A comparative analysis of pharmacists' perspectives on codeine use and misuse - a three country survey

Background: The misuse of codeine is of increasing concern in a number of countries, particularly as this relates to over -the-counter pain and cough relief medication, and is also supplied as a prescription medicine. The study aimed to obtain and analyse the opinions and experience of pharmacy staff with regard to codeine misuse. Methods: A cross-sectional web-based survey of pharmacy staff’s perspectives on this issue was administered through professional or regulatory bodies and completed by samples drawn in South Africa (n = 124), Ireland (n = 464) and the United Kingdom (n = 129). Results: The majority of participants reported combination codeine-containing products as most popular, but significantly more pharmacy staff in South Africa reported codeine-containing cough syrups as most commonly popular (X2 = 122.7(2), p < 0.001). Codeine use was also seen significantly more of a public health problem in South Africa than in the other two countries (X2 = 7.6(2), p = 0.02). There was no difference across countries in the level of codeine misuse reported by pharmacy staff. Further findings indicate that professional training and education is desired, with unequivocal findings for the need for greater codeine control (X2 = 12.0(2), p = 0.002). Conclusion: In conclusion, there were some inter-country differences, but overall the findings seem to suggest that pharmacists across all three countries view codeine misuse as a problem among their customers. Recommendations centre on risk management, surveillance and staff training

Medical Professionals' Perspectives on Prescribed and Over-The-Counter Medicines Containing Codeine: A Cross-Sectional Study

Objectives: To explore prescribing practitioners' perspectives on prescribed codeine use, their ability to identify dependence and their options for treatment in the UK. Design: Cross-sectional design using a questionnaire containing closed-ended and open-ended items. Setting: A nationally representative sample of prescribing professionals working in the UK. Participants: 300 prescribing professionals working in primary care and pain settings. Results: Participants stated that they regularly reviewed patients prescribed codeine, understood the risks of dependence and recognised the potential for codeine to be used recreationally. Over half the participants felt patients were unaware of the adverse health consequences of high doses of combination codeine medicines. One-quarter of participants experienced patient resentment when asking about medicines containing codeine. Just under 40% of participants agreed that it was difficult to identify problematic use of codeine without being informed by the patient and did not feel confident in identification of codeine dependence. Less than 45% of all participants agreed that codeine dependence could be managed effectively in general practice. Slow or gradual withdrawal was the most popular suggested treatment in managing dependence. Education and counselling was also emphasised in managing codeine-dependent patients in primary care. Conclusions: Communication with patients should involve assessment of patient understanding of their medication, including the risk of dependence. There is a need to develop extra supports for professionals including patient screening tools for identifying codeine dependence. The support structure for managing codeine-dependent patients in primary care requires further examination

Study of the impact of the post-MS evolution of the host star on the orbits of close-in planets. I. Sample definition and physical properties

Context: To date, more than 30 planets have been discovered around giant stars, but only one of them has been found to be orbiting within 0.6 AU from the host star, in direct contrast to what is observed for FGK dwarfs. This result suggests that evolved stars destroy/engulf close-in planets during the red giant phase. Aims: We are conducting a radial velocity survey of 164 bright G and K giant stars in the southern hemisphere with the aim of studying the effect of the host star evolution on the inner structure of planetary systems. In this paper we present the spectroscopic atmospheric parameters (\Teff, \logg, $\xi$, [Fe/H]) and the physical properties (mass, radius, evolutionary status) of the program stars. In addition, rotational velocities for all of our targets were derived. Methods: We used high resolution and high S/N spectra to measure the equivalent widths of many Fe{\sc\,i} and Fe{\sc\,ii} lines, which were used to derive the atmospheric parameters by imposing local thermodynamic and ionization equilibrium. The effective temperatures and metallicities were used, along with stellar evolutionary tracks to determine the physical properties and evolutionary status of each star. Results: We found that our targets are on average metal rich and they have masses between $\sim$\,1.0\,M$_\odot$ and 3.5\,M$_\odot$. In addition, we found that 122 of our targets are ascending the RGB, while 42 of them are on the HB phase.Comment: Accepted for publication in A&

On the early evolution of the Galactic Halo

It is shown that the low metallicity tail of the stellar metallicity distribution predicted by simple Outflow models for the Milky Way halo depends sensitively on whether Instantaneous Recycling is adopted or relaxed. In both cases, current - and still preliminary - data suggest a ``G-dwarf problem'' for the halo (reminiscent of the local disk). We suggest that the problem can be solved by introducing a (physically motivated) early infall phase. We point out several important implications of such a modification, concerning: the putative Pop. III (super)massive stars, the number of stars expected at very low metallicities, the questions of primary nitrogen and of the dispersion in abundance ratios of halo stars.Comment: Astronomy and Astrophysics, accepted for publication (5 pages, 1 fig.

