Critical care pharmacy workforce: a 2020 re-evaluation of the UK deployment and characteristics

INTRODUCTION

Critical care pharmacists improve the quality and efficiency of medication therapy whilst reducing treatment costs where they are available. UK critical care pharmacist deployment was described in 2015, highlighting a deficit in numbers, experience level, and critical care access to pharmacy services over the 7-day week. Since then, national workforce standards have been emphasised, quality indicators published, and service commissioning documents produced, reinforced by care quality assessments. Whether these initiatives have resulted in further development of the UK critical care pharmacy workforce is unknown. This evaluation provides a 2020 status update.

METHODS

The 2015 electronic data entry tool was updated and circulated for completion by UK critical care pharmacists. The tool captured workforce data disposition as it was just prior to the COVID-19 pandemic, at critical care unit level.

MAIN FINDINGS

Data were received for 334 critical care units from 203 organisations (96% of UK critical care units). Overall, 98.2% of UK critical care units had specific clinical pharmacist time dedicated to the unit. The median weekday pharmacist input to each level 3 equivalent bed was 0.066 (0.043-0.088) whole time equivalents, a significant increase from the median position in 2015 (+ 0.021, p < 0.0001). Despite this progress, pharmacist availability remains below national minimum standards (0.1/level 3 equivalent bed). Most units (71.9%) had access to prescribing pharmacists. Geographical variation in pharmacist staffing levels were evident, and weekend services remain extremely limited.

CONCLUSIONS

Availability of clinical pharmacists in UK adult critical care units is improving. However, national standards are not routinely met despite widely publicised quality indicators, commissioning specifications, and assessments. Additional measures are needed to address persistent deficits and realise gains in organisational and patient-level outcomes. These measures must include promotion of cross-professional collaborative working, adjusted funding models, and a nationally recognised training pathway for critical care pharmacists.

Evaluating Palin Stammering Therapy for School Children (Palin STSC 8–14): protocol for a feasibility randomised controlled trial comparing Palin STSC(8–14) with usual treatment

Background

Having a stammer can have a significant effect on a child’s social, emotional and educational development. With approximately 66,000 children in the UK having a stammer, there is a need to establish an adequate evidence base to inform clinical practice. We describe a feasibility trial to explore the effectiveness of a new therapy programme for children aged 8–14: Palin Stammering Therapy for School Children (Palin STSC(8–14)). Preliminary data from the Michael Palin Centre, where the programme was developed, indicate that Palin STSC(8–14) is effective in reducing stammering frequency and impact for children, with beneficial effects for parents too. We will investigate the feasibility of the methods required for a definitive randomised controlled trial to investigate the application of this therapy by NHS speech and language therapists (SLTs), compared with ‘treatment as usual’ (TAU), beyond the specialist context in which it was developed.

Methods

This is a two-arm feasibility cluster-randomised controlled trial of Palin STSC(8–14) with TAU control arm, and randomisation at the level of the SLT. Quantitative and qualitative data will be collected to examine the following: the recruitment and retention of therapists and families, the acceptability of the research processes and the therapeutic intervention and the appropriateness of the therapy outcome measures. Assessments will be completed by children and parents at baseline and 6 months later, including measures of stammering severity; the impact of child’s stammering on both children and parents; child temperament, behaviour and peer relations, anxiety; quality of life; and economic outcomes. There will also be a qualitative process evaluation, including interviews with parents, children, SLTs and SLT managers to explore the acceptability of both the research and therapy methods. Treatment fidelity will be examined through analysis of therapy session records and recordings.

Discussion

The findings of this feasibility trial will inform the decision as to whether to progress to a full-scale randomised controlled trial to explore the effectiveness of Palin STSC(8–14) when compared to Treatment as Usual in NHS SLT services. There is a strong need for an evidence-based intervention for school age children who stammer.

Trial registration

ISRCTN. ISRCTN17058884. Registered on 18 December 2019.

Bonding Social Capital, Afghan Refugees, and Early Access to Employment

This IMR Research Note examines the impact of the level of bonding social capital on access to employment among newly arrived Afghan refugees in Victoria (Australia). Based on a mixed-methods analysis of biographical interviews with 80 Afghan refugees, it examines their use of social capital, year by year, during the first three years after their arrival. Our analysis shows that higher levels of bonding social capital are associated with greater success in finding employment during the first and second year of settlement. In the third year, however, bonding social capital for Afghan refugees in Victoria is no longer a significant predictor of employment. This Research Note helps clarify inconsistent findings in the literature on the effects of social capital on obtaining employment by suggesting that bonding social capital’s impact on refugee employment success changes significantly across the first three years after arrival. This finding has important implications for migration policy and the prioritization of resources toward services for newly arrived refugees.

