Role of pharmacists in optimising opioid therapy for chronic non-malignant pain; A systematic review

BACKGROUND

Opioid optimisation is a global issue in Chronic Non-malignant Pain (CNMP) management.

OBJECTIVE

This systematic review aims to assess the effectiveness of interventions delivered by pharmacists in outpatient clinical settings, community pharmacies and primary care services in optimising opioid therapy for people with CNMP and to explore stakeholders' opinions about role of pharmacists in optimising opioid therapy.

METHODS

We conducted searches in PubMed, CINAHL, Psych Info, EMBASE, ISI Web of Science and Conference Proceedings and International Pharmaceutical Abstracts. All studies where pharmacists in outpatient clinical settings, community pharmacies and patient care services helped in optimisation of opioids in the treatment of CNMP as individuals or part of a team were included. Authors followed the 27-item PRISMA guidelines and the review was registered in PROSPERO. All authors were involved in screening and selection of studies and included studies between January 1990-June 2020. Studies not published in English language and participants with cancer pain were excluded. All the included studies were descriptively synthesized.

RESULTS

Fourteen studies were included in the final data synthesis of this review and the total number of participants in all studies was 1175. Interventions by pharmacists were successful in decreasing opioid dose in 4 studies and improved patient opioid safety in 5 studies. Stakeholders considered that the role of pharmacists in optimisation of opioid therapy for people with CNMP can be promising and should be further developed.

CONCLUSION

This systematic review gives an overview of pharmacist intervention feasibility, stakeholders' opinions and possible benefits on opioid optimisation in people with CNMP in outpatient clinical settings, community pharmacies and primary care settings. However, further research is warranted, which can guide the development of new policies and guidelines for the utilisation of pharmacists to promote opioid safety in people using prescription opioids for CNMP management.

The pharmacy workforce in public primary healthcare centers: promoting access and information on medicines

Background:

Only few studies have analyzed the pharmaceutical workforce in primary healthcare centers, and a global recommendation calls for better understanding of the trends that shape workforce development and capacity.

Objective:

To analyze the distribution of the pharmaceutical workforce in primary healthcare centers in the national health system [Sistema Único de Saúde (SUS)] in Brazil.

Methods:

The study was conducted using data from the National Survey on Access, Use and Promotion of Rational Use of Medicines in Brazil. Secondary data referring to the socioeconomic indicators of each municipality were obtained from national public databases. Data stratification in geographic regions was considered, and data on workers in the management of the municipal pharmaceutical services and medicines dispensing centers were analyzed. Crude and adjusted prevalence ratios were calculated by Poisson regression in the study investigating the factors associated with low and high-density pharmacists per 10,000 inhabitants.

Results:

The results showed that most Brazilian municipalities have a rate of 1 or more pharmacist per 10,000 inhabitants in primary healthcare public facilities, with a higher concentration of pharmacists in small municipalities. Even in Brazilian municipalities with lower economic capacity, the conditions of access to medicines and pertinent information on medicines were directly related to the number of pharmacists available in these centers.

Conclusions:

This study showed a high number of pharmacists in the public health system. The higher density of pharmacists in primary healthcare public facilities correlated to increased access to medicines information and better municipal social development.

Challenges and opportunities in conducting health services research through international collaborations: A review of personal experiences

There is increasing attention to international collaborations in health services research with a number of benefits. For developing and nurturing international collaboration, a growing number of funding opportunities are available globally. Having observed and experienced the growth of international collaborations in the global health research field, the authors reflect upon their own experiences in international collaboration between the United Kingdom and many different countries in the process of health services and educational research and discuss challenges and opportunities to conduct impactful research in international settings. The commentary also highlights key issues and strategies for learning and achieving more impact from global health research, including: communication, co-creation, strong leadership and sustainability.

The pharmacy workforce in public primary healthcare centers: promoting access and information on medicines

BACKGROUND

Only few studies have analyzed the pharmaceutical workforce in primary healthcare centers, and a global recommendation calls for better understanding of the trends that shape workforce development and capacity.

OBJECTIVE

To analyze the distribution of the pharmaceutical workforce in primary healthcare centers in the national health system [Sistema Único de Saúde (SUS)] in Brazil.

