Of cortex and consciousness: “Phenomenal,” “access,” or otherwise

From the perspective of a comparative neuroanatomist studying the avian pallium, Woodruff’s (2017) claims about the behavioral and electrophysiological evidence for teleost sentience blur the lines between phenomenal and access consciousness (Block, 1995). I discuss the bias that complex cognition can only arise in the cortical layering typical of the mammalian pallium and conclude that Woodruff makes a good case that the tecto-pallial connections in teleosts are sufficiently complex to support something like sentience

Integrating Science and Practice in Pharmacy Curricula

An integrated curriculum is one where the summation of different academic disciplines forms a co- herent whole and, importantly, where the relationships between the different disciplines have been carefully and strategically considered when forming the composite. Within pharmacy curriculum in- tegration is important in order to produce graduates who have the capacity to apply their knowledge to a range of complex problems where available information is often incomplete. This paper discusses the development of an integrated curriculum in which students are presented with an organized, logical sequence of material, but still challenged to make their own integrations and develop as integrative thinkers. An evidence-based model upon which an interdisciplinary undergraduate pharmacy curric- ulum can be built is presented

Safety profile of lamotrigine in overdose

Background: Lamotrigine is an anticonvulsant as well as a mood stabilizer. Apart from its established use in the treatment of epilepsy, there has been an expansion of its use in the treatment of mental disorders. Patients with epilepsy as well as those with mental disorders are at increased risk of deliberate drug overdoses. An evidence base for the safety profile of lamotrigine in overdose is an essential tool for prescribers. The objective of this study was to carry out a narrative synthesis of the existing evidence for the safety profile of lamotrigine in overdose. Methods: A systematic search was conducted of EMBASE (1974 to December 2015), MEDLINE (1946 to December 2015), PsycINFO (1806 to December 2015) and CINAHL (1981 to December 2015) databases. Studies were included in which there was a deliberate or accidental single drug overdose of lamotrigine, with its toxic effects described. Studies that did not involve an overdose were excluded. A narrative synthesis of the described toxic effects was carried out. Results: Out of 562 articles identified, 26 studies were included, mainly in the form of case reports and series. The most commonly described toxic effects of lamotrigine were on the central nervous system, specifically seizures, movement disorders and reduced consciousness. Other toxic effects included QTc interval and QRS complex prolongations, hypersensitivity reactions, serotonin syndrome as well as rhabdomyolysis possibly due to seizures and/or agitation. Deaths were recorded in two studies, with cardiovascular and neurological toxic effects described. Conclusions: Even though lamotrigine has been reported to be well tolerated, there is a risk of toxic effects which can be life threatening in overdose. This needs to be borne in mind when prescribing to patients at an increased risk of deliberate drug overdose

Deprescribing in advanced illness

Patients with advanced illness such as cancer, chronic obstructive pulmonary disease, and Parkinson's disease experience acute symptoms and are usually prescribed medications to manage these, alongside drugs to treat other co-morbid, long-term conditions. As such, the pharmacotherapeutic burden for these patients is high and polypharmacy is common. Previous studies have revealed the prevalence of potentially inappropriate prescribing within this group of patients, and identified the need for attention to ‘deprescribing’. Deprescribing can be defined as a process of optimization of medication regimens through cessation of potentially inappropriate or unnecessary medications. Patients usually have reservations about taking medications and may be willing to discontinue one or more medications considered ‘inappropriate’. Similarly, healthcare professionals experience some challenges discussing deprescribing approaches to patients with advanced illness. This article reviews research on prescribing medicines to patients with advanced illness, focusing on the identification of the prevalence of inappropriate or unnecessary medicines to the initiation of the deprescribing process. The review demonstrates the paramount importance of further research exploring the perspective of healthcare professionals and patients on the subject of deprescribing to facilitate its further acceptance in practice

Patients using antifungals following laryngectomy : a qualitative study of community pharmacists in the North of England

