A pilot study of the S-MAP (Solutions for Medications Adherence Problems) intervention for older adults prescribed polypharmacy in primary care: Study protocol

Background: Adhering to multiple medications as prescribed is challenging for older patients (aged ≥ 65 years) and a difficult behaviour to improve. Previous interventions designed to address this have been largely complex in nature but have shown limited effectiveness and have rarely used theory in their design. It has been recognised that theory ('a systematic way of understanding events or situations') can guide intervention development and help researchers better understand how complex adherence interventions work. This pilot study aims to test a novel community pharmacy-based intervention that has been systematically developed using the Theoretical Domains Framework (12-domain version) of behaviour change. Methods: As part of a non-randomised pilot study, pharmacists in 12 community pharmacies across Northern Ireland (n = 6) and London, England (n = 6), will be trained to deliver the intervention to older patients who are prescribed ≥ 4 regular medicines and are non-adherent (self-reported). Ten patients will be recruited per pharmacy (n = 120) and offered up to four tailored one-to-one sessions, in the pharmacy or via telephone depending on their adherence, over a 3-4-month period. Guided by an electronic application (app) on iPads, the intervention content will be tailored to each patient's underlying reasons for non-adherence and mapped to the most appropriate solutions using established behaviour change techniques. This study will assess the feasibility of collecting data on the primary outcome of medication adherence (self-report and dispensing data) and secondary outcomes (health-related quality of life and unplanned hospitalisations). An embedded process evaluation will assess training fidelity for pharmacy staff, intervention fidelity, acceptability to patients and pharmacists and the intervention's mechanism of action. Process evaluation data will include audio-recordings of training workshops, intervention sessions, feedback interviews and patient surveys. Analysis will be largely descriptive. Discussion: Using pre-defined progression criteria, the findings from this pilot study will guide the decision whether to proceed to a cluster randomised controlled trial to test the effectiveness of the S-MAP intervention in comparison to usual care in community pharmacies. The study will also explore how the intervention components may work to bring about change in older patients' adherence behaviour and guide further refinement of the intervention and study procedures. Trial registration: This study is registered at ISRCTN: https://doi.org/10.1186/ISRCTN7383153

Retrospective longitudinal study of patients and prescriber characteristics associated with new DOAC prescriptions in a CCG without restrictions to DOAC use

yesDirect oral anticoagulants (DOACs) uptake for stroke prevention in atrial fibrillation has been slow.[1] This study aimed to profile the prescribing of DOACs over three years to identify factors associated with DOAC prescribing in a Clinical Commissioning Group (CCG) without restrictions to DOACs use. The objectives were to identify: - Characteristics of patients prescribed oral anticoagulant (OAC) in a sample of general practices; - Who initiated the prescribing of OAC; - Recorded reasons for prescribing a DOAC rather than warfarin

Improving adherence to multiple medications in older people in primary care: Selecting intervention components to address patient-reported barriers and facilitators

Background: Medication adherence is vital to ensuring optimal patient outcomes, particularly amongst multimorbid older people prescribed multiple medications. Interventions targeting adherence often lack a theoretical underpinning and this may impact on effectiveness. The theoretical domains framework (TDF) of behaviour can aid intervention development by systematically identifying key determinants of medication adherence. Objectives: This study aimed to (i) identify determinants (barriers, facilitators) of adherence to multiple medications from older people's perspectives; (ii) identify key domains to target for behaviour change; and (iii) map key domains to intervention components [behaviour change techniques (BCTs)] that could be delivered in an intervention by community pharmacists. Method Focus groups were conducted with older people (>65 years) receiving ≥4 medications. Questions explored the 12 domains of the TDF (eg “Knowledge,” “Emotion”). Data were analysed using the framework method and content analysis. Identification of key domains and mapping to intervention components (BCTs) followed established methods. Results: Seven focus groups were convened (50 participants). A wide range of determinants were identified as barriers (eg forgetfulness, prioritization of medications) and facilitators (eg social support, personalized routines) of adherence to multiple medications. Eight domains were identified as key targets for behaviour change (eg “Social influences,” “Memory, attention and decision processes,” “Motivation and goals”) and mapped to 11 intervention components (BCTs) to include in an intervention [eg “Social support or encouragement (general),” “Self-monitoring of the behaviour,” “Goal-setting (behaviour)”]. Conclusion: This study used a theoretical underpinning to identify potential intervention components (BCTs). Future work will incorporate the selected BCTs into an intervention that will undergo feasibility testing in community pharmacies

