Medication management in patients with diabetes:Exploring the role of the pharmacist

Successful medication use depends on several factors, including medication management. Medication management is the monitoring, evaluation and optimization of medication use by a particular patient and is a multidisciplinary effort between patient, pharmacist and physician. The aim of this thesis is to explore how the role of the pharmacist in medication management in patients with diabetes can be enhanced. We used both quantitative and qualitative methods and we combined patient’s perspectives and healthcare provider’s perspectives to gain insight into this subject. A considerable proportion of patients with diabetes treated in primary care have uncontrolled HbA1c values. This is partly due to problems with medication management. Among primary healthcare providers, pharmacists are the medication experts and previous studies have shown their added value in medication management support. This role is also acknowledged by other primary care providers and patients. Patients particularly value the supportive role of pharmacists and indicate the accessibility of pharmacists when it comes to sharing problems, either directly or indirectly related to medication use. However, a trusted relationship between patient and pharmacist is key in the process of sharing problems. Pharmacists have an open attitude towards patients when it comes to communication, though conversations are often non-explicit. This could lead to less efficient consultations and missing the actual cause of the problem. On the other hand, pharmacists are able to offer appropriate support in case of known medication management problems. To conclude, adequate medication management is a complex matter and requires continuous collaboration between all parties involved

A systematic review in select countries of the role of the pharmacist in consultations and sales of non-prescription medicines in community pharmacy

Background Much has been studied in regard to non-prescription medicines (NPMs), but the impact of greater emphasis toward patient self-selection of such agents is still not well understood, and evidence in the literature might be equivocal. Objective The aim was to examine whether or not pharmacist interventions are important in the sale of NPMs and to summarize the evidence of pharmacists' contribution in maintaining patient safety and improving the quality of consultations involving NPMs. Methods Seven online databases were searched to identify the literature on studies conducted within the UK and in countries comparable to the UK reporting on consultations and selling of NPMs published between 1980 and 2013. All study designs except for quantitative surveys were eligible for inclusion into the review. The data extraction and quality assessment were performed according to the National Institute for Health and Care Excellence guidelines. The data extracted from the studies were analyzed and presented qualitatively. Results Eighty-three studies from an original 12,879 citations were included in this review. Just under half of the studies were published between 2000 and 2009 (n = 38; 46%). Thirty-three (44%) of the studies were conducted in the UK. The review showed that in terms of the contribution of community pharmacy staff in consultations for NPMs, non-pharmacist staff dealt with a large proportion of the consultations and pharmacists were usually involved in the consultation through referral from non-pharmacist staff member. Counseling was not consistently offered to everyone. Where counseling was provided it was not always of sufficient quality. Consultations were performed much better when symptoms were presented compared to when people made a direct product request. Pharmacists were reported to conduct better consultations than non-pharmacist staff. There was evidence to suggest that where counseling was appropriately provided this afforded the person a safe environment to utilize their NPMs. Conclusions Seeking methods to develop better engagement with customers accessing pharmacy services for NPMs is necessary to enhance the interaction between these two parties. Efforts to enhance the community pharmacy environment to bring about a more positive experience for people using pharmacy is needed at present and will be important if the model for the selection of NPMs is modified in the UK. More studies are needed to allow a better understanding of the impact self-selection may have on patient safety in the community pharmacy context

Third generation vaccine for world eradication of poliomyelitis

Great efforts have been undertaken by the World Health Organization to achieve eradication of poliomyelitis, a paralytic disease. At present, two different vaccines are available: inactivated polio vaccine (IPV) developed by Salk based on chemical inactivation of the virus and oral polio vaccine (OPV) developed by Sabin based on live attenuated virus strains. The risks associated with IPV concern the safety of the production process as it is based on highly virulent wild type strains, and in contrast, the OPV risks are associated with the reversibility of the attenuated viruses to a transmissible paralytic form. There is therefore a need for a new generation polio vaccines capable to overcome outbreaks and manufacturing risks. With the evolution of molecular virology of Sabin vaccine strains, it is now possible to design extremely genetically stable and hyperattenuated strains without the associated reversion risks. Sabin poliovirus strains were therefore genetically modified giving rise to the third generation of polio vaccine strains [1, 2]. In the present work we have explored the possibility of using the already well-established IPV production process, developed at our site [3] and integrated worldwide [4] for the production and manufacturing of third generation of IPV strains. Specifically, we have produced third generation vaccines in animal component free medium and at 50-L pilot scale. The product obtained did show acceptable yields and was immunogenic in rats. Together, our results indicate that the third generation vaccine strains produced under the flexible platform process are potential candidates which provide increased biosafety during manufacturing which is necessary after polio eradication. In addition, the flexibility and scalability of the process constitute a platform for the production of a large range of vaccines worldwide. 1. Knowlson, S., et al., New Strains Intended for the Production of Inactivated Polio Vaccine at Low-Containment After Eradication. PLoS Pathog, 2015. 11(12): p. e1005316. 2. Macadam, A.J., et al., Rational design of genetically stable, live-attenuated poliovirus vaccines of all three serotypes: relevance to poliomyelitis eradication. J Virol, 2006. 80(17): p. 8653-63. 3. Thomassen, Y.E., et al., Scale-down of the inactivated polio vaccine production process. Biotechnol Bioeng, 2013. 110(5): p. 1354-65. 4. Wezel, v., Monolayer growth systems: Homogeneous unit processes. Spier, R. E. and Griffiths, J. B., eds., 1985: p. 266-281