Objective: To explore community pharmacists’ understanding and opinions in relation to prevention of fungal colonisation of voice prostheses amongst laryngectomy patients. Method: Semi-structured interviews were conducted on a purposive sample of 12 community pharmacists from the North of England. Interviews were undertaken until data saturation was reached and responses were transcribed verbatim and analysed using a thematic approach. Key findings: Six themes emerged from the data analysis. These were: terminology confusion about laryngectomy, stoma and voice prostheses; smoking as a risk factor for the development of laryngeal cancer; using nystatin to prevent biofilm formation; counselling information related to nystatin; prescription intervention and additional education in relation to laryngectomy. The theme of counselling information related to nystatin use and additional education was a key finding: our data show that when dispensing nystatin to patients with a voice prosthesis, community pharmacists would either give no advice related to medication use or would give incorrect advice that may lead to premature prosthesis failure amongst this patient group. Conclusion: This study highlights that community pharmacists lack understanding in relation to laryngectomy and are unaware of the off-label doses and administration methods of the drugs (specifically nystatin) used to prevent fungal colonisation on voice prostheses. Additional information sources – possibly obtained through the local Speech and Language Therapy Department – in the form of an educational leaflet would be perceived as a valuable resource to support community pharmacists who are required to manage these patients in the community

What are the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population? A systematic review

\ua9 2024 The Authors. Endocrinology, Diabetes & Metabolism published by John Wiley & Sons Ltd.Aims: This review aims to identify the evidence base for the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population. Method: In this systematic review, we searched MEDLINE, Embase, PubMed, CINAHL and the Cochrane Library for studies from January 2001 to 15th August 2022. We included a variety of study types that assessed and reported frailty including patients ≥18 years old. Studies included those that reported the prevalence of over or undertreatment of diabetes mellitus in a frail population and those examining outcomes related to glucose control in frail older people living with diabetes. Data were extracted using a bespoke extraction table using a narrative synthesis approach. Results: A total of 4114 articles were identified with 112 meeting inclusion criteria. These included 15,130 participants across the 11 studies with sample sizes ranging from 101 to 11,140. Several areas were identified in the included studies where under or overtreatment of diabetes impacted outcomes for patients. These included hospital admissions, readmissions, length of stay, falls, mortality, cognitive impairment and cardiovascular disease outcomes. Conclusion: The results showed that there was a high heterogeneity of outcomes between the studies and that many examined small numbers of participants. In this review, both over and undertreatment were shown to increase adverse outcomes in frail older people. Further research around optimal glycaemic control for frail older people living with diabetes is required with the aim to identify ideal target ranges and produce practical clinical guidelines to promote attainment of these

Identifying clustering at high redshift through actively star-forming galaxies

Identifying galaxy clustering at high redshift (i.e. z > 1) is essential to our understanding of the current cosmological model. However, at increasing redshift, clusters evolve considerably in star-formation activity and so are less likely to be identified using the widely-used red sequence method. Here we assess the viability of instead identifying high redshift clustering using actively star-forming galaxies (SMGs associated with over-densities of BzKs/LBGs). We perform both a 2- and 3-D clustering analysis to determine whether or not true (3D) clustering can be identified where only 2D data are available. As expected, we find that 2D clustering signals are weak at best and inferred results are method dependant. In our 3D analysis, we identify 12 SMGs associated with an over-density of galaxies coincident both spatially and in redshift - just 8% of SMGs with known redshifts in our sample. Where an SMG in our target fields lacks a known redshift, their sightline is no more likely to display clustering than blank sky fields; prior redshift information for the SMG is required to identify a true clustering signal. We find that the strength of clustering in the volume around typical SMGs, while identifiable, is not exceptional. However, we identify a small number of highly clustered regions, all associated with an SMG. The most notable of these, surrounding LESSJ033336.8-274401, potentially contains an SMG, a QSO and 36 star-forming galaxies (a > 20sig over-density) all at z~1.8. This region is highly likely to represent an actively star-forming cluster and illustrates the success of using star-forming galaxies to select sites of early clustering. Given the increasing number of deep fields with large volumes of spectroscopy, or high quality and reliable photometric redshifts, this opens a new avenue for cluster identification in the young Universe.Comment: 24 pages, 14 figures, accepted MNRA