An international survey on aminoglycoside practices in critically ill patients: the AMINO III study

BACKGROUND

While aminoglycosides (AG) have been used for decades, debate remains on their optimal dosing strategy. We investigated the international practices of AG usage specifically regarding dosing and therapeutic drug monitoring (TDM) in critically ill patients. We conducted a prospective, multicentre, observational, cohort study in 59 intensive-care units (ICUs) in 5 countries enrolling all ICU patients receiving AG therapy for septic shock.

RESULTS

We enrolled 931 septic ICU patients [mean ± standard deviation, age 63 ± 15 years, female 364 (39%), median (IQR) SAPS II 51 (38-65)] receiving AG as part of empirical (761, 84%) or directed (147, 16%) therapy. The AG used was amikacin in 614 (66%), gentamicin in 303 (33%), and tobramycin in 14 (1%) patients. The median (IQR) duration of therapy was 2 (1-3) days, the number of doses was 2 (1-2), the median dose was 25 ± 6, 6 ± 2, and 6 ± 2 mg/kg for amikacin, gentamicin, and tobramycin respectively, and the median dosing interval was 26 (23.5-43.5) h. TDM of C_max and C_min was performed in 437 (47%) and 501 (57%) patients, respectively, after the first dose with 295 (68%) patients achieving a C_max/MIC > 8 and 353 (71%) having concentrations above C_min recommended thresholds. The ICU mortality rate was 27% with multivariable analysis showing no correlation between AG dosing or pharmacokinetic/pharmacodynamic target attainment and clinical outcomes.

CONCLUSION

Short courses of high AG doses are mainly used in ICU patients with septic shock, although wide variability in AG usage is reported. We could show no correlation between PK/PD target attainment and clinical outcome. Efforts to optimize the first AG dose remain necessary. Trial registration Clinical Trials, NCT02850029, registered on 29th July 2016, retrospectively registered, https://www.clinicaltrials.gov.

Fever in a patient with osteomyelitis: the diagnosis could be serotonin syndrome

Awareness of rare differential diagnoses of common clinical presentations helps promote early detection and prompt management of serious conditions. A 54-year-old man, with an infected non-union following a high tibial osteotomy, presented with an acutely discharging abscess to his proximal tibia. He was generally unwell with a Staphylococcus aureus bacteraemia. The tibia was debrided, CERAMENT G used as dead space management and a spanning external fixator applied. Postoperatively, pregabalin and tapentadol were commenced in addition to amitriptyline and sertraline, which the patient was taking regularly. Overnight, the patient developed hyperthermia, inducible clonus, hyperreflexia, agitation, confusion and rigors. Prompt recognition of the possibility of serotonin syndrome resulted in early cessation of serotonergic medications and a positive outcome. From this case an important message is that fever in a patient taking serotonergic medications should prompt a screening neurological examination. Clinicians should also be wary when patients are commenced on multimodal analgesia, including tapentadol.

Economic evidence for nonpharmacological asthma management interventions: A systematic review

Asthma management, education and environmental interventions have been reported as cost‐effective in a previous review (Pharm Pract (Granada), 2014;12:493), but methods used to estimate costs and outcomes were not discussed in detail. This review updates the previous review by providing economic evidence on the cost‐effectiveness of studies identified after 2012, and a detailed assessment of the methods used in all identified studies. Twelve databases were searched from 1990 to January 2016, and studies included economic evaluations, asthma subjects and nonpharmacological interventions written in English. Sixty‐four studies were included. Of these, 15 were found in addition to the earlier review; 53% were rated fair in quality and 47% high. Education and self‐management interventions were the most cost‐effective, in line with the earlier review. Self‐reporting was the most common method used to gather resource‐use data, accompanied by bottom‐up approaches to estimate costs. Main outcome measures were asthma‐related hospitalizations (69%), quality of life (41%) and utility (38%), with AQLQ and the EQ‐5D being the most common questionnaires measured prospectively at fixed time points. More rigorous costing methods are needed with a more common quality of life tool to aid greater replicability and comparability amongst asthma studies.

Critical care pharmacy workforce: UK deployment and characteristics in 2015

OBJECTIVE

Clinical pharmacists reduce medication errors and optimize the use of medication in critically ill patients, although actual staffing level and deployment of UK pharmacists is unknown. The primary aim was to investigate the UK deployment of the clinical pharmacy workforce in critical care and compare this with published standards.

METHODS

An electronic data entry tool was created and distributed for UK critical care pharmacy services to record their critical care workforce deployment data.