Dihydrocodeine for detoxification and maintenance treatment in individuals with opiate use disorders

BACKGROUND: Medical treatment and detoxification from opiate disorders includes oral administration of opioid agonists. Dihydrocodeine (DHC) substitution treatment is typically low threshold and therefore has the capacity to reach wider groups of opiate users. Decisions to prescribe DHC to patients with less severe opiate disorders centre on its perceived safety, reduced toxicity, shorter half-life and more rapid onset of action, and potential retention of patients. This review set out to investigate the effects of DHC in comparison to other pharmaceutical opioids and placebos in the detoxification and substitution of individuals with opiate use disorders. OBJECTIVES: To investigate the effectiveness of DHC in reducing illicit opiate use and other health-related outcomes among adults compared to other drugs or placebos used for detoxification or substitution therapy. SEARCH METHODS: In February 2019 we searched Cochrane Drugs and Alcohol's Specialised Register, CENTRAL, PubMed, Embase and Web of Science. We also searched for ongoing and unpublished studies via ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and Trialsjournal.com. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and the included studies. SELECTION CRITERIA: We included randomised controlled trials that evaluated the effect of DHC for detoxification and maintenance substitution therapy for adolescent (aged 15 years and older) and adult illicit opiate users. The primary outcomes were abstinence from illicit opiate use following detoxification or maintenance therapy measured by self-report or urinalysis. The secondary outcomes were treatment retention and other health and behaviour outcomes. DATA COLLECTION AND ANALYSIS: We followed the standard methodological procedures that are outlined by Cochrane. This includes the GRADE approach to appraise the quality of evidence. MAIN RESULTS: We included three trials (in five articles) with 385 opiate-using participants that measured outcomes at different follow-up periods in this review. Two studies with 150 individuals compared DHC with buprenorphine for detoxification, and one study with 235 participants compared DHC to methadone for maintenance substitution therapy. We downgraded the quality of evidence mainly due to risk of bias and imprecision. For the two studies that compared DHC to buprenorphine, we found low-quality evidence of no significant difference between DHC and buprenorphine for detoxification at six-month follow-up (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.25 to 1.39; P = 0.23) in the meta-analysis for the primary outcome of abstinence from illicit opiates. Similarly, low-quality evidence indicated no difference for treatment retention (RR 1.29, 95% CI 0.99 to 1.68; P = 0.06). In the single trial that compared DHC to methadone for maintenance substitution therapy, the evidence was also of low quality, and there may be no difference in effects between DHC and methadone for reported abstinence from illicit opiates (mean difference (MD) -0.01, 95% CI -0.31 to 0.29). For treatment retention at six months' follow-up in this single trial, the RR calculated with an intention-to-treat analysis also indicated that there may be no difference between DHC and methadone (RR 1.04, 95% CI 0.94 to 1.16). The studies that compared DHC to buprenorphine reported no serious adverse events, while the DHC versus methadone study reported one death due to methadone overdose. AUTHORS' CONCLUSIONS: We found low-quality evidence that DHC may be no more effective than other commonly used pharmacological interventions in reducing illicit opiate use. It is therefore premature to make any conclusive statements about the effectiveness of DHC, and it is suggested that further high-quality studies are conducted, especially in low- to middle-income countries

Integrated Spectroscopy of Bulge Globular Clusters and Fields. II. Implications for stellar population models and elliptical galaxies

Synthetic Lick indices (e.g. Mg_2, Fe, etc.) of Simple Stellar Population (SSP) models are calibrated for the first time up to solar metallicity with a sample of Milky Way globular clusters (GCs) which includes the metal rich GCs of the Galactic bulge. This metallicity range is relevant to elliptical galaxies. It is shown that the Bulge GCs and integrated light follow the same correlation between Mg and Fe indices of elliptical galaxies, showing weaker Fe indices at given Mg indices with respect to models that assume solar-scaled abundances. This similarity is the robust empirical evidence for enhanced alpha/Fe ratios in the stellar populations of elliptical galaxies, since the globular clusters are independently known to be alpha-enhanced. The uniqueness of this alpha-overabundance solution is checked by exploring the whole range of model ingredients. We argue that the standard models reproduce the Mg-Fe correlation at low metallicities because the stellar templates used in the synthesis are the alpha-enhanced stars of the galactic Halo. These same models, however, fail to recover the Mg-Fe pattern of Bulge clusters and ellipticals at high metallicities because the high-metallicity templates are disk stars, which are not alpha-enhanced. The new SSP models by Thomas, Maraston & Bender (2002) which incorporate the dependence on alpha/Fe reproduce the Mg and Fe indices of GCs at all metallicities, with alpha/Fe=+0.3, which is in agreement with spectroscopic abundance determinations. The Balmer indices (Hbeta, Hdelta, Hgamma) are very well calibrated, provided the Horizontal Branch morphology is taken into account. In particular, we reproduce the Balmer lines of NGC 6388 and NGC 6441, which are metal-rich GCs with a tail of warm Horizontal Branch stars. {Abridged}Comment: 19 pages, 13 figures, Astronomy and Astrophysics in press. Only minor changes after the referee repor

