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1.  Six years of a national antimicrobial stewardship programme in Scotland: where are we now? 
The Scottish Antimicrobial Prescribing Group (SAPG) was established in 2008 to lead delivery of the national antimicrobial stewardship programme. We performed a national self-reported survey in 2014 to evaluate stewardship activities delivered by regional Antimicrobial Management Teams (AMTs). An on-line survey was developed utilising validated indicators from a published European study along with questions specific to the Scottish context. Descriptive statistics were used to evaluate the responses received.
The survey was completed by 14 of the 15 AMTs (response rate 93 %). Results demonstrated good compliance with 9 of the 10 key European indicators included in the survey; 7 (50 %) of AMTs achieved all 9 indicators and 14 (100 %) of AMTs achieved at least 6 out of 9 indicators (67 %). Progress was also demonstrated across a range of stewardship activities and areas for further work were identified.
The survey results suggest the national stewardship programme in Scotland has reached maturity but consolidation and ongoing development are required. Collaborative working between SAPG and AMTs together with central funding has been key to achieving this level of success.
PMCID: PMC4504067  PMID: 26185619
Antimicrobial stewardship; Structural and function indicators; Antimicrobial resistance
2.  Cost-effectiveness of ranibizumab versus aflibercept in the treatment of visual impairment due to diabetic macular edema: a UK healthcare perspective 
Ranibizumab and aflibercept are alternative anti-vascular endothelial growth factor agents approved for the treatment of visual impairment (VI) due to diabetic macular edema (DME).
To estimate, from a UK healthcare perspective, the cost-effectiveness of ranibizumab 0.5 mg pro re nata (PRN) and ranibizumab 0.5 mg treat and extend (T&E) compared with aflibercept 2 mg every 8 weeks after five initial monthly doses (2q8) in the treatment of VI due to DME.
A Markov model previously reviewed by the National Institute for Health and Care Excellence was used to simulate the long-term outcomes and costs of treating DME. Health states were defined by increments of ten letters in best-corrected visual acuity (BCVA), with a 3-month cycle length. Patients could gain (or lose) a maximum of two health states between cycles. A 3-year treatment time frame and a lifetime horizon were used. Future costs and health outcomes were discounted at 3.5% per annum. Patient baseline characteristics and the efficacy of ranibizumab PRN were derived using data from the RESTORE study. The relative efficacies of ranibizumab PRN, ranibizumab T&E, and aflibercept were assessed with a network meta-analysis. Different utilities were assigned based on BCVA and whether the treated eye was the better- or the worse-seeing eye. Sensitivity analyses tested the robustness of the model.
Lifetime costs per patient of treating DME were £20,019 for ranibizumab PRN, £22,930 for ranibizumab T&E, and £25,859 for aflibercept 2q8. Ranibizumab was dominant over aflibercept, with an incremental gain of 0.05 quality-adjusted life-years (QALYs) and cost savings of £5,841 (PRN) and £2,930 (T&E) compared with aflibercept. Ranibizumab PRN and ranibizumab T&E had 79% and 67% probability, respectively, of being cost-effective relative to aflibercept at a willingness-to-pay threshold of £20,000/QALY. When assuming the higher end of PRN injection frequency (15.9 over 3 years), the cost savings associated with ranibizumab were £3,969.
From a UK healthcare perspective, ranibizumab provides greater health gains with lower overall costs than aflibercept in patients with VI due to DME.
PMCID: PMC4427067  PMID: 25999748
Markov model; cost-utility; health states; macula; retina
3.  Efficacy of Anti-VEGF and Laser Photocoagulation in the Treatment of Visual Impairment due to Diabetic Macular Edema: A Systematic Review and Network Meta-Analysis 
PLoS ONE  2014;9(7):e102309.
Compare the efficacy of ranibizumab, aflibercept, laser, and sham in the first-line treatment of diabetic macular edema (DME) to inform technology assessments such as those conducted by the UK National Institute for Health and Care Excellence (NICE).
Data sources
MEDLINE, Embase, Cochrane Library, congress abstracts, registry and Novartis data on file.
Inclusion criteria
Studies reporting 6- or 12-month results of randomized controlled trials (RCTs) evaluating at least two of ranibizumab 0.5 mg pro re nata, aflibercept 2.0 mg bi-monthly, laser photocoagulation or sham. Study quality was assessed based on likelihood of bias in selection, attrition, detection and performance.
