Pleural effusion associated with D‐penicillamine therapy: a case report

This case report illustrates the occurrence of a large pleural effusion associated with long‐term D‐penicillamine therapy. This complication has not previously been reported.     

Development and use of a gastropathy index for ranking the safety of non-steroidal anti-inflammatory drugs in the elderly

This study, conducted at the Royal Devon & Exeter Hospital, Department of Geriatric Medicine, was carried out using 2987 sets of admission data. The number of patients taking non-steroidal anti-inflammatory drugs was identified together with a suite of clinical factors used to indicate the presence of gastrointestinal pathology. From this a gastropathy index was developed to establish a rank order for the individual drugs. Ketoprofen, piroxicam and fenbufen were all significantly associated with factors suggestive of gastropathy, whereas indomethacin, diclofenac and ibuprofen appeared relatively free of such association. Naproxen, azapropazone and mefenamic acid ranked in an intermediate category. This noninvasive analysis of routinely acquired data provides a potentially useful discriminator between individual non-steroidal anti-inflammatory drugs for this age group.     

PAROXETINE AND HYPONATRAEMIA

SUMMARY This case illustrates the need to be aware of potential hyponatraemia in patients taking paroxetine and other selective serotonin reuptake inhibitors.     

Long-term survival of intensive care and hospital patient cohorts compared with the general Australian population: a relative survival approach

Rationale Long‐term post‐hospital survival of intensive care cohorts has been poorly characterized. The relative survival of septic and non‐septic intensive care and general hospital patient cohorts, compared with the Australian population, was determined Methods A retrospective cohort study in a tertiary‐level adult intensive care. Index intensive care admissions, July 1993 to June 1999, with sepsis and surviving hospital, constituted the intensive care sepsis cohort; residual patients, the intensive care non‐sepsis cohort. Hospital cohorts, infected and non‐infected, and Charlson Comorbidity Score (CCS) were obtained electronically, from ICD‐9 codes. Follow‐up was until death, or for a minimum of 4.2 years, to a maximum of 9.6 years. Time‐to‐death was sourced from the State registry. Relative survival was determined using the Esteve method and excess hazard modelled by covariate adjusted generalized linear models. Results The ICU sepsis (n = 224) and non‐sepsis (n = 1798) cohorts were of mean (standard deviation, SD) age of 63.2 (15.6) and 59.8 (18.9) years; with co‐morbidity score 1.2 (1.3) and 0.5 (0.9) respectively. Hospitalized infected (n = 8455) and non‐infected (n = 51 152) cohorts were of age 56.5 (22.2) and 52.2 (20.9) years; co‐morbidity score 0.4 (0.9) and 0.3 (0.9) respectively. Relative survival of all cohorts was less than the Australian population; for the two intensive care cohorts, progressive relative survival decline suggested a perpetuating excess mortality. Both age and CCS increments were associated with progressive increases in excess hazard. There was a reduced hazard for intensive care sepsis versus non‐sepsis cohorts; 0.42 [95% confidence interval (CI): 0.25–0.71, P = 0.001] and surgical versus medical patients, 0.64 (95% CI: 0.50–0.84, P = 0.001); and an excess hazard for men, 1.38 (95% CI: 1.08–1.74, P = 0.009). Conclusions Adverse long‐term survival of intensive care and hospital patients was demonstrated. For hospital patients there was additional infection‐related mortality risk, not evident for ICU patients after case mix control.     

Beyond needs and expectations: identifying the barriers and facilitators to written medicine information provision and use in Australia

Purpose This study aimed to explore peoples’ needs and expectations of written medicines information (WMI), and to determine the barriers and facilitators experienced or perceived in the context of WMI provision and use. Methods We conducted eight focus groups with 62 participants over 6 weeks in late 2008 in New South Wales, Australia. Using a semi‐structured topic schedule and examples of WMI from Australia and other English‐speaking countries as a guide, we explored themes relevant to WMI, including participant experiences, attitudes, beliefs and expectations. Findings Our findings suggest less than half had previously received WMI, with many unaware of its availability. Many, but not all, wanted WMI to supplement the spoken information they received but not to replace it, and it was predominantly used to facilitate informed choice, ascertain medicine suitability and review instructions. The current leaflets were considered technical and long, and a summary leaflet in addition to comprehensive information was favoured. Accurate side‐effect information was the most important element that participants desired. The most common barriers to effective WMI use were time constraints and patient confidence, with participants citing empowerment, time and health‐care professional (HCP)–patient relationships as important facilitators. Conclusion The findings provide insight and understanding of peoples needs and expectations, and clarify issues associated with use and non‐use of WMI. Challenges include addressing the barriers, especially of time and HCP attitudes to drive changes to workplace practices, and learning from the facilitating factors to encourage awareness and accessibility to WMI as a tool to empower patients.     

