Acquired Methemoglobinemia

Cases of acquired methemoglobinemia have been identified with increasing frequency in Los Angeles during the last several years. Among 18 patients, both infants and adults, the most commonly incriminated agent was silver nitrate used for topical antibacterial prophylaxis of burn wounds. One burned child died from overwhelming septicemia complicated by hypoxia with a methemoglobin level of 5.4 grams per dl. Other causative factors included nitrate-rich vegetables used in early infancy, additives in ethnic foods, and prescribed and overdosed drugs. Discontinuation of the precipitating agent and methylene blue therapy were usually followed by prompt improvement. In burned patients treated with silver nitrate, careful regular monitoring of serum methemoglobin levels and early initiation of specific therapy are mandatory.     

Worden psychofarmaca in het verpleeghuis te vaak voorgeschreven?

Are psychotropic drugs too frequently prescribed in Dutch nursing homes? In 1993 Ribbe en Hertogh published a paper in which they expressed their concern about the high prevalence of psychotropic drug use in Dutch nursing homes. Since then, this situation does not seem to have been changed significantly. Recent figures from psychotropic drug use in patients with dementia show prevalence rates of over 60%. The Dutch government decided to choose the prevalence of psychotropic drug use as an indicator of the quality of care and invested in a specific improvement project that aims to reduce psychotropic drug use among nursing home patients. There is a small body of evidence from international research that antipsychotics safely can be reduced without a rise in problem behaviours. In combination with the limited effectiveness and the risk of stroke and increased mortality, the question raises whether these agents should be prescribed at all at least for patients with dementia. A recent study from the UK however, found a significant decrease of antipsychotic drug use by heavily investing in all kinds of person-centered care skills of the nursing staff. These findings underscore the necessity of investing in the caregivers of nursing homes to be able to cope with the complex problems they are faced with. Tijdschr Gerontol Geriatr 2007; 38: 270-273     

Onthand Ouderenbeleid. Kanttekeningen bij regeringsplannen 2007

In 1993 Ribbe en Hertogh published a paper in which they expressed their concern about the high prevalence of psychotropic drug use in Dutch nursing homes. Since then, this situation does not seem to have been changed significantly. Recent figures from psychotropic drug use in patients with dementia show prevalence rates of over 60%. The Dutch government decided to choose the prevalence of psychotropic drug use as an indicator of the quality of care and invested in a specific improvement project that aims to reduce psychotropic drug use among nursing home patients. There is a small body of evidence from international research that antipsychotics safely can be reduced without a rise in problem behaviours. In combination with the limited effectiveness and the risk of stroke and increased mortality, the question raises whether these agents should be prescribed at all at least for patients with dementia. A recent study from the UK however, found a significant decrease of antipsychotic drug use by heavily investing in all kinds of person-centered care skills of the nursing staff. These findings underscore the necessity of investing in the caregivers of nursing homes to be able to cope with the complex problems they are faced with.     

Physical healthcare of people with severe mental illness: everybody's business!

Aim People with severe mental illness are at higher risk of physical health problems. Guidelines recommend annual monitoring. An audit cycle was completed on individuals with severe mental illness under the care of an early interventions in psychosis (EIP) service to evaluate and improve physical health monitoring practice.Methods The number of patients who had undergone a physical health check in the previous year, and those having a record of it in their EIP notes, was examined. Interventions made between baseline audit and re-audit included improving awareness within the multidisciplinary EIP mental health team about the importance of physical health monitoring of people with severe mental illness and liaison with primary care health services.Results The number of patients undergoing at least one annual physical health check increased from 20% to 58%. Among patients who had undergone a physical health check at re-audit, a record of some or all the checks was available in the notes for 75% of patients.Clinical implications There is a need to improve awareness among mental health professionals about the importance of the physical health of people with severe mental illness and to make appropriate organisational changes.     

Extending lactational amenorrhoea in Manila: a successful breast-feeding education programme.

An experimental breast-feeding education programme conducted at the Philippine General Hospital in Manila demonstrated that women could be motivated to improve their breast-feeding practices and lengthen their period of lactational amenorrhoea in comparison to a control group. Mothers who participated in the programme breast-fed their babies more frequently, delayed the introduction of regular supplements, used fewer bottles and pacifiers and maintained night feeding longer than mothers who were not exposed to the positive breast-feeding messages. The programme was successful in lengthening the period of amenorrhoea among women with elementary, high school, or technical school education, but not among college-educated women. Different educational approaches may be necessary for women of different education levels.     

