Development of a tool to support person-centred medicine-focused consultations with stroke survivors

Objective: To develop a tool to support medicine-focused person-centred consultations between community pharmacists and stroke survivors. Method: Semi-structured interviews with 15 stroke survivors and 16 community pharmacists were conducted. Thematic analysis of the data was performed and emerging themes examined to determine their relevance to the principles of delivering person-centred care. Findings were used to generate a framework from which a consultation tool was created. Face validity and the feasibility of using the tool in practice were explored with participating pharmacists. Results: Three major themes were identified; personal, process and environmental factors. A tool, in two parts, was developed, A ‘Getting to know me’ form which would help the pharmacist to appreciate the individual needs of the stroke survivor and a consultation guide to facilitate the consultation process. Pharmacists considered that both were useful and would support a person-centred medicine-focussed consultation. Conclusion: A consultation tool, reflecting the needs of stroke survivors, has been developed and is feasible for use within community pharmacy practice. Practice implications: Pharmacists must recognise the individual needs of stroke survivors to ensure that they provide consultations which are truly person-centred. The tool developed could support medicine-related consultations with patients with other long term conditions

Finite Element Analysis of Concrete Fracture Specimens

The effects of the descending branch of the tensile stress-strain curve, fracture energy, grid refinement, and load-step size on the response of finite element models of notched concrete beams are studied. The width of the process zone and constraint of crack angles are investigated. Nonlinearity is 1 imited to cracking of the concrete. A limiting tensile stress criterion governs crack initiation. Concrete is represented as linear elastic prior to cracking. Cracks are modeled using a smeared representaion. The post-cracking behavior is controlled by the shape of the descending branch, fracture energy, crack angle, and element size. Unloading occurs at a slope equal to the i nitia 1 modulus of the material. load deflection curves and cracking patterns are used to evaluate the beam's response. Comparisons of the process zone size are made. All analyses are performed on a 200 x 200 x GOO mm concrete beam, with an initial notch length of 80 mm. The fracture energy, tensile strength, and shape of the descending branch interact to determine the stiffness and general behavior of the specimen. The width of the process zone has a negligible influence on the beam's response. The importance of proper crack orientation is demonstrated. The model is demonstrated to be objective with respect to grid refinement and load-step size

Pneumococcal and influenza immunization in asplenic persons: a retrospective population-based cohort study 1990-2002

<p>Abstract</p> <p>Background</p> <p>Splenectomy is associated with increased risk for bacteremia, due to impaired clearance of bloodborne agents and to altered phagocytosis and humoral immunity. We conducted a retrospective cohort study of patients at risk for splenectomy for a 13-year period to determine immunization coverage, and outcomes of those with and without splenectomy, and with or without receipt of influenza or pneumococcal vaccine.</p> <p>Methods</p> <p>Data were extracted from the provincial Medical Services Insurance database for insured services rendered by a physician for 1990-2002, and from the Vital Statistics Death database. The eligible cohort was selected based on diagnostic codes for hematologic conditions for which splenectomy might be considered, such as immune thrombocytopenia. Each patient was followed longitudinally from the date of first diagnosis until 31Dec2002, or death, or relocation out-of province. In addition, persons with splenectomy and no hematologic condition were identified and followed for 6 months post-surgery. Infectious illness rates per 100 person-years of observation and death rates were calculated with and without splenectomy. Death rates were determined using splenectomy status as a time-dependent covariate. The relationship between splenectomy and death according to immunization status was examined using Cox proportional hazard ratios.</p> <p>Results</p> <p>Of 38,812 persons in the cohort 427 subjects with a hematologic diagnosis had splenectomy and another 452 subjects without a hematologic diagnosis had this surgery. 72% were > 18 years of age. Pneumococcal immunization was recorded in 16.5% of asplenic patients overall, and was not associated with reduced risk of death in these persons (adjusted Hazard Ratio [HR] = 1.07, 95% CI 0.70 - 1.65). Influenza immunization was recorded in 53.1% of asplenic patients overall, and was associated with reduced risk of death (adjusted HR = 0.46, 0.33-0.62). No pneumococcal or influenza immunization was recorded in patients with a hematologic diagnosis without splenectomy. Infectious illness visits were higher among all patients who had a splenectomy than among those without a splenectomy (151 visits/100 person-years of observation in the post-splenectomy period vs. 120 visits/100 person-years; p < 0.0001).</p> <p>Conclusions</p> <p>In asplenic patients, influenza immunization is associated with a 54% reduced risk of death compared to unimmunized asplenic persons; no reduction in risk was demonstrated with (polysaccharide) pneumococcal vaccine. Vaccine coverage in the entire cohort was less than routinely recommended. Improved delivery of infection prevention programs to this population is warranted. Conjugate pneumococcal vaccines should be urgently studied in this immunocompromised population.</p

An investigation into the number and nature of the urgent care consultations managed and referred by community pharmacists in South-East England

