The implementation of a hepatitis C testing service in community pharmacies: I-COPTIC consensus statement

OBJECTIVES

This aimed to develop a blueprint for an effective community pharmacy Hepatitis C virus (HCV) testing service by producing a consensus statement.

STUDY DESIGN

This was a modified Delphi process.

METHODS

We recruited a heterogenous panel of experts (who had been involved in the setup or delivery of a community pharmacy HCV testing service) by purposive and chain referral methods. We had three rounds of a modified Delphi process. The first was a series of questions with free text responses and was analysed using thematic analysis, and the second and third were statements for the respondents to rate using a 7-point Likert scale. Consensus was predefined in a published protocol, and the results were reviewed by a public and patient involvement panel before the statement was finalised.

RESULTS

We had 24 participants, including community and hospital-based pharmacists, local pharmaceutical committee members, charity representatives (Hepatitis C Trust), local clinical service lead, nurse specialists and doctors. The response rate of the first, second and third rounds were 100%, 96% and 88%, respectively. After the third round, we had 60 statements that reached consensus. We discussed the accepted statements with a patient and public involvement group. We used these statements to produce the I-COPTIC statement and a graphical summary.

CONCLUSIONS

We developed a blueprint for the design of a gold standard community pharmacy HCV testing service. We believe this will support the successful implementation of community pharmacy testing for HCV. Community pharmacy testing is an important service to help achieve and maintain HCV elimination.

Relationship between pelvic tilt control, horse-rider synchronisation, and rider position in sitting trot

Investigation of dressage riders suggests that the performance outcomes of riding can be enhanced by a rider correctly adapting the motion of their pelvis. The pelvis has been identified as an important component of the physical connection of the horse and the rider. This preliminary study aimed to assess whether riders with better control of their pelvic movement, had increased postural stability and horse-rider synchronicity. Twenty-six amateur riders competing in Novice to Grand Prix level dressage rode 35 mixed breed horses in active dressage training which they were used to riding. Riders were divided into two groups according to their ability to perform posterior pelvic tilt whilst sat on a Swiss ball. High-speed motion-capture was captured from the left and right sides and used to assess rider body position, angular measurements and horse-rider synchronicity whilst riding a pre-defined test at collected trot on an artificial surface. Appropriate statistical analyses were used to compare variables between groups. Differences between groups were compared using one-way ANOVA or independent samples t-tests; the significance level was set at P<0.05. No riders in the study were able to perform anterior or posterior pelvic tilt whilst seated on a ball without demonstrating mild or major compensations; the most common of these were inclusion of the lumbar spine or leaning forwards or backwards. The results suggest that riders who could not perform pelvic tilt without major compensations had a more leaning forward posture, were more asymmetrical between the left and right sides and more phase shifted during the swing and stance phases than riders who could perform pelvic tilt with mild compensations.

Effect of time of admission on compliance with deep vein thrombosis prophylaxis in a tertiary medical intensive care unit

OBJECTIVE

We sought to evaluate deep vein thrombosis (DVT) prophylaxis compliance according to time of admission in a medical intensive care unit (MICU).

METHODS

This was a retrospective cohort study at a closed tertiary MICU. We classified patients into three groups (week days, weekends, and week nights), according to time of admission. An unweighted risk factor score (RFS) was calculated from 20 known risk factors. We defined DVT prophylaxis compliance as any type of prophylaxis (mechanical or pharmacologic) for RFS 3. Non-compliance was defined as no prophylaxis or single-type prophylaxis for RFS > 3.

RESULTS

We analyzed 105 admissions. Eighty (76.19%) patients received compliant DVT prophylaxis, and 25 (23.81%) patients received non-compliant regimens of whom 11 (10.48%) were not on any prophylaxis. DVT prophylaxis compliance was not different across the three admission groups. The non-compliant DVT prophylaxis group had a higher RFS (3.48 +/- 2.1 vs. 2.25 +/- 1.5; P = 0.011), a trend towards fewer female patients (40% vs. 60%; P = 0.079), and a higher percentage of admissions by interns at the first postgraduate year (PGY) level (28% vs. 5.4%; P = 0.01). Logistic regression revealed that only RFS and PGY level were independent predictors for compliance (P = 0.015 and 0.005 respectively). Time of admission was not a significant factor.

