Understanding the implementation and medium-longer term sustainability of the primary care prescribing safety intervention, PINCER: preliminary results from a longitudinal process evaluation

Introduction

Medication errors are an important cause of morbidity and mortality across primary care in England. In the National Health Service, approximately 71% of 237 million medication errors made annually are attributable to primary care(1). The complex pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) intervention has been shown to significantly reduce medication errors when tested in a cluster randomised controlled trial and when implemented on a larger scale across one geographical region of England. However, with a national rollout of PINCER now underway across England, there remains a limited understanding of whether and how wider implementation, impact and medium-longer term sustainability across diverse regions is achieved, and what factors may influence these processes.

Aim

This study aimed to explore the contextual factors that influenced the nature and extent of translation, implementation and sustained use of PINCER in diverse settings over time.

Methods

Intervention developers and personnel involved in the PINCER rollout and staff members from Academic Health Science Networks (AHSNs), Clinical Commissioning Groups (CCGs) and general practices from four regions of England, UK, were purposively recruited via research team connections and Clinical Research Networks. Interviews aimed to capture short-term (≤6 months), medium-term (6 – 18 months) and long-term (≥ 18 months) use of PINCER. Interview guides were informed by Normalisation Process Theory (NPT). Semi-structured, face-to-face or telephone interviews were conducted and digitally recorded. A preliminary thematic analysis was performed on the data collected.

Results

Forty-eight participants from 30 establishments, including two intervention developers, three involved in the PINCER rollout and five AHSN, seven CCG and thirty-one general practice employees were interviewed between June 2018 – June 2020. Their engagement with PINCER had either been in the medium (n=13) or long-term (n=17), (range 8 months - 5 years plus). Emerging themes identified in the preliminary analysis were: development and spread which incorporated intervention and training improvements as well as uptake, perceptions of PINCER which included awareness of PINCER as well as opinions on it and factors influencing the use of PINCER and sustainability which were mainly contextual but also related to PINCER functionalities. Within the development and spread theme, and relating to perceptions of PINCER theme, clear communication and ensuring there was an understanding of what PINCER entailed was considered important in initiating interest and uptake. Overall, PINCER was perceived positively. Key challenges to the implementation of PINCER identified were initial IT issues and workload. Policies advocating the use of PINCER, evidencing impact in reductions in the number of patients identified as being ‘at risk’ of hazardous prescribing and being able to benchmark results against other CCGs and practices helped facilitate the implementation and sustainability. Some changes made to prescribing and monitoring processes as a result of the implementation and use of PINCER, appeared to have become embedded into routine practice giving an indication of sustainable use.

Conclusion

Further interviews will establish if and how PINCER has been more widely adopted and normalised within primary care, in order to generate important learning to support its optimal and sustainable impact.

References

1. Elliott R, Camacho E, Campbell F, Jankovic D, St James MM, Kaltenthaler E, et al. Prevalence and economic burden of medication errors in the NHS in England. Rapid evidence synthesis and economic analysis of the prevalence and burden of medication error in the UK. 2018.

Legacy and current pesticide residues in Syr Darya, Kazakhstan: Contamination status, seasonal variation and preliminary ecological risk assessment

The Syr Darya is one of two major rivers in Central Asia supplying critical fresh water to the Aral Sea. In spite of the river's importance and agriculturally-intensive history, few studies have provided a modern evaluation of and the occurrence of pesticide residues potential effects to aquatic life. The primary goal of this investigation was to determine seasonal variations in ambient concentrations of modern and legacy pesticides in bottom sediment and water of the Syr Darya in Kazakhstan (KZ) downstream from an agriculturally-intensive watershed in Uzbekistan. Grab samples and passive samplers were used at five remote sampling stations during June 2015 to provide a baseline for ecotoxicological evaluation. Results were compared with samples collected during and after the agricultural growing season. Polar organic chemical integrative samplers (POCIS) were used in June and calibrated for time-weighted average concentrations of current use pesticides. Among legacy chlorinated pesticides measured in grab samples from the river, lindane (γ-HCH) was detected most frequently with the highest concentrations occurring during June. For all the sampling events, residues of lindane (γ-HCH) ranged from 0.014 to 0.24 μg/L detected in water samples, are among the highest concentrations reported for rivers globally. Concentrations of γ-HCH, p,p'-DDE and dieldrin were highest in October when dieldrin concentrations approached 0.4 μg/L. Sources of legacy pesticides may be either illicit upstream use or evidence of previous atmospheric contamination of glacial meltwater. Chronic exposure to these residues may lead to ecological risk to lower order organisms in both the sediment and water column.

