Poetry and Neuroscience: : An Interdisciplinary Conversation

Dialogues and collaborations between scientists and non-scientists are now widely understood as important elements of scientific research and public engagement with science. In recognition of this, the authors, a neuroscientist and a poet, use a dialogical approach to extend questions and ideas first shared during a lab-based poetry residency. They recorded a conversation and then expanded it into an essayistic form, allowing divergent disciplinary understandings and uses of experiment, noise, voice and emotion to be articulated, shared and questioned

Evolution of a transdisciplinary "One Medicine-One Health" approach to global health education at the University of California, Davis.

In today's world health events in one nation or geographic area often have repercussions for the health and well-being of populations beyond that region; sometimes even globally. In recent years many factors, most notably concern about emerging infectious diseases, have contributed to an increasing appreciation of the interdependency of human, animal and ecosystem health worldwide. Integrated global approaches to improve the health of humans, animals and their shared environments are proving to be in the best interest of many countries. A special symposium and award were established in memoriam to the internationally renowned epidemiologist, Dr. Calvin W. Schwabe, who (while at the University of California, Davis) was a significant advocate of the "One Medicine" approach to public health, calling upon all health professionals, including veterinarians, to work collaboratively and comparatively to improve human health. This paper discusses the evolution of the "One Medicine" concept into a global "One Health" approach to research, training capacity and service infrastructure, focused not only on disease, but also on health at the individual, population, and ecosystem levels. Projects involving UCD faculty which attempt to integrate a One Health approach include the Health for Animals and Livelihood Improvement (HALI) Project in Tanzania, Envirovet Summer Institute, Avian Flu School and Newcastle Immunization Program in Africa, a web-based virtual global health training program, and the Calvin Schwabe One Health Project

A qualitative synthesis of pharmacist, other health professional and lay perspectives on the role of Community Pharmacy in facilitating care for people with long-term conditions.

Background: There is increasing interest in an enhanced role for community pharmacy (CP) in facilitating care for people with long-term conditions (LTCs). It is important to understand the perspectives of stakeholders in order to identify key issues that may impact on future development of the role and related services. Objectives: Explore pharmacist, other health professional and lay perspectives on the role of CP in facilitating care for people with LTCs. Methods: Synthesis of qualitative research from UK based studies published between 2007 and January 2017 using a meta-ethnographic interpretative approach. Results: Variation in the conceptualisation of the role of CP in facilitating the care of people with LTCs was apparent across and within lay and health professional accounts. Despite evidence of positive attitudes and a culture amenable to change, there remains a lack of clarity about the existing and potential role of the pharmacist in this area. A theoretical framework is proposed that highlights the dynamic nature of the process involved in the development of lay and health professionals’ understanding of the role and engagement with services. Influences on this process include experience and perceived need, service operationalisation, and ongoing developments within wider healthcare policy and commercial environments. Perceived integration with existing professional and peer support structures, views about traditional medical hierarchies and concerns about potential duplication are important influences on the value attributed to the role of CP and the services provided. Conclusions: There is acknowledged potential for an extended role in CP to support the care of people with LTCs. To ensure the likelihood of successful engagement with patients and positive health outcomes, developments should acknowledge influences within and beyond the CP setting. Potential overlap with other healthcare services should be explicitly addressed, ensuring this is framed and delivered as valued reinforcement with clearly defined boundaries of responsibility

The Lived Experience of Klinefelter Syndrome: A Narrative Review of the Literature

open access articl

Unlicensed medicines use in the UK: A systematic review and quality assessment of published guidelines

