Implementing formulary recommendations in primary care: effect on patient outcomes.

This research aimed to measure the effect on health outcomes of implementing selected recommendations of the Grampian Joint Drug Formulary in primary care. Antibiotics used in the treatment of uncomplicated lower urinary tract infections (UTIs), ulcer healing agents and peripheral vasodilators were selected for study, thereby reflecting both acute and chronic prescribing. For the UTI study, 12 randomly selected high and low prescribers of trimethoprim, the recommended agent, each agreed to distribute 20 patient questionnaires. Following a period of 18 months and despite repeated contact with the GPs, only 89/480 (19%) questionnaires had been distributed. Patient response was, however, very high with 80 (90%) questionnaires returned. Health outcome measures identified that trimethoprim resulted in no or mild symptoms in 40/45 (91 %) of patients. These findings must be interpreted with caution due to the low level of questionnaire distribution and thus cannot be extrapolated to the total population of patients. In addition, the poor questionnaire distribution did not permit comparison between trimethoprim and non-recommended therapy. One hundred and eighty four patients receiving repeat prescriptions for ulcer healing agents were identified from one general practice. Therapy in 95 patients did not adhere to formulary recommendations. Changes to therapy were considered inappropriate in 11 patients due to factors such as severe depression and a further 8 were deemed unsuitable for participation for non-clinical reasons. The remaining 76 patients were contacted with 19 (25%) refusing to participate. Fifty seven patients were interviewed using the Glasgow Dyspepsia Severity Score and Short Form 36 (SF-36). Changes in health outcomes were measured for 21 patients where a change in therapy had taken place. These results were difficult to interpret due to the diversity of changes recommended and the lack of data relating to those patients not participating. Work involving peripheral vasodilators aimed to determine the effect on health outcomes of cessation of therapy. Forty five patients receiving these agents in 2 practices were identified, although 8 had not requested a prescription in the previous year. Two further patients were excluded from the study due to cancer and old age. The remaining 35 agreed to be interviewed using the Walking Impairment Questionnaire and SF-36. All patients were subsequently instructed to stop therapy for 2 months, although 6 (17%) refused to follow this instruction, one patient was seriously ill thus was excluded and 3 refused to be reinterviewed. Of the remaining 25 patients, no significant differences were observed in the domains studied. Seventeen patients (68%) expressed no desire to restart therapy, generating considerable savings. These results must be interpreted with caution since those not stopping therapy or refusing re-interview are likely to have responded differently to those completing the study. The measurement of health outcomes following formulary implementation deserves further work

An exploration of key stakeholders' perspectives on the implementation of ehealth policy in community pharmacy in Scotland.

Scotland's eHealth strategy promotes the use of information technology to 'improve communications across the healthcare team', which aligns with the quality strategy in placing the 'focus on outcomes and real benefits delivered rather than technologies.' The more recently published 2020 Workforce Vision envisages 'making more and better use of technology and facilities to increase access to services and improve efficiency', which was reinforced by the Prescription for Excellence and the Review of NHS Pharmaceutical Care of Patients in the Community in Scotland. Policies are supportive of ehealth in facilitating collaborative health and social care in providing integrated, person-centred, patient care enabling community pharmacy to offer extended and accessible services. This research aimed to explore and describe key stakeholders' perspectives on the implementation of ehealth policy in community pharmacy in Scotland

Patient and pharmacist perceptions of a pharmacist-led educational intervention for people with psoriasis.

