Sharon Reid

Meta-analysis of randomised controlled trials comparing latanoprost with brimonidine in the treatment of open-angle glaucoma, ocular hypertension or normal-tension glaucoma

Aim: To compare the efficacy and tolerability of latanoprost versus brimonidine in the treatment of open-angle glaucoma, ocular hypertension or normal-tension glaucoma. Method: Systematic review of randomised controlled trials comparing latanoprost and brimondine, identified by searches including Medline, Embase and Cochrane Controlled Trials Register. Two reviewers independently assessed trials for eligibility and quality and extracted data. Data were synthesised (random effects model) and expressed as the absolute mean intraocular pressure (IOP) reduction difference from baseline to end point for efficacy and relative risk for adverse events. Subgroup analysis and regression were used to explore heterogeneity according to patient characteristics, trial design and quality. Results: 15 publications reporting on 14 trials (1784 participants) were included for meta-analysis. IOP reduction favoured latanoprost (weighted mean difference (WMD) = 1.10 mm Hg (95% confidence interval (CI) 0.57 to 1.63)). Significant heterogeneity was present (χ213 = 38.29, p = 0.001, I2 = 66.0%). Subgroup analysis showed greater WMD for studies where data were analysed from end points >6 months duration, cross-over design, open-angle glaucoma or ocular hypertension and monotherapy. Multiple regression showed no significant association of WMD with trial duration (t9 = 1.92, p = 0.09), trial design (t9 = 1.79, p = 0.11), trial quality (t9 = −0.46, p = 0.66), or monotherapy or adjunctive therapy (t9 = −2.14, p = 0.06). Fatigue was less commonly associated with latanoprost (RR = 0.27, 95% CI 0.08 to 0.88). Publication bias was not evident on visual inspection of a funnel plot. Conclusion: Latanoprost is more effective than brimonidine as monotherapy in lowering IOP. Brimonidine is associated with a higher rate of fatigue.

Linkage into specialist hepatitis C treatment services of injecting drug users attending a needle syringe program-based primary healthcare centre

Injecting drug users (IDUs), the key risk population for hepatitis C virus (HCV) infection, constitute just a small proportion of HCV treatment clients. This study describes an HCV treatment assessment model developed by an inner-city IDU-targeted primary healthcare (PHC) facility and, using a retrospective clinical audit, documents predictors of successful referrals to a tertiary liver clinic. Between July 2006-December 2010, 479 clients attended the PHC, of whom 353 (74%) were screened for HCV antibody. Sixty percent (212/353) tested positive, of whom 93% (197/212) were screened for HCV-RNA with 73% (143/197) positive. Referrals to a tertiary liver clinic were provided to 96 clients, of whom 68 (71%) attended. Eleven clients commenced antiviral therapy (AVT), with seven achieving sustained virological responses by December 2010. Clients who had not recently injected drugs and those with elevated ALT levels were more likely to attend the referrals, while those not prescribed psychiatric medications were more likely to commence AVT. The relatively high uptake of referrals, the number of individuals commencing AVT and final treatment outcomes are reasonably encouraging, highlighting the potential of targeted PHC services to facilitate reductions in liver disease burden among IDUs.

Pap smears in general practice: a secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991

Abstract: We investigated the characteristics of Australian general practice that predict performance of Pap smears by secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991. Chi–squared analysis identified potential associations between Pap smear rate and patient, doctor and practice variables. Significant associations were examined using logistic regression and generalised estimating equations. Participants were 495 general practitioners who collected information on 113 468 doctor–patient encounters, of which 43 211 encounters involved females aged 18 to 70 years. Pap smear encounters (2449) were identified and classified as patient–requested (62 per cent), diagnostic (5 per cent) or opportunistic (33 per cent). The large difference in the unadjusted Pap smear rates per 100 female encounters for female general practitioners (11.7) and male general practitioners (4.2) required separate analysis by sex of the general practitioner. For male general practitioners, a Pap smear was less likely: as patient age increased; for new patients; for general practitioners with less general practice experience; for general practitioners with no postgraduate qualifications; with metropolitan practice location; and if the practice had more than 25 per cent of patients with English as a second language. For female general practitioners, a Pap smear was less likely: for older known patients; as the age of the general practitioners increased; and for management of fewer problems per 100 encounters. A Pap smear was less likely to be opportunistic: as patient age increased; for general practitioners who were Australian graduates; and for general practitioners with no postgraduate qualifications. Consideration of patient, doctor, and general practice characteristics may facilitate the design of interventions to improve cervical cancer screening.