Interventions to improve the appropriate use of polypharmacy in older people: a Cochrane systematic review

OBJECTIVE: To summarise the findings of an updated Cochrane review of interventions aimed at improving the appropriate use of polypharmacy in older people. DESIGN: Cochrane systematic review. Multiple electronic databases were searched including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (from inception to November 2013). Hand searching of references was also performed. Randomised controlled trials (RCTs), controlled clinical trials, controlled before-and-after studies and interrupted time series analyses reporting on interventions targeting appropriate polypharmacy in older people in any healthcare setting were included if they used a validated measure of prescribing appropriateness. Evidence quality was assessed using the Cochrane risk of bias tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation). SETTING: All healthcare settings. PARTICIPANTS: Older people (≥65 years) with ≥1 long-term condition who were receiving polypharmacy (≥4 regular medicines). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes were the change in prevalence of appropriate polypharmacy and hospital admissions. Medication-related problems (eg, adverse drug reactions), medication adherence and quality of life were included as secondary outcomes. RESULTS: 12 studies were included: 8 RCTs, 2 cluster RCTs and 2 controlled before-and-after studies. 1 study involved computerised decision support and 11 comprised pharmaceutical care approaches across various settings. Appropriateness was measured using validated tools, including the Medication Appropriateness Index, Beers’ criteria and Screening Tool of Older Person's Prescriptions (STOPP)/ Screening Tool to Alert doctors to Right Treatment (START). The interventions demonstrated a reduction in inappropriate prescribing. Evidence of effect on hospital admissions and medication-related problems was conflicting. No differences in health-related quality of life were reported. CONCLUSIONS: The included interventions demonstrated improvements in appropriate polypharmacy based on reductions in inappropriate prescribing. However, it remains unclear if interventions resulted in clinically significant improvements (eg, in terms of hospital admissions). Future intervention studies would benefit from available guidance on intervention development, evaluation and reporting to facilitate replication in clinical practice

A feasibility study of a theory-based intervention to improve appropriate polypharmacy for older people in primary care

Background: A general practitioner (GP)-targeted intervention aimed at improving the prescribing of appropriate polypharmacy for older people was previously developed using a systematic, theory-based approach based on the UK Medical Research Council’s complex intervention framework. The primary intervention component comprised a video demonstration of a GP prescribing appropriate polypharmacy during a consultation with an older patient. The video was delivered to GPs online and included feedback emphasising the positive outcomes of performing the behaviour. As a complementary intervention component, patients were invited to scheduled medication review consultations with GPs. This study aimed to test the feasibility of the intervention and study procedures (recruitment, data collection). Methods: GPs from two general practices were given access to the video, and reception staff scheduled consultations with older patients receiving polypharmacy (≥4 medicines). Primary feasibility study outcomes were the usability and acceptability of the intervention to GPs. Feedback was collected from GP and patient participants using structured questionnaires. Clinical data were also extracted from recruited patients’ medical records (baseline and 1 month post-consultation). The feasibility of applying validated assessment of prescribing appropriateness (STOPP/ START criteria, Medication Appropriateness Index) and medication regimen complexity (Medication Regimen Complexity Index) to these data was investigated. Data analysis was descriptive, providing an overview of participants’ feedback and clinical assessment findings. Results: Four GPs and ten patients were recruited across two practices. The intervention was considered usable and acceptable by GPs. Some reservations were expressed by GPs as to whether the video truly reflected resource and time pressures encountered in the general practice working environment. Patient feedback on the scheduled consultations was positive. Patients welcomed the opportunity to have their medications reviewed. Due to the short time to follow-up and a lack of detailed clinical information in patient records, it was not feasible to detect any prescribing changes or to apply the assessment tools to patients’ clinical data. Conclusion: The findings will help to further refine the intervention and study procedures (including time to follow-up) which will be tested in a randomised pilot study that will inform the design of a definitive trial to evaluate the intervention’s effectiveness

Mineralogia e química de um Latossolo câmbico desenvolvido de rocha pelítica do grupo Bambuí, MG.