BACKGROUND: Chronic plaque psoriasis is an inflammatory skin condition that affects up to 3% of the UK population and most patients have mild to moderate disease that can be effectively managed with topical therapies in primary care. In recent years, community pharmacists in the UK have been encouraged to adopt a more clinically focused role, particularly around supporting those with longterm conditions. However, little is known about how pharmacists might help support those with longterm skin conditions. OBJECTIVES: To determine patient and participating pharmacists' views of an educational intervention delivered in community pharmacy to those with mild to moderate chronic plaque psoriasis. METHODS: Pharmacists recruited patients either opportunistically when they presented at the pharmacy with a prescription for psoriasis treatment, or via a letter of invitation to those identified from their pharmacy medication records as using prescribed topical treatment for psoriasis. The intervention consisted of one face-to-face consultation and a follow-up appointment after approximately 6 weeks. Structured telephone interviews were conducted with 38 of the patients who participated in the intervention after completion of the follow-up visit. The interviews sought information on patients' reasons for joining the study, measures of satisfaction with the pharmacy consultation and perceptions on whether the pharmacist's advice improved their skin condition. The data generated were analysed quantitatively with open responses coded for subsequent analysis. In addition, semi-structured telephone interviews conducted with all seven participating pharmacists, explored their perceptions on the value of the intervention for both themselves and patients and the potential for wider adoption of such a service. All interviews were audio-recorded, transcribed verbatim and analysed thematically. RESULTS: Nearly three-quarters of patients (74%) joined the study to learn more about their condition and its management and half, (51%) reported improvements in knowledge after the intervention. The majority (84%) of patients believed that their psoriasis had improved as a result of the advice they received during the intervention. Pharmacists also improved their knowledge of psoriasis and its management and welcomed the opportunity for greater patient interaction, believing that patients benefited from the intervention and saw pharmacists as members of the healthcare team managing their condition. However, ensuring patients returned for the second appointment and juggling the demands of the study with other work was sometimes problematic. There were mixed views on the wider adoption of the intervention. CONCLUSION: In the present study, patients felt that their psoriasis improved as a result of the advice from pharmacists and this view was shared by pharmacists. Further work with a larger patient cohort is necessary to explore the extent to which these findings are generalisable to the wider population of pharmacists and patients with mild to moderate psoriasis

National Health Service healthcare staff experience and practices regarding complementary and alternative medicine: an online survey.

The use of complementary and alternative medicine (CAM) is increasing. The most common reported reason for CAM use is dissatisfaction with conventional healthcare. Several studies have reported factors influencing CAM usage and beliefs in the general public but the beliefs of healthcare staff are less well known. This paper reports the results of an online survey of 537 healthcare staff. Our study demonstrated an increased rate of patient referral for CAM from both personal CAM users and those trained in CAM. There was a high level of optimism amongst respondents as to the role CAM may play in patient care with mental health, depression and palliative care cited as the areas with highest expected benefit. Doctors were generally less optimistic about the likelihood of benefit compared to other healthcare staff. Implications for clinical practice, future research and staff education are discussed

Neural effects of oxytocin and mimicry in frontotemporal dementia: A randomized crossover study

OBJECTIVE: To determine whether intranasal oxytocin, alone or in combination with instructed mimicry of facial expressions, would augment neural activity in patients with frontotemporal dementia (FTD) in brain regions associated with empathy, emotion processing, and the simulation network, as indexed by blood oxygen-level dependent (BOLD) signal during fMRI. METHODS: In a placebo-controlled, randomized crossover design, 28 patients with FTD received 72 IU intranasal oxytocin or placebo and then completed an fMRI facial expression mimicry task. RESULTS: Oxytocin alone and in combination with instructed mimicry increased activity in regions of the simulation network and in limbic regions associated with emotional expression processing. CONCLUSIONS: The findings demonstrate latent capacity to augment neural activity in affected limbic and other frontal and temporal regions during social cognition in patients with FTD, and support the promise and need for further investigation of these interventions as therapeutics in FTD. CLINICALTRIALSGOV IDENTIFIER: NCT01937013. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that a single dose of 72 IU intranasal oxytocin augments BOLD signal in patients with FTD during viewing of emotional facial expressions

Safety of levetiracetam in pregnancy and lactation: a systematic review.

Most women with active seizures are often encouraged to continue their antiepileptic medications during pregnancy to avoid serious fetal or maternal complications. Levetiracetam (LEV) is a newer antiepileptic drug used as adjunctive therapy in patients with refractory partial seizures with or without secondary generalization. Because of its broad-spectrum activity, LEV is becoming increasingly used in women with epilepsy of childbearing potential, during pregnancy and thus also during lactation. First generation anti-epileptics are known to cause Major Congenital Malformations (MCM) and developmental problems. However, there is paucity of literature on information regarding safety of Levetiracetam (second generation), use in pregnancy and breastfeeding. The purpose of the present study was to summarize the scientific evidence behind use of LEV during pregnancy and lactation

Fragment properties at the catastrophic disruption threshold: The effect of the parent body's internal structure

