Supervised self-administration of outpatient parenteral antibiotic therapy: a report from a large tertiary hospital in Australia.

INTRODUCTION: Outpatient parenteral antibiotic therapy (OPAT) has become established as a standard of care in most Australian hospitals to treat a variety of infections. Since 1998, the Alternate Site Infusion Service (ASIS) has provided an OPAT service to five hospitals in southern Brisbane, Queensland, using predominantly a patient or carer administration model (self-administered, S-OPAT). The aim of this study was to evaluate outcomes of our S-OPAT programme. METHODS: Consecutive patients treated by ASIS at the Princess Alexandra Hospital from January 1, 2011 to December 31, 2011 were reviewed. Data on patient demographics, diagnoses, microbiology, antimicrobial therapy, duration, outcome, and complications were sourced from a prospectively collected database and from patient medical records. RESULTS: There were 150 episodes involving 144 patients resulting in 3520 days of OPAT; the median duration on the programme was 22 days (range 4­106 days). Patient or carer administration occurred in the majority of episodes. The most common indication by far was bone or joint infection (47% of patients), followed by infective endocarditis (9%). Staphylococcus aureus was the most frequently treated organism. The overall cure rate was 93%. On multivariate analysis, patients with two or more comorbidities had an increased risk of failure. Line-related complications occurred in 1.4/1000 catheter-days. Rash was the most common drug-related event. Despite the extensive use of broad-spectrum antibiotics there were no cases of Clostridium difficile infection during therapy and for up to 28 days post cessation of intravenous antibiotics. The cost of OPAT per patient excluding drug administration and home visits was approximately A$ 150.00/day, significantly lower than the cost of an inpatient bed, which is estimated to be A$ 500­800/day.5 CONCLUSION: OPAT using a patient or carer administration model is an effective and safe option for the management of selected patients with infection requiring intravenous antibiotics.

Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing.

OBJECTIVES: Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of accuracy, safety and appropriateness. Our aim was to evaluate a new model of service for the Australia healthcare system, of inpatient medication prescribing by a pharmacist in an elective surgery preadmission clinic (PAC) against usual care, using an endorsed performance framework. DESIGN: Single centre, randomised controlled, two-arm trial. SETTING: Elective surgery PAC in a Brisbane-based tertiary hospital. PARTICIPANTS: 400 adults scheduled for elective surgery were randomised to intervention or control. INTERVENTION: A pharmacist generated the inpatient medication chart to reflect the patient's regular medication, made a plan for medication perioperatively and prescribed venous thromboembolism (VTE) prophylaxis. In the control arm, the medication chart was generated by the Resident Medical Officers. OUTCOME MEASURES: Primary outcome was frequency of omissions and prescribing errors when compared against the medication history. The clinical significance of omissions was also analysed. Secondary outcome was appropriateness of VTE prophylaxis prescribing. RESULTS: There were significantly less unintended omissions of medications: 11 of 887 (1.2%) intervention orders compared with 383 of 1217 (31.5%) control (p<0.001). There were significantly less prescribing errors involving selection of drug, dose or frequency: 2 in 857 (0.2%) intervention orders compared with 51 in 807 (6.3%) control (p<0.001). Orders with at least one component of the prescription missing, incorrect or unclear occurred in 208 of 904 (23%) intervention orders and 445 of 1034 (43%) controls (p<0.001). VTE prophylaxis on admission to the ward was appropriate in 93% of intervention patients and 90% controls (p=0.29). CONCLUSIONS: Medication charts in the intervention arm contained fewer clinically significant omissions, and prescribing errors, when compared with controls. There was no difference in appropriateness of VTE prophylaxis on admission between the two groups. TRIAL REGISTRATION: Registered with ANZCTR-ACTR Number ACTRN12609000426280.

Adverse effects of corticosteroid therapy in neuromuscular diseased patients are common and receive insufficient prophylaxis.