Foram realizados analises quimica e mineralogica das fracoes argila e silte de amostras de um perfil de solo com tres camadas distintas: uma superficies xantizada, uma camada de subsuperficie vermelha e um horizonte C apresentado variegados amarelos e vermelhos. Os minerais de maior ocorrencia sao caulinita, mica/vermiculita e goethita. A cor do solo esta relacionada a proporcao hematita/goethita (determinada pela espectroscopia Mossbauer). A substituicao isomorfica de ferro por aluminio na goethita aumenta uniformemente, de 20 a 40 mol%, da base para o topo de perfil; SiO2 decresce uniformemente e ha, ainda, uma tendencia de o Fe 2+ ser continuamente oxidado, na medida em que mica se transforma em vermiculita. O aparecimento de hematita na camada vermelha nao pode ser explicado quantitativamente pela hipotese de que os silicatos sejam a unica fonte de ferro, a menos que haja uma consideravel reducao de volume de camada siltosa amarela do horizonte C para as camadas vermelhas do horizonte B. Os dados sugerem uma transformacao reversivel goethita hematita, em resposta as condicoes ambientais

Writing a manuscript for publication in a peer-reviewed scientific journal:Guidance from the European Society of Clinical Pharmacy

Publishing in reputable peer-reviewed journals is an integral step of the clinical pharmacy research process, allowing for knowledge transfer and advancement in clinical pharmacy practice. Writing a manuscript for publication in a journal requires several careful considerations to ensure that research findings are communicated to the satisfaction of editors and reviewers, and effectively to the readers. This commentary provides a summary of the main points to consider, outlining how to: (1) select a suitable journal, (2) tailor the manuscript for the journal readership, (3) organise the content of the manuscript in line with the journal’s guidelines, and (4) manage feedback from the peer review process. This commentary reviews the steps of the writing process, identifies common pitfalls, and proposes ways to overcome them. It aims to assist both novice and established researchers in the field of clinical pharmacy to enhance the quality of writing in a research paper to maximise impact

High Altitude Long Endurance Air Vehicle Analysis of Alternatives and Technology Requirements Development

The objective of this study was to develop a variety of High Altitude Long Endurance (HALE) Unmanned Aerial Vehicle (UAV) conceptual designs for two operationally useful missions (hurricane science and communications relay) and compare their performance and cost characteristics. Sixteen potential HALE UAV configurations were initially developed, including heavier-than-air (HTA) and lighter-than-air (LTA) concepts with both consumable fuel and solar regenerative (SR) propulsion systems. Through an Analysis of Alternatives (AoA) down select process, the two leading consumable fuel configurations (one each from the HTA and LTA alternatives) and an HTA SR configuration were selected for further analysis. Cost effectiveness analysis of the consumable fuel configurations revealed that simply maximizing vehicle endurance can lead to a sub-optimum system solution. An LTA concept with a hybrid propulsion system (solar arrays and a hydrogen-air proton exchange membrane fuel cell) was found to have the best mission performance; however, an HTA diesel-fueled wing-body-tail configuration emerged as the preferred consumable fuel concept because of the large size and technical risk of the LTA concept. The baseline missions could not be performed by even the best HTA SR concept. Mission and SR technology trade studies were conducted to enhance understanding of the potential capabilities of such a vehicle. With near-term technology SR-powered HTA vehicles are limited to operation in favorable solar conditions, such as the long days and short nights of summer at higher latitudes. Energy storage system specific energy and solar cell efficiency were found to be the key technology areas for enhancing HTA SR performance