Safety and Efficacy of Anidulafungin for Fungal Infection in Patients With Liver Dysfunction or Multiorgan Failure.

BACKGROUND: The objective of this study was to review our clinical experience on the safety and efficacy of anidulafungin, an echinocandin antifungal, in the treatment of invasive fungal infections (IFIs) in patients with moderate to severe abnormal liver function tests or multiorgan failure and IFI, in a large United Kingdom Liver Centre. METHODS: The clinical records of the first 50 consecutive patients treated for IFI with anidulafungin between January 7, 2009 and March 2, 2011 were analyzed. Data were collected on demographics, underlying disease, disease characteristics, hematological and biochemical parameters, IFI, concomitant bacterial and viral infections, response to anidulafungin, and anidulafungin-related adverse events. RESULTS: The patients' median age was 54.3 years (range, 19.6-75.9); 60% were male. Twenty-two (44%) patients were liver transplant recipients. Others had hepatopancreaticobiliary disease (n = 15, 30%) or chronic liver disease (n = 11, 22%). Invasive fungal infection (predominantly Candida spp) was proven in 36 (72%) patients, probable in 14 (28%). Of 46 evaluable patients, 35 (76%) had a favorable anidulafungin treatment outcome. Forty-nine (98%) had abnormal liver function tests (LFTs) pretreatment; 31 (62%) had ≥1 LFT raised to ≥2× baseline during anidulafungin treatment. CONCLUSIONS: In this highly specialized group of patients, anidulafungin treatment was efficacious and well tolerated by those with decompensated liver disease, multiorgan failure, and high-risk liver transplant with proven or probable IFI.

The UK patient experience of relapse in Multiple Sclerosis treated with first disease modifying therapies.

BACKGROUND: The fixed, progressive disability associated with late Multiple Sclerosis (MS) is known to have a major impact on patients and their families, but the impact of relapse earlier in the disease course is less well documented, particularly from the patient׳s perspective. This study aimed to understand the effects of relapse for people with MS (PwMS), focussing on the years immediately after starting disease modifying therapy (DMT) when experience of a relapse may particularly influence a patient׳s opinions of their disease and its therapy. METHODS: This was a multi-centre, retrospective, observational research study, recruiting patients from 7 UK NHS Hospital Trusts. Consenting patients with relapsing-remitting MS (RRMS), who had started a DMT more than 36 months before screening, were sent a study questionnaire. Data on MS relapses and treatments over 3 years were collected simultaneously from medical records. RESULTS: One hundred and three patients completed the questionnaires. Relapses were under-reported to health care professionals, with 28% of respondents failing to report their most recent attack and 46% declaring they had failed to report an attack in the past. During their most recent relapse, 67% of those in paid employment reported taking time off sick, 48% reduced working hours temporarily, and 41% worked reduced hours and took time off sick. Sixty-six percent required additional support to undertake routine daily tasks during their most recent relapse. A range of effects of relapse which cannot be measured in financial terms were also reported, including effects on physical abilities, mental health and family roles and relationships. CONCLUSION: This contemporary UK-based study provides an insight into the experience of relapse early in the treatment of RRMS from the patient perspective. The comparison of documented patient reported relapses reveals some deficiencies in the recording of relapses which is important to address in view of the reported impact of individual relapses, and emphasises relapse reduction as a worthy treatment aim.

Effectiveness of omalizumab in severe allergic asthma: a retrospective UK real-world study.

OBJECTIVE: The aim of this study was to evaluate the "real world" effects of the monoclonal antibody omalizumab (OMB) when used to treat severe persistent allergic asthma in UK clinical practice. METHODS: A 10-center retrospective observational study was carried out to compare oral corticosteroid (OCS) use and exacerbation frequency in 12 months pre- versus post-OMB initiation in 136 patients aged ≥12 years with severe persistent allergic asthma. All patients received ≥1 dose of OMB. Patients who had received OMB in a clinical trial were excluded. Data were obtained from hospital and if necessary general practitioners' (GPs') records on OCS use, lung function, hospital resource use, and routinely used quality of life (QoL) measures at baseline (pre-OMB), 16 weeks, and up to 12 months post-OMB initiation. RESULTS: Mean total quantity of OCS prescribed per year decreased by 34% between the 12 months pre- and post-OMB initiation. During the 12 months post-OMB initiation, 87 patients (64%) stopped/reduced OCS use by 20% or more and 66 (49%) stopped OCS completely. Mean percent predicted forced expiratory volume in one second (FEV(1)) increased from 66.0% at baseline to 75.2% at week 16 of OMB therapy. The number of asthma exacerbations decreased by 53% during the 12 months post-initiation. Accident and emergency visits reduced by 70% and hospitalizations by 61% in the 12 months post-OMB initiation. CONCLUSION: This retrospective analysis showed a reduction in exacerbations and improved QoL as per previous studies with OMB. However, the total reduction in annual steroid burden and improved lung function in this severely ill group of patients taking regular or frequent OCS is greater than that seen in previous trials.

