STUDY ON THE PRESCRIBING PATTERNS OF ANTIPSYCHOTIC MEDICATION IN A RURAL ENGLAND COMMUNITY MENTAL HEALTH TEAM

Introduction: Providing comprehensive services for about 400 patients in the South Herefordshire area, the community mental health team manages cases of varying severity and complexity, ranging from Schizophrenia, to neuroses and disorders of adult personality. Antipsychotic medication remains a mainstay of treatment and management for patients under the team case load; hence a need exists for a detailed look into the prescription patterns of such medications. Aim: The aim of this study was to look into the prescribing patterns of antipsychotics for a sample of 50 patients in the South Herefordshire community team during the year of 2016 (from Jan 2016 to Dec 2016), as well as investigate whether these antipsychotics were licensed to be used for the corresponding diagnoses of these patients. We also looked into whether patients were prescribed antipsychotics within BNF limits. As a part of this audit we looked into whether patients were made aware that they were on unlicensed antipsychotics or on above the BNF maximum doses of antipsychotics. Methodology: A random sample of 50 patients was taken from the case load of the South community team as is documented on RIO. The mean age of the patients in the sample was 46.1 (SD= +14.6) Sample selection was done by selecting every seventh patient in the patient case load (if not using antipsychotics the next patient was chosen). Patients studied involved those with F1-F19 Mental and behavioural disorders due to psychoactive substance use, F20-F29 Schizophrenia/Schizotypal/Delusional disorder, F31 Bipolar affective disorders, F32 Depression, F40-F48 Anxiety Neurotic and stress related disorders and somatoform disorders, F50-F59 Behaviour syndromes associated with physiological disturbances and physical factors, F60-F69 Disorders of adult personality and behaviour. The patients selected had to be followed up by the recovery team during the year 2016 and they had to be on an antipsychotic medication at any point during that time period. A scale was utilized to help the orderly collection of information as dose, patient diagnoses, comorbid substance use etc. SPC was relied upon for investigating the licensing of the different antipsychotics. Results: It was found that the most commonly prescribed antipsychotic was Quetiapine (28.07%) followed by Olanzapine (24.56%), Aripiprazole (14.04%) and Depot drugs (12.28%). It was found that the most commonly used depot drugs were Modecate and Depixol. It was also found that 14% of our patients were prescribed two antipsychotics at the same time. Unlicensed antipsychotics made up 17.54% of all prescribed antipsychotics. It was also found that no documentation on the system evidenced that patients were told about the use of unlicensed antipsychotics. Quetiapine and olanzapine made up 60 % of the unlicensed antipsychotics followed by risperidone and aripiprazole 40%. The conditions that were found to be given unlicensed medications were anxiety neurotic and stress related disorders and somatoform disorders (F40-48), disorders of adult personality and behaviour (F60-F69) and multiple conditions. The most common daily doses prescribed for Aripiprazole were found to be 5, 10 and 15 mg doses. For Quetiapine, it was the 300mg dose and for Olanzapine it was found to be the 10mg dose. In all but one patient antipsychotics were prescribed within BNF limits. One patient was prescribed Olanzapine 25 mg (BNF maximum dose 20 mg). Polypharmacy was found to be used more in the multiple diagnosis and schizophrenia conditions. Patients with schizophrenia and adult personality disorders were found to be the most patients who abused alcohol, cannabis and prescription opioid analgesic medications. Conclusion: Antipsychotics have a range of central nervous system effects and there are situations where it becomes necessary to use them off-license. However, it is essential to explain to the patient about the unlicensed use of antipsychotics and document this on the system. The effects of unlicensed antipsychotics need to be carefully monitored and their benefits regularly assessed and recorded. Antipsychotics interact with physical health medication and could adversely affect the physical health condition. Hence it is necessary to look into healthier means of pain management and review the long term prescription of opioid analgesics. It is important to investigate more into how to manage comorbidities such as substance misuse of alcohol and cannabis and whether cross referral between services is the best way to address this issue. Further audits can look into the follow up of patients on polypharmacy, and on the general effect on disease prognosis, and physical health side effects of such regimens

In vitro activity of fluconazole and voriconazole against clinical isolates of Candida spp. by E-test method.

The in vitro susceptibility of clinical Candida isolates towards fluconazole and voriconazole was determined using the E-test method. A total of 41 clinical isolates recovered from patients since 2004 until 2009 from two local hospitals in Kuala Lumpur, Malaysia were used. These comprised Candida tropicalis, Candida albicans, Candida krusei, Candida parapsilosis, Candida rugosa, Candida dubliniensis and Candida glabrata. Strains from American Type Culture Collection were used as quality control. Lawn cultures of the isolates on RPMI-1640 agar medium supplemented with 2% glucose were incubated with the E-test strips at 35°C for 48 h. Our results show that 71% were susceptible to fluconazole and 90% were susceptible to voriconazole. All strains of C. krusei were resistant to fluconazole and 50% were susceptible in a dose-dependent manner to voriconazole. There were 66% and 33% of C. glabrata that were resistant to fluconazole and voriconazole. Our study revealed that majority of the clinical Candida isolates was susceptible to fluconazole and voriconazole with a small percentage being resistant to both the drugs

