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

Engaging patients to access the community pharmacy medicine review service after discharge from hospital: a cross-sectional study in England

Background The post-discharge Medicines-Use-Review (dMUR) is a commissioned service in England and Wales whereby community pharmacists facilitate patients’ understanding of their medicines and resolve any medicine-related problems. This service is poorly utilised. Objective To explore the impact of raising hospital patients’ awareness of dMURs on their uptake. Setting Hospital in South East England. Method Patients on medical wards with at least one change (medicine, or dose regimen) to their admission medicines were provided with standardized written and verbal information about the service. Participants were responsible for their own medicines and anticipated that they would be discharged home. Structured telephone interviews conducted 4 weeks after discharge explored any medicine-related issues experienced, and reasons for engaging, or not, with the dMUR service. Responses to closed questions were analysed using descriptive statistics. Responses to open questions were analysed thematically. Ethics approval was obtained. Main outcome measure Proportion of patients who received a dMUR and their motivations or barriers to accessing the service. Results Hundred patients were recruited and 84 interviewed. Their mean (SD) age was 73 (11) years. They were taking a median (range) of 9 (2–19) medicines. 67% (56/84) remembered receiving information about dMURs. Nine (11%) had attempted to make an appointment although four had not received the service because the pharmacist was unavailable. Most (88%) were not planning to access the service. The most common reason given was poor morbidity or mobility (13/31, 42%). Conclusion The use of written and verbal information to encourage patients to use the dMUR service had minimal impact

How Low Can You Go?: Widespread Challenges in Measuring Low Stream Discharge and a Path Forward

Low flows pose unique challenges for accurately quantifying streamflow. Current field methods are not optimized to measure these conditions, which in turn, limits research and management. In this essay, we argue that the lack of methods for measuring low streamflow is a fundamental challenge that must be addressed to ensure sustainable water management now and into the future, particularly as climate change shifts more streams to increasingly frequent low flows. We demonstrate the pervasive challenge of measuring low flows, present a decision support tool (DST) for navigating best practices in measuring low flows, and highlight important method developmental needs

Altered H19/miR‐675 expression in skeletal muscle is associated with low muscle mass in community‐dwelling older adults

Background: Despite increasing knowledge of the pathogenesis of muscle ageing, the molecular mechanisms are poorly understood. Based on an expression analysis of muscle biopsies from older Caucasian men, we undertook an in-depth analysis of the expression of the long non-coding RNA, H19, to identify molecular mechanisms that may contribute to the loss of muscle mass with age. Methods: We carried out transcriptome analysis of vastus lateralis muscle biopsies from 40 healthy Caucasian men aged 68–76 years from the Hertfordshire Sarcopenia Study (HSS) with respect to appendicular lean mass adjusted for height (ALMi). Validation and replication was carried out using qRT-PCR in 130 independent male and female participants aged 73–83 years recruited into an extension of the HSS (HSSe). DNA methylation was assessed using pyrosequencing. Results: Lower ALMi was associated with higher muscle H19 expression (r2 = 0.177, P < 0.001). The microRNAs, miR-675-5p/3p encoded by exon 1 of H19, were positively correlated with H19 expression (Pearson r = 0.192 and 0.182, respectively, P < 0.03), and miR-675-5p expression negatively associated with ALMi (r2 = 0.629, P = 0.005). The methylation of CpGs within the H19 imprinting control region (ICR) were negatively correlated with H19 expression (Pearson r = −0.211 to −0.245, P ≤ 0.05). Moreover, RNA and protein levels of SMAD1 and 5, targets of miR-675-3p, were negatively associated with miR-675-3p (r2 = 0.792 and 0.760, respectively) and miR-675-5p (r2 = 0.584 and 0.723, respectively) expression, and SMAD1 and 5 RNA levels positively associated with greater type II fibre size (r2 = 0.184 and 0.246, respectively, P < 0.05). Conclusions: Increased expression profiles of H19/miR-675-5p/3p and lower expression of the anabolic SMAD1/5 effectors of bone morphogenetic protein (BMP) signalling are associated with low muscle mass in older individuals