METHODS

The study was conducted using data from the National Survey on Access, Use and Promotion of Rational Use of Medicines in Brazil. Secondary data referring to the socioeconomic indicators of each municipality were obtained from national public databases. Data stratification in geographic regions was considered, and data on workers in the management of the municipal pharmaceutical services and medicines dispensing centers were analyzed. Crude and adjusted prevalence ratios were calculated by Poisson regression in the study investigating the factors associated with low and high-density pharmacists per 10,000 inhabitants.

RESULTS

The results showed that most Brazilian municipalities have a rate of 1 or more pharmacist per 10,000 inhabitants in primary healthcare public facilities, with a higher concentration of pharmacists in small municipalities. Even in Brazilian municipalities with lower economic capacity, the conditions of access to medicines and pertinent information on medicines were directly related to the number of pharmacists available in these centers.

CONCLUSIONS

This study showed a high number of pharmacists in the public health system. The higher density of pharmacists in primary healthcare public facilities correlated to increased access to medicines information and better municipal social development.

Exploring barriers to the sustainability of an electronic administration system in long-term care facilities: A case study approach

BACKGROUND

The safe provision of medicines administration is a fundamental challenge faced in long-term care facilities (LTCFs). Many residents of LTCFs are frail older persons with multiple morbidities, and in addition to polypharmacy, are particularly at risk of harm due to concomitant disease and disability. One potential method to optimise medication safety and facilitate medicines administration within LTCFs is the introduction of technology.

OBJECTIVE

This paper explores the barriers to long-term sustainability concerning the use of an electronic administration system (eMAR) in LTCFs.

METHODS

Fifteen in depth, semi-structured interviews were conducted with LTCF staff (9), eMAR service commissioners (2), members of the implementation team (2) and care home strategy managers (2) across three LTCF sites. The study participants were purposefully sampled and each interview audio-recorded, transcribed verbatim and analysed using Nvivo 11. In addition to interviews, observational notes were taken by the lead researcher from visits to the LCTFs as a form of data collection. The analysis process consisted of a two-stage process of thematic analysis then theoretical mapping.

RESULTS

Barriers identified were split into four main overarching areas: structural, implementation team, system user and operational barriers. The adoption of eMAR within this setting was welcomed by top-level stakeholders, however, LTCF staff displayed concerns over its usability. The lack of co-development and on-going training need highlighted barriers to its sustainability, in addition to risks associated with current legislation. The themes identified throughout the framework highlight challenges faced when exploring the sustainability of eMAR in LTCF.

CONCLUSIONS

The use of technology in health care is evolving. Awareness of actors relating to its introduction can have significant impact on success and service sustainability.

Prevalence of second-hand tobacco smoke in relation to smoke-free legislation in the European Union

Background

Second-hand smoke (SHS) is still an important public health problem. With joining the Framework Convention on Tobacco Control (FCTC), all parties acknowledged the health risks of SHS and agreed to implement policies to protect their populations from SHS in public places. The aim of this study was to explore the SHS exposure in restaurants and bars as well as its associations with smoke-free legislation in the European Union.

Methods

Data of Eurobarometer surveys 2014 and 2017 were used to estimate prevalence of SHS exposure. We also extracted data on individual confounders such as smoking status, gender, sex, age and information on social economic status. Additionally, we collected data on country specific data on smoking regulations in restaurants and bars from the Tobacco Control Scale to analyse associations with SHS exposure using multilevel logistic regression. Smoking regulations were categorized into the following three categories: partial ban, comprehensive ban with minor exceptions, and complete ban.

Results

Preliminary results on the prevalence of SHS in restaurants showed a decrease from 11.8% (95% confidence intervals (CI) 11.2-12.5) in 2014 to 8.8% (95% CI 8.3-9.3) in 2017. The crude multilevel model controlling only for smoking prevalence resulted in an odds ratio of 0.39 (95% CI 0.19-0.77) for comprehensive ban with minor exceptions and 0.28 (95% CI 0.16-0.50) for complete ban versus partial ban. Odds ratios remained at significant levels when controlling for all available confounders.

