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 387children. 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.

“Who wants to go repeatedly to the hospital?” : Perceptions and experiences of simplified medical abortion in Rajasthan, India

The aim of this study is to explore women's experiences and perceptions of home use of misoprostol and of the self-assessment of the outcome of early medical abortion in a low-resource setting in India. In-depth interviews were conducted with 20 women seeking early medical abortion, who administered misoprostol at home and assessed their own outcome of abortion using a low-sensitivity pregnancy test. With home use of misoprostol, women were able to avoid inconvenience of travel, child care, and housework, and maintain confidentiality. The use of a low-sensitivity pregnancy test alleviated women's anxieties about retained products. Majority said they would prefer medical abortion involving a single visit in future. This study provides nuanced understanding of how women manage a simplified medical abortion in the context of low literacy and limited communication facilities. Service delivery guidelines should be revised to allow women to have medical abortion with fewer visits.

A quantitative coronary angiography-matched comparison between a prospective randomised multicentre cutting balloon angioplasty and bare metal stent trial (REDUCE III) and the Rapamycin-Eluting Stent Evaluation At Rotterdam Cardiology Hospital (RESEARCH) study

Aims: There remains significant concern about the long-term safety of drug-eluting stents (DES). However, bare metal stents (BMS) have been used safely for over two decades. There is therefore a pressing need to explore alternative strategies for reducing restenosis with BMS. This study was designed to examine whether IVUS-guided cutting balloon angioplasty (CBA) with BMS could convey similar restenosis rates to DES. Methods and results: In the randomised REstenosis reDUction by Cutting balloon angioplasty Evaluation (REDUCE III) study, 521 patients were divided into four groups based on device and IVUS use before BMS (IVUS-CBA-BMS: 137 patients; Angio-CBA-BMS: 123; IVUS-BA-BMS: 142; and Angio-BA-BMS: 119). At follow-up, the IVUS-CBA-BMS group had a significantly lower restenosis rate (6.6%) than the other groups (p=0.016). We performed a quantitative coronary angiography (QCA) based matched comparison between an IVUS-guided CBA-BMS strategy (REDUCE III) and a DES strategy (Rapamycin-Eluting-Stent Evaluation At Rotterdam Cardiology. Hospital, the RESEARCH study). We matched the presence of diabetes, vessel size, and lesion severity by QCA. Restenosis (>50% diameter stenosis at follow-up) and target vessel revascularisation (TVR) were examined. QCA-matched comparison resulted in 120-paired lesions. While acute gain was significantly greater in IVUS-CBA-BMS than DES (1.65 +/- 0.41 mm vs. 1.28 +/- 0.57 mm, p=0.001), late loss was significantly less with DES than with IVUS-CBA-BMS (0.03 +/- 0.42 mm vs. 0.80 +/- 0.47 mm, p=0.001). However, no difference was found in restenosis rates (IVUS-CBA-BMS: 6.6% vs. DES: 5.0%, p=0.582) and TVR (6.6% and 6.6%, respectively). Conclusions: An IVUS-guided CBA-BMS strategy yielded restenosis rates similar to those achieved by DES and provided an effective alternative to the use of DES.

The use of canonical correlation analysis to assess the relationship between executive functioning and verbal memory in older adults

Executive functioning (EF), which is considered to govern complex cognition, and verbal memory (VM) are constructs assumed to be related. However, it is not known the magnitude of the association between EF and VM, and how sociodemographic and psychological factors may affect this relationship, including in normal aging. In this study, we assessed different EF and VM parameters, via a battery of neurocognitive/psychological tests, and performed a Canonical Correlation Analysis (CCA) to explore the connection between these constructs, in a sample of middle- aged and older healthy individuals without cognitive impairment (N = 563, 50+ years of age). The analysis revealed a positive and moderate association between EF and VM independently of gender, age, education, global cognitive performance level, and mood. These results confirm that EF presents a significant association with VM performance.

Promoting hospital-based smoking cessation services at major Swiss hospitals: a before and after study.