BACKGROUND: Corticosteroid therapy is known to have long-term adverse effects and complications, but our knowledge of the adverse effects of corticosteroids within a neuromuscular patient population is limited. AIMS OF THE STUDY: We sought to determine the prevalence and impact of corticosteroid use in a population of patients with neuromuscular diseases, as well as possible clinical associations for presence of adverse effects. METHODS: A retrospective chart review from a comprehensive database from a tertiary care neuromuscular clinic spanning 1988-2007 was performed. RESULTS: Corticosteroids led to adverse effects in 74% of exposed patients, without proper prophylaxis considered in about 50% of cases. There were no associations determined to have impact upon adverse effect occurrence, including the exposure to cumulative corticosteroid dosing or diagnosis. CONCLUSION: Corticosteroid therapy is frequently associated with adverse effects, although prediction of their occurrence is not clear. Prophylaxis of their occurrence is underperformed in our tertiary care clinic patient population.

Effect of age and gender on sweat lactate and ammonia concentrations during exercise in the heat.

The dependence of sweat composition and acidity on sweating rate (SR) suggests that the lower SR in children compared to adults may be accompanied by a higher level of sweat lactate (Lac-) and ammonia (NH3) and a lower sweat pH. Four groups (15 girls, 18 boys, 8 women, 8 men) cycled in the heat (42 degrees C, 20% relative humidity) at 50% VO2max for two 20-min bouts with a 10-min rest before bout 1 and between bouts. Sweat was collected into plastic bags attached to the subject's lower back. During bout 1, sweat from girls and boys had higher Lac- concentrations (23.6 +/- 1.2 and 21.2 +/- 1.7 mM; P < 0.05) than sweat from women and men (18.2 +/- 1.9 and 14.8 +/- 1.6 mM, respectively), but Lac- was weakly associated with SR (P > 0.05; r = -0.27). Sweat Lac- concentration dropped during exercise bout 2, reaching similar levels among all groups (overall mean = 13.7 +/- 0.4 mM). Children had a higher sweat NH3 than adults during bout 1 (girls = 4.2 +/- 0.4, boys = 4.6 +/- 0.6, women = 2.7 +/- 0.2, and men = 3.0 +/- 0.2 mM; P < 0.05). This difference persisted through bout 2 only in females. On average, children's sweat pH was lower than that of adults (mean +/- SEM, girls = 5.4 +/- 0.2, boys = 5.0 +/- 0.1, women = 6.2 +/- 0.5, and men = 6.2 +/- 0.4 for bout 1, and girls = 5.4 +/- 0.2, boys = 6.5 +/- 0.5, women = 5.2 +/- 0.2, and men = 6.9 +/- 0.4 for bout 2). This may have favored NH3 transport from plasma to sweat as accounted for by a significant correlation between sweat NH3 and H+ (r = 0.56). Blood pH increased from rest (mean +/- SEM; 7.3 +/- 0.02) to the end of exercise (7.4 +/- 0.01) without differences among groups. These results, however, are representative of sweat induced by moderate exercise in the absence of acidosis.

Effect of age and gender on sweat lactate and ammonia concentrations during exercise in the heat