Meta-analysis of randomized controlled trials comparing timolol with brimonidine in the treatment of glaucoma

This paper aims to compare the efficacy and tolerability of timolol versus brimonidine in the treatment of glaucoma. Comprehensive searches were performed using Medline, Embase and the Cochrane Controlled Trials Register for randomized controlled trials comparing timolol and brimonidine. Two reviewers independently assessed trials for eligibility and quality and extracted data. A random effects model was used to combine studies. Outcome was defined as the absolute mean intraocular pressure (IOP) reduction from baseline to end‐point for efficacy, and relative risk (RR) for adverse events. Subgroup analysis and meta‐regression were used to explore heterogeneity according to trial design and quality. Ten publications reporting on eight trials with 2387 participants were included in the meta‐analysis. Two further trials were commented on qualitatively. IOP reduction was not significantly different between timolol and brimonidine. Weighted mean difference (WMD) of IOP reduction was 0.24 mmHg (favouring brimonidine) with a 95% confidence interval of −0.57 to 1.04 mmHg. There was significant heterogeneity between studies (χ213 = 73.75, P < 0.00001, I2 = 91%). Subgroup analysis showed no significant WMD for studies where data were analysed from end‐points ≥6 months or <6 months. Meta‐regression analysis showed increased WMD IOP reduction in favour of brimonidine with increased trial quality (t3 = −4.58, P = 0.01), but no significant association with trial duration (t3 = 0.73, P = 0.51) or size (t3 = −0.59, P = 0.57). The RR of ocular allergy was much lower with timolol than brimonidine (RR = 0.08, 95% confidence interval 0.01 to 0.47). Publication bias was not evident on a funnel plot, although the number of studies was small. The conclusion is that both drugs are equally effective in lowering IOP. Brimonidine is associated with a higher rate of allergy.

Experiences of mothers with substance dependence: Informing the development of parenting support

AIMS AND OBJECTIVES To understand the experiences of women with a history of substance dependence when they attempted to gain parenting support. BACKGROUND Becoming a mother provides a window of opportunity to support women with a substance dependence make changes to their lives and the way they will parent their infants and young children. Yet there are many barriers and a constant fear of the removal of their children from their care. DESIGN Focus groups were conducted using a qualitative interpretive descriptive approach to enable exploration of the womens experiences as mothers with infants and young children. METHOD A series of three focus groups were facilitated with three to six women per group. Thirteen women who were substance dependent participated in this study. Semi-structured interviews guided the collection of data. Thematic content analysis was used to work with the data. RESULTS Four themes were identified: (1) feelings of guilt, (2) judged by others, (3) normalising and (4) support and learning to be a mother. CONCLUSION The mothers expressed alienation from mainstream health services. Providing parenting and child health services, which avoid mothers feeling judged by the staff and other mothers, is an important step to enabling these women to appropriately and sensitively care for their infants and young children. RELEVANCE TO CLINICAL PRACTICE Midwives and nurses working with mothers and their infants and young children are well positioned to support women who are or have experienced substance dependence. Working with this group of mothers requires the development of a therapeutic relationship to provide optimum support, education and, if necessary, intervention.

Opportunistic and continuing health care for injecting drug users from a nurse‐run needle syringe program‐based primary health‐care clinic