Whether a 1-year nationwide, government supported programme is effective in significantly increasing the number of smoking cessation clinics at major Swiss hospitals as well as providing basic training for the staff running them. We conducted a baseline evaluation of hospital services for smoking cessation, hypertension, and obesity by web search and telephone contact followed by personal visits between October 2005 and January 2006 of 44 major public hospitals in the 26 cantons of Switzerland; we compared the number of active smoking cessation services and trained personnel between baseline to 1 year after starting the programme including a training workshop for doctors and nurses from all hospitals as well as two further follow-up visits. At base line 9 (21%) hospitals had active smoking cessation services, whereas 43 (98%) and 42 (96%) offered medical services for hypertension and obesity respectively. Hospital directors and heads of Internal Medicine of 43 hospitals were interested in offering some form of help to smokers provided they received outside support, primarily funding to get started or to continue. At two identical workshops, 100 health professionals (27 in Lausanne, 73 in Zurich) were trained for one day. After the programme, 22 (50%) hospitals had an active smoking cessation service staffed with at least 1 trained doctor and 1 nurse. A one-year, government-supported national intervention resulted in a substantial increase in the number of hospitals allocating trained staff and offering smoking cessation services to smokers. Compared to the offer for hypertension and obesity this offer is still insufficient.

Cardiovascular risk estimation and eligibility for statin therapy using different scoring systems in Europe: a population-based study in Switzerland

BACKGROUND: Recommendations for statin use for primary prevention of coronary heart disease (CHD) are based on estimation of the 10- year CHD risk. We compared the 10-year CHD risk assessments and eligibility percentages for statin therapy using three scoring algorithms currently used in Europe. METHODS: We studied 5683 women and men, aged 35-75, without overt cardiovascular disease (CVD), in a population-based study in Switzerland. We compared the 10-year CHD risk using three scoring schemes, i.e., the Framingham risk score (FRS) from the U.S. National Cholesterol Education Program's Adult Treatment Panel III (ATP III), the PROCAM scoring scheme from the International Atherosclerosis Society (IAS), and the European risk SCORE for low-risk countries, without and with extrapolation to 60 years as recommended by the European Society of Cardiology guidelines (ESC). With FRS and PROCAM, high-risk was defined as a 10- year risk of fatal or non-fatal CHD>20% and a 10-year risk of fatal CVD≥5% with SCORE. We compared the proportions of high-risk participants and eligibility for statin use according to these three schemes. For each guideline, we estimated the impact of increased statin use from current partial compliance to full compliance on potential CHD deaths averted over 10 years, using a success proportion of 27% for statins. RESULTS: Participants classified at high-risk (both genders) were 5.8% according to FRS and 3.0% to the PROCAM, whereas the European risk SCORE classified 12.5% at high-risk (15.4% with extrapolation to 60 years). For the primary prevention of CHD, 18.5% of participants were eligible for statin therapy using ATP III, 16.6% using IAS, and 10.3% using ESC (13.0% with extrapolation) because ESC guidelines recommend statin therapy only in high-risk subjects. In comparison with IAS, agreement to identify eligible adults for statins was good with ATP III, but moderate with ESC. Using a population perspective, a full compliance with ATP III guidelines would reduce up to 17.9% of the 24′ 310 CHD deaths expected over 10 years in Switzerland, 17.3% with IAS and 10.8% with ESC (11.5% with extrapolation). CONCLUSIONS: Full compliance with guidelines for statin therapy would result in substantial health benefits, but proportions of high-risk adults and eligible adults for statin use varied substantially depending on the scoring systems and corresponding guidelines used for estimating CHD risk in Europe.

Externalizing disorders and substance use: empirically derived subtypes in a population-based sample of adults.

PURPOSE: Attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD) are common externalizing disorders of childhood. The common effects of these disorders on substance abuse need further investigation. The current study investigated the joint clusters of childhood/adolescence ADHD, CD, and ODD, and their influence on substance abuse/dependence in a population-based sample of adults. METHODS: The data were drawn from the PsyCoLaus study (n = 3,720) conducted in Lausanne, Switzerland. The population-based sample included 238 subjects meeting criteria for ADHD/ODD/CD diagnoses before the age of 15. Latent class analyses (LCA) were performed to derive comorbidity subtypes, which were subsequently characterized with respect to psychosocial correlates and substance use. RESULTS: The best fit in LCAs was achieved with three latent classes: an ADHD subtype (35.7 %); an externalizing multimorbid subtype (33.6 %) involving ODD, ADHD, and CD; and a third subtype with CD (30.7 %). The CD subtype showed the highest association with substance use. Apart from this, the externalizing multimorbid subtype was also significantly linked to substance use. The ADHD subtype had only elevated frequencies for alcohol dependence in comparison with subjects that had no history of ADHD, ODD, and CD during childhood or adolescence. Finally, important interactions between subtypes and sex were observed with regard to substance use. CONCLUSIONS: This study provides evidence showing that subtyping the externalizing disorders, ADHD, ODD and CD, along their comorbidity patterns leads to important differences regarding substance use. This could have implications for the etiology, prevention, and treatment of substance use disorders.

