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Wider Choice (wider + choice)
Selected AbstractsLatest news and product developmentsPRESCRIBER, Issue 12 2007Article first published online: 4 OCT 200 NAO: GPs still not prescribing efficiently The National Audit Office (NAO) says NHS funds are being wasted through inefficient GP prescribing and patients not taking their medicines. The NAO's long-awaited report, Prescribing Costs in Primary Care (www.nao.org.uk), found large variations between PCTs in generic prescribing of statins, ACE inhibitors and angiotensin-II antagonists, and protonpump inhibitors; PCTs were also paying widely differing prices for these products. There was a five-fold variation in prescribing volume for clopidogrel between PCTs. These four drugs accounted for only 19 per cent of total spending but, if all practices matched the performance of the best 25 per cent, the NHS would save £200 million annually. PCTs should do more to rationalise prescribing and support their GPs, the NAO concludes. The NAO says that the cost of medicines dispensed for but not taken by patients lies somewhere in the range £100-£800 million annually. Strategies to reduce waste include public awareness campaigns and restricting supplies to four weeks (or two weeks for new medicines). Rosiglitazone may increase CV death risk A meta-analysis of 42 clinical trials has suggested that rosiglitazone is associated with increased risks of myocardial infarction (MI) and cardiovascular death (N Engl J Med 2007; published online 21 May: doi 10.1056/ NEJMoa072761). Like the COX-2 inhibitors, rosiglitazone was licensed without determining its possible effects on long-term cardiovascular outcomes, and interpretation of the latest findings is complicated by the multiple comparisons involved. For risk of MI, there was no significant difference between rosiglitazone and placebo (though this was of borderline statistical signifi-cance , p=0.07), metformin, sulphonylureas or insulin. Rosiglitazone was associated with a statistically significant 43 per cent increased risk compared with all comparators combined but the absolute increase in risk was very small (0.02 per cent). The trends were similar for risk of cardiovascular death, though rosiglitazone was associated with a 64 per cent increased risk compared with all comparators combined that was of borderline statistical significance (p=0.06). The authors acknowledge that their analysis pooled short-term studies that excluded patients at risk of heart disease and was not designed to determine cardiovascular outcomes, and they had no access to patientlevel data; as a result, there is uncertainty about their findings. Nevertheless, they say there is now an urgent need to clarify the risk associated with rosiglitazone. GlaxoSmithKline has rebutted the findings, stating that the cardiovascular risk profile of rosiglitazone is comparable with that of other oral antidiabetic drugs. The MHRA says warnings in the current SPCs for Avandia and Avandamet already reflect most of the data in the latest US review. The possible effects of rosiglitazone on cardiovascular events is currently being evaluated in the Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of glycaemia in Diabetes (RECORD) study. Good management tool The Department of Health has published a disease management tool to enable PCTs to model local interventions that could reduce emergency admissions. The web-based ,voluntary good practice tool' will demonstrate how interventions in primary care and social care settings can improve the management of long-term conditions including cardiovascular disease, asthma and COPD, and dementia and depression. Counterfeit medicines The MHRA has issued an unprecedented three alerts about fake medicines in the legitimate supply chain, recalling all affected lot numbers. Three batches of Zyprexa 10mg tablets (olanzapine) were withdrawn after a company printing labels became suspicious and alerted Eli Lilly. Two of the batches, which contained 60 per cent of the stated active ingredient, had reached patients but no adverse events were reported. Two lots of parallel-imported Plavix 75mg tablets (clopidogrel) have been withdrawn after counterfeit packs were identified. The lots were in French original packaging but will have been overlabelled for the UK market. The counterfeits were mixed with genuine packs from Sanofi-Aventis. Fake Casodex 50mg tablets (bicalutamide) have been identified in a parallel import from France. The Royal Pharmaceutical Society reports that the fake contains 75 per cent of the stated dose of bicalutamide. Alcohol-free mometasone Schering-plough has introduced an alcohol-free formulation of mometasone furoate nasal spray (Nasonex) for hay fever. The company says that an alcohol vehicle causes nasal irritation and leaves an unpleasant aftertaste, adding that over 40 per cent of patients cite this as the main reason for stopping treatment, and over 50 per cent state a preference for an alcohol-free product. Aid to improve statin adherence Adherence to statin therapy can be improved if patients use a decision aid when they are offered treatment,US investigators say (Arch Intern Med 2007;167:1076-82). The decision aid estimated the individual's 10-year cardiovascular risk and the risk reduction from treatment, and summarised the disadvantages of statins.Patients with diabetes who used the aid knew more about their risk and were less indecisive about treatment than those who did