KEY FINDINGS

Data were received for 279 critical care units in 171 organizations. Clinical pharmacist input was identified for 98.6% of critical care units. The median weekday pharmacist input to critical care was 0.045 whole time equivalents per Level 3 (ICU) bed with significant interregional variation. Weekend services were sparse. Pharmacists spent 24.5% of time on the multidisciplinary team ward round, 58.5% of time on independent patient review and 17% of time on other critical care professional support activities. There is significant variation in staffing levels when services are stratified by highest level of competence of critical care pharmacist within an organization (P = 0.03), with significant differences in time spent on the multi-disciplinary ward round (P = 0.010) and on other critical care activities (P = 0.009), but not on independent patient review.

CONCLUSIONS

Investment in pharmacy services is required to improve access to clinical pharmacy expertise at weekends, on MDT ward rounds and for other critical care activities.

A pilot randomized controlled trial comparing effectiveness of prism glasses, visual search training and standard care in hemianopia

OBJECTIVE

Pilot trial to compare prism therapy and visual search training, for homonymous hemianopia, to standard care (information only).

METHODS

Prospective, multicentre, parallel, single-blind, three-arm RCT across fifteen UK acute stroke units.

PARTICIPANTS

Stroke survivors with homonymous hemianopia.

INTERVENTIONS

Arm a (Fresnel prisms) for minimum 2 hours, 5 days per week over 6 weeks. Arm b (visual search training) for minimum 30 minutes, 5 days per week over 6 weeks. Arm c (standard care-information only).

INCLUSION CRITERIA

Adult stroke survivors (>18 years), stable hemianopia, visual acuity better than 0.5 logMAR, refractive error within ±5 dioptres, ability to read/understand English and provide consent.

OUTCOMES

Primary outcomes were change in visual field area from baseline to 26 weeks and calculation of sample size for a definitive trial. Secondary measures included Rivermead Mobility Index, Visual Function Questionnaire 25/10, Nottingham Extended Activities of Daily Living, Euro Qual, Short Form-12 questionnaires and Radner reading ability. Measures were post-randomization at baseline and 6, 12 and 26 weeks.

RANDOMIZATION

Randomization block lists stratified by site and partial/complete hemianopia.

BLINDING

Allocations disclosed to patients. Primary outcome assessor blind to treatment allocation.

RESULTS

Eighty-seven patients were recruited: 27-Fresnel prisms, 30-visual search training and 30-standard care; 69% male; mean age 69 years (SD 12). At 26 weeks, full results for 24, 24 and 22 patients, respectively, were compared to baseline. Sample size calculation for a definitive trial determined as 269 participants per arm for a 200 degree² visual field area change at 90% power. Non-significant relative change in area of visual field was 5%, 8% and 3.5%, respectively, for the three groups. Visual Function Questionnaire responses improved significantly from baseline to 26 weeks with visual search training (60 [SD 19] to 68.4 [SD 20]) compared to Fresnel prisms (68.5 [SD 16.4] to 68.2 [18.4]: 7% difference) and standard care (63.7 [SD 19.4] to 59.8 [SD 22.7]: 10% difference), P=.05. Related adverse events were common with Fresnel prisms (69.2%; typically headaches).

CONCLUSIONS

No significant change occurred for area of visual field area across arms over follow-up. Visual search training had significant improvement in vision-related quality of life. Prism therapy produced adverse events in 69%. Visual search training results warrant further investigation.

Postnatal Hyperoxia Exposure Durably Impairs Right Ventricular Function and Mitochondrial Biogenesis

Prematurity complicates 12% of births, and young adults with a history of prematurity are at risk to develop right ventricular (RV) hypertrophy and impairment. The long-term risk for pulmonary vascular disease, as well as mechanisms of RV dysfunction and ventricular-vascular uncoupling after prematurity, remain poorly defined. Using an established model of prematurity-related lung disease, pups from timed-pregnant Sprague Dawley rats were randomized to normoxia or hyperoxia (fraction of inspired oxygen, 0.85) exposure for the first 14 days of life. After aging to 1 year in standard conditions, rats underwent hemodynamic assessment followed by tissue harvest for biochemical and histological evaluation. Aged hyperoxia-exposed rats developed significantly greater RV hypertrophy, associated with a 40% increase in RV systolic pressures. Although cardiac index was similar, hyperoxia-exposed rats demonstrated a reduced RV ejection fraction and significant RV-pulmonary vascular uncoupling. Hyperoxia-exposed RV cardiomyocytes demonstrated evidence of mitochondrial dysregulation and mitochondrial DNA damage, suggesting potential mitochondrial dysfunction as a cause of RV dysfunction. Aged rats exposed to postnatal hyperoxia recapitulate many features of young adults born prematurely, including increased RV hypertrophy and decreased RV ejection fraction. Our data suggest that postnatal hyperoxia exposure results in mitochondrial dysregulation that persists into adulthood with eventual RV dysfunction. Further evaluation of long-term mitochondrial function is warranted in both animal models of premature lung disease and in human adults who were born preterm.

Infusion medication concentrations in UK's critical care areas: Are the Intensive Care Society's recommendations being used?