Trends in drug consumption and risk of transmission of HIV and hepatitis C virus among injecting drug users in Switzerland, 1993-2006

As a part of the HIV behavioural surveillance system in Switzerland, repeated cross-sectional surveys were conducted in 1993, 1994, 1996, 2000 and 2006 among attenders of all low threshold facilities (LTFs) with needle exchange programmes and/or supervised drug consumption rooms for injection or inhalation in Switzerland. Data were collected in each LTF over five consecutive days, using a questionnaire that was partly completed by an interviewer and partly self administered. The questionnaire was structured around three topics: socio-demographic characteristics, drug consumption, health and risk/preventive behaviour. Analysis was restricted to attenders who had injected drugs during their lifetime (IDUs). Between 1993 and 2006, the median age of IDUs rose by 10 years. IDUs are severely marginalised and their social situation has improved little. The borrowing of used injection equipment (syringe or needle already used by other person) in the last six months decreased (16.5% in 1993, 8.9% in 2006) but stayed stable at around 10% over the past three surveys. Other risk behaviour, such as sharing spoons, cotton or water, was reported more frequently, although also showed a decreasing trend. The reported prevalence of HIV remained fairly stable at around 10% between 1993 and 2006; reported levels of hepatitis C virus (HCV) prevalence were high (56.4% in 2006). In conclusion, the overall decrease in the practice of injection has reduced the potential for transmission of infections. However as HCV prevalence is high this is of particular concern, as the current behaviour of IDUs indicates a potential for further spreading of the infection. Another noteworthy trend is the significant decrease in condom use in the case of paid sex.

Cannabis use in a Swiss male prison: qualitative study exploring detainees' and staffs' perspectives.

BACKGROUND: Several studies suggest a high prevalence of cannabis use before and during imprisonment, but subjective perspectives of detainees and staff towards its use in prison are lacking. This issue was explored in the framework of an observational study addressing tobacco use in three Swiss prisons in 2009 and 2010 that involved multiple strands (quantitative and qualitative components). This article presents qualitative data on cannabis use collected in one of the settings. METHODS: We used in-depth semi-structured interviews with both detainees and staff to explore their attitudes towards cannabis in one post-trial male Swiss prison. We performed specific coding and thematic analysis for cannabis with the support of ATLAS.ti, compared detainees' and staff's opinions, and considered the results with regard to drug policy in prison in general. RESULTS: 58 participants (31 male offenders, mean age 35 years, and 27 prison staff, mean age 46 years, 33% female) were interviewed. Detainees estimated the current use of cannabis use to be as high as 80%, and staff 50%. Participants showed similar opinions on effects of cannabis use that were described both at individual and institutional levels: analgesic, calming, self-help to go through the prison experience, relieve stress, facilitate sleep, prevent violence, and social pacifier. They also mentioned negative consequences of cannabis use (sleepiness, decreased perception of danger and social isolation), and dissatisfaction regarding the ongoing ambiguous situation where cannabis is forbidden but detection in the urine was not sanctioned. However, the introduction of a more restrictive regulation induced fear of violence, increased trafficking and a shift to other drug use. CONCLUSION: Although illegal, cannabis use is clearly involved in daily life in prison. A clearer and comprehensive policy addressing cannabis is needed, including appropriate measures tailored to individual users. To sustain a calm and safe environment in prison, means other than substance or medication use are required.