Differential Impact of Two Risk Communications on Antipsychotic Prescribing to People with Dementia in Scotland: Segmented Regression Time Series Analysis 2001–2011

Background

Regulatory risk communications are an important method for disseminating drug safety information, but their impact varies. Two significant UK risk communications about antipsychotic use in older people with dementia were issued in 2004 and 2009. These varied considerably in their content and dissemination, allowing examination of their differential impact.

Methods

Segmented regression time-series analysis 2001–2011 for people aged ≥65 years with dementia in 87 Scottish general practices, examining the impact of two pre-specified risk communications in 2004 and 2009 on antipsychotic and other psychotropic prescribing.

Results

The percentage of people with dementia prescribed an antipsychotic was 15.9% in quarter 1 2001 and was rising by an estimated 0.6%/quarter before the 2004 risk communication. The 2004 risk communication was sent directly to all prescribers, and specifically recommended review of all patients prescribed relevant drugs. It was associated with an immediate absolute reduction in antipsychotic prescribing of 5.9% (95% CI −6.6 to −5.2) and a change to a stable level of prescribing subsequently. The 2009 risk communication was disseminated in a limited circulation bulletin, and only specifically recommended avoiding initiation if possible. There was no immediate associated impact, but it was associated with a significant decline in prescribing subsequently which appeared driven by a decline in initiation, with the percentage prescribed an antipsychotic falling from 18.4% in Q1 2009 to 13.5% in Q1 2011. There was no widespread substitution of antipsychotics with other psychotropic drugs.

Conclusions

The two risk communications were associated with reductions in antipsychotic use, in ways which were compatible with marked differences in their content and dissemination. Further research is needed to ensure that the content and dissemination of regulatory risk communications is optimal, and to track their impact on intended and unintended outcomes. Although rates are falling, antipsychotic prescribing in dementia in Scotland remains unacceptably high.     

Intensive attention improves glycaemic control in insulin-dependent diabetes without further advantage from home blood glucose monitoring: results of a controlled trial.

Forty-six diabetics treated with twice-daily insulin were seen every two weeks for six months in an intensive education programme aided by regular home urine glucose testing. Control was improved with a decrease in 24-hour urinary glucose excretion (median 138 mmol/24 h (24.8 g/24 h) falling to 70 mmol/24 h (12.6 g/24 h); p less than 0.002), glycosylated haemoglobin concentration (mean 11.4 +/- SD 2.3% falling to 10.4 +/- 1.5%; p less than 0.001), and Diastix score (median 3.0 falling to 1.3; p less than 0.001). There was no reported increase in hypoglycaemia. Thirty-eight of the diabetics proceeded to a nine-month randomised cross-over study of the effect on blood glucose control of monitoring urinary glucose or blood glucose measured visually or by a reflectance meter using appropriate reagent strips. No further improvement in control was observed after home blood glucose monitoring. Nevertheless, 29 out of 37 patients preferred blood to urine glucose monitoring. During both the education and cross-over studies there was evidence of an initial improvement in control followed by deterioration. This was independent of the monitoring method used in the cross-over period and may have been due to waning enthusiasm. Despite patient enthusiasm and other reports to the contrary, home blood glucose monitoring offered no improvement in control over intensive attention and conventional urine glucose monitoring.     

Psychiatrists' Attitudes toward Metabolic Adverse Events in Patients with Schizophrenia

Background

There is growing concern about the metabolic abnormalities in patients with schizophrenia.

Aims

The aim of this study was to assess the attitudes of psychiatrists toward metabolic adverse events in patients with schizophrenia.

Method

A brief questionnaire was constructed to cover the following broad areas: the psychiatrists'' recognition of the metabolic risk of antipsychotic therapy, pattern of monitoring patients for physical risks, practice pattern for physical risks, and knowledge of metabolic disturbance. In March 2012, the questionnaire was mailed to 8,482 psychiatrists who were working at hospitals belonging to the Japan Psychiatric Hospitals Association.

Results

The overall response rate was 2,583/8,482 (30.5%). Of the respondents, 85.2% (2,200/2,581) reported that they were concerned about prescribing antipsychotics that have a risk of elevating blood sugar; 47.6% (1,201/2,524) stated that their frequency of monitoring patients under antipsychotic treatment was based on their own experiences; and only 20.6% (5,22/2,534) of respondents answered that the frequency with which they monitored their patients was sufficient to reduce the metabolic risks.

Conclusions

Psychiatrists practicing in Japan were generally aware and concerned about the metabolic risks for patients being treated with antipsychotics. Although psychiatrists should monitor their patients for metabolic abnormalities to balance these risks, a limited number of psychiatrists answered that the frequency with which they monitored patients to reduce the metabolic risks was sufficient. Promotion of the best practices of pharmacotherapy and monitoring is needed for psychiatrists treating patients with schizophrenia.     