Functional characterization of the MECP2/IRAK1 lupus risk haplotype in human T cells and a human MECP2 transgenic mouse (P3319)

Genetic polymorphism in MECP2/IRAK1 is a confirmed susceptibility locus for lupus. DNA methylation changes in T cells play a central role in the pathogenesis of lupus, and MeCp-2 is a master regulator of gene expression and is known to recruit DNA methyltransferase 1 (DNMT1) during DNA synthesis. Using human T cells from normal individuals, we demonstrate that the lupus risk variant in MECP2/IRAK1 increases MECP2 mRNA expression in stimulated T cells. By assessing DNA methylation levels at ~ 485,000 methylation sites across the genome, we further show that the lupus risk variant in this locus is associated with significant DNA methylation changes, including in the HLA-DR and HLA-DQ loci, as well as interferon-related genes such as IFI6, IRF6, and BST2. Further, using a human MECP2 transgenic mouse, we show that overexpression of MECP2 alters gene expression in stimulated T cells. This includes overexpression of Eif2c2 that regulates the expression of multiple microRNAs (such as miR-21), and the histone demethylase Jhdm1d. We also show that MECP2 transgenic mice develop antinuclear antibodies. Our data suggest that the lupus associated variant in the MECP2/IRAK1 locus has the potential to affect all 3 epigenetic mechanisms. Importantly, we demonstrate that variants within the MECP2 gene can alter DNA methylation in other genetic loci including the HLA and interferon-regulated genes, thereby providing evidence for genetic-epigenetic interaction in lupus.

Genome-wide DNA methylation study suggests epigenetic accessibility and transcriptional poising of interferon-regulated genes in naïve CD4+ T cells from lupus patients (P4539)

Abnormal T cell DNA methylation and type-1 interferon play an important role in the pathogenesis of systemic lupus erythematosus. We performed a genome-wide DNA methylation study in two independent sets of lupus patients and matched healthy controls to characterize the DNA methylome in naïve CD4+ T cells in lupus. DNA methylation was quantified for over 485,000 methylation sites across the genome, and differentially methylated sites between lupus patients and controls were identified and then independently replicated. Gene expression analysis was also performed from the same cells to investigate the relationship between the DNA methylation changes observed and mRNA expression levels. We identified and replicated 86 differentially methylated CG sites between patients and controls in 47 genes. Importantly, we observed significant hypomethylation in interferon-regulated genes in naïve T cells from lupus patients, suggesting epigenetic transcriptional accessibility of these genetic loci. The hypomethylation in interferon-regulated genes was not related to lupus disease activity. Gene expression analysis showed overexpression of these genes in total but not naïve CD4+ T cells from lupus patients. Our data suggest epigenetic “poising” of interferon-regulated genes in lupus naïve CD4+ T cells, argue for a novel pathogenic implication for abnormal T cell DNA methylation in lupus, and suggest a mechanism for type-1 interferon hyper-responsiveness in lupus T cells.