Northern Ireland Point Prevalence Survey of Hospital-acquired Infections and Antimicrobial Use 2012

The PHA�coordinated Northern Ireland's participation in ECDC's National Prevalence Survey on�Hospital-Acquired Infections & on Antimicrobial Use. Hospitals in Northern Ireland participated in data collection between May and June 2012.This report provides a snapshot of the levels of hospital-acquired infections (HAI) and levels of antimicrobial use (AMU) in hospitals in Northern Ireland during 2012.There have been three previous HAI PPS surveys and the last survey was carried out in 2006. It is difficult to compare each survey as the data was collected in a different way. However, after making allowances, there was an overall drop in HAI prevalence of 18% from 2006 to 2012.The PPS data collection was undertaken by hospital teams between May and June 2012 (one hospital deferred data collection until September 2012 because of a move to a new hospital); 16 hospitals surveyed 3,992 eligible patients. The median age of all patients was 66 years. A total of 383 (10 per cent) children under 16 years of age were surveyed.�Key results from this year's survey:The prevalence of HAI was 4.2%. A total of 166 patients were diagnosed with an active HAI with 3 patients having more than one infection.When comparing ward specialties, HAI prevalence was highest for patients in adult intensive care units (ICUs) at 9.1 per cent, followed by care of the elderly wards at 5.7%.The most common types of HCAI were respiratory infections (including pneumonia and infections of the lower respiratory tract) (27.9 per cent of all infections), surgical site infections (18.9 per cent) and urinary tract infections (UTI) (11.8 per cent).Since the last PPS in 2006 there has been a reduction in MRSA infections - from 0.9 per cent �of the hospital population to less than 0.1 per cent in patients; and a five-fold reduction in C. difficile infections (from 1.1 per cent to 0.2 per cent).The prevalence of antimicrobial use was 29.5%.Most antibiotic use (60 per cent) in hospitals was in patients receiving treatment for infections which commenced in the community. Eleven percent of surgical prophylaxis was prescribed for greater than one day.��

Characteristics of victims of violence admitted to a specialized medico-legal unit in Switzerland.

To improve care and services to victims of interpersonal violence, a medico-legal consultation unit was set up at the Lausanne University Hospital, Switzerland in 2006. Adult victims of violence are referred to the consultation by the emergency department. Patients are received by forensic nurses for support, forensic examination and community orientation. A descriptive study of medical reports filled for the 2006 population was conducted in 2007 with the aim to explore characteristics of this specific population and to better orient prevention. Among the 422 patients in 2006, 57% were men and 43% women, with a median age of 31 years old. Violent episodes took place in a public place for 90% of male victims and at home for 70% of female victims. The perpetrators were mostly unknown to male victims (62% of all men victims) and mostly known (usually the partner or a former partner) to female victims (90% of all women victims). For 80% of the women and 47% of the men, the violent event which brought them to the consultation, was not the first one. Because 90% of all patients under study were victimized by men., not only is it necessary to target prevention program to match the potential victims, prevention messages must also focus on potential offenders, especially on young men.

Adolescents' beliefs about marijuana use: a comparison of regular users, past users and never/occasional users.

A questionnaire investigating adolescents' opinions and experiences regarding marijuana use was administered to 163 adolescents and young adults (96 boys and 67 girls) aged 13 to 20 (mean age = 16.8, s.d. = 1.5). Items referred to marijuana and other substances' dangerousness, representations regarding the positive and negative consequences of marijuana use. Responses were compared according to marijuana use status (classified into never/occasional use, current regular use and past regular use). Results show that adolescents' opinions differ according to their experience with marijuana use. Current regular users evaluate marijuana as less dangerous, but alcohol and heroin as more dangerous in comparison with never/occasional and past users. Current and past users are more likely to define marijuana as a medical drug and a plant used in agriculture, and less likely to define it as an illegal drug. Current and past users evaluate marijuana use as a way to cope with stress, to relax to a greater extent than do never/occasional users do. The latter attribute more negative consequences to marijuana use such as diminished driving ability and school performance and a pathway to hard drugs.

Differential effect of Charlson index and its components on in-hospital mortality and health costs