The dependence of sweat composition and acidity on sweating rate (SR) suggests that the lower SR in children compared to adults may be accompanied by a higher level of sweat lactate (Lac-) and ammonia (NH3) and a lower sweat pH. Four groups (15 girls, 18 boys, 8 women, 8 men) cycled in the heat (42°C, 20 percent relative humidity) at 50 percent VO2max for two 20-min bouts with a 10-min rest before bout 1 and between bouts. Sweat was collected into plastic bags attached to the subject's lower back. During bout 1, sweat from girls and boys had higher Lac- concentrations (23.6 ± 1.2 and 21.2 ± 1.7 mM; P < 0.05) than sweat from women and men (18.2 ± 1.9 and 14.8 ± 1.6 mM, respectively), but Lac- was weakly associated with SR (P > 0.05; r = -0.27). Sweat Lac- concentration dropped during exercise bout 2, reaching similar levels among all groups (overall mean = 13.7 ± 0.4 mM). Children had a higher sweat NH3 than adults during bout 1 (girls = 4.2 ± 0.4, boys = 4.6 ± 0.6, women = 2.7 ± 0.2, and men = 3.0 ± 0.2 mM; P < 0.05). This difference persisted through bout 2 only in females. On average, children's sweat pH was lower than that of adults (mean ± SEM, girls = 5.4 ± 0.2, boys = 5.0 ± 0.1, women = 6.2 ± 0.5, and men = 6.2 ± 0.4 for bout 1, and girls = 5.4 ± 0.2, boys = 6.5 ± 0.5, women = 5.2 ± 0.2, and men = 6.9 ± 0.4 for bout 2). This may have favored NH3 transport from plasma to sweat as accounted for by a significant correlation between sweat NH3 and H+ (r = 0.56). Blood pH increased from rest (mean ± SEM; 7.3 ± 0.02) to the end of exercise (7.4 ± 0.01) without differences among groups. These results, however, are representative of sweat induced by moderate exercise in the absence of acidosis.

The structure of empathy during middle childhood and its relationship to prosocial behavior.

This study was an investigation of the structure and development of dispositional empathy during middle childhood and its relationship to altruism. A sample of 478 students from 2nd, 4th, and 6th grades completed an altruism questionnaire and a social desirability scale, both created for this study, and the Interpersonal Reactivity Index (Davis, 1980), adapted for this study. Teachers also rated the students on prosocial behaviors, such as sharing. In addition, as an experimental part of the study, the children could make monetary donations and volunteer time to raise funds. Results of a confirmatory factor analysis on the Interpersonal Reactivity Index supported Davis's (1980) findings that empathy comprises four components: perspective taking, fantasy, empathic concern, and personal distress. Factor intercorrelations, however, were not the same as those reported by Davis. MANOVAs were used to examine gender and age effects on empathy. Girls were more empathic in general than boys, and older children showed more empathic concern than younger children. Only empathic concern and perspective taking were significant predictors of prosocial behavior.

Students' self-reported substance use by grade level and gender.

Over 900 students in the rural northwest at the fourth, sixth, eighth, and tenth grade levels were surveyed for alcohol and drug use. The survey instrument measured self-reported usage of seventeen substances. The descriptive statistical results are reported by gender as well as grade-level usage rates. Discussion includes targeting drug prevention programs for specific grade and gender levels based upon the results.

Students' self-reported substance use by grade level and gender.

Over 900 students in the rural northwest at the fourth, sixth, eighth, and tenth grade levels were surveyed for alcohol and drug use. The survey instrument measured self-reported usage of seventeen substances. The descriptive statistical results are reported by gender as well as grade-level usage rates. Discussion includes targeting drug prevention programs for specific grade and gender levels based upon the results.

Effects of confirmatory and contradictory stimuli and development on children's intergroup attribution.

Intergroup attributional differences were investigated among Canadian children at three developmental levels who received confirmatory and contradictory stimuli about ingroup and outgroup individuals. Participants were 83 public school students divided into three levels of social attribution development. An intergroup attribution questionnaire assessed the degree of internality of participants' explanations of the success and failure of ingroup and outgroup members. Results indicated that the participants responded differently to stimuli that confirmed ethnocentric assumptions than they responded to stimuli that contradicted these assumptions. The precise nature of the responses, however, depended on the developmental level of the participant: Whereas younger children tended to use attributions that favored the ethnic ingroup, older children actually used attributions that favored the outgroup.

Pilot trials of PDF symbology as a means of transfering data on blood units between transfusion centres.

