Primary care use of antipsychotic drugs: an audit and intervention study

BACKGROUND: Concerns regarding the use of antipsychotic medication in secondary care suggested an examination of primary care prescribing. AIM: To audit and intervene in the suboptimal prescribing of antipsychotic drugs to primary care patients. DESIGN OF STUDY: Cross-sectional prevalence: subsequent open treatment intervention. SETTING: Seven of the 29 practices in the Eastern Hull Primary Care Trust. METHODS: Criteria for best practice were developed, against which prescribing standards were tested via audit. Patients identified as suboptimally prescribed for were invited to attend an expert review for intervention. RESULTS: 1 in 100 of 53,000 patients was prescribed antipsychotic treatment. Diagnoses indicating this were impossible to ascertain reliably. Half the regimes failed one or more audit criteria, leaving diagnosis aside. Few practices agreed to patients being approached: of 179 invitations sent, only 40 patients attended. Of 32 still taking an antipsychotic drug, 26 required changes. Mean audit criteria failed were 3.4, lack of psychotic disorder diagnosis and problematic side effects being most frequent. Changes were fully implemented in only 16 patients: reasons for complete or partial failure to implement recommendations included the wishes or inaction of patients and professionals, and worsening of symptoms including two cases of antipsychotic withdrawal syndrome. CONCLUSION: Primary care prescribing of antipsychotic drugs is infrequent, but most is unsatisfactory. Intervention is hampered by pluralistic reluctance: even with expert guidance, rationalisation is not without risk. Use of antipsychotic drugs in primary care patients whose diagnosis does not warrant this should be avoided. HOW THIS FITS IN: This study adds to concerns regarding high levels of off-licence use of potentially harmful medication. It adds evidence of major difficulties in rationalizing suboptimal regimes despite expert input. Relevance to the clinician is that it is better to avoid such regimes in the first place especially if there is no clear 'exit strategy': if in doubt, seek a specialist opinion

Recognising and defining a new crown clade within Stromboidea Rafinesque, 1815 (Mollusca, Gastropoda)

This paper defines a new crown clade Neostromboidea to separate the Strombidae, Rostellariidae, and Seraphsidae from their sister families Struthiolariidae and Aporrhaidae. There is significant value to understanding evolutionary processes within Stromboidea to recognise the universal similarity in the position of the eye on the end of peduncles and a diminished cephalic tentacle that arises from the middle to the end on that peduncle. This is in contrast to other members of the Stromboidea where the eye is located at the base of the cephalic tentacle. These physiological differences represent two set of organisms with divergent and independent evolutionary life histories and therefore these differences need to be identifiable within the nomenclature to bring meaning to the way we name things

Unusual electron density profiles observed by Cassini radio occultations in Titan's ionosphere: Effects of enhanced magnetospheric electron precipitation?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/95188/1/jgra21399.pd

Source mechanism of Saturn narrowband emission

Narrowband emission (NB) is observed at Saturn centered near 5 kHz and 20 kHz and harmonics. This emission appears similar in many ways to Jovian kilometric narrowband emission observed at higher frequencies, and therefore may have a similar source mechanism. Source regions of NB near 20 kHz are believed to be located near density gradients in the inner magnetosphere and the emission appears to be correlated with the occurrence of large neutral plasma clouds observed in the Saturn magnetotail. In this work we present the results of a growth rate analysis of NB emission (~20 kHz) near or within a probable source region. This is made possible by the sampling of in-situ wave and particle data. The results indicate waves are likely to be generated by the mode-conversion of directly generated Z-mode emission to O-mode near a density gradient. When the local hybrid frequency is close <I>n</I> <I>f</I>_ce (<I>n</I> is an integer and <I>f</I>_ce is the electron cyclotron frequency) with <I>n</I>=4, 5 or 6 in our case, electromagnetic Z-mode and weak ordinary (O-mode) emission can be directly generated by the cyclotron maser instability

Radiolytic Gas-Driven Cryovolcanism in the Outer Solar System

Water ices in surface crusts of Europa, Enceladus, Saturn's main rings, and Kuiper Belt Objects can become heavily oxidized from radiolytic chemical alteration of near-surface water ice by space environment irradiation. Oxidant accumulations and gas production are manifested in part through observed H2O2 on Europa. tentatively also on Enceladus, and found elsewhere in gaseous or condensed phases at moons and rings of Jupiter and Saturn. On subsequent chemical contact in sub-surface environments with significant concentrations of primordially abundant reductants such as NH3 and CH4, oxidants of radiolytic origin can react exothermically to power gas-driven cryovolcanism. The gas-piston effect enormously amplifies the mass flow output in the case of gas formation at basal thermal margins of incompressible fluid reservoirs. Surface irradiation, H2O2 production, NH3 oxidation, and resultant heat, gas, and gas-driven mass flow rates are computed in the fluid reservoir case for selected bodies. At Enceladus the oxidant power inputs are comparable to limits on nonthermal kinetic power for the south polar plumes. Total heat output and plume gas abundance may be accounted for at Enceladus if plume activity is cyclic in high and low "Old Faithful" phases, so that oxidants can accumulate during low activity phases. Interior upwelling of primordially abundant NH3 and CH4 hydrates is assumed to resupply the reductant fuels. Much lower irradiation fluxes on Kuiper Belt Objects require correspondingly larger times for accumulation of oxidants to produce comparable resurfacing, but brightness and surface composition of some objects suggest that such activity may be ongoing

The effect of Candida famata and Lactobacillus plantarum on the number of coliforms and the antibiotic resistance and virulence of Escherichia coli in the gut of broilers