Conclusions

Between 2014 and 2017, SHS exposure in restaurants decreased significantly. Furthermore, strong associations with smoking regulations were observed suggesting a high compliance. Many tobacco control policies have been introduced during the last years but several countries need to strengthen their smoke-free tobacco control policies to further reduce SHS exposure preventing death, disease and disability.

Key messages

SHS exposure remains a significant public health challenge. The implementation of effective measures could be strengthened through a convergence of tobacco control strategies and policies among European Union member states.

Anticipatory behaviour in animals: A critical review

A number of studies have investigated anticipatory behaviour in animals as a measure of sensitivity to reward or as an expression of emotional state. A common feature of many studies is that they base inferences on seemingly arbitrary measures, for example, the frequency of behavioural transitions (ie number of times an animal switches between different behaviours). This paper critically reviews the literature and discusses various hypotheses for why specific behavioural responses occur in the anticipatory period between the signal and reward in conditioned animals. We argue that the specific behaviours shown may be the result of superstitious learning and thus highly variable, leaving behavioural transitions as the only response that can be scored consistently, and that sometimes these responses may relate more to frustration than to a positive emotional state. Finally, we propose new research approaches to avoid potential confounds and improve future studies on this topic.

An exploration of the experiences of professionals supporting patients approaching the end of life in medicines management at home. A qualitative study

Background

The management of medicines towards the end of life can place increasing burdens and responsibilities on patients and families. This has received little attention yet it can be a source of great difficulty and distress patients and families. Dose administration aids can be useful for some patients but there is no evidence for their wide spread use or the implications for their use as patients become increasing unwell. The study aimed to explore how healthcare professionals describe the support they provide for patients to manage medications at home at end of life.

Methods

Qualitative interview study with thematic analysis. Participants were a purposive sample of 40 community healthcare professionals (including GPs, pharmacists, and specialist palliative care and community nurses) from across two English counties.

Results

Healthcare professionals reported a variety of ways in which they tried to support patients to take medications as prescribed. While the paper presents some solutions and strategies reported by professional respondents it was clear from both professional and patient/family caregiver accounts in the wider study that rather few professionals provided this kind of support. Standard solutions offered included: rationalising the number of medications; providing different formulations; explaining what medications were for and how best to take them. Dose administration aids were also regularly provided, and while useful for some, they posed a number of practical difficulties for palliative care. More challenging circumstances such as substance misuse and memory loss required more innovative strategies such as supporting ways to record medication taking; balancing restricted access to controlled drugs and appropriate pain management and supporting patient choice in medication use.

Conclusions

The burdens and responsibilities of managing medicines at home for patients approaching the end of life has not been widely recognised or understood. This paper considers some of the strategies reported by professionals in the study, and points to the great potential for a more widely proactive stance in supporting patients and family carers to understand and take their medicines effectively. By adopting tailored, and sometimes, ‘outside the box’ thinking professionals can identify immediate, simple solutions to the problems patients and families experience with managing medicines.

Primary health care policy and vision for community pharmacy and pharmacists in England

The United Kingdom health and care system is changing dramatically to meet the health challenges of the 21^st century. People will increasingly have multiple morbidities. The focus of service delivery is changing from hospital to community, patient to population and curative to preventive. This paper describes the NHS and primary care and community pharmacy in England at the start of 2020, a time of great change. The 10-year vison for the NHS is that everyone gets the best start in life, world class care for major health problems supporting people to age well. It has over 40 mentions of pharmacists and pharmacy. The key aims of the plan are to improve ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community health service in England. All of England is covered by integrated care systems and the newly formed primary care networks which will form the foundation of these new systems. Pharmacy is involved at multiple levels. There are 11,569 community pharmacies and most of their total income comes from the NHS (range 68-85%). Around 60% pharmacies are part of multiple chains, with the remaining 40% independents or small chains of less than six outlets. The new five-year community pharmacy contract provides an opportunity to develop community pharmacy and move towards service delivery away from dispensing volume. The new services are described under medicines optimisation, prevention and urgent care. The pharmacy quality scheme is also described. The new deal will help many community pharmacies to plan their future, particularly for those pharmacies who are ready and able to change and work closely with pharmacists and other health professionals in collaboration with Primary Care Networks. There will be specific challenges around: dispensing efficiencies, freeing up pharmacists’ time, wider use of clinical skills of community pharmacists, community pharmacy viability and consolidations.