Modern concepts of socialisation for dogs: implications for their behaviour, welfare and use in scientific procedures

The provision of a socialisation and training programme for dogs can lead to an improvement in the quality of the data that are produced from scientific procedures, and also to an improvement in animal welfare. A reduction in the number of animals needed to produce statistically significant data can result from decreasing the variability of the experimental data. The effects of a dog's behaviour can be a major source of random variability. A well socialised, habituated and trained dog should be calm during experimental procedures and, for example, during an ECG measurement, thus providing good quality data. A fearful, poorly socialised dog may also appear to be well-behaved on an examination table, and during an ECG measurement, because of the freezing response. However, there is likely to be a difference in the level of stress that these two individuals experience during the procedures. The stress response can have an impact on vital physiological parameters, such as heart rate. The variability in these parameters and the behaviour exhibited within a group of socialised, habituated and trained dogs that have been well prepared for experimental procedures, should be less than the variability present within a similar group of dogs that have not been prepared for these procedures. This paper describes two socialisation programmes, which were designed in order to compare the heart rates and behaviour of dogs which had received different degrees of socialisation, habituation and training. The behaviour of small groups of dogs from this study was compared with that of dogs on a standard socialisation programme, by using a simple, reproducible behavioural score scheme. The heart rate of the dogs was also measured. The results showed that there was little difference in heart rate between the groups, but that there were significant differences in the scores for key behaviours. There was evidence of a decrease in the variability of the behavioural scores for the groups of dogs that had undergone an intensive socialisation programme. Therefore, a socialisation programme can have a significant effect on behaviour and welfare, and has the potential to improve the quality of the data that are recorded.     

Usage Patterns of Devices Designed to Support Diabetes Management: an Educational Needs Assessment

ObjectiveTo determine knowledge, competence, and attitudinal issues among diabetes specialists and primary care providers (PCPs) regarding the use of insulin delivery devices such as insulin pens and insulin pumps and the role of glucose monitoring devices and systems in the care of patients with diabetes.MethodsA quantitative survey tool was developed that contained 51 questions directed to diabetes specialists and 49 questions directed to PCPs. A 5-point, Likert-type scale or multiple-choice format was used. Data were collected from attendees at live symposia across the United States. Results were analyzed for frequency of response and significant relationships among the variables.ResultsThe survey was completed by 136 specialists and 418 PCPs. There were higher usage rates for insulin pens among specialists than PCPs, although there were higher usage rates among more experienced PCPs. Regarding glucose monitoring, most specialists and PCPs did not recommend “block checking,” which has been commonly thought of as a reasonable compromise checking schedule for patients with type 2 diabetes not using insulin. PCPs who were more experienced and used outside educational resources, such as a certified diabetes educator, and specialists who saw more patients on a weekly basis were more likely to prescribe the use of continuous glucose monitoring. There was a general underuse of continuous glucose monitoring in eligible patients.ConclusionsThese findings underscore the discordance between PCPs and specialists with regard to advanced knowledge and confidence required for the use of newer technologies for glucose monitoring and insulin replacement. We have identified important remedial opportunities for qualityand performance-based educational interventions. (Endocr Pract. 2011;17:51-57)     

Structural contributions of antipsychotic drugs to their therapeutic profiles and metabolic side effects

Antipsychotic drugs have various neuropharmacological properties as a result of their structural diversity. Despite their therapeutic benefits, most of the prescribed atypical antipsychotics can induce severe side effects, including weight gain, type II diabetes mellitus, and cardiovascular diseases. Among the developed atypical antipsychotic agents, tetracyclic dibenzodiazepine and thienobenzodiazepine compounds, particularly clozapine and olanzapine, are associated with the greatest weight gain and metabolic disturbances. However, the unique chemical structure of these compounds causes the low risk of side effects reported for typical antipsychotics (e.g. extrapyramidal symptoms and tardive dyskinesia). This report reviews the recent discovery of the potential role of the chemical structure of antipsychotics in their therapeutic properties and metabolic disturbances. By developing structure-activity relationship studies for atypical antipsychotics, we will improve our understanding of the structural modifications of these chemical classes that lead to reduced weight gain, which will be an invaluable step toward the discovery of the next generation of atypical antipsychotics. In this review, we suggest that a novel dibenzodiazepine or thienobenzodiazepine antipsychotic drug with lower affinity for H(1) receptors may significantly advance schizophrenia therapy.     

