was 38.2 months [IC95%: 36.1-40.0] in the cohort of patients who received OV at any time.

Conclusions:This study allows large scale assessment of real life benefit of OV over subsequent lines and shows that OV yields clinical benefit even in heavily pre-treated mBC patients.

Citation Format: Pierre H, Mahasti S, Damien P, Nicolas M, Chritelle L, Florence D, Mony U, Lionel U, William J, Paule A, Audrey M, Claudia L, Mario C, Marie-Paule S, Marie-Ange M-R, Marianne L, Jean-Christophe E, Thierry P, Jean-Marc F, Bruno C, Anthony G, Christian C, Gaëtane S, David P. Real-life activity of oral vinorelbine in metastatic breast cancer patients in the Unicancer ESME database [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-15-12.

Predicting mortality after congenital heart surgeries: evaluation of the Aristotle and Risk Adjustement in Congenital Heart Surgery-1 risk prediction scoring systems: a retrospective single center analysis of 1150 patients

AIMS AND OBJECTIVES

To validate Aristotle basic complexity and Aristotle comprehensive complexity (ABC and ACC) and risk adjustment in congenital heart surgery-1 (RACHS-1) prediction models for in hospital mortality after surgery for congenital heart disease in a single surgical unit.

MATERIALS AND METHODS

Patients younger than 18 years, who had undergone surgery for congenital heart diseases from July 2007 to July 2013 were enrolled. Scoring for ABC and ACC scoring and assigning to RACHS-1 categories were done retrospectively from retrieved case files. Discriminative power of scoring systems was assessed with area under curve (AUC) of receiver operating curves (ROC). Calibration (test for goodness of fit of the model) was measured with Hosmer-Lemeshow modification of χ2 test. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were applied to assess reclassification.

RESULTS

A total of 1150 cases were assessed with an all-cause in-hospital mortality rate of 7.91%. When modeled for multivariate regression analysis, the ABC (χ2 = 8.24, P = 0.08), ACC (χ2 = 4.17 , P = 0.57) and RACHS-1 (χ2 = 2.13 , P = 0.14) scores showed good overall performance. The AUC was 0.677 with 95% confidence interval (CI) of 0.61-0.73 for ABC score, 0.704 (95% CI: 0.64-0.76) for ACC score and for RACHS-1 it was 0.607 (95%CI: 0.55-0.66). ACC had an improved predictability in comparison to RACHS-1 and ABC on analysis with NRI and IDI.

CONCLUSIONS

ACC predicted mortality better than ABC and RCAHS-1 models. A national database will help in developing predictive models unique to our populations, till then, ACC scoring model can be used to analyze individual performances and compare with other institutes.

Nationwide integrated mapping of three neglected tropical diseases in Togo: countrywide implementation of a novel approach

OBJECTIVE

To conduct a nationwide integrated neglected tropical disease (NTD) prevalence survey to define the need for public health interventions using an innovative mapping protocol.

METHODS

Two villages were selected in every peripheral health unit in endemic districts: 29 districts for schistosomiasis and STH, 15 of them for trachoma. In each village, 15 children aged 6-9 years at a randomly selected school were tested. An additional convenience sample of 35 children aged 1-5 years underwent an eye examination for trachoma. This integrated mapping was followed by a 20-cluster trachoma survey in each district that surpassed the WHO-defined threshold of 10% prevalence of trachomatous inflammation-follicular (TF).

RESULTS

A total of 1096 villages were surveyed in <6 weeks. The district prevalence of schistosomiasis ranged from 2 to 49% and of STH from 5 to 70%, with prevalence at the village level ranging from 0 to 100% for both diseases. Two districts passed the threshold of 10% for active trachoma, but the cluster survey indicated this was because of misclassification bias and that the real prevalence was <1%.

CONCLUSION

Results of this mapping were used by the MoH and partners to plan integrated mass drug administration (MDA). Mass drug administration for trachoma was not implemented as no district passed the threshold requiring public health intervention.

Effects of a hybrid recombinant human alpha interferon (A/D) on in vitro cytotoxicity and in vivo localization of monoclonal antibody L6-cytosine deaminase conjugate in a colon cancer model

L6 is an IgG2a murine monoclonal antibody which we have demonstrated binds well to HT29 human colon carcinoma cells by flow cytometry, whole cell ELISA, and mixed hemadsorption. In vitro cytotoxicity studies revealed that the monoclonal antibody L6-cytosine deaminase (L6-CD) immunoconjugate plus the nontoxic prodrug, 5-fluorocytosine (5-FC), is equivalent to 5-fluorouracil (5-FU) in its ability to kill HT29 cells. Human alpha-interferon (A/D) was able to enhance this cytotoxic effect. The I.C.50's revealed that very small amounts of L6-CD are needed for this cytotoxic effect (approximately, 5 pg/ml resulted in 50% viability). The limiting factor was the amount of 5-FC employed with L6-CD (3 microM yielded 50% cell viability). alpha-Interferon (A/D) lowered the requirement of 5-FC to 1 microM to achieve 50% cell lethality. In vivo biodistribution experiments indicated that 1 microgram of L6-CD is nonspecifically taken up by the liver and spleen and cleared rapidly from the blood. Significant localization of L6-CD to HT29 tumors occurred only when 99 micrograms of unlabeled L6-CD was added to 1 microgram of 125I-labeled immunoconjugate injected intravenously. Further augmentation of tumor/blood ratios without reduction in percent injected dose per gram of tumor was possible with the intravenous injection of 100 micrograms of anti-idiotypic monoclonal antibody 13B, 24 hours after L6-CD, which bound unreacted L6-CD and cleared it from the blood. The addition of 100,000 U of alpha-interferon (A/D) given intraperitoneally every day increased the clearance of L6-CD by the liver and spleen, but impaired tumor localization (percent injected dose per gram). These studies demonstrated that in vivo localization of the L6-CD conjugate to HT29 tumors could be optimized by injecting excess L6-CD followed by an equal amount of L6 anti-idiotype mAb 13B, 24 hours after L6-CD.

