Is there scope to discontinue non-essential medication in patients with advanced lung cancer?

Focal Points 1. Patients with advanced lung cancer take many ‘non-essential’ medicines 2. A simple audit tool could be used to identify ‘non-essential’ medicines that could be discontinued 3. Pharmacists have a potential role in identifying and reviewing ‘non-essential’ medicines Background Lung cancer patients can present with complex medical histories often taking medications to manage existing conditions and prevent future morbidity e.g. antihypertensives and antiplatelets. Guidelines for discontinuing these medications in life-limiting illnesses, such as advanced lung cancer, have not been produced despite the potential to reduce burden, in terms of cost and, more importantly, discomfort to the patient.1 The objectives of this work was to audit the number of medications in patients taking erlotinib for the treatment of advanced lung cancer; and, develop a draft tool that can be used to identify non-essential medications which could, potentially, be discontinued. Methods This clinical audit was undertaken at an acute NHS Trust in April 2011. A clinical audit tool was used to extract data from medical notes of patients receiving erlotinib for non-small cell lung cancer (NSCLC) and compared to a set of criteria to establish if the medicine is essential, non-essential or uncertain. These criteria were based on a study that defined unnecessary medication as where there is no anticipated short-term benefit to patients with respect to survival, quality of life or symptom control.2 All patients who had received erlotinib in the Trust for the treatment of NSCLC within 18 months were selected for the audit. A consensus group (consultant pharmacist, lung nurse specialist and consultant oncologist) reviewed results and considered which medications they would have stopped. Results Of the 20 patients audited, 19 were taking at least one medication that could have been discontinued. The mean number of medications taken was 8 (range 1–16). Seventeen patients were taking essential medications (e.g. analgesics) necessary for symptom control in cancer. Non-essential medicines were regarded as those which provided no short term benefit to the patients with respect to survival, quality of life or symptom control or any medicine which had potential to cause harm. The focus group concurred that the majority of non-essential medications identified by the criteria could have been discontinued. Medications classified as uncertain were taken by 7 patients. These medications need to be further reviewed. Discussion For patients undergoing treatment for terminal lung cancer the issue of discontinuing medications is not an immediate priority. However, at some point in their treatment pathway a discussion regarding their medications should be instigated. The focus group revealed that timing of this discussion is crucial. The futile use of medication in terminally ill cancer patients has been reported in the literature and this work is in agreement with this by showing that patients with NSCLC taking erlotinib are taking unnecessary medications.2 Patients take medications such as statins and antihypertensives with the belief that they will be taking them for the rest of their lives, therefore if an appropriate explanation for discontinuation is not given the patients and/or their families may misconceive this as a death-hastening intervention. This work also showed that a significant number of patients who are taking erlotinib also take a proton pump inhibitor (PPI) despite the fact there is a clinically significant drug interaction between erlotinib and PPIs where the absorption of erlotinib is reduced.3 In conclusion, patients taking erlotinib for the treatment of advanced NSCLC take many unnecessary medications and written guidelines on what can be withdrawn are needed. There is the potential for pharmacists to become involved in the review of patients with terminal cancer to facilitate discontinuing potentially unnecessary medicines

Post discharge medicines use review service for older patients: recruitment issues in a feasibility study

Background The community pharmacy medicines use review (MUR) service in England has been identified as a way of providing support with medication to recently discharged patients; however initial uptake of post-discharge MUR has been low. Objective To identify barriers to recruitment into a randomised controlled feasibility study of a hospital referral system to older patients’ regular community pharmacists. Method Ward pharmacists at Southport District General Hospital identified patients aged over 65 to be approached by a researcher to assess eligibility and discuss involvement in the trial. Participants were randomised to referral for a post discharge MUR with their regular community pharmacist, or to standard discharge care. Reasons for patients not participating were collected. Results Over a 9-month period 337 potential participants were identified by ward pharmacists. Of these, 132 were eligible and 60 were recruited. Barriers to recruitment included competing priorities among ward pharmacists, and national restrictions placed on MURs e.g. housebound patients and those requiring carer support with medication. Lack of expected benefit resulted in a high proportion of patient refusals. Conclusion The current provisions for post discharge MURs exclude many older people from participation, including those possibly in greatest need. Unfamiliarity with the role of the pharmacist in transitional care may have affected patients’ perceived ‘cost-benefit’ of taking part in this study

Exploring an extended role for pharmacy assistants on inpatient wards in UK hospitals: using mixed methods to develop the role of medicines assistants