Genome-wide DNA methylation study suggests epigenetic accessibility and transcriptional poising of interferon-regulated genes in naïve CD4+ T cells from lupus patients

Systemic lupus erythematosus is an autoimmune disease characterized by multi-system involvement and autoantibody production. Abnormal T cell DNA methylation and type-I interferon play an important role in the pathogenesis of lupus. We performed a genome-wide DNA methylation study in two independent sets of lupus patients and matched healthy controls to characterize the DNA methylome in naïve CD4+ T cells in lupus. DNA methylation was quantified for over 485,000 methylation sites across the genome, and differentially methylated sites between lupus patients and controls were identified and then independently replicated. Gene expression analysis was also performed from the same cells to investigate the relationship between the DNA methylation changes observed and mRNA expression levels. We identified and replicated 86 differentially methylated CG sites between patients and controls in 47 genes, with the majority being hypomethylated. We observed significant hypomethylation in interferon-regulated genes in naïve CD4+ T cells from lupus patients, including IFIT1, IFIT3, MX1, STAT1, IFI44L, USP18, TRIM22 and BST2, suggesting epigenetic transcriptional accessibility in these genetic loci. Indeed, the majority of the hypomethylated genes (21 out of 35 hypomethylated genes) are regulated by type I interferon. The hypomethylation in interferon-regulated genes was not related to lupus disease activity. Gene expression analysis showed overexpression of these genes in total but not naïve CD4+ T cells from lupus patients. Our data suggest epigenetic "poising" of interferon-regulated genes in lupus naïve CD4+ T cells, argue for a novel pathogenic implication for abnormal T cell DNA methylation in lupus, and suggest a mechanism for type-I interferon hyper-responsiveness in lupus T cells.

Functional characterization of the MECP2/IRAK1 lupus risk haplotype in human T cells and a human MECP2 transgenic mouse

Genetic polymorphism in MECP2/IRAK1 on chromosome Xq28 is a confirmed and replicated susceptibility locus for lupus. High linkage disequilibrium in this locus suggests that both MECP2 and IRAK1 are candidate genes for the disease. DNA methylation changes in lupus T cells play a central role in the pathogenesis of lupus, and MeCp-2 (encoded by MECP2) is a master regulator of gene expression and is also known to recruit DNA methyltransferase 1 (DNMT1) during DNA synthesis. Using human T cells from normal individuals with either the lupus risk or the lupus protective haplotype in MECP2/IRAK1, we demonstrate that polymorphism in this locus increases MECP2 isoform 2 mRNA expression in stimulated but not unstimulated T cells. By assessing DNA methylation levels across over 485,000 methylation sites across the entire genome, we further demonstrate that the lupus risk variant in this locus is associated with significant DNA methylation changes, including in the HLA-DR and HLA-DQ loci, as well as interferon-related genes such as IFI6, IRF6, and BST2. Further, using a human MECP2 transgenic mouse, we show that overexpression of MECP2 alters gene expression in stimulated T cells. This includes overexpression of Eif2c2 that regulates the expression of multiple microRNAs (such as miR-21), and the histone demethylase Jhdm1d. In addition, we show that MECP2 transgenic mice develop antinuclear antibodies. Our data suggest that the lupus-associated variant in the MECP2/IRAK1 locus has the potential to affect all 3 epigenetic mechanisms: DNA methylation, microRNA expression, and histone modification. Importantly, these data support the notion that variants within the MECP2 gene can alter DNA methylation in other genetic loci including the HLA and interferon-regulated genes, thereby providing evidence for genetic-epigenetic interaction in lupus.

Variants within MECP2, a key transcription regulator, are associated with increased susceptibility to lupus and differential gene expression in patients with systemic lupus erythematosus

OBJECTIVE

Both genetic and epigenetic factors play an important role in the pathogenesis of lupus. The aim of this study was to examine methyl-CpG-binding protein 2 gene (MECP2) polymorphisms in a large cohort of patients with lupus and control subjects, and to determine the functional consequences of the lupus-associated MECP2 haplotype.

METHODS

We genotyped 18 single-nucleotide polymorphisms within MECP2, located on chromosome Xq28, in a large cohort of patients with lupus and control subjects of European descent. We studied the functional effects of the lupus-associated MECP2 haplotype by determining gene expression profiles in B cell lines in female lupus patients with and those without the lupus-associated MECP2 risk haplotype.