Background An unlicensed medicine is defined as a medicinal product for which there is no marketing authorisation granted by the Medicines Healthcare and Regulatory Agency (MHRA)1. Unlicensed medicines are widely used within the UK and there are many guidance documents which exist to support their use. However, each guidance document is published for individual organisations and there has never been an analysis of the different approaches these documents take nor an evaluation of their quality. Aims and Objectives To analyse the content and quality of unlicensed medicines guidance documentation in use in the UK. Methods A systematic search of the published literature was conducted between April and June 2015. Databases used to identify published guidance included Medline, Embase, ISI Web of Knowledge, Google Scholar, PubMed and International Pharmaceutical Abstracts. Search terms included ‘unlicensed medicine’ or ‘specials’ combined with; guideline, policy, framework, standardized operating procedure, standard operating procedure or recommendation. Additionally, a call for guidance was also distributed to encourage organisations to submit their guidance documentation for the review. This was distributed to secondary care, primary care, community pharmacy and pharmaceutical industry networks both locally and nationally. The quality of the guidelines was assessed using the AGREE II tool2 and content was evaluated by conducting a thematic analysis. The AGREE tool rates the quality of the documentation across six domains and provides a score from 0% for very poor quality to 100% for excellent quality. Results A total of 52 guidance documents were included in the analysis. This included those from NHS secondary and tertiary care trusts (n=28), professional bodies and regulators (n=11), community pharmacy organisations (n=3) and others (n=10). Documents included within the analysis ranged from guidelines (n=28), policies (n=10), standard operating procedures (n=9) and frameworks (n=5). AGREE II scoring revealed that the content of the documents assessed overall scored well in the ‘Scope and Purpose’ (70.6%) domain and the ‘Clarity of Presentation’ domain (70.4%). This was due to the documents having specific objectives that were well described within the content of the document and the target audience being easily identifiable. In the majority of cases the presentation of information was good, enabling key recommendations to be easily identified that were specific and unambiguous. In contrast to these positive results the ‘Rigour and Development’ domain (12.1%) and the ‘Editorial Independence’ domain (2.6%) scored poorly. Rigour and development had low scores throughout, due to the lack of documented reference to a clear evidence base. With regards to editorial independence, it was not clear in the majority of cases if there were any funding bodies or competing interests from the guideline development group. In terms of the ‘Applicability’ domain (23.9%), whilst some documents provided advice and tools in implementation of the recommendations, many did not and there was a deficit in the acknowledgement of the potential barriers and facilitators to implementation of recommendations. The ‘Stakeholder development’ scores (30%) revealed that it wasn’t always apparent if there was a diverse mix of professionals involved in the development of the guidance documentation and there was little to no involvement of the target population in which the guideline was to be used in, in this case patients within the NHS. Thematic analysis of the guidance documents revealed four parent themes across the documentation which included; responsibility around the use of unlicensed medicines, the practicalities surrounding use of unlicensed medicines, risk versus benefit and controlling use of unlicensed medicines. Responsibility around the use of unlicensed medicine incorporated subthemes around understanding the definitions around unlicensed medicines which was common to almost all of the guidance documentation analysed, awareness of patients and professionals when using an unlicensed medicine, responsibilities of individuals and organisations involved in using unlicensed medicines and references to the guidance and legislation which informed the individual documents. The practicalities of using unlicensed medicines included subthemes on selecting the pharmaceutical formulation, the role of the pharmacist and the wider pharmacy team in managing the use of unlicensed medicines, patient involvement, the different stages of using an unlicensed medicine from prescribing to administration, and issues around continuing treatment with unlicensed medicines. Risk versus benefit in using unlicensed medicines was another strong theme across the guidance documentation. This included discussing the evidence to support use of unlicensed medicines and the place of unlicensed medicines in the treatment of a patient and potential alternatives to their use. Describing and assessing risk associated with unlicensed medicines and emphasising reporting of errors and adverse effects associated with unlicensed medicines was also contained within this theme. Controlling the use of unlicensed medicines was a theme that described the strategies that various organisations employ in an attempt to address costs associated with unlicensed medicines, audit of unlicensed medicines use against guidance and recommendations, placing restrictions on the use of unlicensed medicines to minimise risk and the use of organisational decision making surrounding unlicensed medicines, such as the use of formulary applications and stratifying risks according to a wide range of criteria. Discussion Thematic analysis demonstrated a lack of consistency of content across guidance documentation used for unlicensed medicines. The AGREE scores exhibit that there is also a lack of transparency around who writes and updates guidance on unlicensed medicines and on what foundations they base their recommendations. The lack of evidence base for the recommendations contained as revealed in the AGREE scores is likely to reflect a wider issue around lack of evidence for unlicensed medicines use. It has also shown that there is a large deficit in patient involvement in guidance development which needs to be addressed. There was a lack of contribution of documentation from the community pharmacy and primary care sector and it is not clear if this is due to a lack of guidance or a lack of submission to the project for analysis. Conclusion Healthcare organisations would benefit from agreeing a ‘core content’ for unlicensed medicines documentation and there is a need for evidence surrounding unlicensed medicines use to be gained and shared to inform decision making around use of unlicensed medicines

Use of unlicensed medicines by prescribers, pharmacists and patients across primary and secondary care: A qualitative study