Outcome measure
Improvement in best-corrected visual acuity (BCVA) measured as the proportion of patients gaining ≥10 letters on the Early Treatment Diabetic Retinopathy Study scale. The outcome was chosen following acceptance by NICE of a Markov model with 10-letter health states in the assessment of ranibizumab for DME.
Bayesian network meta-analyses with fixed and random effects adjusted for differences in baseline BCVA or central retinal thickness.
The analysis included 1,978 patients from eight RCTs. The random effects model adjusting for baseline BCVA was the best model based on total residual. The efficacy of ranibizumab was numerically, but not statistically, superior to aflibercept (odds ratio [OR] 1.59; 95% credible interval [CrI], 0.61–5.37). Ranibizumab and aflibercept were statistically superior to laser monotherapy with ORs of 5.50 (2.73–13.16) and 3.45 (1.62–6.84) respectively. The probability that ranibizumab is the most efficacious treatment was 73% compared with 14% for aflibercept, 12% for ranibizumab plus laser, and 0% for laser.
Three of the eight RCTs included are not yet published. The models did not adjust for all potential effect modifiers.
Ranibizumab was non-significantly superior to aflibercept and both anti-VEGF therapies had statistically superior efficacy to laser.
PMCID: PMC4100770  PMID: 25029255
4.  Emotional Responses of Mothers of Late-Preterm and Term Infants 
To compare the emotional responses of mothers of late-preterm infants "(34 0/7 to 36 6/7 weeks gestation) with those of mothers of full-term infants.
A mixed method comparative study.
A southeastern tertiary academic medical center postpartum unit.
Sixty mothers: 29 mothers of late-preterm infants and 31 mothers of full-term infants.
Measures of maternal emotional distress "(four standardized measures of anxiety, postpartum depression, posttraumatic stress symptoms, and worry about infant health) and open-ended semistructured maternal interviews were conducted in the hospital following birth and by phone at one month postpartum.
Mothers of late-preterm infants experienced significantly greater emotional distress immediately following delivery, and their distress levels continued to be higher at one month postpartum on each of the standardized measures. Mothers of late-preterm infants also discussed the altered trajectories in their birth and postpartum experiences and feeling unprepared for these unexpected events as a source of ongoing emotional distress.
Mothers of late-preterm infants have greater emotional distress than mothers of term infants for at least one month after delivery. Our findings suggest that it may not be a single event that leads to different distress levels in mothers of late-preterm and full-term infants but rather the interaction of multiple alterations in the labor and delivery process and the poorer-than-expected infant health outcomes. In the future, researchers need to examine how and when mothers’ emotional responses change over time and how their responses relate to parenting and infant health and development.
PMCID: PMC4074409  PMID: 22092914
5.  From intermittent antibiotic point prevalence surveys to quality improvement: experience in Scottish hospitals 
In 2008, the Scottish Antimicrobial Prescribing Group (SAPG) was established to coordinate a national antimicrobial stewardship programme. In 2009 SAPG led participation in a European point prevalence survey (PPS) of hospital antibiotic use. We describe how SAPG used this baseline PPS as the foundation for implementation of measures for improvement in antibiotic prescribing.
In 2009 data for the baseline PPS were collected in accordance with the European Surveillance of Antimicrobial Consumption [ESAC] protocol. This informed the development of two quality prescribing indicators: compliance with antibiotic policy in acute admission units and duration of surgical prophylaxis. From December 2009 clinicians collected these data on a monthly basis. The prescribing indicators were reviewed and further modified in March 2011. Data for the follow up PPS in September 2011 were collected as part of a national PPS of healthcare associated infection and antimicrobial use developed using ECDC protocols.
In the baseline PPS data were collected in 22 (56%) acute hospitals. The frequency of recording the reason for treatment in medical notes was similar in Scotland (75.9%) and Europe (75.7%). Compliance with policy (81.0%) was also similar to Europe (82.5%) but duration of surgical prophylaxis <24hr (68.6%), was higher than in Europe (48.1%, OR: 0.41, p<0.001). Following the development and implementation of the prescribing indicators monthly measurement and data feedback in admission units illustrated improvement in indication documented of ≥90% and compliance with antibiotic prescribing policy increasing from 76% to 90%. The initial prescribing indicator in surgical prophylaxis was less successful in providing consistent national data as there was local discretion on which procedures to include. Following a review and a focus on colorectal surgery the mean proportion receiving single dose prophylaxis exceeded the target of 95% and the mean proportion compliant with policy was 83%. In the follow up PPS of 2011 indication documented (86.8%) and policy compliant (82.8%) were higher than in baseline PPS.