RESULTS

We confirmed, replicated, and extended the genetic association between lupus and genetic markers within MECP2 in a large independent cohort of lupus patients and control subjects of European descent (odds ratio 1.35, P = 6.65 x 10(-11)). MECP2 is a dichotomous transcription regulator that either activates or represses gene expression. We identified 128 genes that are differentially expressed in lupus patients with the disease-associated MECP2 haplotype; most ( approximately 81%) were up-regulated. Genes that were up-regulated had significantly more CpG islands in their promoter regions compared with genes that were down-regulated. Gene ontology analysis using the differentially expressed genes revealed significant association with epigenetic regulatory mechanisms, suggesting that these genes are targets for MECP2 regulation in B cells. Furthermore, at least 13 of the 104 up-regulated genes are regulated by interferon. The disease-risk MECP2 haplotype was associated with increased expression of the MECP2 transcription coactivator CREB1 and decreased expression of the corepressor histone deacetylase 1.

CONCLUSION

Polymorphism in the MECP2 locus is associated with lupus and, at least in part, contributes to the interferon signature observed in lupus patients.

Haemolytic anaemia in a multi-ethnic cohort of lupus patients: a clinical and serological perspective

Systemic lupus erythematosus is a chronic autoimmune disease that can be associated with a variety of haematological manifestations. We identified 76 patients with haemolytic anaemia in a cohort of 1251 unrelated female lupus patients enrolled in our studies. The presence of the various American College of Rheumatology clinical criteria for lupus and serological specificities were determined in lupus patients with haemolytic anaemia and compared with a group of race-matched control lupus patients without haemolytic anaemia. Clinical data were obtained from medical records, and serological specificities were determined in our clinical immunology laboratory at OMRF. The presence of haemolytic anaemia in lupus patients was associated with a higher frequency of proteinuria (OR = 2.70, P = 0.000031), urinary cellular casts (OR = 2.83, P = 0.000062), seizures (OR = 2.96, P = 0.00024), pericarditis (OR = 2.21, P = 0.0019), pleuritis (OR = 1.72, P = 0.028) and lymphopenia (OR = 1.79, P = 0.015). These findings were independent of the presence of thrombocytopenia, which was approximately five times more common in lupus patients with haemolytic anaemia. Lupus patients with haemolytic anaemia were about 8 years younger than lupus patients without haemolytic anaemia at the time of disease onset (P = 0.000001). In the absence of thrombocytopenia, lupus patients with haemolytic anaemia were approximately two times more likely to have anti-dsDNA antibodies (P = 0.024). The presence of haemolytic anaemia is associated with a subset of lupus characterized by a younger age of disease onset, and a more severe disease with a higher likelihood of renal involvement, seizures, serositis and other cytopenias.

Sulpha allergy in lupus patients: a clinical perspective

Abstract

Systemic lupus erythematosus is a chronic, relapsing autoimmune disease that can affect multiple organ systems. An increased prevalence of drug allergy has been reported in lupus patients compared with the general population. Using a cohort of 417 lupus patients, we found a history of sulpha allergy in 27.3% of patients. European-American lupus patients with sulpha allergy are about two times more likely to suffer from lymphopenia, two times more likely to have anti-Ro autoantibody, and four times less likely to have anti-nRNP antibodies compared with lupus patients without a reported sulpha allergy ( P = 0.0075, 0.025, and 0.032, respectively). In African-American lupus patients, a history of sulpha allergy was associated with over three times increased odds of developing pericarditis ( P = 0.005).

Defective DNA methylation and CD70 overexpression in CD4+ T cells in MRL/lpr lupus-prone mice