Focal Points: • This study aimed to explore perceptions of healthcare professionals and patients about the use of unlicensed medicines (ULMs) • Education and training of healthcare professionals is likely to be a key enabler in improving use of ULMs • This study revealed differences in perceptions between patients and professionals, and across care settings Introduction: An unlicensed medicine (ULM) is a product which does not have a marketing authorisation from the MHRA1. Areas that have not previously been explored include; how and why prescribers choose to initiate them, how and where pharmacists source them, patient use and awareness of ULMs. This research study aimed to explore the perceptions of healthcare professionals and patients on the use of ULMs. Methods: Semi-structured face-to-face interviews were conducted with prescribers (n=11), pharmacists (n=10) and patients (n=7) from primary and secondary care. A theoretical sampling approach was used; grounded theory analysis led to the development of themes and informed participant selection. Interviews were audio recorded and transcribed verbatim. Themes were presented back to participants (n=8) using two focus groups (healthcare professionals and patients separately). Ethical approvals from the NHS and University were obtained prior to completion of this research. Results: All interviewees had experience of either; prescribing, reviewing, dispensing or taking unlicensed medicines. Participants discussed several ULM scenarios including imported medicines, ‘Specials’, food supplements, ‘off-label’ use of medicines and investigational medicinal products. Several themes were identified across the data by healthcare professionals and patients in primary and secondary care, including: • Healthcare professionals’ awareness of when they were using an ULM and their definition of an ULM • Perceptions of safety of ULMs was elicited, including the lack of safety and efficacy data compared to licensed products and the perceived under-reporting of adverse effects • Provision of information and whether patients were likely to be informed about the unlicensed status of their medicines, who the person to inform them should be and what information patients would want • The place of unlicensed medicine use in the clinical management of a patient, including whether licensed alternatives were tried first • Trust as an important aspect in the use of unlicensed medicines, this was apparent throughout the interviews and between all actors Lack of education and training for healthcare professionals around what an ULM is and the associated implications of their use, coupled with a lack of information seems to perpetuate problems identified in the use of ULM. Cost implications associated with ULMs was a strong theme among primary care participants, however, many secondary care participants lacked an awareness of the associated costs which could lead to under-utilisation of viable alternatives. Costly and burdensome regulatory processes for medicines licensing were often cited for the use of ULMs and seemed to legitimise their routine use in practice. Discussion: The lack of marketing authorisation creates many issues in the use of ULMs, including a lack of access to information and reduced intelligence around their safety and efficacy. Despite this they are generally perceived as safe. The regulatory implications of using ULMs and the potential variability between products, does not seem to be well understood. Consideration of how the patient will use the medication and the provision of suitable written information seems to be inconsistently considered. There is a need for training and the development of mutually agreed standards on the use of ULMs to inform a more consistent approach to their use by both healthcare professionals and patients. The study was limited by only being able to include those who were willing to participate. References: 1. MHRA. Guidance note 14: The supply of unlicensed medicinal products ("specials"). 2014. http://www.mhra.gov.uk/home/groups/is-lic/documents/publication/con413520.pdf (Accessed 21 March 2016

'We do not seem to engage with dentists':A qualitative study of primary healthcare staff and patients in the North East of England on the role of pharmacists in oral healthcare

Objective: To explore the attitudes towards, and perceptions of, primary care healthcare staff and patients, regarding the role of clinical pharmacists in the provision of oral health advice and collaboration with dentists in general practice. Design: Interpretivist methodology using qualitative semi-structured interviews and focus groups. Participants 22 participants; 10 pharmacists; 3 general practitioners; 2 nurses; 1 practice manager; 6 patients. Setting Primary care general medical practices in the North East of England and the University of Sunderland Patient Carer and Public Involvement group. Methods: One-to-one semi-structured interviews were performed with primary care healthcare staff. An iterative approach using constant comparative analysis facilitated the ongoing enrichment of data; salient themes were identified using Framework Analysis and related back to extant literature. A focus group was held with patients to further explore key themes. Results: Four salient and inter-related themes emerged: enhanced clinical roles; indicating rapidly changing roles of pharmacists working in general practice, increased responsibility and accountability of pharmacist prescribers and the delivery of advanced clinical services; limited knowledge; indicating basic understanding of appropriate oral health advice, but limited insight and provision of advice to patients with regards to links with systemic diseases and medication; geographical/situational isolation of the dental team; indicating the disparate contexts and challenges of multidisciplinary working in oral health, and patients’ attitudes towards dental care; integration of oral health advice; indicating the potential of pharmacists to integrate oral health advice into current roles and to target specific patient groups in practice. Conclusions: The lack of integration between oral and general healthcare services potentially impacts negatively on patient care, requiring further interprofessional oral health education. The developing role of the pharmacist in general practice represents an opportunity to integrate oral health advice and/or interventions into the management of patients in this setting

General dental practitioners' perceptions of, and attitudes towards, improving patient safety through a multidisciplinary approach to the prevention of medication-related osteonecrosis of the jaw (MRONJ):A qualitative study in the North East of England

Objective To explore general dental practitioners’ (GDPs’) perceptions of, and attitudes towards, the risks of medication-related osteonecrosis of the jaw (MRONJ) and the current/potential multidisciplinary approach(es) to prevention of the condition. Design Interpretivist methodology using a grounded theory approach and constant comparative analysis to undertake an iterative series of semistructured interviews. Ritchie and Spencer’s framework analysis facilitated the identification and prioritisation of salient themes. Setting Primary care general dental practices in the North East of England. Participants 15 GDPs. Results GDPs are aware of the risk of MRONJ with commonly implicated medicines; however, they report limited collaboration between professional groups in person-centred avoidance of complications, which is a key requirement of the preventive advice recommended in extant literature. Four salient and inter-related themes emerged: (1) perception of knowledge; indicating the awareness of the risk, limited knowledge of implicated medications and experience of managing the condition; (2) risk; indicating the importance of accurate medication histories, the treatment of low risk patients in primary dental care, counselling of poorly informed patients, the fear of litigation and perceived low priority of oral health in the context of general health and well-being; (3) access and isolation; referring to access to general medical records, professional isolation and somewhat limited and challenging professional collaborative relationships; (4) interprofessional working; indicating oral health education of other professional groups, collaboration and communication, and a focus on preventive care. Conclusions Patients continue to be at risk of developing MRONJ due to limited preventive interventions and relatively disparate contexts of multidisciplinary team healthcare. Effective collaboration, education and access to shared medical records could potentially improve patient safety and reduce the potential risk of developing MRONJ