A patient perspective of pharmacist prescribing: ‘crossing the specialisms‐crossing the illnesses’

Background

The drive for non‐medical prescribing has progressed quickly since the late 1990s and involves a range of healthcare professionals including pharmacists. As part of a commissioned research project, this qualitative element of a larger case study focused on the views of patients of pharmacist prescribers.

Objective

The aim of this study was to explore patients'' perspectives of pharmacists as prescribers.

Methods

Three pharmacists working as independent prescribers in the clinical areas of (i) hypertension, (ii) cardiovascular/diabetes management, (iii) anticoagulation were recruited to three case studies of pharmacist prescribing in Northern Ireland. One hundred and five patients were invited to participate in focus groups after they had been prescribed for by the pharmacist. Focus groups took place between November 2010 and March 2011 (ethical/governance approvals granted) were audio taped, transcribed verbatim, read independently by two authors and analysed using constant comparative analysis.

Results

Thirty‐four patients agreed to participate across seven focus groups. Analysis revealed the emergence of one overarching theme: team approach to patient care. A number of subthemes related to the role of the pharmacist, the role of the doctor and patient benefits. There was an overwhelming lack of awareness of pharmacist prescribing. Patients discussed the importance of a multidisciplinary approach to their care and recognized limitations of the current model of prescribing.

Conclusion

Patients were positive about pharmacist prescribing and felt that a team approach to their care was the ideal model especially when treating those with more complex conditions. Despite positive attitudes, there was a general lack of awareness of this new mode of practice.     

Enhancing global access to cancer medicines

Globally, cancer is the second leading cause of death, with numbers greatly exceeding those for human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis, and malaria combined. Limited access to timely diagnosis, to affordable, effective treatment, and to high-quality care are just some of the factors that lead to disparities in cancer survival between countries and within countries. In this article, the authors consider various factors that prevent access to cancer medicines (particularly access to essential cancer medicines). Even if an essential cancer medicine is included on a national medicines list, cost might preclude its use, it might be prescribed or used inappropriately, weak infrastructure might prevent it being accessed by those who could benefit, or quality might not be guaranteed. Potential strategies to address the access problems are discussed, including universal health coverage for essential cancer medicines, fairer methods for pricing cancer medicines, reducing development costs, optimizing regulation, and improving reliability in the global supply chain. Optimizing schedules for cancer therapy could reduce not only costs, but also adverse events, and improve access. More and better biomarkers are required to target patients who are most likely to benefit from cancer medicines. The optimum use of cancer medicines depends on the effective delivery of several services allied to oncology (including laboratory, imaging, surgery, and radiotherapy). Investment is necessary in all aspects of cancer care, from these supportive services to technologies, and the training of health care workers and other staff.     

HOME SWEET HEN — A GUIDE TO HOME ENTERAL NUTRITION

Initial experience of home enteral nutrition (HEN) was gained from malnourished patients with Crohn's disease.^1–6 The rationale for HEN was to improve the patients' lifestyle by reducing the need for repeated admissions for nutritional support: this method is extremely useful in correcting nutritional problems. Over the past ten years the use of HEN has expanded to cover other clinical areas including correction of growth retardation secondary to gastrointestinal disease,^7,8 cystic fibrosis,^9,10 inborn errors of metabolism,¹¹ congenital heart disease,¹² and chronic renal failure,¹³ in addition to many types of neoplasia¹⁴ and chronic neurological diseases.¹⁴ At the present time, approximately 150 patients receive HEN within the catchment area of the Greater Glasgow Health Board (population 940,000). Despite the increasing availability of HEN many clinicians and dietitians are still reluctant to consider HEN as a ‘routine adjunct’ to clinical management, claiming that it is too dangerous or complicated. The aims of this article are to explain our method of running a HEN service, offer advice on practical problems and discuss further developments and potential difficulties.