This study was undertaken to determine the effect of a yeast (Candida famata) and a bacterium (Lactobacillus plantarum), administered alone or in combination in the drinking water, on the population of yeast, Lactobacillus sp. and coliforms, and the prevalence of antimicrobial resistance (AMR) and virulence genes in Escherichia coli (E. coli) isolated from digesta samples taken throughout the life of broiler chickens. Male (Ross 308) day-old chicks (220) were used. C. famata (isolated from a chicken) and L. plantarum (isolated from a pig) were administered via the drinking water. Water was provided either untreated or with C. famata (CF; 108 /ml), L. plantarum (LP; 105 –108 /ml), or a combination of CF and LP (106 –108 /ml) in water hoppers on 2 days each week for 35 days. Administering probiotics did not affect the growth performance in broiler chickens. No significant interactions were observed between main effects, and neither CF nor LP had any effect on the population size of Lactobacillus sp. or coliforms. The administration of C. famata increased the population density of yeasts in the small intestine at these ages. The population density of coliforms, Lactobacillus sp. and yeast decreased with age (P < 0.001). There was no significant effect of probiotics on the prevalence of phenotypic AMR and virulence genes in these studies. The prevalence of E. coli that was resistant to ampicillin and tetracycline, as well as carrying ≥3 virulence-associated genes, was greatest at the end of the starter phase (around 8 days old), before declining through the grower and finisher phases. There was only limited evidence that administering either CF or LP affected either the AMR or the virulence of E. coli in the bird. However, tetracycline resistance in E. coli was associated (P < 0.001, P < 0.01, P < 0.05, and P < 0.05) with the carriage of the iron uptake systems of E. coli D, iron-repressible protein, increased serum survival and temperaturesensitive haemagglutinin genes respectively, suggesting that the accumulation of iron and the genetic element conferring tetracycline resistance may be intertwined

Continental rupture and the creation of new crust in the Salton Trough rift, Southern California and northern Mexico: Results from the Salton Seismic Imaging Project

A refraction and wide-angle reflection seismic profile along the axis of the Salton Trough, California and Mexico, was analyzed to constrain crustal and upper mantle seismic velocity structure during active continental rifting. From the northern Salton Sea to the southern Imperial Valley, the crust is 17–18 km thick and approximately one-dimensional. The transition at depth from Colorado River sediment to underlying crystalline rock is gradual and is not a depositional surface. The crystalline rock from ~3 to ~8 km depth is interpreted as sediment metamorphosed by high heat flow. Deeper felsic crystalline rock could be stretched preexisting crust or higher-grade metamorphosed sediment. The lower crust below ~12 km depth is interpreted to be gabbro emplaced by rift-related magmatic intrusion by underplating. Low upper mantle velocity indicates high temperature and partial melting. Under the Coachella Valley, sediment thins to the north and the underlying crystalline rock is interpreted as granitic basement. Mafic rock does not exist at 12–18 km depth as it does to the south, and a weak reflection suggests Moho at ~28 km depth. Structure in adjacent Mexico has slower midcrustal velocity, and rocks with mantle velocity must be much deeper than in the Imperial Valley. Slower velocity and thicker crust in the Coachella and Mexicali valleys define the rift zone between them to be >100 km wide in the direction of plate motion. North American lithosphere in the central Salton Trough has been rifted apart and is being replaced by new crust created by magmatism, sedimentation, and metamorphism

Antimicrobial in vitro activities of condensed tannin extracts on avian pathogenic Escherichia coli

Condensed tannins (CTs), which extracted from yew leaves, tilia flower and black locust leaves, were examined for their antimicrobial in vitro activity against avian pathogenic Escherichia coli (APEC). Past research demonstrated that CTs which contain procyanidins and prodelphinidins that could inhibit the growth of a wide range of bacteria. However, there is no information on how these affect pathogenic bacteria from chickens such as APEC. The high concentration of extracts, 10, 5, 2.5 mg/ml, affected the growth curves of APEC, which gave different inhibition values for the three CT extracts. Further, these CTs had significant effects (P≤0.05) on APEC biofilm and motility depending on each CT concentration and composition. However, at low concentration (0.6 mg/ml), the tilia flowers, a high molar percentage of procyanidins, enhanced bacterial cell attachment and improved the swimming motility of APEC. In contrast, yew, an equal molar percentage of procyanidins/prodelphinidins, and black locust, a high molar percentage of prodelphinidins, interrupted and blocked swarming and swimming motility. The data suggested that the antimicrobial activity of the CT extracts was elicited by a positive relationship between anti-biofilm formation and anti-motility capacities

Assessment of Different Tannin Extracts on Avian Pathogenic Escherichia coli Metabolites Using Nuclear Magnetic Resonance

Tannins have been demonstrated to inhibit the growth of several chicken illnesses in vitro. The complex compositions of tannins make it difficult for microorganisms to develop bacterial resistance. This study aimed to evaluate the effect of condensed tannins (CT) extracts on metabolic profile of Avian Pathogenic Escherichia coli (APEC) using Nuclear Magnetic Resonance (1H-NMR). The experimental groups were divided into three groups:control (no CT added), high in procyanidins (PC-CT) group, and high in prodelphinidins (PDCT) group, with exposure times of 0, 10, and 24 h. APEC was observed to respond to CT extracted from Tilia flowers (high PC-CT) and black locust leaves (high PD-CT). The levels of amino acids including lysine, leucine, glutamate, phenylalanine, and pyroglutamate were increased with the high PD-CT treatment; however, no significant differences were observed between the PC-CT group and the control. Treatment of APEC culture with high PD-CT also led to a significant decrease in the level of lactate. Thus, high PD-CT affected these metabolisms and could be exploited to control the proliferation of APEC in poultry, thereby improving their health and performance