Incidence and predictors of single drug discontinuation according to the presence of HCV coinfection in HIV patients from the ICONA Foundation Cohort Study

To evaluate incidence rates of and predictors for any antiretroviral (ART) drug discontinuation by HCV infection status in a large Italian cohort of HIV infected patients. All patients enrolled in ICONA who started combination antiretroviral therapy (cART) containing abacavir or tenofovir or emtricitabine or lamivudine plus efavirenz or rilpivirine or atazanavir/r or darunavir/r (DRV/r) or lopinavir/r or dolutegravir or elvitegravir or raltegravir were included. Multivariate Poisson regression models were used to determine factors independently associated with single ART drug discontinuation. Inverse probability weighting method to control for potential informative censoring was applied. Data from 10,637 patients were analyzed and 1,030 (9.7%) were HCV-Ab positive. Overall, there were 15,464 ART discontinuations due to any reason in 82,415.9 person-years of follow-up (PYFU) for an incidence rate (IR) of 18.8 (95% confidence interval [95%CI] 18.5–19.1) per 100 PYFU. No difference in IR of ART discontinuation due to any reason between HCV-infected and -uninfected patients was found. In a multivariable Poisson regression model, HCV-infected participants were at higher risk of darunavir/r discontinuation due to any reason (adjusted incidence rate ratio?=?1.5, 95%CI 1.01–2.22, p value?=?0.045) independently of demographics, HIV-related, ART and life-style factors. Among DRV/r treated patients, we found that HCV-viremic patients had twice the risk of ART discontinuation due to any reason than HCV-aviremic patients. In conclusion, HIV/HCV coinfected patients had a marginal risk increase of DRV/r discontinuation due to any reason compared with those without coinfection.     

Calculation of composite recovery time: a new pharmacodynamic parameter

A new pharmacodynamic parameter, the composite recovery time (CRT), is described and used to calculate species-specific MIC breakpoints. Moxifloxacin data were used for illustration. This required determination of MICs, kill curves and post-antibiotic sub-MIC effect values. Thirteen test isolates included Staphylococcus aureus, Haemophilus influenzae and Streptococcus pneumoniae. The concentration at which the CRT equals the dosing interval is the minimum effective concentration, and is effectively the breakpoint. The breakpoints were calculated as 2 mg/L for the pneumococci and quinolone-susceptible H. influenzae isolate, 1 mg/L for staphylococci and 0.5 mg/L for Enterobacteriaceae. Calculated pharmacodynamic breakpoints were very similar to traditional published MIC breakpoints.     

Nurses experiences of delivering care in acute inpatient mental health settings: A narrative synthesis of the literature

Inpatient psychiatric care requires a balance between working with consumers' priorities and goals, managing expectations of the community, legal, professional and service responsibilities. In order to improve service delivery within acute mental health units, it is important to understand the constraints and facilitating factors for good care. We conducted a systematic narrative synthesis, where findings of qualitative studies are synthesised to generate new insights. 21 articles were identified. Our results show that personal qualities, professional skills as well as environmental factors all influence the ability to provide recovery focused care. Three overarching themes which either facilitated or hindered were identified. These included: (i) Complexity of the nursing role (clinical care; practical and emotional support: advocacy and education; enforcing aspects of the Mental Health Act. and, maintaining ward safety); (ii) Constraining factors (operational barriers; change in patient characteristic; and competing understandings of care); and (iii) Facilitating factors (ward factors; nursing tools; nurse characteristics; approach to people; approach to work and ability to self‐care). We suggest that the therapeutic use of self is central to the provision of recovery oriented care. However person‐centred practice can be fragile and fluid and a compassionate system of support is needed to enable an understanding of context and self. It is critical to have a work environment which fosters hope and optimism and is supportive of autonomy, ensures workload balance, and is safe.     

Physical activity interventions for fatigue in rheumatoid arthritis: a systematic review

Background: Fatigue is a major symptom of rheumatoid arthritis (RA) and the need for effective interventions is evident. Programmes based upon physical activity (PA) have been shown to improve patient-reported fatigue in other long-term conditions.

Objectives: To investigate the effectiveness of PA interventions for reducing fatigue in adults with RA and to identify key components of effective PA interventions.

Methods: Methods were based on a previous Cochrane systematic review for non-pharmacological interventions for fatigue in RA. The following electronic databases were searched up to October 2016: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; AMED; CINAHL; PsycINFO; Social Science Citation Index; Web of Science; Dissertation Abstracts International; Current Controlled Trials Register; The National Research Register Archive; The UKCRN Portfolio Database. Randomised controlled trials evaluating PA interventions in people with RA with self-reported fatigue as an outcome measure were included.

Results: Eight studies met the inclusion criteria. Results indicated a small beneficial effect of PA on RA fatigue. The type, frequency, duration, and intensity of PA varied between studies. Delivery methods included supervised group programmes and unsupervised home exercise. Information regarding overall adherence to PA interventions was limited.

Conclusions: There is some evidence of the potential for PA to be effective in reducing symptoms of RA fatigue. However, few interventions in the included studies were designed to manage RA fatigue. These findings suggest that further work is needed to identify the optimal PA intervention for fatigue management that meets the needs of people with RA.     