Following two studies done in 2007 and 2009, a follow-up of the adherence to the suggested guidelines on drug standardisation has been performed with a suggestion for future standards that can be achieved, to complement the recently published Carter report. The Intensive Care Society (ICS) introduced recommendations for infusion concentrations of 16 medications commonly used in critical care areas. The importance being improvement in patient safety and rationalised use of available critical care resources. Five years after publication of these recommendations, a further audit has been undertaken to assess the level of acceptance and application. This revealed that 89.5% of the 133 surveyed units (representing 42.49% critical care units across the UK) have adopted the recommendations. There are further medication concentrations which could also be standardised.

Abstract B130: Dysregulated Toll-like receptor responses as an oncogenic driver

Inflammation mediated by the transcription factor NFkB is a hallmark of many cancers. Toll-like receptor (TLR) signaling activates NFkB and many tumors undergo an upregulation of TLR expression. However, it still remains unknown to what extent TLR signaling directly contributes to tumorigenesis. A mutagenesis screen of the Unc93b1 protein, a trafficking factor for endosomal TLRs, identified numerous gain-of-function mutations that lead to enhanced TLR signaling. This system allows me to selectively upregulate the activity of certain TLRs and test their contribution to the development of spontaneous inflammation and cancer. So far, my work has focused on a group of Unc93b1 mutations that confer hyper-responsiveness of TLR7 and TLR9, two endosomal nucleic-acid sensing receptors. Knock-in mice carrying this mutation show an early onset of autoinflammation and autoimmunity, demonstrating the critical role of Unc93b1 in maintaining immunological tolerance of these receptors. In ongoing work, I want to investigate the underlying molecular mechanisms that mediate this TLR hyperresponse and identify new regulators of Unc93b1 that might engage in this pathway. Furthermore, I want to apply this system in exploring the contribution of chronic TLR7 and TLR9 stimulation in the development of B-cell lymphoma, a cancer type whose pathogenesis relies on constitutively active NFkB downstream of TLR engagement. My study will reveal novel regulatory pathways that control TLR-mediated inflammation and their physiological relevance in tumorigenesis.

Citation Format: Olivia Majer, Bo Liu, Angus Yiu-fai Lee, Greg Barton. Dysregulated Toll-like receptor responses as an oncogenic driver [abstract]. In: Proceedings of the Second CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; 2016 Sept 25-28; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2016;4(11 Suppl):Abstract nr B130.

Supervised pharmacy student-led medication review in primary care for patients with type 2 diabetes: a randomised controlled pilot study

OBJECTIVE

To pilot and feasibility-test supervised final year undergraduate pharmacy student-led medication reviews for patients with diabetes to enable definitive trial design.

METHOD

Third year pharmacy students were recruited from one UK School of Pharmacy and trained to review patient's medical records and provide face-to-face consultations under supervision while situated within the patient's medical practice. Patients with type 2 diabetes were recruited by postal invitation letter from their medical practice and randomised via automated system to intervention or usual care. Diabetes-related clinical data, quality of life, patient reported beliefs, adherence and satisfaction with medicines information were collected with validated tools at baseline and 6 months postintervention. The process for collecting resource utilisation data was tested. Stakeholder meetings were held before and after intervention to develop study design and learn from its implementation. Recruitment and attrition rates were determined plus the quality of the outcome data. Power calculations for a definitive trial were performed on the different outcome measures to identify the most appropriate primary outcome measure.

RESULTS

792 patients were identified as eligible from five medical practices. 133 (16.8%) were recruited and randomised to control (n=66) or usual care (n=67). 32 students provided the complete intervention to 58 patients. Initial data analysis showed potential for impact in the right direction for some outcomes measured including glycated haemoglobin, quality of life and patient satisfaction with information about medicines. The intervention was found to be feasible and acceptable to patients. The pilot and feasibility study enabled the design of a future full randomised controlled trial.

CONCLUSIONS

Student and patient recruitment are possible. The intervention was well received and demonstrated some potential benefits. While the intervention was relatively inexpensive and provided an experiential learning opportunity for pharmacy students, its cost-effectiveness remains to be determined.

TRIAL REGISTRATION NUMBER

ISRCTN26445805; Results.

Cost Effectiveness of Using Array-CGH for Diagnosing Learning Disability

OBJECTIVE

To undertake a cost-effectiveness analysis of using microarray comparative genomic hybridisation (array-CGH) as a first-line test versus as a second-line test for the diagnosis of causal chromosomal abnormalities in patients referred to a NHS clinical genetics service in the U.K. with idiopathic learning disability, developmental delay and/or congenital anomalies.