Prescribing of inappropriate medicine in patients with limited life expectancy : a prospective study in a specialist palliative care unit

For patients with limited life expectancy – typically surviving for less than one year – polypharmacy is very common because medication is prescribed to manage acute symptoms associated with the life limiting illness (e.g. cancer) and to treat or prevent other long-term conditions (e.g. cardiovascular disease). As a consequence, this polypharmacy is linked with an increased risk of developing a drug-related toxicity due to the potential of drug-drug or drug-disease interactions. This risk is further heightened in patients with limited life expectancy owing to their unique and dynamic pharmacokinetic and pharmacodynamic parameters (e.g. variation in volume of distribution or altered drug excretion due to declining renal and/or hepatic function). In view of the potential for polypharmacy to cause harm in patients with limited life expectancy, it is essential to optimize patients’ medication to align with therapeutic goals and life expectancy. To date, however, there is a growing body of evidence that suggests inappropriate medication continues to be prescribed to patients with limited life expectancy

Widening the scope for early cancer detection: identification of alarm symptoms by community pharmacies

Background Cancers are one of the leading causes of death in the world and, due to the aging population, incidence rates are set to rise. As such, considerable effort has been placed on initiatives that aid the early detection of cancer, as this may improve patient survival outcome. One such initiative is the development of guidelines that explain how and when patient reported alarm symptoms suggestive of an underlying malignancy should be referred to a specialist. However, despite being conveniently placed to deliver interventions to promote the early detection of cancer, it is not clear what role community pharmacists could have in the development and implementation of these guidelines. Objective To: (1) assess the frequency and mean of patient reported alarm symptoms in a community pharmacy setting; (2) determine the demographics of patients presenting with the alarm symptom; and (3) explore the relationship between deprivation index of the community pharmacy and average frequency of alarm symptoms per pharmacy. Setting Thirty-three community pharmacies in the North of England. Method A prospective study from September 2013 to February 2014. Each community pharmacy team was provided training in relation to alarm symptoms to ensure there was consistency in reporting. Deprivation tertiles for each community pharmacy were calculated using the IMD 2010 deprivation index. The data were analysed using a Kruskal-Wallis test in order to determine whether there were any statistically significant associations between average frequency of alarm symptoms presented per pharmacy and the deprivation tertile. Main outcome measure Frequency of patient reported alarm symptoms

A systematic review and thematic synthesis of patients' experience of medicines adherence

Background: Medicines non-adherence continues to be problematic in health care practice. After decades of research, few interventions have a robust evidence-based demonstrating their applicability to improve adherence. Phenomenology has a place within the health care research environment. Objective: To explore patients’ lived experiences of medicines adherence reported in the phenomenonologic literature. Methods: A systematic literature search was conducted to identify peer-reviewed and published phenomenological investigations in adults that aimed to investigate patients’ lived experiences of medicines adherence. Studies were appraised using the Critical Appraisal Skills Programme (CASP) Qualitative Research Tool. Thematic synthesis was conducted using a combination of manual coding and NVivo10 [QSR International, Melbourne] coding to aid data management. Results: Descriptive themes identified included i) dislike for medicines, ii) survival, iii) perceived need, including a) symptoms and side-effects and b) cost, and iv) routine. Analytic themes identified were i) identity and ii) interaction. Conclusions: This work describes adherence as a social interaction between the identity of patients and medicines, mediated by interaction with family, friends, health care professionals, the media and the medicine, itself. Health care professionals and policy makers should seek to re-locate adherence as a social phenomenon, directing the development of interventions to exploit patient interaction with wider society, such that patients ‘get to know’ their medicines, and how they can be taken, throughout the life of the patient and the prescription