A study on the health economics of general practitioners in Malaysia: trends, challenges and moving forward

Introduction: Health care systems play a vital role in providing health services and in optimising the population’s health of each nation. The Malaysian health care system primarily consists of the public and private health services. One of the prominent private health care services offered in the General Practitioner’s (GP) Clinic. Despite the prominent role GPs play in the health care system in this country, little is known about their practices, the issues and challenges faced by GPs in this country. The objective of this study was to describe the current GP practice operations in Malaysia in terms of its general operations, financial expenditure and revenue, market competitiveness and laboratory services offered by the clinics. Methods: A cross-sectional survey design was used in this study. The study sample comprised of 1800 GPs throughout the West of Malaysia selected using convenient sampling technique. This study provides the general description of the GP operations in terms of the nature of business, operations hours, and number of patients, the third party administrator and managed care organisation linkages, financial expenditure, market competitiveness and laboratory services. Results: The findings of the study reveal that the expenditure of managing GP services has increased over the years due to the changes in policies as well as the involvement of third party administrators in the healthcare system despite it playing an instrumental role in complimenting the healthcare services for the public at large

Spin distribution as a probe to investigate the dynamical effects in fusion reactions

The spin distributions are measured for the compound nucleus 80Sr populated in the reactions 16O+64Zn and 32S+48Ti. The comparison of the experimental results for both the systems shows that the mean γ-ray multiplicity values for the system 32S+48Ti are lower than those for 16O+64Zn. The spin distribution of the compound nucleus populated through the symmetric channel is also found to be lower than the asymmetric channel. Present investigation directly shows the effect of entrance channel mass asymmetry on the reaction dynamics

Phenotypic and molecular genetic profiles of fluconazole and voriconazole sensitive versus resistant candida spp

Frequent use of azole group of antifungal drugs for prophylaxis and treatment of Candida infections has contributed to the emergence of resistant strains, especially among non-albicans Candida species. The present study was done to identify genetic variations and changes in cellular morphology among non-albicans Candida isolates resistant to fluconazole and voriconazole. Candida isolates obtained from two local hospitals were identified using CHROMagar CandidaTM and commercial biochemical test kits. Among these 41 isolates, the most predominant species was C. alis (n=10), followed by C. albicans (n=7), C. parapsilosis (n=6), C. krusei (n=6), C. rugosa (n=6), C. dubliniensis (n=3) and C. glabrata (n=3). Resistance breakpoints of fluconazole and voriconazole were determined for these 41 Candida isolates using the E-test method. C. glabrata and C. parapsilosis strains that were susceptible and resistant towards the two azoles were selected for further studies as they were commonly isolated pathogens in patients with candidiasis in various parts of the world. A less commonly studied species, C. rugosa was also selected. The variations of genes in the resistant and susceptible strains of Candida species wereinvestigated using Random Amplification of Polymorphic DNA-PCR (RAPD-PCR). The isolates were genotyped and grouped into 3 major groups according to their species using composite DNA type (based on three primers) comprising C. glabrata,C. parapsilosis and C. rugosa. Although some of the strains within the same group were highly similar, they were not clones, as indicated by variations in their genotypic profiles. The morphological differences between the drug-resistant and drug-susceptible strains treated with fluconazole and voriconazole were observed with scanning and transmission electron microscopy. A scoring system developed in this study revealed pronounced damage on the cell membrane for cells treated with 10X MIC of fluconazole and MIC of voriconazole. Biofilm formation was studied in these three species, followed by the effect of fluconazole and voriconazole on the pre-formed biofilms using the XTT metabolic assay. The biofilm cells exhibited etween 2 and 64 folds higher MIC50 and MIC80 for both the azoles compared to the planktonic cells. Coating the wells with the azole drugs reduced the MIC of the biofilms for all clinical strains. Expression of candidate genes was compared between the drug-resistant and drug-susceptible strains using semi-quantitative reverse transcription-PCR method in C. glabrata. Candidate genes selected were based on their involvement in ergosterol biosynthesis (ERG11), efflux of drugs (CDR1) and biofilm formation (EPA1, EPA6 and EPA7). The expression level of the selected genes of the Candida isolates was normalized to beta actin gene of Candida and was reported as a ratio. Upregulations were observed in all genes except for EPA7 gene in the resistant strain compared to the ATCC strain. In the susceptible strain, upregulations were observed only in EPA7 and CDR1 genes treated with fluconazole, and in all except EPA7 gene in the voriconazole treated cells. The results obtained in this research contribute to the knowledge on the morphological and genetic characteristics of clinical strains of C. glabrata, C. parapsilosis and C.rugosa sensitive and resistant to fluconazole and voriconazole

The diagnostic significance of enzyme linked immuno-sorbent assay for herpes simplex, varicella zoster and cytomegalovirus retinitis.