Real world evaluation of three models of NHS smoking cessation service in England.

BACKGROUND: NHS Stop Smoking Services provide various options for support and counselling. Most services have evolved to suit local needs without any retrospective evaluation of their efficiency.Three local service evaluations were carried out at Bournemouth & Poole Teaching Primary Care Trust (PCT) (PCT1), NHS South East Essex (PCT2) and NHS Warwickshire (PCT3) to describe the structure and outcomes associated with different services. RESULT: Standardised interviews with key personnel in addition to analysis of data from 400 clients accessing the service after 1st April 2008 in each PCT. The PCTs varied in geography, population size and quit rate (47%-63%). Services were delivered by PCT-led specialist teams (PCT1), community-based healthcare providers (PCT3) and a combination of the two (PCT2) with varying resources and interventions in each.Group support resulted in the highest quit rates (64.3% for closed groups v 42.6% for one-to-one support (PCT1)). Quit rates were higher for PCT (75.0%) v GP (62.0%) and pharmacist-delivered care (41.0%) where all existed in the same model (PCT2). The most-prescribed therapy was NRT (55.8%-65.0%), followed by varenicline (24.5%-34.3%), counselling alone (6.0%-7.8%) and bupropion (2.0%-4.0%). CONCLUSION: The results suggest that service structure, method of support, healthcare professional involved and pharmacotherapy all play a role in a successful quit. Services must be tailored to support individual needs with patient choice and access to varied services being key factors.

How much does it cost a specialist palliative care unit to manage constipation in patients receiving opioid therapy?

The burden of constipation from the patient's perspective has been well described. The aim of this study was to evaluate the cost of managing constipation in patients taking opioids in a specialist palliative care inpatient unit. A retrospective review of the medical records of 58 patients (70 admissions) who died during a six-month period was undertaken to identify prescribing patterns for opioids and oral laxatives and tasks associated with managing constipation in these patients. A prospective time and motion study also was undertaken, whereby staff recorded the time and resources required to perform each task. These data were then applied to the actual frequency recorded in the retrospective review to calculate the direct cost of managing constipation in those 70 admissions during that six-month period. There was no discernable pattern in oral laxative prescribing. The mean cost of managing constipation was 29.81 pounds (48.74 USD) per admission, with staff time accounting for 85% of the cost. The most time-consuming activity was staff discussion about bowel management, which occurred at least once daily for doctors and twice for nurses and involved up to eight members of staff at a time. The cost of managing constipation is skewed in that it costs 30 pounds (49 USD) or less in 71% of admissions but exceeded 100 pounds (163 USD) in 5%. In the latter group, earlier and/or more effective intervention for constipation could lead to clinical and economic benefits.

Acute medical care. The right person, in the right setting--first time: how does practice match the report recommendations?

An acute medicine Royal College of Physicians report makes key recommendations. This study reviews organisational issues and consultant working patterns against these recommendations. Thirty-nine trusts in England and Wales were asked to participate in an online survey, which 27 completed. Twenty-six sites had an acute medical unit (AMU) and all had a lead consultant. Two trusts had no written operational policy. Of the 26 AMUs, 22 had at least level 1 facilities and 21 used an early warning score at point of entry to care. Ten reported a minimum of twice daily ward rounds seven days a week. Consultant of the day was the most common pattern of work. Ten trusts cancelled other clinical duties for consultants responsible for acute take. The pilot shows evidence of good practice in leadership and operational policies. Further work to standardise and improve acute care is needed including a more consistent twice daily consultant review.