Introduction: The Charlson index (Charlson, 1987) is a commonly used comorbidity index in outcome studies. Still, the use of different weights makes its calculation cumbersome, while the sum of its components (comorbidities) is easier to compute. In this study, we assessed the effects of 1) the Charlson index adapted for the Swiss population and 2) the sum of its components (number of comorbidities, maximum 15) on a) in-hospital deaths and b) cost of hospitalization. Methods: Anonymous data was obtained from the administrative database of the department of internal medicine of the Lausanne University Hospital (CHUV). All hospitalizations of adult (>=18 years) patients occurring between 2003 and 2011 were included. For each hospitalization, the Charlson index and the number of comorbidities were calculated. Analyses were conducted using Stata. Results: Data from 32,741 hospitalizations occurring between 2003 and 2011 was analyzed. On bivariate analysis, both the Charlson index and the number of comorbidities were significantly and positively associated with in hospital death. Conversely, multivariate adjustment for age, gender and calendar year using Cox regression showed that the association was no longer significant for the number of comorbidities (table). On bivariate analysis, hospitalization costs increased both with Charlson index and with number of comorbidities, but the increase was much steeper for the number of comorbidities (figure). Robust regression after adjusting for age, gender, calendar year and duration of hospital stay showed that the increase in one comorbidity led to an average increase in hospital costs of 321 CHF (95% CI: 272 to 370), while the increase in one score point of the Charlson index led to a decrease in hospital costs of 49 CHF (95% CI: 31 to 67). Conclusion: Charlson index is better than the number of comorbidities in predicting in-hospital death. Conversely, the number of comorbidities significantly increases hospital costs.

Individual monitoring of internal exposure for nuclear medicine workers in Switzerland.

Monitoring of internal exposure for nuclear medicine workers requires frequent measurements due to the short physical half-lives of most radionuclides used in this field. The aim of this study was to develop screening measurements performed at the workplace by local staff using standard laboratory instrumentation, to detect whether potential intake has occurred. Such measurements do not enable to determine the committed effective dose, but are adequate to verify that a given threshold is not exceeded. For radioiodine, i.e. (123)I, (124)I, (125)I and (131)I, a calibrated surface contamination monitor is placed in front of the thyroid to detect whether the activity threshold has been exceeded. For radionuclides with very short physical half-lives (≤6 h), such as (99m)Tc and those used in positron emission tomography  imaging, i.e. (11)C, (15)O, (18)F and (68)Ga, screening procedures consist in performing daily measurements of the ambient dose rate in front of the abdomen. Other gamma emitters used for imaging, i.e. (67)Ga, (111)In and (201)Tl, are measured with a scintillation detector located in front of the thorax. For pure beta emitters, i.e. (90)Y and (169)Er, as well as beta emitters with low-intensity gamma rays, i.e. (153)Sm, (177)Lu, (186)Re and (188)Re, the procedure consists in measuring hand contamination immediately after use. In Switzerland, screening procedures have been adopted by most nuclear medicine services since such measurements enable an acceptable monitoring while taking into account practical and economic considerations.

Comparison of in-hospital mortality for acute myocardial infarction in Switzerland with admission during routine duty hours versus admission during out of hours (insight into the AMIS plus registry).

To improve long-term survival, prompt revascularization of the infarct-related artery should be done in patients with acute myocardial infarction (AMI); therefore, a large proportion of these patients would be hospitalized during out of hours. The clinical effects of out-of-hours AMI management were already questioned, with conflicting results. The purpose of this investigation was to compare the in-hospital outcome of patients admitted for AMI during out of hours and working hours. All patients with AMI included in the AMIS Plus Registry from January 1, 1997, to March 30, 2006, were analyzed. The working-hours group included patients admitted from 7 a.m. to 7 p.m. on weekdays, and the out-of-hours group included patients admitted from 7 p.m. to 7 a.m. on weekdays or weekends. Major cardiac events were defined as cardiovascular death, reinfarction, and stroke. The study primary end points were in-hospital death and major adverse cardiac event (MACE) rates. A total of 12,480 patients met the inclusion criteria, with 52% admitted during normal working hours, and 48%, during out of hours. Patients admitted during weekdays included more women (28.1% vs 26%; p = 0.009), older patients (65.5 +/- 13 vs 64.1 +/- 13 years; p = 0.0011), less current smokers (40.1% vs 43.5%; p <0.001), and less patients with a history of ischemic heart disease (31.5% vs 34.5%; p = 0.001). A significantly higher proportion of patients admitted during out of hours had Killip's class III and IV. No differences in terms of in-hospital survival rates between the 2 groups (91.5% vs 91.2%; p = 0.633) or MACE-free survival rates (both 88.5%; p = 1.000) were noted. In conclusion, the outcome of patients with AMI admitted out of hours was the same compared with those with a weekday admission. Of predictors for in-hospital outcome, timing of admission had no significant influence on mortality and/or MACE incidence.