Mesh reinforcement increases bursting strength of intestinal anastomoses in steroid-treated rabbits

We tested the hypothesis that reinforcement of small bowel anastomoses with polyglycolic acid mesh (PGAM) would increase bursting strength in steroid-treated subjects. Twenty-two New Zealand white rabbits weighing 3-4 kg received methylprednisolone 0.2 mg/kg/day IM for 7-13 days preoperatively and until killed 4-5 days postoperatively. Steroid effect was confirmed by a 58.3 per cent decrease in absolute lymphocyte count and a histologic reduction in anastomotic fibroblast proliferation and collagen deposition. Two small bowel anastomoses were performed in each animal using standard two-layer suture technique. One of the two anastomoses, randomly assigned, was circumferentially reinforced with PGAM such that each animal served as its own control. Anastomotic bursting pressures, determined on postoperative Day 4-5, were significantly higher in mesh-reinforced anastomoses (P = 0.003). Histologic examination of the reinforced anastomoses revealed a well-developed layer of fibroblasts and collagen between the PGAM and bowel wall serosa. These results demonstrate that polyglycolic acid mesh reinforcement significantly increases the bursting strength of small bowel anastomoses in steroid-treated rabbits.

Tissue-specific regulation of bovine heart cytochrome-c oxidase activity by ADP via interaction with subunit VIa

The activity of reconstituted cytochrome-c oxidase (EC 1.9.3.1) from bovine heart is stimulated by intraliposomal ADP but not by NaCl of the same ionic strength. A monoclonal antibody which reacts with subunits VIa-H (heart-type) and VIc, due to the evolutionary relationship between these subunits, also stimulates the activity of the enzyme from bovine heart but not from bovine liver. The antibody induces a conformational change in the heart enzyme but not in the liver enzyme, as shown by the visible difference spectrum. Preincubation of heart cytochrome-c oxidase with the antibody prevents stimulation of activity by intraliposomal ADP after reconstitution in liposomes. Reconstituted liver cytochrome c oxidase is not stimulated by intraliposomal ADP. The data suggest tissue-specific regulation of the activity of cytochrome-c oxidase by ADP via interaction with the matrix domain of subunit VIa-H.

Cross reactivity of monoclonal antibodies and cDNA hybridization suggest evolutionary relationships between cytochrome c oxidase subunits VIa and VIc and between VIIa and VIIb

Monoclonal antibodies to subunits of bovine heart cytochrome c oxidase were prepared by immunizing mice with the isolated enzyme. The majority of antibody-producing cell lines were found to react with two different subunits of similar molecular mass, as shown by Western blotting and ELISA titrations with the HPLC-purified subunits. The affinities of the monoclonal antibodies to the subunits were determined by ELISA titrations with increasing concentrations of NH4SCN. Two monoclonal antibodies with a low affinity to subunit VIa had a high affinity to subunit VIc, whereas two other antibodies showed the same affinity to subunits VIIa and VIIb. The same affinity of monoclonal antibodies suggested an evolutionary relationship of subunits VIIa and VIIb, which was further supported by reactivity of these antibodies to subunits VIIa and VIIb of cytochrome c oxidase from different species and tissues. Also the evolutionary relationship between subunit VIa and VIc was shown by hybridization at low stringency of cDNAs for rat cytochrome c oxidase subunits VIc and VIa-h (heart-type), after amplification by the polymerase chain reaction, with a probe of VIa-l (liver-type).

Different isozymes of cytochrome c oxidase are expressed in bovine smooth muscle and skeletal or heart muscle

Cytochrome c oxidase (COX) was isolated from bovine smooth muscle (rumen), and compared with the enzyme from bovine liver, heart and skeletal muscle. A new isozyme of COX was found to be expressed in smooth muscle, which differs from the isozyme in liver and heart or skeletal muscle. SDS-PAGE as well as N-terminal amino acid sequencing of separated subunits from gel bands revealed the expression of the liver isoforms for subunits VIa and VIII and of the heart isoform for subunits VIIa in COX from smooth muscle.

Quantitative determination of benzoyl peroxide by high-performance liquid chromatography and comparison to the iodometric method

A selective high-performance liquid chromatographic (HPLC) procedure for the quantitative determination of benzoyl peroxide in pharmaceutical dosage forms is described. Benzoyl peroxide was dissolved or extracted in the presence of an internal standard, acenaphthylene. The specificity of the stability-indicating HPLC and iodometric procedures are presented for benzoyl peroxide.