not. The odds of having missed a dose over three months were three times higher for patients who had not used the aid. Online tool calculates switch savings A new online tool can help GPs estimate the savings achievable from switching patients to cheaper medicines. The Switch Saving Calculator, developed by the Prescribing Analysis & Support Team at the NHS Regional Drug and Therapeutics Centre in Newcastle, calculates potential savings based on past, current or projected use of the target drug. It can be applied to individual prescribers or scaled up to practice, commissioning group, PCT, health authority or even national level. Separate calculators are available for primary and secondary care. The current version calculates potential savings by switching from atorvastatin to simvastatin. The Newcastle team says other drugs will be added and they will update prices regularly. The calculator is at www.nyrdtc.nhs.uk:80/Services/presc_supp/ switch_saving_calculator/switch_saving_calculator.html. No improvement in drug information for patients leaving hospital The information given to patients discharged from hospital is not improving, according to the Healthcare Commission's annual patient survey (www.healthcare commission.org.uk). The 2006 survey found that the commonest reason patients were kept waiting for at least four hours to leave hospital was the delay in providing discharge medicines. Provision of written information increased from 62 per cent of patients in 2005 to 65 per cent in 2006. However, only 76 per cent said they had been told about their medicines in a way they could ,completely' understand (79 per cent in 2002). The proportion of patients reporting complete information about sideeffects also fell (from 40 per cent in 2005 to 37 per cent). Aspirin in preeclampsia A new meta-analysis has found that primary prevention with low-dose aspirin modestly but consistently reduces the risk of preeclampsia (Lancet 2007; published online 18 May). The study of 31 trials involving 32 217 women at low to moderate risk found that antiplatelet agents (mostly aspirin) reduced the risk of pre-eclampsia and preterm birth by 10 per cent without an increased risk of bleeding. The benefit was similar across subgroups. There were also nonsignificant reductions in the risk of small for age, stillborn and death before discharge. New from NICE NICE approves varenicline for NHS NICE has endorsed the use of varenicline (Champix) as an aid to smoking cessation within the NHS for England and Wales; it has already been approved for use in Scotland by the Scottish Medicines Consortium. Varenicline is a partial agonist at the ,4,2 nicotinic receptor. It alleviates craving and withdrawal symptoms, and reduces the rewarding and reinforcing effects of smoking. The commonest adverse effect is mild to moderate nausea, which improves with time.1 Varenicline is licensed for smoking cessation in adults; NICE says it should be offered as an option for smokers who say they want to quit as part of a programme of behavioural support. However, treatment should not be withheld if counselling and support are not available. NICE was critical of manufacturer Pfizer's economic arguments in favour of varenicline, which inappropriately included US data, assumed a single quit attempt and may have overestimated its efficacy. It nonetheless concluded that varenicline is more effective than nicotine replacement therapy (NRT) or bupropion (Zyban) in achieving continuous abstinence. NICE estimated that, compared with NRT, the odds of abstinence at one year with varenicline were 54 per cent greater. A Cochrane review1 concluded that abstinence was 66 per cent more likely with varenicline than with bupropion, and three times more likely than with placebo. There was also a benefit from offering smokers a wider choice of treatments. A 12-week course of varenicline costs £163.80; it is also licensed for an additional 12-week course and dose tapering may be considered for those at high risk of relapse. The final appraisal determination does not state which is the treatment of first choice for smoking cessation. NICE is currently preparing guidance on smoking cessation in pri-mary care, pharmacies and workplaces. Copyright © 2007 Wiley Interface Ltd [source] Electrically heated cables protect vines from frost damage at early floweringAUSTRALIAN JOURNAL OF GRAPE AND WINE RESEARCH, Issue 1 2009D.W. LAMB Abstract Background and Aims:, Current methods of frost protection in vineyards involve fans, air heaters or sprinklers; each is limited by environmental constraints or available water. An alternative, all-electrical technique offers growers wider choice to match options with their vineyard operations. This study evaluates the ability of electrical heating cables, wrapped around the vine cordons, to protect inflorescences from frost damage. Methods and Results:, Five heating cable treatments in six replicates were applied to a 2-ha block of Sauvignon Blanc in the southern New England Region of Australia. Vines were subjected to a single ,3°C frost event in November 2006 when at approximately 30% capfall. Non-heated vines suffered 41% (Control) and 46% (No heat) inflorescence loss. Those subjected to Low heat suffered a 28% loss, Medium-heated vines suffered a 16% loss and High-heated vines suffered a 13% loss. Qualitative scoring of the vines indicated that more than half of the Medium-/High-heated vines suffered no appreciate damage, whereas all non-heated vines suffered