Monitoring and prevalence rates of metabolic syndrome in military veterans with serious mental illness

Background

Cardiovascular disease is the leading cause of mortality among patients with serious mental illness (SMI) and the prevalence of metabolic syndrome—a constellation of cardiovascular risk factors—is significantly higher in these patients than in the general population. Metabolic monitoring among patients using second generation antipsychotics (SGAs)—a risk factor for metabolic syndrome—has been shown to be inadequate despite the release of several guidelines. However, patients with SMI have several factors independent of medication use that predispose them to a higher prevalence of metabolic syndrome. Our study therefore examines monitoring and prevalence of metabolic syndrome in patients with SMI, including those not using SGAs.

Methods and Findings

We retrospectively identified all patients treated at a Veterans Affairs Medical Center with diagnoses of schizophrenia, schizoaffective disorder or bipolar disorder during 2005–2006 and obtained demographic and clinical data. Incomplete monitoring of metabolic syndrome was defined as being unable to determine the status of at least one of the syndrome components. Of the 1,401 patients included (bipolar disorder: 822; schizophrenia: 222; and schizoaffective disorder: 357), 21.4% were incompletely monitored. Only 54.8% of patients who were not prescribed SGAs and did not have previous diagnoses of hypertension or hypercholesterolemia were monitored for all metabolic syndrome components compared to 92.4% of patients who had all three of these characteristics. Among patients monitored for metabolic syndrome completely, age-adjusted prevalence of the syndrome was 48.4%, with no significant difference between the three psychiatric groups.

Conclusions

Only one half of patients with SMI not using SGAs or previously diagnosed with hypertension and hypercholesterolemia were completely monitored for metabolic syndrome components compared to greater than 90% of those with these characteristics. With the high prevalence of metabolic syndrome seen in this population, there appears to be a need to intensify efforts to reduce this monitoring gap.     

Metabolic outcomes of bergamot polyphenolic fraction administration in patients treated with second-generation antipsychotics: a pilot study

Second-generation antipsychotics (SGAs) are notoriously associated with a marked increase in body weight and with a wide range of metabolic adverse effects, and their chronic use is related with an increased risk for the development of metabolic syndrome (MS). Different adjunctive treatments have been proposed to reduce SGAs-induced weight gain and/or metabolic abnormalities with inconsistent or too limited evidence to support their regular clinical use, thus suggesting the need to find new possible treatments. Bergamot polyphenolic fraction (BPF) has been proven effective in patients with MS, as demonstrated by a concomitant improvement in lipemic and glycemic profiles. The present study was aimed to explore the efficacy and safety of BPF treatment on metabolic parameters in a sample of subjects receiving atypical antipsychotics. Fifteen outpatients treated with SGAs assumed BPF at the oral daily dose of 1000 mg/day for 30 days. Fasting levels of glucose, glycated hemoglobin, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides were determined. BPF administration resulted in a statistically significant reduction of body weight (P=.004) and in a trend for body mass index decrease (P=.005). No significant differences in other and metabolic parameters were observed. Our findings suggest that BPF, at the daily dose of 1000 mg for 30 days, could be an effective and safe agent to prevent weight gain associated with atypical antipsychotic use. However, further clinical trials with adequately powered and well-designed methodology are needed to better explore the BPF effectiveness on the SGAs-induced weight gain and metabolic side effects.     

Quality improvement programme to achieve acceptable colonoscopy completion rates: prospective before and after study

Problem A large audit of colonoscopy in the United Kingdom showed that the unadjusted completion rate was 57% when stringent criteria for identifying the caecum were applied. The caecum should be reached 90% of the time. Little information is available on what units or operators need to do to improve to acceptable levels.Design Quality improvement programme using two completed cycles of audit.Setting Endoscopy department in a university linked general hospital in northeast England.Key measures for improvement Colonoscopy completion rate.Strategy for change Two audit cycles were completed between 1999 and 2002. Changes to practice were based on results of audit and took into account the opinions of relevant staff. Lack of time for each colonoscopy, poor bowel preparation, especially in frail patients, and a mismatch between number of colonoscopies done and completion rate for individual operators were responsible for failed colonoscopies. Appropriate changes were made.Effects of change The initial crude colonoscopy completion rate was 60%, improving to 71% after the first round of audit and 88% after the second round, which approximates to the agreed audit standard of 90%. The final adjusted completion rate was 94%.Lessons learnt Achievement of the national targets in a UK general hospital is possible by lengthening appointments, admitting frail patients for bowel preparation to one ward, and allocating colonoscopies to the most successful operators.     

Subjective and psychopathological response in patients under different antipsychotic treatments: are there differences in real clinical practice?