We have determined that abnormal DNA methylation in T cells coincides with the development of autoimmunity, using a mouse model that exhibits an age-dependent lupus-like disease (MRL/lpr mice). Splenic CD4(+) T cells were isolated from these mice at 5 and 16 wk of age (before and after autoimmunity is established) and the expression of DNA methyltransferase 1 (Dnmt1) and the methylation-sensitive gene Tnfsf7 (CD70) was measured. Bisulfite DNA sequencing was used to monitor the methylation status of the Tnfsf7 gene. We found that Dnmt1 steady-state mRNA levels were significantly lower in 16-wk-old MRL/lpr mice, which had established autoimmunity, compared to the 5-wk-old MRL/lpr mice. Furthermore, the expression of CD70 was higher in MRL/lpr mice at 16 wk. CD70 was overexpressed in MRL/lpr mice compared to age- and sex-matched MRL(+/+) controls. Bisulfite DNA sequencing of the Tnfsf7 gene in MRL/lpr mice revealed that at 16 wk, CG pairs were hypomethylated compared to 5-wk-old mice, and that Tnfsf7 from MRL/lpr mice was hypomethylated at 16 wk relative to age-matched MRL(+/+) controls. Our data indicate that decreased expression of Dnmt1 and the corresponding T cell DNA hypomethylation correlate with the development of age-dependent autoimmunity in MRL/lpr mice.

The DNA degradation product uric acid directly promotes T cell autoreactivity (90.1)

Purpose: Abnormally high serum uric acid levels have been associated with several disease conditions including gout and kidney stone disease. More recently, it was shown that uric acid crystals stimulate dendritic cell maturation, activate the NALP3 inflammasome, and enhance antigen-specific immune response. We hypothesize that uric acid can also stimulate T cells directly and in the absence of antigen presentation.

Methods: Purified primary human T cells were incubated with and without uric acid at concentrations of 50, 100, 150 and 200 μg/ml. This range of uric acid concentrations covers the normal physiologic serum uric acid concentration as well as a spectrum of hyperuricemic values in human. The expression of T cell activation markers CD25 and CD70 was assessed by flow cytometry. Purified human T cell proliferation response to the various uric acid concentrations was quantified using a colorimetric proliferation assay.

Results: Uric acid treatment resulted in antigen-independent T cell activation as determined by increased expression of CD25 in both CD4+ as well as CD8+ T cells. CD4+ T cells also overexpressed CD70, a co-stimulation molecule important in T cell-dependent B cell activation. In addition, we demonstrate a dose response relationship between T cell proliferation and uric acid concentration in vitro.

Conclusion: The finding that uric acid directly promotes T cell proliferation and activation in an antigen-independent system is novel and might play a mechanistic role in the inflammatory response observed in gout and other uric acid associated diseases.

This work is supported by NIH Grant Number P20-RR015577 and the University of Oklahoma Health Sciences Center.

Current practice patterns of primary care physicians in the management of patients with hepatitis C

Approximately 4 million Americans are infected with the hepatitis C virus (HCV). Most patients with hepatitis C have no symptoms until cirrhosis is established. Thus, initial diagnosis and management of hepatitis C rely on primary care physicians identifying and screening high-risk individuals. We administered a survey to 1,233 primary care physicians in a health maintenance organization (HMO) in April 1997 to assess their knowledge of the risk factors for HCV infection and approach to the management of 2 hypothetical HCV antibody-positive patients, 1 with elevated and the other with normal alanine transaminase (ALT). Four hundred four (33%) physicians returned the survey. Ninety percent of respondents correctly identified the risk factors for HCV infection, but 20% still considered blood transfusion in 1994 as a significant risk factor for HCV infection. Sixty-two percent of respondents would refer HCV antibody-positive patients with abnormal transaminase levels, but 33% would follow these patients themselves, even though none of the respondents had treated any hepatitis C patient on their own. Forty-three percent of respondents overestimated, while 29% did not know the efficacy of interferon treatment. Sixty-five percent of respondents would retest patients for HCV antibody, regardless of risk factors and transaminase levels. We found that most primary care physicians correctly identified the significant risk factors for HCV infection and appropriately managed the 2 hypothetical patients, but there was considerable confusion about the use of HCV tests and the effectiveness of treatment. Educational programs for primary care physicians are needed to implement hepatitis C screening and to initiate further evaluation and management of those who test positive.