METHODS

A cost-effectiveness study was conducted. The perspective is that of a U.K. NHS clinical genetics service provider (with respect to both costs and outcomes). A cohort of patients (n = 1590) referred for array-CGH testing of undiagnosed learning disability and developmental delay by a single NHS regional clinical genetics service (South East Thames Regional Genetics Service), were split into a before-and-after design where 742 patients had array-CGH as a second-line test (before group-comparator intervention) and 848 patients had array-CGH as a first-line test (after group-evaluated intervention). The mean costs were calculated from the clinical genetics testing pathway constructed for each patient including the costs of genetic testing undertaken and clinical appointments scheduled. The outcome was the number of diagnoses each intervention produced so that a mean cost-per-diagnosis could be calculated. The cost effectiveness of the two interventions was calculated as an incremental cost-effectiveness ratio to produce an incremental cost-per-diagnosis (in 2013 GBP). Sensitivity analyses were conducted by altering both costs and effects to check the validity of the outcome.

RESULTS

The incremental mean cost of testing patients using the first-line testing strategy was -GBP241.56 (95% CIs -GBP256.93 to -GBP226.19) and the incremental mean gain in the percentage diagnoses was 0.39% (95% CIs -2.73 to 3.51%), which equates to an additional 1 diagnosis per 256 patients tested. This cost-effectiveness study comparing these two strategies estimates that array-CGH first-line testing dominates second-line testing because it was both less costly and as effective. The sensitivity analyses conducted (adjusting both costs and effects) supported the dominance of the first-line testing strategy (i.e. lower cost and as effective).

CONCLUSIONS

The first-line testing strategy was estimated to dominate the second-line testing strategy because it was both less costly and as effective. These findings are relevant to the wider UK NHS clinical genetics service, with two key strengths of this study being the appropriateness of the comparator interventions and the direct applicability of the patient cohort within this study and the wider UK patient population.

The ADMIN-ICU survey: a survey on antimicrobial dosing and monitoring in ICUs

OBJECTIVES

There is little evidence and few guidelines to inform the most appropriate dosing and monitoring for antimicrobials in the ICU. We aimed to survey current practices around the world.

METHODS

An online structured questionnaire was developed and sent by e-mail to obtain information on local antimicrobial prescribing practices for glycopeptides, piperacillin/tazobactam, carbapenems, aminoglycosides and colistin.

RESULTS

A total of 402 professionals from 328 hospitals in 53 countries responded, of whom 78% were specialists in intensive care medicine (41% intensive care, 30% anaesthesiology, 14% internal medicine) and 12% were pharmacists. Vancomycin was used as a continuous infusion in 31% of units at a median (IQR) daily dose of 25 (25-30) mg/kg. Piperacillin/tazobactam was used as an extended infusion by 22% and as a continuous infusion by 7%. An extended infusion of carbapenem (meropenem or imipenem) was used by 27% and a continuous infusion by 5%. Colistin was used at a daily dose of 7.5 (3.9-9) million IU (MIU)/day, predominantly as a short infusion. The most commonly used aminoglycosides were gentamicin (55%) followed by amikacin (40%), with administration as a single daily dose reported in 94% of the cases. Gentamicin was used at a daily dose of 5 (5-6) mg/day and amikacin at a daily dose of 15 (15-20) mg/day. Therapeutic drug monitoring of vancomycin, piperacillin/tazobactam and meropenem was used by 74%, 1% and 2% of the respondents, respectively. Peak aminoglycoside concentrations were sampled daily by 28% and trough concentrations in all patients by 61% of the respondents.

CONCLUSIONS

We found wide variability in reported practices for antibiotic dosing and monitoring. Research is required to develop evidence-based guidelines to standardize practices.

Pharmacokinetic considerations and dosing strategies of antibiotics in the critically ill patient

The treatment of sepsis remains a significant challenge and is the cause of high mortality and morbidity. The pathophysiological alterations that are associated with sepsis can complicate drug dosing. Critical care patients often have capillary leak, increased cardiac output and altered protein levels which can have profound effects on the volume of distribution (Vd) and clearance (Cl) of antibacterial agents, both of which may affect the pharmacokinetics (PK) / pharmacodynamics (PD) of the drug. Along with antibacterial factors such as the hydrophilicity and its kill characteristics and the susceptibility and site of action of the microorganism, different dosing and administration strategies may be needed for the different drug classes. In conclusion, developing dosing and administration regimes of antibacterials that adhere to PK/PD principles increase antibacterial exposure. Tailoring therapy to the individual patient combined with TDM may contribute to improved clinical efficacy and contain the spread of resistance.