Numerical simulations of asteroid break-ups, including both the fragmentation of the parent body and the gravitational interactions between the fragments, have allowed us to reproduce successfully the main properties of asteroid families formed in different regimes of impact energy, starting from a non-porous parent body. In this paper, using the same approach, we concentrate on a single regime of impact energy, the so-called catastrophic threshold usually designated by Q*D, which results in the escape of half of the target's mass. Thanks to our recent implementation of a model of fragmentation of porous materials, we can characterize Q*D for both porous and non-porous targets with a wide range of diameters. We can then analyze the potential influence of porosity on the value of Q*D, and by computing the gravitational phase of the collision in the gravity regime, we can characterize the collisional outcome in terms of the fragment size and ejection speed distributions, which are the main outcome properties used by collisional models to study the evolutions of the different populations of small bodies. We also check the dependency of Q*D on the impact speed of the projectile. In the strength regime, which corresponds to target sizes below a few hundreds of meters, we find that porous targets are more difficult to disrupt than non-porous ones. In the gravity regime, the outcome is controlled purely by gravity and porosity in the case of porous targets. In the case of non-porous targets, the outcome also depends on strength. We then propose some power-law relationships between Q*D and both target's size and impact speed that can be used in collisional evolution models.Comment: 18 pages, 19 Figures. Accepted for publication in Icaru

A cross-sectional survey of the access of older people in the Scottish Highlands to general medical practices, community pharmacies and prescription medicines.

Access to medicines and healthcare is more problematic in remote and rural areas. The purpose of this study was to quantify issues of access to general practitioners (GPs), community pharmacies and prescribed medicines in older people resident in the Scottish Highlands. Anonymized questionnaires were mailed to a random sample of 2000 older people (≥60 years) resident in the Scottish Highlands. Questionnaire items were: access and convenience to GP and pharmacy services (10 items); prescribed medicines (13 items); attitudinal statements based on the Theoretical Domains Framework (12 items); quality of life (SF8, 8 items); and demographics (12 items). Results were analysed using descriptive, inferential and spatial statistics, and principal component analysis (PCA) of attitudinal items. With a response rate of 54.2%, the majority reported convenient access to GPs (89.1%) and community pharmacies (84.3%). Older age respondents (p < 0.0001) were more likely to state that their access to GP services was not convenient and those in rural areas to community pharmacies (p < 0.01). For access to prescribed medicines, those in poorer health (p < 0.001) and taking five or more regular prescribed medicines (p = 0.002) were more likely to state access not convenient. PCA identified three components of beliefs of capabilities, emotions and memory. Those with poorer health had more negative scores for all (p < 0.001). Those reporting issues of access to prescribed medicines had more negative scores for beliefs of capabilities (p < 0.001) while those of older age, living alone, and taking five or more regular prescribed medicines (all p < 0.001) had more negative scores for emotions. In conclusion, while the majority of respondents have convenient access to their GP practice, pharmacy and prescribed medicines, there is a need for further review of the pharmaceutical care of those of older age with poorer health, living alone in the more remote and rural areas and taking five or more prescribed medicines

Formation of Kuiper Belt Binaries by Gravitational Collapse

A large fraction of 100-km-class low-inclination objects in the classical Kuiper Belt (KB) are binaries with comparable mass and wide separation of components. A favored model for their formation was capture during the coagulation growth of bodies in the early KB. Instead, recent studies suggested that large objects can rapidly form in the protoplanetary disks when swarms of locally concentrated solids collapse under their own gravity. Here we examine the possibility that KB binaries formed during gravitational collapse when the excess of angular momentum prevented the agglomeration of available mass into a solitary object. We find that this new mechanism provides a robust path toward the formation of KB binaries with observed properties, and can explain wide systems such as 2001 QW322 and multiples such as (47171) 1999 TC36. Notably, the gravitational collapse is capable of producing 100% binary fraction for a wide range of the swarm's initial angular momentum values. The binary components have similar masses (80% have the secondary-over-primary radius ratio >0.7) and their separation ranges from ~1,000 to ~100,000 km. The binary orbits have eccentricities from e=0 to ~1, with the majority having e<0.6. The binary orbit inclinations with respect to the initial angular momentum of the swarm range from i=0 to ~90 deg, with most cases having i<50 deg. Our binary formation mechanism implies that the primary and secondary components in each binary pair should have identical bulk composition, which is consistent with the current photometric data. We discuss the applicability of our results to the Pluto-Charon, Orcus-Vanth, (617) Patroclus-Menoetius and (90) Antiope binary systems.Comment: Astronomical Journal, in pres