Genome-wide approaches to identify pharmacogenetic contributions to adverse drug reactions.

Adverse drug reactions (ADRs) have a major impact on patients, physicians, health care providers, regulatory agencies and pharmaceutical companies. Identifying the genetic contributions to ADR risk may lead to a better understanding of the underlying mechanisms, identification of patients at risk and a decrease in the number of events. Technological advances have made the routine monitoring and investigation of the genetic basis of ADRs during clinical trials possible. We demonstrate through simulation that genome-wide genotyping, coupled with the use of clinically matched or population controls, can yield sufficient statistical power to permit the identification of strong genetic predictors of ADR risk in a prospective manner with modest numbers of ADR cases. The results of a 500,000 single nucleotide polymorphism analysis of abacavir-associated hypersensitivity reaction suggest that the known HLA-B gene region could be identified with as few as 15 cases and 200 population controls in a sequential analysis.

Governance and autonomy in alternatives to hospital care.

Older people with complex illness and disability should have the same equitable opportunities and safeguards for treatment and care as do younger people. These should be based on needs, likely health gain and personal preference. Comprehensive assessment and goal setting, with monitoring of progress and outcomes, should be an integral feature of alternatives to hospital care, wherever they are provided. To satisfy the principles of clinical governance the development of innovative intermediate rehabilitative and long-term care programmes may require more time and expertise than small purchasing groups can reasonably provide. Pooled health and care budgets managed in partnership by larger providers may offer a solution. There is an urgent need for pilot projects to inform development.

Acute hospital admissions from nursing homes: some may be avoidable.

A retrospective survey of acute hospital admissions from nursing homes over a year to a district hospital revealed high overall hospital admission rates and wide variations of admission rates from similar homes. Medical admissions dominated, infections and poorly controlled heart failure being notably common. A significant proportion of admissions may have been avoided by active chronic disease management, together with better information for doctors responding to emergency calls and specialist support programmes facilitating in situ treatment.

Cognitive impairment associated with beta-blockade in the elderly.

We report the cases of three elderly patients presenting with insidious mental impairment whilst receiving both lipophilic and hydrophilic beta-adrenoceptor blocking agents (propranolol and atenolol respectively). In each case marked improvement occurred on drug withdrawal. Two of our cases probably had early senile dementia of the Alzheimer's type and continued to exhibit signs of mild mental impairment, but the third was restored to normal functioning. We found no evidence of impaired perfusion to suggest a vascular basis for the effect or of depression. We believe that beta-blockade may cause or exacerbate mental impairment in the elderly.

Problems of care in a private nursing home.

To assess problems of care in a private nursing home an observational study was carried out over two months, during which a research nurse worked as a member of the staff in a home caring for 25 patients aged 62-90. During the second month a consultant physician visited the home weekly to hold case conferences and assess each patient's functional ability and drug regimen. Various problems in medical, nursing, and bureaucratic matters were identified--for example, staff failed to understand the appropriate response to various medical symptoms; no clear policy existed for managing pressure sores; and one patient's anticoagulant state could not be assessed when industrial action meant that transport to take him to hospital was not available--and several changes in drug treatments were recommended. The problems that were identified were mainly due to poor communication between the home and general practitioners and hospitals and to the lack of guidance policy on common issues that arise in long term care. Such a policy could be produced by health authority staff, general practitioners, and representatives of nursing homes.

A survey of private nursing home residents in Weston Super Mare.

A representative sample of 351 patients in Private Nursing Homes in Weston Super Mare was surveyed with regard to their origins, admission assessment and continuing care, with particular reference to the nature of medical review during their residency. The results suggest inadequate medical care especially for 'imported' patients and those admitted for psychiatric reasons.

Digestion in the soil predatory mite Pergamasus longicornis (Berlese) (Acari: Mesostigmata: Parasitidae)--detectable hydrolases.

Nineteen hydrolytic enzymes were detected in individual adult Pergamasus longicornis (Berlese) mites--amylase, hide protease, alkali phosphatase, esterase (C4), esterase lipase (C8), lipase (C14), leucine arylamidase, valine arylamidase, cystine arylamidase, acid phosphatase, phosphoamidase, alpha-galactosidase, beta-galactosidase, beta-glucuronidase, alpha-glucosidase, beta-glucosidase, N-acetyl-beta-glucosaminidase, alpha-mannosidase, and alpha-fucosidase. All but the phosphatases were detected for the first time. Tryptic and chymotryptic activity were consistently not demonstrable. Comparisons are made with saprophagous mites. No clear enzymic specialization for predation was found.

A fatal case of creosote poisoning.

A case of fatal creosote poisoning is described. On presentation, extensive oropharyngeal ulceration was noted and gastric lavage withheld. Post-mortem examination showed an intact oesophagus and stomach.