Sir—Needle syringe programs (NSPs) are an important point of contact with injecting drug users (IDUs) and can play a crucial role in the provision of essential health care. Accordingly, in some parts of the world, NSPs have been enhanced to offer low-threshold primary health-care services [1].These enhanced NSPs typically provide non-judgemental and often anonymous services allowing clients to access harm minimisation, primary health care, welfare services and referrals for other health care. This model of care has not been widely adopted in Australia, in part because: (i) this is a relatively new model of health care with limited published evidence of effectiveness [2]; (ii) belief that IDUs, like the general population, have adequate access to health care under the universal health insurance system; (iii) the notion that harm reduction should be limited to delivery of sterile injecting equipment and that primary health care is a separate issue; and (iv) cross-organisational barriers and administrative constraints. Amidst these obstacles a few NSP-based primary health-care centres have led the way to address the unmet health-care needs of IDUs. The Kirketon Road Centre at Kings Cross in Sydney, established in 1987, is one of the pioneers in primary health care for IDUs [3]. Following on, in 2001, as part of the ‘Saving Lives’ strategy, the Victorian State Government provided funding to establish primary health services for street-based IDUs in five areas of Melbourne with high drug usage rates [4]. The Redfern Harm Minimisation Clinic (RHMC), Sydney, established in 2006 [2], provides primary health care to IDUs via an enhanced NSP model. It is a nurse-run service co-located with an existing NSP, with a sessional visiting medical officer. Clients present on a walk-in, first-come first-serve basis from the NSP shopfront or are referred by local health-care services. We describe an example of how opportunistic health care and support provided by the RHMC to an IDU with a longstanding physical disability enabled commencement of HCV treatment and viral clearance. This 42-year-old man was an IDU with a long history of polydrug use. He had known HCV infection for several years, longstanding visual impairment and challenges with mobility, social isolation and difficult interpersonal interactions. He presented to the NSP requesting sterile injecting equipment as he was intermittently injecting drugs despite being on opioid maintenance treatment for 4 years, currently receiving buprenorphine. His frequency of injecting had reduced in recent years and he had considered HCV treatment before, but the barriers to accessing appointments in a tertiary centre were considered too great. Furthermore, his HCV infection, which was of the ‘treatment resistant’ genotype 1, also contributed to his considering treatment as neither worthwhile nor feasible. Over a period of several NSP service visits, the registered nurse at RHMC engaged him in discussions about HCV treatment and ways to circumvent perceived barriers. Ultimately, through liaison with the nearby tertiary liver clinic, an individualised care plan was developed for HCV treatment. To support treatment adherence, RHMC staff drove the patient to the tertiary liver clinic monthly to pick up medication and attend specialist appointments, supervised self-administration of weekly interferon injections, filled a dosette box with oral antiviral (ribavirin) medication every 2 weeks, performed periodic blood tests as per HCV protocol, assessed and managed side-effects of treatment, including mood disturbance, provided ongoing emotional and other support, liaised with the methadone clinic where necessary to maintain opioid maintenance treatment and reminded him (via SMS and phone) about upcoming or missed appointments. The patient successfully completed all 48 weeks of treatment and achieved a sustained virological response. The patient attributed his success to the ongoing support and care he received from the RHMC. This is just one example of the type of the specialist care that can be provided by an NSP-based primary health-care clinic. Clearly, co-location with NSP is an added advantage for this type of service and has the potential of providing both opportunistic and continuing health care. This patient is still in regular contact with RHMC. Successful treatment, management and prevention of HCV requires a trusting relationship with health-care providers who can provide practical but R E V I E W

A primary healthcare clinic in a needle syringe program may contribute to HIV prevention by early detection of incident HIV in an injecting drug user

A composite score with a maximum total of 33 was calculated for each application. The scoring system weighted each domain as follows: coverage (10 points), accuracy (8 points), applicability (6 points), user-friendliness (6 points) and accountability (3 points). The final composite score for each application was converted to a percentage with applications scored as good (≥70%), fair (50-69%) or poor (≤49%). Of the 403 applications located, 92 met inclusion criteria for downloading, but 35 did not meet the inclusion criteria on closer examination and three had technical problems. Overall, eight applications were rated as good. They were five “calorie and physical activity counters” and three “BMI or weight trackers”. Thirty-two of the applications were rated as fair and 14 were rated as poor. The applications that were rated as good had better coverage and accuracy scores compared to those rated as fair or poor. Less than a third of all applications had complete accuracy. All applications scored well for user-friendliness, but scored poorly for author’s accountability. The USDA Nutrient Database of Foods was used in all applications and energy intake was tracked with “calories” instead of “kilojoules”, the measure used in Australia. As many manufactured and takeaway foods consumed in the US differ to those commonly eaten in Australia the applicability for Australians is limited. Thus, while the majority of applications did not score well, those rated as good may be a useful adjunct treatment to health professionals’ advice to assist their patients’ weight loss efforts. The assessment tool devised to rate the applications may be useful for future use with new applications and some customisation of the good applications, such as the use of Australian food databases, is indicated.

Vertical transmission of hepatitis C: Testing and health-care engagement: Vertical transmission of hepatitis C

To investigate hepatitis C virus (HCV) testing patterns and engagement with health care for women positive for HCV antibodies (anti‐HCV) in pregnancy and their children through pregnancy and the first 2 years of the childs life.