Preventive medical care in remote Aboriginal communities in the Northern Territory: a follow-up study of the impact of clinical guidelines, computerised recall and reminder systems, and audit and feedback

Background Interventions to improve delivery of preventive medical services have been shown to be effective in North America and the UK. However, there are few studies of the extent to which the impact of such interventions has been sustained, or of the impact of such interventions in disadvantaged populations or remote settings. This paper describes the trends in delivery of preventive medical services following a multifaceted intervention in remote community health centres in the Northern Territory of Australia. Methods The intervention comprised the development and dissemination of best practice guidelines supported by an electronic client register, recall and reminder systems and associated staff training, and audit and feedback. Clinical records in seven community health centres were audited at regular intervals against best practice guidelines over a period of three years, with feedback of audit findings to health centre staff and management. Results Levels of service delivery varied between services and between communities. There was an initial improvement in service levels for most services following the intervention, but improvements were in general not fully sustained over the three year period. Conclusions Improvements in service delivery are consistent with the international experience, although baseline and follow-up levels are in many cases higher than reported for comparable studies in North America and the UK. Sustainability of improvements may be achieved by institutionalisation of relevant work practices and enhanced health centre capacity

Medicines containing codeine: perspectives of medical professionals in the Republic of Ireland

Aims: The aim of the study was to examine prescribing professional's perceptions on prescribed and OTC medicines, containing codeine in the Republic of Ireland. A secondary aim was to examine perceptions on codeine dependence, screening and treatment. Methods: A cross sectional study of a nationally representative group of prescribing professionals was conducted using a questionnaire containing a number of open and closed ended items. Data were analysed using SPSS version 21 and content analysis techniques. Results: 398 medical professionals participated in the study giving a response rate of 18%. 77% of respondents agreed to routinely review patient prescribed codeine. 59% of respondents routinely asked patients about their use of OTC medicines and 50% documented use of OTC codeine in their patients' medical notes. 93% indicated concern about the potential to purchase codeine from multiple sources. 88% implied that patients did not fully understand the risks of taking OTC medicine containing codeine. Only 21% of respondents were confident in identifying codeine dependence without being informed by the patient and 11.4% agreed to having suitable screening methods in practice. 76% indicated that they would like more instruction on prescribing addictive medicines. Conclusion: Policy should examine the need for greater public health awareness on codeine use and should examine the role of OTC and internet sales in the development of dependence. Further consideration should be given to training and support for those who prescribe addictive medicines in practice

Will Patients Benefit from Regionalization of Gynecologic Cancer Care?

OBJECTIVE: Patient chances for cure and palliation for a variety of malignancies may be greatly affected by the care provided by a treating hospital. We sought to determine the effect of volume and teaching status on patient outcomes for five gynecologic malignancies: endometrial, cervical, ovarian and vulvar carcinoma and uterine sarcoma. METHODS: The Florida Cancer Data System dataset was queried for all patients undergoing treatment for gynecologic cancers from 1990-2000. RESULTS: Overall, 48,981 patients with gynecologic malignancies were identified. Endometrial tumors were the most common, representing 43.2% of the entire cohort, followed by ovarian cancer (30.9%), cervical cancer (20.8%), vulvar cancer (4.6%), and uterine sarcoma (0.5%). By univariate analysis, although patients treated at high volume centers (HVC) were significantly younger, they benefited from an improved short-term (30-day and/or 90-day) survival for cervical, ovarian and endometrial cancers. Multivariate analysis (MVA), however, failed to demonstrate significant survival benefit for gynecologic cancer patients treated at teaching facilities (TF) or HVC. Significant prognostic factors at presentation by MVA were age over 65 (HR = 2.6, p<0.01), African-American race (HR = 1.36, p<0.01), and advanced stage (regional HR = 2.08, p<0.01; advanced HR = 3.82, p<0.01, respectively). Surgery and use of chemotherapy were each significantly associated with improved survival. CONCLUSION: No difference in patient survival was observed for any gynecologic malignancy based upon treating hospital teaching or volume status. Although instances of improved outcomes may occur, overall further regionalization would not appear to significantly improve patient survival