Anti-inflammatory role of IL-10 producing macrophages during early Brucella abortus infection (117.20)

Chronic bacterial diseases such as Brucellosis may result from the pathogen’s ability to evade the initial immune response. Moreover, since Brucella spp. is known to target phagocytes, we investigated its effects on macrophage (mø) phenotype and induction of anti-inflammatory responses. Brucella did not induce alternative activation of mø in cultured bone marrow-derived mø (BMM) or in splenic CD11b+ cells isolated from mice during early infection. However, upregulation of interleukin 10 (IL-10) in serum, spleen and splenic mø from B. abortus infected mice was observed as early as 3 days post infection. Infection of BMM from MyD88-/-, TLR2-/-, TLR4-/-, TLR2/4-/- and TLR9-/- mice demonstrated that IL-10 induction was MyD88 dependent and was partially dependent on pathogen recognition by TLR2 and TLR4. Functionally, in vitro IL-10-/- BMM infection resulted in significantly higher pro-inflammatory cytokine production and decreased bacterial intracellular survival. In vivo 9 days infection of IL-10-/- mice confirmed a lower ability of B. abortus to survive in absence of IL-10, as well as higher induction of pro-inflammatory cytokines, resulting in increased pathology in liver and spleen of infected mice. Taken together, our results suggest that early IL-10 induction by infected mø contributes to an initial balance between pro-inflammatory and anti-inflammatory cytokines that is beneficial to the pathogen, thereby leading to enhanced bacterial survival and persistent infection.

The landscape of services for drug users in Yogyakarta, Indonesia

INTRODUCTION AND AIMS

Drug use has increased rapidly in Indonesia since the late 1990s. The formal drug treatment sector has grown within the bounds of available government funding; however, there is also a substantial informal sector which provides a range of services for current and former users. While information regarding the former is available from the provincial and national governments, there are few sources that detail the latter. The aim of the current study, therefore, is to document the drug treatment services in one Indonesian city, Yogyakarta.

DESIGN AND METHODS

This qualitative study utilised nine key informant interviews with drug treatment workers from nine government and non-government treatment services. Transcripts were analysed thematically.

RESULTS

There exists a patchwork of enthusiastic yet under-resourced non-government services that complement the government rehabilitation and withdrawal programs in Yogyakarta. The focus of most such services is on abstinence (including several faith-based residential rehabilitation programs); however, some harm reduction programs have emerged in recent years. Under-utilisation is a feature of many non-government services, and all respondents acknowledged a significant gap in service coordination.

DISCUSSION AND CONCLUSIONS

Yogyakarta has a drug treatment sector in which most major treatment types are represented, and there appears to be potential for growth within many organisations. Nevertheless, the number and reach of the services are limited by a lack of resources and collaboration, and there are substantial cultural barriers to improving inter-organisational coordination. This study suggests that Yogyakarta and greater Indonesia may benefit from greater service coordination facilitated by local government.

A study of the safety and harms of antidepressant drugs for older people: a cohort study using a large primary care database

OBJECTIVES

The aim of this study was to establish the relative safety and balance of risks for antidepressant treatment in older people. The study objectives were to (1) determine relative and absolute risks of predefined adverse events in older people with depression, comparing classes of antidepressant drugs [tricyclic and related antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs) and other antidepressants] and commonly prescribed individual drugs with non-use of antidepressant drugs; (2) directly compare the risk of adverse events for SSRIs with TCAs; (3) determine associations with dose and duration of antidepressant medication; (4) describe patterns of antidepressant use in older people with depression; and (5) estimate costs of antidepressant medication and primary care visits.

DESIGN

A cohort study of patients aged 65 years and over diagnosed with depression.

SETTING

The study was based in 570 general practices in the UK supplying data to the QResearch database.

PARTICIPANTS

Patients diagnosed with a new episode of depression between the ages of 65 and 100 years, from 1 January 1996 to 31 December 2007. Participants were followed up until 31 December 2008.

INTERVENTIONS

The exposure of interest was treatment with antidepressant medication. Antidepressant drugs were grouped into the major classes and commonly prescribed individual drugs were identified.

MAIN OUTCOME MEASURES

There were 13 predefined outcome measures: all-cause mortality, sudden cardiac death, suicide, attempted suicide/self-harm, myocardial infarction, stroke/transient ischaemic attack (TIA), falls, fractures, upper gastrointestinal bleeding, epilepsy/seizures, road traffic accidents, adverse drug reactions and hyponatraemia.