<b>Purpose:</b> To evaluate the diagnostic usefulness of enzyme linked immuno-sorbent assay (ELISA) in single serum samples to associate herpes simplex virus (HSV), varicella zoster virus (VZV) or cytomegalovirus (CMV) with viral retinitis as against polymerase chain reaction (PCR) on intraocular specimens. It was also designed to study the seroprevalence in normal healthy individuals, and the genomic prevalence of HSV, VZV and CMV in patients without an active viral inflammatory process. <b> Methods: </b> PCR for the detection of HSV, VZV and CMV genomes was done on 33 and 90 intraocular fluids from viral retinal patients and non-viral controls respectively. ELISA was done on 30 and 100 serum samples from viral retinitis patients and normal healthy controls respectively. <b> Results:</b> PCR did not detect HSV, VZV and CMV genomes except one, in which VZV-DNA was detected. ELISA showed prevalence rates of 28&#x0025;, 83&#x0025; and 90&#x0025; for antibodies against HSV, VZV and CMV respectively in the normal population. In the 30 viral retinitis patients, PCR detected HSV-DNA in 2 (6.7&#x0025;), VZV-DNA in 7 (23.3&#x0025;) and CMV-DNA in 6 (20.0&#x0025;) patients, while ELISA detected antibodies against HSV, VZV and CMV in 13 (43.3&#x0025;), 24 (80.0&#x0025;) and 23 (76.7&#x0025;) patients respectively. ELISA was of value in indirect diagnosis only in 6 (20.0&#x0025;) as compared to 15 (50.0&#x0025;) of 30 patients by PCR, this difference was statistically significant (McNemar test, P value = 0.005). <b> Conclusion: </b> Serology by ELISA is no longer a useful diagnostic tool to associate HSV, VZV and CMV viruses with viral retinitis

Diagnostic value of enzyme linked immuno-sorbent assay for cytomegalovirus disease.

BACKGROUND: Since interpretation of results of enzyme linked immuno-sorbent assay (ELISA) for diagnosis of Cytomegalovirus (CMV) infection in India is difficult, its diagnostic value required evaluation. AIMS: To evaluate the diagnostic value of ELISA against polymerase chain reaction (PCR) in CMV disease. SETTINGS AND DESIGN: Results of ELISA test for CMV antibodies in CMV-DNA PCR positive and negative patients and normal healthy blood donors were analysed. METHODS AND MATERIAL: Anti-CMV antibodies were assayed by ELISA on the sera of 26 CMV PCR positive and 21 PCR negative patients and 35 normal healthy blood donors. STATISTICAL ANALYSIS: Chi square and Fischer exact test were used for statistical analysis. RESULTS: Anti-CMV antibodies (IgG or IgG and IgM) were present in 20 (76.9&#x0025;) of 26 PCR positive and 13 (61.9&#x0025;) of 21 PCR negative patients. ELISA was negative in six (23.1&#x0025;) of 26 PCR positive patients. Of the 28 paediatric patients, ELISA was positive in 14 (73.7&#x0025;) of 19 PCR positive and three (33.3&#x0025;) of nine PCR negative patients showing a statistically significant difference (Chi square test, P value 0.038). Among the 19 patients having complications after organ transplant, ELISA showed anti-CMV antibodies in six (85.7&#x0025;) of seven PCR positive and 11 (91.7&#x0025;) of 12 PCR negative patients showing no significant difference. CMV-DNA was not detected in the buffy coat of 35 sero-positive blood donors. CONCLUSION: ELISA has no diagnostic value in the detection of CMV activation although it may help in the differential diagnosis of CMV infection in the paediatric age group

Brief Report - Diagnostic Value of Enzyme Linked Immuno-sorbent Assay for Cytomegalovirus Disease

Background: Since interpretation of results of enzyme linked immuno-sorbent assay (ELISA) for diagnosis of Cytomegalovirus (CMV) infection in India is difficult, its diagnostic value required evaluation. Aims: To evaluate the diagnostic value of ELISA against polymerase chain reaction (PCR) in CMV disease. Settings and Design: Results of ELISA test for CMV antibodies in CMV-DNA PCR positive and negative patients and normal healthy blood donors were analysed. Methods and Material: Anti-CMV antibodies were assayed by ELISA on the sera of 26 CMV PCR positive and 21 PCR negative patients and 35 normal healthy blood donors. Statistical analysis: Chi square and Fischer exact test were used for statistical analysis. Results: Anti-CMV antibodies (IgG or IgG and IgM) were present in 20 (76.9%) of 26 PCR positive and 13 (61.9%) of 21 PCR negative patients. ELISA was negative in six (23.1%) of 26 PCR positive patients. Of the 28 paediatric patients, ELISA was positive in 14 (73.7%) of 19 PCR positive and three (33.3%) of nine PCR negative patients showing a statistically significant difference (Chi square test, P value 0.038). Among the 19 patients having complications after organ transplant, ELISA showed anti-CMV antibodies in six (85.7%) of seven PCR positive and 11 (91.7%) of 12 PCR negative patients showing no significant difference. CMV-DNA was not detected in the buffy coat of 35 sero-positive blood donors. Conclusion: ELISA has no diagnostic value in the detection of CMV activation although it may help in the differential diagnosis of CMV infection in the paediatric age group. (J Postgrad Med 2002;48:176-178