Prevention of reperfusion injury in surgically induced gastric dilatation-volvulus in dogs

Canine gastric dilatation-volvulus (GDV) is a naturally acquired condition of large-breed dogs primarily and is associated with high mortality. The clinical course suggests that reperfusion injury may be important in the pathogenesis of GDV. To evaluate the role of xanthine oxidase and iron-dependent lipid peroxidation (which are purported mechanisms of reperfusion injury) in the pathogenesis of GDV-related mortality, we created experimental GDV in 21 dogs. These dogs were then treated with either allopurinol (a xanthine oxidase inhibitor), U74006F (an experimental lipid peroxidation inhibitor), or saline solution (NaCl, 0.85%). Three of 8 dogs died in the allopurinol-treated group, none of 5 died in the U74006F-treated group, and 4 of 8 died in the saline solution-treated group. Tissue malondialdehyde concentration, a nonspecific indicator of lipid peroxidation, was significantly (P less than 0.05) greater in the duodenum, jejunum, colon, liver, and pancreas of the saline-solution treated and allopurinol-treated dogs than in the same tissues of the U74006F-treated dogs after surgical correction of the GDV (ie, during reperfusion), compared with malondialdehyde concentrations determined before inducing GDV. The results of this study support the concept that lipid peroxidation associated with reperfusion injury is important in the pathogenesis and high mortality of canine GDV. Furthermore, this lipid peroxidation and mortality may be preventable by appropriate and timely treatment.

Characterization of nonactivated and activated glucocorticoid-receptor complexes from intact rat thymus cells

In cells exposed to glucocorticoids at 37 degrees C activated glucocorticoid-receptor complexes (complexes with affinity for nuclei and DNA) are formed after nonactivated complexes. Activation thus appears to be an obligatory physiological process. To investigate this process we have characterized cytoplasmic complexes formed in rat thymocytes at 0 and 37 degrees C. Complexes in cytosols stabilized with molybdate were analyzed by sucrose gradient centrifugation and by chromatography on DNA-cellulose, DEAE-cellulose, and agarose gels. Two major complexes were observed: the nonactivated complex, eluted from DEAE at approximately 200 mM KCl, was formed at 0 and 37 degrees C, gave S20,w = 9.2 S, Stokes radius = 8.3 nm, and calculated Mr = 330,000; the activated complex, eluted from DEAE at approximately 50 mM KCl, appeared only at 37 degrees C, gave S20,w = 4.8 S, Stokes radius = 5.0 nm, and Mr = 100,000. A third, minor complex, probably mero-receptor, which appeared mainly at 37 degrees C, bound to neither DNA nor DEAE, and gave S20,w = 2.9 S, Stokes radius = 2.3 nm, and Mr = 27,000. With three small columns in series (DNA-cellulose, DEAE-cellulose and hydroxylapatite), the three complexes can be separated in 5-10 min. By this method we have examined the stability of complexes under our conditions. We conclude that in intact thymus cells glucocorticoid-receptor complexes occur principally in two forms, nonactivated and activated, and that activation is accompanied by a large reduction in size. The origin of the mero-receptor complex remains uncertain.

The changing role of "second-look" laparotomy in the management of epithelial carcinoma of the ovary

Thirty-seven of 137 patients had a "second-look" laparotomy in the course of their management of carcinoma of the ovary. Patients were stratified according to three indications: (1) evaluation of disease with intent of stopping therapy, (2) assessment of signs of recurrent or persistent disease with a view to debulking tumor mass and changing chemotherapy, and (3) further tumor resection following cis-platinum combination therapy and determination of further chemotherapeutic agents. "Second-look" laparotomy may be performed after a shorter time interval when combination therapy is given because of the dose-limiting side effects of some of these agents and a more aggressive surgical approach in debulking tumors. At the time of laparotomy, cytologic testing is performed on the peritoneal fluid, and only areas suspicious for malignancy are biopsied. Thirteen percent of patients with no evidence of disease at "second-look" laparotomy developed recurrent disease. Twenty-nine percent of patients classified as clinically free of disease had malignancy present at the time of operation. Continued routine use of "second-look" laparotomy after appropriate chemotherapy is recommended.