RESULTS

In total, 60,746 patients were included in the study cohort. Of these, 54,038 (89.0%) received at least one prescription for an antidepressant during follow-up. The associations with the adverse outcomes were significantly different between the classes of antidepressant drugs for seven outcomes. SSRIs were associated with the highest adjusted hazard ratios (HRs) for falls [1.66, 95% confidence interval (CI) 1.58 to 1.73] and hyponatraemia (1.52, 95% CI 1.33 to 1.75), and the group of other antidepressants was associated with the highest HRs for all-cause mortality (1.66, 95% CI 1.56 to 1.77), attempted suicide/self-harm (5.16, 95% CI 3.90 to 6.83), stroke/TIA (1.37, 95% CI 1.22 to 1.55), fracture (1.63, 95% CI 1.45 to 1.83) and epilepsy/seizures (2.24, 95% CI 1.60 to 3.15) compared with when antidepressants were not being used. TCAs did not have the highest HR for any of the outcomes. There were also significantly different associations between the individual drugs for seven outcomes, with trazodone, mirtazapine and venlafaxine associated with the highest rates for several of these outcomes. The mean incremental cost (for all antidepressant prescriptions) ranged between £51.58 (amitriptyline) and £641.18 (venlafaxine) over the 5-year post-diagnosis period.

CONCLUSIONS

This study found associations between use of antidepressant drugs and a number of adverse events in older people. There was no evidence that SSRIs or drugs in the group of other antidepressants were associated with a reduced risk of any of the adverse outcomes compared with TCAs; however, they may be associated with an increased risk for certain outcomes. Among individual drugs trazodone, mirtazapine and venlafaxine were associated with the highest rates for some outcomes. Indication bias and residual confounding may explain some of the study findings. The risks of prescribing antidepressants need to be weighed against the potential benefits of these drugs.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Randomised clinical trial: the clinical effects of a novel neurokinin receptor antagonist, DNK333, in women with diarrhoea-predominant irritable bowel syndrome

BACKGROUND

Neurokinin receptors may play an important role in the visceral hypersensitivity and exaggerated motor/secretory activity associated with diarrhoea-predominant irritable bowel syndrome (IBS-D).

AIM

To evaluate the effects of DNK333, a novel neurokinin antagonist, in women with IBS-D.

METHODS

In two consecutive phase II studies, women with IBS-D were randomised to twice-daily (b.d.) DNK333 25 mg, DNK333 100 mg or placebo for 2 weeks (Trial 1), or DNK333 25 mg b.d. or placebo for 4 weeks (Trial 2). Primary efficacy variables studied were change from baseline of stool form at week 2, and satisfactory relief of IBS-related abdominal pain/discomfort and global IBS-D symptoms. Secondary efficacy variables, pharmacokinetics and safety were also evaluated.

RESULTS

In total, 315 subjects were randomised. There were no statistically significant differences between treatment groups for the primary efficacy variables. However, analysis of combined data from both trials revealed significant differences favouring DNK333 25 mg over placebo for satisfactory relief of IBS-related abdominal pain/discomfort and global IBS-D symptoms. Trends favouring improvement with DNK333 25 mg vs. placebo were seen for all secondary efficacy variables. DNK333 had a safety profile similar to placebo.

CONCLUSIONS

DNK333 25 mg b.d. appears to be effective and well tolerated in women with IBS-D. Further studies with neurokinin antagonists are warranted.

A randomised controlled equivalence trial to determine the effectiveness and cost-utility of manual chest physiotherapy techniques in the management of exacerbations of chronic obstructive pulmonary disease (MATREX)

OBJECTIVES

To estimate the effect, if any, of manual chest physiotherapy (MCP) administered to patients hospitalised with chronic obstructive pulmonary disease (COPD) exacerbation on both disease-specific and generic health-related quality of life. To compare the health service costs for those receiving and not receiving MCP.

DESIGN

A pragmatic, randomised controlled trial powered for equivalence. It was not possible to blind participants, clinicians or research staff to study arm allocation during the intervention.

SETTING

Four UK hospitals in Norwich, Great Yarmouth, King's Lynn and Liverpool.

PARTICIPANTS

526 participants aged 34-91 years were recruited between November 2005 and April 2008; of these, 372 provided evaluable data for the primary outcome. All persons hospitalised with COPD exacerbation and evidence of sputum production on examination were eligible for the trial providing there were no contraindications to performing MCP.

INTERVENTIONS

Participants were allocated to either MCP or no MCP on an intention-to-treat (ITT) basis. However, active cycle of breathing techniques (ACBT) was used in both arms. Participants allocated to the intervention were guided to perform ACBT while the physiotherapist delivered MCP. Participants allocated to the control arm received instruction on ACBT only.

MAIN OUTCOME MEASURES

The primary outcome was COPD-specific quality of life, measured using the St George's Respiratory Questionnaire (SGRQ) at 6 months post randomisation. The European Quality of Life-5 Dimensions (EQ-5D) questionnaire was used to calculate the quality-adjusted life-year (QALY) gain associated with MCP compared with no MCP. Secondary physiological outcome measures were also used.