River ecosystem conceptual models and non‐perennial rivers: A critical review

Conceptual models underpin river ecosystem research. However, current models focus on continuously flowing rivers and few explicitly address characteristics such as flow cessation and drying. The applicability of existing conceptual models to nonperennial rivers that cease to flow (intermittent rivers and ephemeral streams, IRES) has not been evaluated. We reviewed 18 models, finding that they collectively describe main drivers of biogeochemical and ecological patterns and processes longitudinally (upstream-downstream), laterally (channel-riparian-floodplain), vertically (surface water-groundwater), and temporally across local and landscape scales. However, perennial rivers are longitudinally continuous while IRES are longitudinally discontinuous. Whereas perennial rivers have bidirectional lateral connections between aquatic and terrestrial ecosystems, in IRES, this connection is unidirectional for much of the time, from terrestrial-to-aquatic only. Vertical connectivity between surface and subsurface water occurs bidirectionally and is temporally consistent in perennial rivers. However, in IRES, this exchange is temporally variable, and can become unidirectional during drying or rewetting phases. Finally, drying adds another dimension of flow variation to be considered across temporal and spatial scales in IRES, much as flooding is considered as a temporally and spatially dynamic process in perennial rivers. Here, we focus on ways in which existing models could be modified to accommodate drying as a fundamental process that can alter these patterns and processes across spatial and temporal dimensions in streams. This perspective is needed to support river science and management in our era of rapid global change, including increasing duration, frequency, and occurrence of drying.info:eu-repo/semantics/publishedVersio

Criminalising vulnerability: Protecting ‘vulnerable’ children and punishing ‘wicked’ mothers

This article aims to uncover how, in attempting to ameliorate the vulnerability of children, the offence of ‘causing or allowing the death of the child’ criminalises abused mothers. It explores how, in the courtroom, tropes of female criminality and constructs of the ‘bad’ mother are mobilised in ways that are both gendered and ‘classed’. The effect is to silence female defendants, deprive their actions of context, and deny them agency. This argument has implications for assessing the moral and legal culpability of abused women who fail to protect their children, because it shifts the focus onto how the abuser has exploited and exacerbated the vulnerability of both mother and child. This approach also challenges law’s preoccupation with scrutinising (and punishing) women who do not adhere to a glorified, middle class ideal of motherhood. More broadly, by focusing on the context of a woman’s alleged ‘failure’, there opens a space within legal discourse to refute the characterisation of female criminality as being either ‘mad’ or ‘bad’, and of women who engage in criminal behaviour as being either ‘virgins’ or ‘whores’. Finally, in focusing on vulnerability as a universal and unavoidable part of the human experience, gendered assumptions of autonomy and the self/other dichotomy are challenged

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease

Background: Experimental and clinical data suggest that reducing inflammation without affecting lipid levels may reduce the risk of cardiovascular disease. Yet, the inflammatory hypothesis of atherothrombosis has remained unproved. Methods: We conducted a randomized, double-blind trial of canakinumab, a therapeutic monoclonal antibody targeting interleukin-1β, involving 10,061 patients with previous myocardial infarction and a high-sensitivity C-reactive protein level of 2 mg or more per liter. The trial compared three doses of canakinumab (50 mg, 150 mg, and 300 mg, administered subcutaneously every 3 months) with placebo. The primary efficacy end point was nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. RESULTS: At 48 months, the median reduction from baseline in the high-sensitivity C-reactive protein level was 26 percentage points greater in the group that received the 50-mg dose of canakinumab, 37 percentage points greater in the 150-mg group, and 41 percentage points greater in the 300-mg group than in the placebo group. Canakinumab did not reduce lipid levels from baseline. At a median follow-up of 3.7 years, the incidence rate for the primary end point was 4.50 events per 100 person-years in the placebo group, 4.11 events per 100 person-years in the 50-mg group, 3.86 events per 100 person-years in the 150-mg group, and 3.90 events per 100 person-years in the 300-mg group. The hazard ratios as compared with placebo were as follows: in the 50-mg group, 0.93 (95% confidence interval [CI], 0.80 to 1.07; P = 0.30); in the 150-mg group, 0.85 (95% CI, 0.74 to 0.98; P = 0.021); and in the 300-mg group, 0.86 (95% CI, 0.75 to 0.99; P = 0.031). The 150-mg dose, but not the other doses, met the prespecified multiplicity-adjusted threshold for statistical significance for the primary end point and the secondary end point that additionally included hospitalization for unstable angina that led to urgent revascularization (hazard ratio vs. placebo, 0.83; 95% CI, 0.73 to 0.95; P = 0.005). Canakinumab was associated with a higher incidence of fatal infection than was placebo. There was no significant difference in all-cause mortality (hazard ratio for all canakinumab doses vs. placebo, 0.94; 95% CI, 0.83 to 1.06; P = 0.31). Conclusions: Antiinflammatory therapy targeting the interleukin-1β innate immunity pathway with canakinumab at a dose of 150 mg every 3 months led to a significantly lower rate of recurrent cardiovascular events than placebo, independent of lipid-level lowering. (Funded by Novartis; CANTOS ClinicalTrials.gov number, NCT01327846.