Background: Community pharmacies are recognised as an under-utilised, accessible resource that could support the urgent care agenda. This study aimed to provide a snapshot of the number and nature of urgent care requests presented to a sample of community pharmacies in three counties in southern England, to determine how requests are managed, whether management is appropriate, as assessed by a group of experts, and whether customers receiving the care are satisfied with pharmacists’ interventions. Methods: A representative sample of pharmacists across the region was invited to keep a log-book documenting all urgent care requests over a two-week period. Data were analysed to estimate frequency and type of requests and to compare consultations in core and non-core hours. Log-book entries were scrutinised blind by an expert panel to determine appropriateness of pharmacist’s responses. Customers receiving pharmacists’ interventions were surveyed to assess satisfaction. Results: Seventeen pharmacies kept log-books detailing 432 urgent care consultations, equating to 13 consultations per pharmacy per week. Of these, 70% (n = 302) were dealt with by the pharmacist in-house with 30% (n = 130) resulting in referrals. Locum pharmacists were significantly more likely to refer to other NHS services than regular pharmacists. Over half the requests were for symptom management, skin problems presenting most commonly (38% of all symptoms presented). Forty-seven percent of consultations were considered to have ‘averted the need for other NHS services’. Pharmacists’ referral (but not assessment of urgency) was deemed appropriate by the expert panel in 90% of consultations. Ninety-five percent of customers surveyed were satisfied with the service and would use the pharmacy again. Conclusion: Extrapolating findings across the study population (approximately 4.4 million) suggests that community pharmacists manage over 11 500 urgent care consultations per week, with 8050 managed independently. These prevent approximately 5400 other NHS encounters, while also meeting customer expectations and expert panel endorsement

Grid Size Effects With Smeared Cracking in Finite Element Analysis of Reinforced Concrete

The effects of modeling parameters on the response of finite element representations of reinforced concrete members are examined. Convergence of load-deflection curves and cracking patterns is studied. Nonlinear behavior is limited to cracking of the concrete and yielding of the reinforcement. The ''smeared" crack representation is governed by a limiting tensile stress criterion. Concrete is treated as linear elastic in compression. Reinforcement has a bilinear stress-strain curve. Constant strain bar elements and rectangular isoparametric elements model the steel and the concrete, respectively. Analyses are performed for flexural members with span-to-depth ratios of 12-1, 5-l and 2-1, under both a uniformly distributed load and a concentrated load at midspan, using a minimum of three variations in grid refinement. Load-deflection curves exhibit convergence with grid refinement. Concrete tensile s tr eng th has a negligible influence on response for the members studied. Load increment size affects the response only in unstable regions of the load deflection curve and does not affect the stiff ness or the post-yield response

Magnitude of income-related disparities in adverse perinatal outcomes

BACKGROUND: To assess and compare multiple measurements of socioeconomic position (SEP) in order to determine the relationship with adverse perinatal outcomes across various contexts. METHODS: A birth registry, the Nova Scotia Atlee Perinatal Database, was confidentially linked to income tax and related information for the year in which delivery occurred. Multiple logistic regression was used to examine odds ratios between multiple indicators of SEP and multiple adverse perinatal outcomes in 117734 singleton births between 1988 and 2003. Models for after tax family income were also adjusted for neighborhood deprivation to gauge the relative magnitude of effects related to SEP at both levels. Effects of SEP were stratified by single- versus multiple-parent family composition, and by urban versus rural location of residence. RESULTS: The risk of small for gestational age and spontaneous preterm birth was higher across all the indicators of lower SEP, while risk for large for gestational age was lower across indicators of lower SEP. Higher risk of postneonatal death was demonstrated for several measures of lower SEP. Higher material deprivation in the neighborhood of residence was associated with increased risk for perinatal death, small for gestational age birth, and iatrogenic and spontaneous preterm birth. Family composition and urbanicity were shown to modify the association between income and some perinatal outcomes. CONCLUSIONS: This study highlights the importance of understanding the definitions of SEP and the mechanisms that lead to the association between income and poor perinatal outcomes, and broadening the types of SEP measures used in some cases

Targeting Policy for Obesity Prevention: Identifying the Critical Age for Weight Gain in Women

The obesity epidemic requires the development of prevention policy targeting individuals most likely to benefit. We used self-reported prepregnancy body weight of all women giving birth in Nova Scotia between 1988 and 2006 to define obesity and evaluated socioeconomic, demographic, and temporal trends in obesity using linear regression. There were 172,373 deliveries in this cohort of 110,743 women. Maternal body weight increased significantly by 0.5 kg per year from 1988, and lower income and rural residence were both associated significantly with increasing obesity. We estimated an additional 82,000 overweight or obese women in Nova Scotia in 2010, compared to the number that would be expected from obesity rates of just two decades ago. The critical age for weight gain was identified as being between 20 and 24 years. This age group is an important transition age between adolescence and adulthood when individuals first begin to accept responsibility for food planning, purchasing, and preparation. Policy and public health interventions must target those most at risk, namely, younger women and the socially deprived, whilst tackling the marketing of low-cost energy-dense foods at the expense of healthier options