RESULTS

Of the 526 participants, 261 were allocated to MCP and 264 to control, with 186 participants evaluable in each arm. ITT analyses indicated no significant difference at 6 months post randomisation in total SGRQ score [adjusted effect size (no MCP - MCP) 0.03 (95% confidence interval, CI -0.14 to 0.19)], SGRQ symptom score [adjusted effect size 0.04 (95% CI -0.15 to 0.23)], SGRQ activity score [adjusted effect size -0.02 (95% CI -0.20 to 0.16)] or SGRQ impact score [adjusted effect size 0.02 (95% CI -0.15 to 0.18)]. The imputed ITT and per-protocol results were similar. No significant differences were observed in any of the outcome measures or subgroup analyses. Compared with no MCP, employing MCP was associated with a slight loss in quality of life (0.001 QALY loss) but lower health service costs (cost saving of 410.79 pounds). Based on these estimates, at a cost-effectiveness threshold of lambda = 20,000 pounds per QALY, MCP would constitute a cost-effective use of resources (net benefit = 376.14 pounds). There was, however, a high level of uncertainty associated with these results and it is possible that the lower health service costs could have been due to other factors.

CONCLUSIONS

In terms of longer-term quality of life the use of MCP did not appear to affect outcome. However, this does not mean that MCP is of no therapeutic value to patients with COPD in specific circumstances. Although the cost-effectiveness analysis suggested that its use was cost-effective, much uncertainty was associated with this finding and it would be difficult to justify providing MCP therapy on the basis of cost-effectiveness alone. Future research should include evaluation of MCP for patients with COPD producing high volumes of sputum, and an evaluation of the effectiveness of ACBT in COPD exacerbation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13825248.

EMAAS: an extensible grid-based rich internet application for microarray data analysis and management

Background

Microarray experimentation requires the application of complex analysis methods as well as the use of non-trivial computer technologies to manage the resultant large data sets. This, together with the proliferation of tools and techniques for microarray data analysis, makes it very challenging for a laboratory scientist to keep up-to-date with the latest developments in this field. Our aim was to develop a distributed e-support system for microarray data analysis and management.

Results

EMAAS (Extensible MicroArray Analysis System) is a multi-user rich internet application (RIA) providing simple, robust access to up-to-date resources for microarray data storage and analysis, combined with integrated tools to optimise real time user support and training. The system leverages the power of distributed computing to perform microarray analyses, and provides seamless access to resources located at various remote facilities. The EMAAS framework allows users to import microarray data from several sources to an underlying database, to pre-process, quality assess and analyse the data, to perform functional analyses, and to track data analysis steps, all through a single easy to use web portal. This interface offers distance support to users both in the form of video tutorials and via live screen feeds using the web conferencing tool EVO. A number of analysis packages, including R-Bioconductor and Affymetrix Power Tools have been integrated on the server side and are available programmatically through the Postgres-PLR library or on grid compute clusters. Integrated distributed resources include the functional annotation tool DAVID, GeneCards and the microarray data repositories GEO, CELSIUS and MiMiR. EMAAS currently supports analysis of Affymetrix 3' and Exon expression arrays, and the system is extensible to cater for other microarray and transcriptomic platforms.

Conclusion

EMAAS enables users to track and perform microarray data management and analysis tasks through a single easy-to-use web application. The system architecture is flexible and scalable to allow new array types, analysis algorithms and tools to be added with relative ease and to cope with large increases in data volume.

Wolf-Hirschhorn syndrome--two case-study reports focusing particularly on long-term survival

BACKGROUND

The clinical features of this rare chromosomal syndrome are described in two individuals. Our limited knowledge of the natural history of this disorder has made it difficult to counsel parents as well as outline specific treatment and management plans.

METHOD

Interviews were undertaken with subjects, carers and next of kin, and the literature was searched.

RESULTS

Pertinent features of the syndrome are reported.

MAIN CONCLUSIONS

These two cases highlight that long-term survival may occur and that accurate diagnosis is paramount so that healthcare professionals are able to provide accurate information.

Patterns of critical incidents and their effect on outcome in an adolescent inpatient service

OBJECTIVES

To identify patterns in critical incidents at an inpatient adolescent unit, to determine differences among patients who engage in critical incidents and those who do not, and to ascertain if there is an association between involvement in incidents and outcome of treatment.

METHOD

Retrospective review of all critical incidents reported at an adolescent unit over 30 months.

RESULTS

Of 243 adolescents consecutively admitted, 100 (41%) were involved in critical incidents. Aggressive acts were more common in male adolescents, among patients with conduct or oppositional disorder and/or in those with specific learning disorders, and occurred throughout the day. Self-destructive events were more common in female adolescents and among patients with borderline personality disorder, and took place mainly in the evening. Adolescents involved in critical incidents tended to have longer admissions and had a worse outcome, irrespective of other factors.

CONCLUSIONS

Critical incidents are common among hospitalized adolescents and result in a poorer outcome. Increased structure during the evenings, problem-solving and social skills programmes for patients, and specific training for staff regarding management and minimization of critical incidents should be provided.