Pharmacist-Led Self-management Interventions to Improve Diabetes Outcomes:A Systematic Literature Review and Meta-Analysis

Background: Treatment of diabetes requires a strict treatment scheme which demands patient self-management. Pharmacists are in a good position to provide self-management support. This review examines whether pharmacist-led interventions to support self-management in diabetes patients improve clinical and patient-reported outcomes.Methods: This review was conducted according to the PRISMA guidelines. An extended literature search was conducted with the keywords “pharmacist,” “diabetes,” and “self-management” using the electronic databases Pubmed, Embase, CINAHL, PsycINFO, Web of Science, and the Cochrane Library from the beginning of the database through September 2017. In addition reference lists of systematic reviews and included studies were searched. Eligibility criteria included; self-management intervention tested with an RCT, performed in an ambulatory care setting, led by a pharmacist and reporting at least one clinical- or patient-reported outcome. Primary outcomes were HbA1c (—as this is a clinical parameter for long-term diabetes follow-up), self-management and components of intervention. Secondary outcomes were blood glucose, blood pressure, BMI, lipids, adherence to medication, quality of life, and diabetes knowledge. For the meta-analysis HbA1c values were pooled with a random-effects model in Revman 5.3. Risk of bias was assessed with the Cochrane Risk of Bias tool.Results: Twenty-four studies representing 3,610 patients were included. Pharmacist-led self-management interventions included education on diabetes complications, medication, lifestyle, and teaching of self-management skills. Some studies focused on patient needs through a tailored intervention. No key components for a successful self-management intervention could be identified. Pharmacist-led self-management interventions improve HbA1c levels with a mean of 0.71% (CI −0.91, −0.51; overall effect P < 0.0001) and had a positive effect on blood pressure (SBP −5.20 mm Hg [−7.58; −2.92], DBP −3.51 mmHg [−6.00; −1.01]), BMI (−0.49 kg/m2 [−0.79; −0.19]), lipids (total cholesterol −0.19 mmol/l [−0.33; −0.05], LDL-C mmol/l −0.16 [−0.26; −0.06], HDL-C 0.32 mmol/l [0.02; 0.61]), self-management skill development, and adherence to medication.Conclusion: Pharmacist-led self-management interventions significantly improve HbA1c values in diabetes patients. These results underline the added value of pharmacists in patient-related care. Pharmacists should offer self-management support to diabetes patients in order to improve diabetes outcomes

Pharmacy student decision making in over-the-counter medicine supply: a critical incident study.

Background: Various factors influence decision making in over-the-counter (OTC) medicine consultations, yet limited studies have focused, in-depth, on the thought process of pharmacy staff. This includes pharmacy students as pharmacists-in-training. Aim: To explore the factors that influence pharmacy students’ decisions in relation to OTC consultations and choice of OTC medicine/s. Methods: Semi-structured interviews using the critical incident technique were undertaken with ten pharmacy students in Australia, who also worked as part-time pharmacy staff. Results: Nine key themes were identified to influence pharmacy student decision making in OTC consultations, including customer response, confidence and scope of practice. Product requests were reported as more challenging due to customer expectations and experiences in other pharmacies, states or countries. Although negative customer response influenced some students to supply medicines in contradiction of evidence, an overarching concern for safety meant that a medicine was only supplied if unlikely to cause harm. Students reported developing confidence in OTC decision making more from real-life practice than university training; greater confidence was identified for inquiries more frequently experienced in the pharmacy. Students perceived that customers had assumptions around support staff, and were happier to talk to students than assistants. Conclusion: This study further identified that OTC decision making is a complex process for pharmacy students. Additional opportunities for experiential learning within this area are suggested, such as work-based placements or in-class activities such as role-plays with simulated patients