PDF 417, a two-dimensional barcode, was used as a portable data file to transfer key information on blood units and delivery documentation between two Regional Blood Transfusion Centres. Multiple Codabar messages currently displayed on blood packs, as well as other useful information, i.e. microbiology conformance, were encoded in a 45-character single PDF barcode. The delivery note which accompanied each consignment of blood consisted of a series of PDF barcodes, each representing 20 blood units. Computer validation showed 100% reconciliation of PDF data with Codabar data. Readability of the code was excellent with a greater than 98% first-pass read rate. The delivery note PDF barcode identified eight operator errors which would have been undetected by the present manual system. We conclude that PDF 417 is an effective, secure and space efficient means of transferring data associated with the transfer of blood.

Quantitation of D sites on selected 'weak D' and 'partial D' red cells.

Measurements have been made of the number of available sites on 10 examples of red cells in which the only abnormality appeared to be a quantitative reduction in the expression of D (weak D cells); these estimates were carried out using three monoclonal anti-D antibodies, Fog-1, Brad-3 and Los-2. The values varied with the monoclonal antibody that was used and fell within the range of 170-1,870 sites/cell. A further 3 examples of weak D cells which had brought about immunisation following transfusion were found to have between 390 and 1,470 sites per red cell. The implications of the D site density on the immunogenicity of weak D cells are discussed. The number of sites on red cells with structurally abnormal D (partial D cells) were also estimated, using the antibody Fog-1. Four of the 5 examples of cells of category IVa (probable phenotype Ror) were found to have a high expression of D (range 29,300-41,300), but the available D sites of categories DVa, DVIa, and DVII were considerably reduced (< 500, < 500 and 2,400-7,500 sites/cell, respectively). As a working hypothesis, it is suggested that there are two types of genetic abnormality leading to an abnormal expression of D. First, a defect in genomic DNA leading only to a quantitative reduction in the number of available D sites; this genomic lesion should be termed 'weak D'. Secondly, genomic defects leading to amino acid sequence abnormalities and structural change in the D polypeptide; these lesions should be collectively known as 'partial D'.

A versatile hand splint.

Splintage plays a major part in the management and rehabilitation of the hand following injury, infection and operation. It is essential to have a simple, comfortable, and firm but flexible splint. This should be available "off the shelf", but be acceptable to the patient and to the treating clinician. This paper will describe a splint which not only has these qualities, but is cheap and is re-usable after washing. The splint is made of high density Plastazote and is available in two sizes for each hand. It is moulded into the shape of the functional position of the hand and can easily be trimmed with bandage scissors to give a precise fitting. The splint has been evaluated following surgery on fifty hands. Its fabrication, use and simplicity are discussed.

Further characterisation of a human monoclonal antibody to the rhesus D antigen produced in vitro.

UCH D4 is a human monoclonal antibody produced by an Epstein-Barr (EB) virus-transformed lymphoblastoid cell line. The antibody is specific for the rhesus D antigen, and is a good laboratory reagent for red blood cell typing. UCH D4 can be purified from the culture supernatant medium with the removal of all detectable DNA and infectious EB virus particles. This purified antibody will be used for in vivo assessment of its ability to prevent Rhesus disease of the newborn.

Is anti-Pseudomonas therapy warranted in acute respiratory exacerbations in children with cystic fibrosis?

A controlled study was designed to clarify the indications for antibiotic therapy in children with advanced cystic fibrosis hospitalized with respiratory exacerbations. Twenty-two children with severe CF and signs of acute lower respiratory infection were randomly assigned to receive either cloxacillin or carbenicillin plus gentamicin administered intravenously for ten days. Other aspects of therapy were constant. The groups were comparable in all respects and Pseudomonas aeruginosa was the predominant sputum pathogen in most patients. Clinical improvement, chest radiograph changes, evidence of airway obstruction, and bacteriologic flora of sputum were no different regardless of the regimen used. These results suggest that the use of anti-Pseudomonas medication in these children may not always be necessary. These observations need to be confirmed by blind-controlled studies in larger numbers of patients with mild as well as severe respiratory involvement.