Objectives: This project explored the deployment of pharmacy assistants to inpatient wards in a new role as ‘medicines assistants’ (MA). Methods: Ward-based MAs were introduced to six wards across two UK hospitals to support medicines administration. Each 30-bed ward delivered acute inpatient services with MAs supporting typical nursing medication administration rounds to 15 patients. Data were collected using activity diaries, observations, clinical audit and semistructured interviews with pharmacy assistants, pharmacy technicians, clinical pharmacists, nurses, ward managers and pharmacy managers. Thematic analysis, descriptive statistics and the Mann-Whitney U test were used to analyse qualitative and quantitative data, respectively. Results: MAs were able to act as a point of contact between the ward and the pharmacy department and were perceived to save nursing time. A statistically significant reduction in the length of time to complete morning medication administration to 15 patients was observed (mean 74.5 vs 60.8 min per round, p<0.05). On average, 17.4 hours of medicines-related activity per ward per week was carried out by MAs rather than by nursing staff. Participants identified broader training and clarity was needed in relation to the accountability and governance of patient-facing roles. Conclusion: Pharmacy assistants deployed as MAs can contribute to saving nursing time and bridge the gap between nursing and pharmacy professionals

An exploration of the attitudes and perceptions of the UK public towards self-care for minor ailments

Aims and objectives: The purpose of this pilot study was to explore the attitudes and perceptions of members of the UK public towards self-care for minor ailments. Background: With an ageing and increasing population, and a National Health Service in extremis with plummeting performance indicators and the huge disparity between available funding and costs of treatments, methods to reduce demand upon health services are key. Increasing the use of self-care for minor ailments is one way in which this pressure could be alleviated. Design + Method: This study utilised qualitative methods including semi-structured telephone interviews. This data was then valuated, and key themes are drawn out of the data using thematic analysis. Findings: The results showed that the public are aware of the notion of self-care, and some are engaging with it. However, for a number of reasons, patients are still likely to want a face to face appointment despite the use of internet and telephone advice services. Conclusion: The study highlighted that there are multifactorial aspects impacting upon a patient’s likelihood to engage in self-care when faced with a minor illness. The results are not generalisable to every member of the UK public, but interesting questions are raised with regards to the usefulness of current public health messages being portrayed across various media when there appears to be a lack of desire from the public to use some recommended services

Pengaruh Fraksi Nano (TiO2:SnO2) terhadap Struktur dan Efisiensi DSSC TiO2:SnO2/β-Karoten/FTO

Penggunaan energi terbarukan berbasis energi matahari banyak dikembangkan dalam beberapa tahun terakhir berupa solar sel khususnya dalam bentuk DSSC. Semikonduktor SnO2 memiliki band gap yang paling besar yaitu 3,6 eV dan TiO2 dalam bentuk anatase dan rutil memiliki nilai 3,2 dan 3,0 eV. SnO2 dan TiO2 memiliki beberapa kemiripan pada sifat elektronik dan struktural. Pada penelitian ini, pembentukan komposit TiO2/SnO2 dilakukan dengan menggunakan variasi Wt% massa TiO2 100, 97, 94, 88  dan 85%. Metode dalam sintesis menggunakan kopresipitasi untuk TiO2 dan solgel untuk SnO2. Karaktersisasi XRD menunjukkan nano partikel TiO2 dengan struktur anatase dengan ukuran butir 8,89 nm dan nano partikel SnO2 28 nm. Pada variasi massa, efisiensi meningkat dengan bertambahnya massa TiO2. Nilai efisiensi maksimum yang dihasilkan pada 100 % TiO2 yaitu 0,18 %. DOI: http://dx.doi.org/10.17977/um024v3i22018p06

Modeling of single mode optical fiber having a complicated refractive index profile by using modified scalar finite element method

A numerical method based on modified scalar finite element method (SC-FEM) is presented and programmed on MATLAB platform for optical fiber modeling purpose. We have estimated the dispersion graph, mode cut off condition, and group delay and waveguide dispersion for highly complicated chirped type refractive index profile fiber. The convergence study of our FEM formulation is carried out with respect to the number of division in core. It has been found that the numerical error becomes less than 2 % when the number of divisions in the core is more then 30. To predict the accurate waveguide dispersion characteristics, we need to compute expression (d^2 (Vb))/(dV^2 ) numerically by the FEM method. For that the normalized propagation constant b (in terms of β) should be an accurate enough up to around 6 decimal points. To achieve this target, we have used 1 million sampling points in our FEM simulations. Further to validate our results we have derived the higher order polynomial expression for each case. Comparison with other methods in calculation of normalized propagation constant is found to be satisfactory. In traditional FEM analysis a spurious solution is generated because the functional does not satisfy the boundary conditions in the original waveguide problem, However in our analysis a new term that compensate the missing boundary condition has been added in the functional to eliminate the spurious solutions. Our study will be useful for the analysis of optical fiber having varying refractive index profile