A systematic review of community pharmacies’ staff diagnostic assessment and performance in patient consultations

Background: Increases in patients seeking advice at pharmacies has led to pharmacy staff engaging in diagnostic behaviours. Approaches to diagnosis include using mnemonics and clinical reasoning. Objectives: The primary aim of this review was to assess the degree to which the criteria authors use to evaluate diagnostic performance in pharmacy consultations, in studies that use simulated patients or vignettes, conform with a clinical reasoning and a mnemonic framework. A secondary aim of the review was to characterise staff performance in the studies, based on the authors’ comments of their results. Methods: MEDLINE, EMBASE and Web of Science were searched between October 2016 and April 2017. Only peer-reviewed studies assessing pharmacy staff’s diagnostic performance by using simulated patients or vignettes were eligible for inclusion. Data were extracted about how each study’s criteria conformed with clinical reasoning and mnemonic frameworks. A scoring system between 0 and 4 was devised to determine the degree to which studies aligned to these two approaches. Risk of bias was assessed using the NHI Study Quality Assessment Tools. The review was registered in PROSPERO with identification number CRD42017054827. Results: Sixty-eight studies (55 cross-sectional, 11 educational interventions and 2 RCTs) with sample sizes between 10 and 2700 were included in the review. Most studies were of poor or fair quality. Performance of pharmacy staff was overwhelmingly reported as poor by study authors. This was the case regardless of geography, scenario used or whichever assessment framework was utilised. Scrutiny on how authors arrived at these conclusions revealed that mnemonic criteria were employed to assess pharmacy staff’s diagnostic performance rather than a clinical reasoning approach. Conclusions: Potentially important aspects of the decision-making process, that clinical reasoning accounts for, were left unexplored. The scope of the number and locations of the included studies is a strength of this review, however, the system employed does not represent a validated tool

Application of modular control analysis to inhibition of the adenine nucleotide translocator by palmitoyl-CoA.

Modular kinetic analysis was used to characterize inhibition of adenine nucleotide translocation by palmitoyl-CoA in isolated rat-liver mitochondria. To this purpose, oxidative phosphorylation has been divided into two modules with the fraction of matrix ATP as linking intermediate. The adenine nucleotide translocator is the matrix ATP-consuming module and the remainder of oxidative phosphorylation (ATP synthesis, respiratory chain and transport of phosphates and respiratory substrate) is the matrix ATP-producing module. We found that palmitoyl-CoA inhibits ATP-consuming module (ANT) and has no effect on ATP-producing module. There were no significant differences between kinetic curves obtained with oligomycin and myxothiazol, inhibitors that have opposite effect on membrane potential, suggesting that the use of the fraction of matrix ATP as the only intermediate is a good approximation. A new method has been used to determine the fraction of ATP in the mitochondrial matrix

Daily practice performance (Work-as-Done) compared to guidelines (Work-as-Imagined) of medication reconciliation at discharge: Outcomes of a FRAM study

Objectives: Performing medication reconciliation (MR) is an important safety initiative. However, its implementation is complex. We used the Functional Resonance Analysis Method (FRAM) to gain more understanding of healthcare professionals’ low compliance with the standards for MR by comparing Dutch guidelines and hospital protocols (Work-as-Imagined/WAI) with daily clinical practice (Work-as-Done/WAD). Methods: Nine cardiology and orthopaedics wards participated in this study. We applied the FRAM to construct several models to visualise MR at the point of discharge. WAI models were based on national guidelines and hospital protocols. Data to construct the WAD models were collected through semi-structured interviews with the healthcare professionals involved. Results: Sixty-three healthcare professionals were interviewed. These occasionally had to adjust their work in order to manage a lack of time or resources, resulting in variation in healthcare professionals’ performance. This had an impact upon the flow of the reconciliation process due to the interdependency of all the healthcare professionals involved. Conclusion: Collaboration between healthcare professionals is essential to ensure complete reconciliation for discharged patients. We identified a distinction between daily practice and both the guidelines and protocols followed. Future research should indicate the impact of specific variations in practice, and deviations from the protocols on medication safety, during reconciliation