some form of potential crop loss or damage. Conclusion:, Electrical heating cables of minimum 10 W/m power rating were found to significantly reduce frost damage to inflorescences at 30% capfall. Significance of the Study:, At approximately 43 kW/ha, electrical heating cable offers an alternative frost protection method for small vineyards. [source] A comparative study of a 595-nm with a 585-nm pulsed dye laser in refractory port wine stainsBRITISH JOURNAL OF DERMATOLOGY, Issue 3 2005A. Yung Summary Background, The pulsed dye laser (PDL) is the treatment of choice for port wine stains (PWS); however, some patients' PWS become refractory to further treatments. Technological advances have enabled new machines with the advent of surface cooling devices to deliver longer wavelengths and higher fluence more safely. These advances have the potential to achieve improved response rates in refractory PWS. There are few studies comparing the efficacy of standard PDL treatments for refractory PWS with the wider choice of treatment variables available from newer PDL machines. Objectives, To determine if there is any advantage of using a longer wavelength (595 nm) and pulse widths (1·5 ms, 6 ms and 20 ms) over conventional PDL settings (wavelength 585 nm, pulse width 1·5 ms) in refractory PWS. Methods, Eighteen consecutive consenting patients with Fitzpatrick skin types 1,4 with a mean age 35 years (range 17,59 years) with refractory PWS were treated routinely with three separate test areas using 595-nm PDL (using three different pulse width settings of 1·5 ms, 6 ms and 20 ms), compared with test areas treated with 585-nm PDL (pulse width 1·5 ms). All test areas were treated with an identical fluence (15 J cm,2), spot size (7 mm) and cooling setting (dynamic cooling 60 ms, delay 60 ms). Results, We found a statistically significant advantage of 595-nm PDL (pulse width 1·5 ms) over 595-nm PDL (pulse width 6 ms) (P < 0·05) in the treatment of refractory PWS; however, we found no significant advantage using longer pulse widths of 20 ms compared with 1·5 ms with the 595-nm PDL. There was no statistically significant advantage in using a 595-nm PDL over a 585-nm PDL using identical pulse widths of 1·5 ms, spot size, fluence and cryogen cooling settings; however, the number of directly comparable test areas was smaller. Some individual patients in our study obtained a better response with certain 595-nm PDL settings (pulse width 1·5 ms and 6 ms) compared with 585-nm PDL (pulse width 1·5 ms). Conclusions, Our experience of high fluence PDL in the treatment of refractory PWS suggests patients treated with 585 nm (pulse width 1·5 ms) improve to a similar degree as patients treated with 595-nm PDL (pulse width 1·5 ms). However, the use of the 595-nm PDL with longer pulse widths yields no extra advantage. For those patients who have failed to improve with high-fluence 585-nm PDL (pulse width 1·5 ms), test areas using 595-nm PDL (pulse width 1·5 ms and 6 ms) should be undertaken to ascertain if individual patients may benefit from the longer pulse width 595-nm PDL. [source] Routine mammography is associated with earlier stage disease and greater eligibility for breast conservation in breast carcinoma patients age 40 years and older,CANCER, Issue 5 2003Gary M. Freedman M.D. Abstract BACKGROUND Reduction in breast carcinoma mortality is a major benefit of screening mammography and has been demonstrated in multiple randomized clinical trials and service screening programs. Another benefit from screening is that it allows the patient a wider choice of treatment options, particularly the possibility of conservation surgery. The current study analyzed the impact of mammography in the staging and treatment of breast carcinoma. METHODS A total of 1591 women aged , 40 years were treated for breast carcinoma between July 1995 and October 2001. Three subgroups were defined and compared. Group 1 had 192 patients with no previous mammography, Group 2 was comprised of 695 patients who underwent mammography on average less often than once yearly, and Group 3 was comprised of 704 patients who on average underwent mammography once yearly or more often. RESULTS The difference in tumor stage was found to be statistically significant between the groups (P < 0.0001). In Group 1, 15% of the patients had ductal carcinoma in situ (DCIS) compared with 21% of patients in Group 2 and 26% of patients in Group 3. In addition, 32% of patients in Group 1 had T1 tumors, whereas 50% of patients in Group 2 and 56% of patients in Group 3 had T1 tumors. The tumor size was , 1 cm in 8% of the patients in Group 1 compared with 20,23% of patients in Groups 2 and 3 (P = 0.0092). Breast conservation was an option for 41% of the patients in Group 1 but mastectomy was recommended in another 41% of patients. However, in Groups 2 and 3, 61% of patients were offered breast conservation and mastectomy was recommended to 28% (P < 0.0001). CONCLUSIONS In the current study, women age , 40 years with breast carcinoma who underwent mammography at least once yearly were diagnosed with DCIS more often compared with patients who underwent mammography less frequently or those who had no prior mammography. Women who underwent mammo-graphic screening were found to have smaller tumors, which resulted in a majority of these patients being able to consider breast conservation as an alternative to mastectomy. Cancer 2003;98:918,25. © 2003 American Cancer Society. DOI 10.1002/cncr.11605 [source] | ||||||||||