The aim of this study is to investigate whether subjective well-being in patients under treatment with typical (ATPs) and atypical antipsychotic (ATPsA) compounds can be compared with the improvement of psychopathological state and to verify if both variables correlate to adherence to treatment. We assessed 106 consecutive patients receiving ATPs or ATPsA in the University Psychiatric Ward of L?Aquila, according to DSM-IV diagnosis of Schizophrenia and Bipolar Disorder. Psychopathological state was assessed by Brief Psychiatric Rating Scale-4.0 version (BPRS), adherence to treatment and subjective well-being was assessed by Drug Attitude Inventory (DAI-10) and Subjective Well-being under Neuroleptics (SWN), respectively. BPRS and DAI-10 were administered on admission (T0) and at the end of recovery (T1). The subjects enrolled in this study were divided into 2 groups according to ATP prescribed. We observed an improvement of BPRS and SWN total scores in each group, and increasing scores in DAI-10, from admission to discharge, both in total samples and in each group. There were statistical differences between the patients receiving ATPs and those receving ATPsA regardindg the SWN total score and its different dimensions. This study emphasizes that patients receiving ATPsA show better subjective response compared with patients undergoing ATP treatment, although the adherence to pharmacotherapy and clinical improvement do not differ between the groups.     

Evaluating the effectiveness of a process medical audit in a teaching general hospital.

Medical auditing has moved beyond the traditional chart review to the process audit, which identifies deficiencies in care and suggests remedies. In 1981 the audit committee of the Department of Psychiatry at Toronto General Hospital audited the use of hypnotic drugs in the inpatient unit. The audit produced two recommendations: that nursing staff record sleep graphs for inpatients more often, and that an educational program be instituted to change the physicians'' patterns of prescribing hypnotics. In 1983 the audit was repeated to test the effectiveness of the 1981 auditing process. The 1981 recommendation produced the desired improvement in recording of sleep graphs. However, the medical staff failed to change their patterns of prescribing hypnotics: oxazepam remained the preferred hypnotic. For the process audit to be effective in improving patient care those using it must ensure that the methods reflect the nature and structure of the professional group they are trying to influence.     

Advances in the Management of Post-Radical Prostatectomy Erectile Dysfunction: Treatment Strategies When PDE-5 Inhibitors Don't Work

Phosphodiesterase type-5 (PDE-5) inhibitors have revolutionized the treatment of post-radical prostatectomy erectile dysfunction. For those patients who undergo a non-nerve-sparing radical prostatectomy or whose condition fails to respond to PDE-5 inhibitors, alternative treatment with intracavernous injection therapy, transurethral alprostadil, vacuum erection devices, and recently described combination therapy is available. The goals of therapy are to provide the patient with a means of obtaining an erection so that the patient and his partner may resume sexual relations as soon as possible following radical prostatectomy. There is evidence that early institution of treatment may promote improvement in the return of spontaneous erections in patients who have undergone nerve preservation. In patients who undergo non-nerve-sparing procedures, therapy may improve penile rigidity. Intracavernous injection therapy, transurethral alprostadil, and vacuum devices are highly effective in the management of post-prostatectomy erectile dysfunction. High dropout rates, which are not related to adverse effects, have been described with all 3 modalities. Pre- and postoperative counseling may improve patient and partner satisfaction.     

Management of adverse side-effects after chemotherapy in macaques as exemplified by streptozotocin: case studies and recommendations

The chemotherapeutic streptozotocin is used for induction of diabetes in animal models including non-human primates. Being a cytotoxic nitrosourea compound, it can be associated with adverse events (AEs), mainly nausea and emesis, nephrotoxicity, elevated liver transaminase levels, pulmonary oedema and, most prominently, metabolic acidosis: these can be severe in some cases. The incidence and gravity are to some extent related to the characteristics of the individual animal, diagnostic tools, prompt recognition of symptoms and supportive measures. Careful animal selection, dose adaptation and supportive actions such as renal protective hydration are the main tools in managing AEs, but do not fully eliminate unavoidable and sometimes life-threatening conditions. In our centre we have built experience in a cohort of 78 cynomolgus and rhesus macaques in which six cases manifested severe AEs (8%). This experience has prompted implementation of strategies for early detection and management of adverse effects, together with an animal refinement programme. We present here specific pretreatment regimens, post-infusion laboratory evaluations, and flow charts to assess/treat metabolic acidosis and precipitating factors. Case reports of the six animals with severe AEs are presented to illustrate management of AEs, especially metabolic acidosis, and criteria for early euthanasia where appropriate. We conclude that improved monitoring and validated tools allow for optimal management of adverse effects in an early stage of their manifestation. Reduced morbidity and mortality not only improve individual animal wellbeing but also avoid model-induced confounding that diminishes the translational value of the experimental protocol.