Comparative in vitro activity of telithromycin against macrolide-resistant and -susceptible Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae

OBJECTIVES: The first objective was to investigate the in vitro activity of telithromycin against respiratory tract pathogens in comparison with other antimicrobial agents. The second objective was to identify the influence of the erm(B) and mef(A) genes on the susceptibility of Streptococcus pneumoniae to telithromycin. METHODS: The in vitro activity of telithromycin against S. pneumoniae, Moraxella catarrhalis and Haemophilus influenzae, isolated from the UK and 40 macrolide-resistant S. pneumoniae from four different countries was compared with a variety of antimicrobial agents. The 140 isolates were examined for the presence of the erm(B) and mef(A) genes. The impact of 5% CO(2) on susceptibility testing was also investigated. RESULTS: Telithromycin showed greatest activity against S. pneumoniae, but also had good activity against M. catarrhalis and H. influenzae, which was independent of their resistance profiles to other antibiotics. The MIC(90) of telithromycin for S. pneumoniae was 0.12 mg/L, which was 64-fold lower than the lowest macrolide MIC; 21% of the S. pneumoniae were macrolide resistant. Thirty-eight per cent of the macrolide-resistant strains were erm(B)-positive and 62% were mef(A)-positive, but no strain contained both genes. The activity of telithromycin was similar to that of azithromycin against both M. catarrhalis and H. influenzae, Erythromycin was slightly less active: 1% and 8% of M. catarrhalis and H. influenzae, respectively, were resistant to erythromycin, but none were resistant to telithromycin. Five per cent of the S. pneumoniae strains and 4% of the H. influenzae strains changed from telithromycin susceptible to non-susceptible entirely because of the incubation conditions. The MIC(50)s and MIC(90)s of S. pneumoniae, M. catarrhalis and H. influenzae increased by one dilution when incubated in CO(2). CONCLUSIONS: Telithromycin has shown high in vitro activity against S. pneumoniae, including those strains that are macrolide susceptible and resistant as well as M. catarrhalis and H. influenzae. This study has also demonstrated that there is no cross-resistance between erythromycin and telithromycin. The impact of 5% CO(2) on susceptibility testing should be investigated further before providing definite guidelines on telithromycin susceptibility testing.     

The experiences of older people on discharge from hospital following assessment by the public health nurse

Aims and objectives. The aim of the study was to explore the experiences of older people on discharge from hospital following assessment by the public health nurse. The objectives of the study were to: (i) identify needs as perceived by older people, (ii) examine if older people felt that these needs were met, (iii) examine the support/care/services received by older people, and (iv) explore any unmet needs of older people. Background. A review of the literature revealed that discharge from hospital remains an area of concern as older people had varying degrees of met and unmet need following discharge from acute hospital. Design/methods. A qualitative study using a phenomenological approach was undertaken. The researcher carried out interviews with a purposive sample of 11 older people in their homes two weeks following discharge from acute hospital. Data were analysed using Colaizzi's method. Results. Older people experienced a wide variety of difficulties in managing aspects of their own care. A reassuring finding of this study is that older people received assistance in this initial discharge period, i.e. they experienced significant informal support complemented by statutory and voluntary support. Even though these older people were assessed by the public health nurse, their need to access services, for statutory service provision, social aspects of their lives and safety measures in their environment were not met. Older people expressed the wish to remain in their own homes. Conclusion. Assessment of older people by the public health nurse is meaningful to identify the needs of older people and provide for the needs of older people though this does not necessarily mean that all the needs of older people can be met by the public health nurse. This study supports the findings of other studies of the problems after discharge and provides an understanding of the experiences of older people on discharge from hospital following assessment by the public health nurse from their perspective. Relevance to clinical practice. The study will provide information that will contribute to current public health nurse practice and will contribute to the understanding of public health nurse practice.     

High-level telithromycin resistance in laboratory-generated mutants of Streptococcus pneumoniae

Resistance to macrolides in Streptococcus pneumoniae is usually mediated by methylation of 23S ribosomal RNA, encoded by the erm(B) methylation gene, or by efflux mediated by the mef(A) gene. Changes in the L4 and L22 ribosomal proteins have also been associated with macrolide resistance and reduced telithromycin activity. This study generated in vitro mutants from three parent strains of S. pneumoniae: 02J1175 [mef(A) +], 02J1095 [erm(B) +] and NCTC 13593 (macrolide susceptible). The erm(B) and the erm(B) upstream region, the mef(A) genes and the mef(A) upstream and downstream regions, the 23S rRNA genes encoding domains II and V and the L4 and L22 genes of the telithromycin-resistant strains were all amplified by PCR and all, except the mef(A) upstream and downstream regions, were sequenced. No changes were present in any of the genes of the mef(A) + mutants. No changes were found in the erm(B) genes, the 23S rRNA genes or the L4 protein genes of the erm(B) + mutants. However, a Lys-94 to Gln-94 amino acid mutation did occur in a mutant derived from erm(B) + with a telithromycin MIC of >32 mg/L. A 210 base pair deletion in the erm(B) upstream region was also present in this strain. We believe this is the first incidence of a Lys-94 to Gln-94 change in L22 associated with telithromycin resistance and also the first time that such a large deletion in the erm(B) upstream region has been identified in S. pneumoniae.