CONCLUSIONS

Time of admission did not influence DVT prophylaxis compliance. Compliance improved with higher PGY level and lower RFS. A higher level of knowledge probably explains the association with PGY level; however, we cannot explain the inverse relationship between RFS and compliance.

The treatment of stupor associated with MRI evidence of cerebrovascular disease

OBJECTIVE

To describe the treatment and outcome of organic stupor associated with MRI evidence of cerebrovascular disease.

DESIGN

A case series of three patients.

SETTING

An urban mental health of the elderly service in southeast London.

PATIENTS

Aged 69 years, 72 years and 78 years. Two had organic catatonic disorder and the third organic depressive disorder.

INTERVENTIONS

Diazepam, carbamazepine, antidepressants or electroconvulsive therapy (ECT).

MAIN OUTCOME MEASURES

Resolution of symptoms and discharge from hospital.

RESULTS

Symptoms resolved between 1 and 10 days. All patients were able to return home but relapsed over the following 12 months. One relapse occurred when a patient stopped diazepam and moclobemide.

CONCLUSIONS

It is proposed that the initial treatment of organic stupor associated with cerebrovascular disease should include a benzodiazepine or carbamazepine. If patients fail to respond then ECT should be considered. The safety of ECT is not known, when treating patients with depressive disorder associated with cerebrovascular disease.

Identification of conduction block in cardiac muscle: in vitro observations in canine epicardium

OBJECTIVE

The aim was to examine the ability of several previously proposed criteria and of "vector mapping" to distinguish slow conduction from conduction block in canine myocardium.

METHODS

Two different in vitro preparations of canine epicardium were used. In 10 tissues, an anatomical barrier was simulated by a cut (five longitudinal and five transverse to fibre orientation). Eleven tissues removed two weeks after occlusion-reperfusion infarction were also studied. Isochronal activation maps were constructed from extracellular and intracellular recordings and vector loops formed by summing two orthogonally recorded bipolar electrograms were used to indicate the direction of cardiac activation.

RESULTS

In the cut model, electrograms recorded from over the anatomical barrier were usually normal or showed double potentials but could occasionally be fractionated. Isochronal activation maps obtained from extracellular recordings were able to identify five of five anatomical barriers transverse to, but only one of five barriers longitudinal to, fibre orientation. The direction of cardiac activation indicated by vector loops identified conduction block in all 10 preparations. In 11 tissues removed from canine ventricles with experimental myocardial infarction, microelectrode recordings were used to characterise regions as either slow conduction or conduction block. Isochronal activation patterns obtained from extracellular recordings generally showed impulses proceeding through zones of conduction and around zones of conduction block but disagreed with the results of microelectrode impalements in two of 11 cases. Electrogram morphology was also not always able to distinguish slow conduction from block. The direction of cardiac activation determined by vector mapping accurately characterised all regions of tissue as showing either slow conduction or conduction block.

CONCLUSIONS

Limited regions of conduction block or slow conduction are frequently present in epicardial tissues removed from experimental myocardial infarction. The morphology of extracellular electrograms and isochronal activation mapping performed from extracellular recordings is often but not always able to distinguish slow conduction from conduction block. Vector mapping is useful in distinguishing slow conduction from conduction block in these situations and may help evaluate myocardial conduction patterns.

Combined APACHE II score and serum lactate dehydrogenase as predictors of in-hospital mortality caused by first episode Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome

We retrospectively analyzed data from 75 hospitalized patients with a first episode of Pneumocystis carinii pneumonia to compare the ability of four parameters, including admission serum albumin, serum lactate dehydrogenase (LDH), alveolar-arterial oxygen gradient, and the APACHE II score, to predict mortality and response to initial antipneumocystis therapy. The eight patients who died due to pneumocystosis and the 12 who failed initial antipneumocystis therapy had significantly higher admission mean APACHE II scores and serum LDH levels and lower mean serum albumin levels than did the 65 who survived and the 61 who responded to initial therapy (p less than 0.05 for each). Differences in mean alveolar-arterial oxygen gradients were not statistically significant with respect to survival or response to initial therapy. In a stepwise discriminant analysis of parameters associated with mortality, APACHE II score and LDH level were statistically significant (p less than 0.0001 for each). In a stepwise discriminant analysis of parameters associated with response to initial therapy, APACHE II score and LDH level were again statistically significant (p less than 0.0001, respectively). The addition of the alveolar-arterial oxygen gradient and serum albumin level did not further increase the predictive ability of the discriminant analyses. When analyzed alone, neither the alveolar-arterial oxygen gradient nor the serum albumin were statistically significant in each discriminant analysis. The APACHE II score combined with the serum LDH may be more useful than other parameters, singly or combined, to more closely match patients with regard to severity of illness due to first episode Pneumocystis carinii pneumonia when comparing experimental new therapies with standard agents.

Randomized study of intravenous/oral ciprofloxacin versus ceftazidime in the treatment of hospital and nursing home patients with lower respiratory tract infections

This study determined the efficacy of intravenous ciprofloxacin in the treatment of institutionalized patients with lower respiratory tract infections. Hospitalized adults with hospital/nursing home-acquired pneumonia were randomly assigned to receive either intravenous ciprofloxacin or ceftazidime. When deemed feasible, therapy was changed to oral ciprofloxacin for patients who received ciprofloxacin intravenously or to any alternative oral therapy for patients who received ceftazidime. All 23 patients who received ciprofloxacin had a favorable response versus 15 of 21 patients who received ceftazidime (p less than 0.025). One patient with a favorable response to ceftazidime developed a superinfection and one patient had a relapse during subsequent alternative oral therapy. However, patients who received ceftazidime were more severely ill than those who received ciprofloxacin on the basis of APACHE II scores.

Diagnosis of human immunodeficiency virus infection in seronegative homosexuals presenting with an acute viral syndrome

Early diagnosis of acute human immunodeficiency virus (HIV) infection is difficult because patients may be seronegative for HIV at the time of presentation. We have used a serum HIV antigen (HIV-Ag) enzyme immunoassay (EIA) to diagnose acute HIV infection in four high-risk patients. The clinical syndrome in these four patients was characterized by fever (four), rash (three), myalgias-arthralgias (three), and pharyngitis (two). All patients had spontaneous resolution of their symptoms within eight to 12 days. Serum HIV antibody, as measured by a commercially available screening EIA and by Western blot analysis, was negative in all patients at time of presentation and all seroconverted on subsequent testing. Human immunodeficiency virus was isolated from two of two patients during the acute illness. Initial serum samples from all four patients were positive for HIV-Ag. Serum samples of three of four patients became negative for HIV-Ag and positive for HIV antibody. These data suggest that serum HIV-Ag detection by EIA may be useful in the diagnosis of the acute syndrome caused by HIV infection.

Deficiency of plasma protein S, protein C, or antithrombin III and arterial thrombosis

Protein C and protein S are vitamin K-dependent coagulation factors that together act as an anticoagulant, and antithrombin III is a plasma protein that inhibits several activated factors in the coagulation cascade. Although deficiencies of any of these three proteins have been associated with deficiencies of these factors. We report one patient with a protein S deficiency, another with a protein C deficiency, and a third with an antithrombin III deficiency, each of whom who had extensive arterial thrombosis. We suggest that deficiencies of these proteins may constitute risk factors for arterial thrombosis.

The relationship between atrioventricular nodal refractoriness and the functional refractory period in the dog

We studied the relationship between the atrioventricular nodal functional refractory period (FRP) and refractoriness by mathematical analysis and by measurement during antegrade Wenckebach cycles in 16 dogs. The FRP relates directly to the conduction time of the control beat, and inversely to the coordinates of the point on the A'-H' vs. A-A refractory curve where the slope is -1. The FRP can vary without any change in refractoriness as measured by the effective refractory period (ERP) or the refractory curve. In 16 dogs the ERP and the FRP were measured during 4:3 Wenckebach cycles. Because of changes in the control conduction times, the FRP declined and did not reflect the progressive increase in refractoriness recorded during Wenckebach cycles. The FRP is a complex parameter and does not reliably measure refractoriness.