The baseline PPS identified priorities for quality improvement. SAPG has demonstrated that implementation of regularly reviewed national prescribing indicators, acceptable to clinicians, implemented through regular systematic measurement can drive improvement in quality of antibiotic use in key clinical areas. However, our data also show that the ESAC PPS method may underestimate the proportion of surgical prophylaxis with duration <24hr.
PMCID: PMC3573889  PMID: 23320479
Antimicrobial stewardship; Quality improvement; Prescribing indicators; Point prevalence survey; Antibiotic; Hospital prescribing; Surgical prophylaxis
6.  Antimicrobial stewardship in Scotland: impact of a national programme 
The Scottish Antimicrobial Prescribing Group (SAPG) was established by the Scottish Government in 2008 to lead the first national initiative to actively address antimicrobial stewardship. Healthcare associated infection (HAI) is a priority in Scotland and the work of SAPG contributes to the national HAI Delivery Plan. SAPG's early work has focused on restricting the use of antibiotics associated with a high risk of Clostridium difficile infection (CDI) and development of national prescribing indicators to support reduction of CDI.
Scottish Antimicrobial Prescribing Group has developed prescribing indicators for hospital and primary care, which are measured and reported in all 14 NHS board areas. Improvement in compliance with the indicators has been demonstrated with resultant reductions in CDI rates and no adverse effect on mortality or antimicrobial resistance patterns.
The establishment of a Scottish national antimicrobial stewardship programme has made a significant contribution to the HAI agenda, particularly in relation to CDI. The programme is supported by local antimicrobial teams, a national framework for education, surveillance of antimicrobial use and resistance and sharing of data for improvement. Antimicrobial stewardship has been integrated with other national programmes on patient safety and quality improvement.
PMCID: PMC3436612  PMID: 22958296
Antimicrobial stewardship; Clostridium difficile infection; prescribing indicators; quality improvement
7.  Long-term morbidities associated with vocal cord paralysis after surgical closure of a patent ductus arteriosus in extremely low birth weight infants 
Determine associations between left vocal cord paralysis (LVCP) and poor respiratory, feeding, and/or developmental outcomes in extremely low birth weight (ELBW) infants following surgical closure of a patent ductus arteriosus (PDA).
Study design:
ELBW infants who underwent PDA ligation between January 2004 and December 2006 were identified. We compared infants with and without LVCP following ligation to determine relationships between LVCP and respiratory morbidities, feeding and growth difficulties, and neurodevelopmental impairment at 18-22 month follow-up. Student's t test, Fisher exact test, and multivariable regression analyses were used to determine associations.
60 ELBW infants with a mean gestational age of 25 weeks and mean birth weight of 725 g had a PDA surgically closed. Twenty-two of 55 survivors (40%) were diagnosed with LVCP post-operatively. Infants with LVCP were significantly more likely to develop bronchopulmonary dysplasia (82% vs. 39%, p = 0.002), reactive airway disease (86% vs. 33%, p<0.0001), or need for gastrostomy tube (63% vs. 6%, p<0.0001).
LVCP as a complication of surgical ductal ligation in ELBW infants is associated with persistent respiratory and feeding problems. Direct laryngoscopy should be considered for all infants who experience persistent respiratory and/or feeding difficulties following PDA ligation.
PMCID: PMC2878380  PMID: 19759545
infant, premature; ductus arteriosus, patent; growth & development; infant nutrition disorders; bronchopulmonary dysplasia; asthma
8.  Vocal fold paralysis following surgical ductal closure in extremely low birth weight infants: A case series of feeding and respiratory complications 
Surgical closure of a Patent Ductus Arteriosus (PDA) continues to be frequent among Extremely Low Birth Weight (ELBW) infants, despite improvements in the medical management of PDA’s and rising questions about its pathophysiologic role. Among other possible complications of this surgical intervention, left vocal fold paralysis (LVFP) has been reported. Only more recently, however, neonatologists are realizing the frequency and impact of this complication on chronic respiratory and feeding difficulties in the ELBW population. In this case series, we describe the clinical course of three sets of multiple births, for which at least one infant underwent surgical closure of his PDA and subsequently developed feeding and/or respiratory difficulties due to LVFP, and compare them to their respective siblings who did not sustain this complication.
PMCID: PMC2864228  PMID: 18974752
Patent Ductus Arteriosus; Vocal cord paralysis; Infant, Premature; Infant, Low Birth Weight; Feeding

Results 1-8 (8)