Extent and nature of unlicensed and off-label medicine use in hospitalised children in Palestine

Objective of the study: To determine the extent and nature of unlicensed/off-label prescribing patterns in hospitalised children in Palestine. Setting: Four paediatric wards in two public health system hospitals in Palestine [Caritas children’s hospital (Medical and neonatal intensive care units) and Rafidia general hospital (Medical and surgical units)]. Method: A prospective survey of drugs administered to infants and children <18 years old was carried out over a five-week period in the four paediatric wards. Main outcome measure: Drug-licensing status of all prescriptions was determined according to the Palestinian Registered Product List and the Physician’s Desk Reference. Results: Overall, 917 drug prescriptions were administered to 387 children. Of all drug prescriptions, 528 (57.5%) were licensed for use in children; 65 (7.1%) were unlicensed; and 324 (35.3%) were used off-label. Of all children, 49.6% received off-label prescriptions, 10.1% received unlicensed medications and 8.2% received both. Seventy-two percent of off-label drugs and 66% of unlicensed drugs were prescribed for children <2 years. Multivariate analysis showed that patients who were admitted to the neonatal intensive care unit and infants aged 0–1 years were most likely to receive a greater number of off-label or unlicensed medications (OR 1.80; 95% CI 1.03–3.59 and OR 1.99; 95% CI 0.88–3.73, respectively). Conclusion: The present findings confirmed the elevated prevalence of unlicensed and off-label paediatric drugs use in Palestine and strongly support the need to perform well designed clinical studies in children.

Children’s views on unlicensed/off-label paediatric prescribing and paediatric clinical trials.

Objectives: To explore the views and perspectives of children on the unlicensed/off-label use of medicines in children and on the participation of children in clinical trials. Methods: Focus-group discussions, involving school children, were carried out in a range of primary and secondary schools in Northern Ireland. A purposeful sample was chosen to facilitate representation of various socioeconomic groupings. Results: A total of 123 pupils, aged from 10 to 16 years, from six schools, participated in 16 focus groups. In general, pupils viewed the unlicensed/off-label use of medicines in children as unsafe and unethical and felt it is necessary to test medicines in children to improve the availability of licensed products. The majority felt that older children should be told, and that parents should be told, about the unlicensed/off-label use of medicines in children, yet they recognised some implications of this, such as potential medication non-adherence. Conclusions: This is the first study to explore the views of healthy children on unlicensed medicine use in children. Children were able to recognise potential risks associated with the unlicensed use of medicines and felt it is necessary to test and license more medicines in children. Practice implications Health care professionals should consider the views of children in decisions that affect their health.

Abatement technologies for road surface run-off

Heavy metals, primarily zinc, copper, lead, and chromium, and Polycyclic Aromatic Hydrocarbons (PAHs) are the main hazardous constituents of road runoff. The main sources of these contaminants are vehicle emission, mostly through wear and leakage, although erosion of the road surface and de-icing salts are also recognised pollution sources. The bioavailability of these toxic compounds, and more importantly their potential biomagnification along food chains, could affect aquatic communities persistently exposed to road runoff. Several internationally approved abatement technologies are available for the management of road runoff on new motorway schemes. Recent studies conducted in Cork and Dublin, Ireland demonstrated the efficacy of infiltration trenches as abatement technologies in the removal of both heavy metals and PAHs prior to discharge; the technology was however inefficient in mitigating first flush events. Gully traps with sedimentation chambers, another technology investigated, demonstrated to have a substantially lower removal potential but appeared to be more effective in attenuating surges of contaminants attributed to first flush events. Consequently the employment of combined abatement techniques could efficiently minimise deviations from required effluent concentrations. The studies determined a relatively stationary accumulation of heavy metals and PAHs in sediments close to the point of discharge with a rapid decline in concentration in nearby downstream sediments (<50m). Further, Microtox® Solid Phase testing reported a negligible impact on assemblages exposed to contaminated sediments for all sites investigated. This paper describes pollutant loading from road runoff and mitigation measures from a freshwater deterioration in a water quality perspective. The results and analysis of field samples collected adjacent to a number of roads and motorways in Ireland is also presented. Finally sustainable drainage systems, abatement techniques and technologies available for onsite treatment of runoff are presented to improve and mitigate impacts of vehicular transport on the environment.

Perceptions and attitudes of Jordanian paediatricians towards off-label paediatric prescribing

Objective To assess current experiences and attitudes of hospital based paediatricians towards off-label medicine prescribing. Setting Paediatric hospital wards and out-patient clinics. Design A prospective, questionnaire based study. Results A 30 item questionnaire was sent to 300 hospital based paediatricians and 250 (83%) were returned completed. Over 69% of responders were familiar with the term off-label medicines. However, only 28% were knowingly prescribing off-label medicines to children. The majority of respondents (90%) expressed concerns about the safety and efficacy of off-label medicines. Only 15% had observed Adverse Drug Reactions, and 31% a treatment failure. The vast majority of respondents (83%) did not obtain informed consent or tell parents they were prescribing off label medicines to their children. Conclusions Off-label prescribing of medicines to children is a familiar concept to the majority of paediatricians in Jordan although only a smaller number are aware that it is common in their practice. Respondents showed concern about off label prescribing, although the majority do not consider it necessary to inform parents. More comprehensive research is needed in this area in Jordan and other Middle Eastern countries.

Late Pleistocene history of turbidite sedimentation in a submarine canyon off the northern Great Barrier Reef, Australia

Cores from slopes east of the Great Barrier Reef (GBR) challenge traditional models for sedimentation on tropical mixed siliciclastic-carbonate margins. However, satisfactory explanations of sediment accumulation on this archetypal margin that include both hemipelagic and turbidite sedimentation remain elusive, as submarine canyons and their role in delivering coarse-grained turbidite deposits, are poorly understood. Towards addressing this problem we investigated the shelf and canyon system bordering the northern Ribbon Reefs and reconstructed the history of turbidite deposition since the Late Pleistocene. High-resolution bathymetric and seismic data show a large paleo-channel system that crosses the shelf before connecting with the canyons via the inter-reef passages between the Ribbon Reefs. High-resolution bathymetry of the canyon axis reveals a complex and active system of channels, sand waves, and local submarine landslides. Multi-proxy examination of three cores from down the axis of the canyon system reveals 18 turbidites and debrites, interlayered with hemipelagic muds, that are derived from a mix of shallow and deep sources. Twenty radiocarbon ages indicate that siliciclastic-dominated and mixed turbidites only occur prior to 31 ka during Marine Isotope Stage (MIS) 3, while carbonate-dominated turbidites are well established by 11 ka in MIS1 until as recently as 1.2 ka. The apparent lack of siliciclastic-dominated turbidites and presence of only a few carbonate-dominated turbidites during the MIS2 lowstand are not consistent with generic models of margin sedimentation but might also reflect a gap in the turbidite record. These data suggest that turbidite sedimentation in the Ribbon Reef canyons, probably reflects the complex relationship between the prolonged period (> 25 ka) of MIS3 millennial sea level changes and local factors such as the shelf, inter-reef passage depth, canyon morphology and different sediment sources. On this basis we predict that the spatial and temporal patterns of turbidite sedimentation could vary considerably along the length of the GBR margin.