Challenges Calibrating Hydrology for Groundwater-Fed Wetlands: a Headwater Wetland Case Study

This study aims to adapt the Soil and Watershed Assessment Tool (SWAT), a ubiquitously used watershed model, for ground-water dominated surface waterbodies by accounting for recharge from the aquifers. Using measured flow to a headwater slope wetland in Alabama's coastal plain region as a case study, we present challenges and relatively simple approaches in using the SWAT model to predict flows from the draining watershed and relatively simple approaches to model groundwater upwelling. SWAT-simulated flow at the study watershed was limited by precipitation, and consequently, simulated flows were several times smaller in magnitude than observed flows. Thus, our first approach involved a separate stormflow and baseflow calibration which included the use of a regression relationship between observed and simulated baseflow (E NASH = 0.67). Our next approach involved adapting SWAT to simulate upwelling groundwater discharge instead of deep aquifer losses by constraining the range of deep losses, β deep parameter, to negative values (E NASH = 0.75). Finally, we also investigated the use of artificial neural networks (ANN) in conjunction with SWAT to further improve calibration performance. This approach used SWAT-calibrated flow, evapotranspiration, and precipitation as inputs to ANN (E NASH = 0.88). The methods investigated in this study can be used to navigate similar flow calibration challenges in other groundwater dominant watersheds which can be very useful tool for managers and modelers alike.

Implementing FIP's global pharmaceutical education transformation vision in Sub-Saharan African Countries

The realization of a competent, versatile and adaptable Pharmaceutical workforce which is a key component in achieving the World Health Organization Universal Health Coverage agenda in 2030 depends on the supply of adequately trained pharmacy workforce who can improve access to quality medicines while delivering quality pharmaceutical services. Despite the rise in the density of pharmacists across all World Health Organization regions, African countries still stay considerably behind in terms of absolute capacity per capita which means that the pharmacy workforce in Africa continues to be very low and not adequate to deliver the pharmaceutical services needs of the region. The International Pharmaceutical Federation is leading the transformation of pharmacy education in Sub-Saharan African countries to bridge this gap with a spotlight on increasing academic capacity, establishing needs-based education strategies and creating an enabling practice environment through advocacy. This commentary paper seeks to discuss the strategies such as the FIP-UNITWIN Programme and the Kenya-Nottingham Partnership utilized in transforming the pharmacy education and therefore the pharmaceutical workforce within the Sub-Saharan African Countries. This paper also gives a clue on subsequent steps which can advance pharmaceutical practice and science in the region.

An Overview of Pharmaceutical Production in Thai Hospitals

Purpose: The purpose of this research was to provide an overview of pharmaceutical production in Thai hospitals. Methods: A cross-sectional survey was developed to study pharmaceutical production in the 1347 Thai hospitals. A representative sample was chosen using multistep selection arriving at a final total of 750 hospitals. Five experts in hospital pharmacy production were recruited to evaluate the content validity. The questionnaire consisted of 2 parts: (1) general details of the hospitals and (2) the type of pharmaceutical products. The latter classification were further divided into 6 types: (1) nonsterile products, (2) extemporaneous preparations, (3) total parenteral nutrition, (4) intravenous admixtures, (5) cytotoxic preparations, and (6) herbal medicine products. All data were analyzed via descriptive statistics. Results: From the 750 questionnaires sent out, 395 hospitals (52.67%) responded to the questionnaires. Regarding the 395 respondent sample group, approximately 60% of the hospitals were involved in pharmaceutical production. The top 3 pharmaceutical products were as follows: (1) cytotoxic preparations (315 items); (2) liquid nonsterile preparations (60 items), and (3) liquid extemporaneous preparations (52 items). The most frequently mentioned reasons for the production of each dosage form were as follows: (1) no commercially available product in appropriate dosage form or strength needed and (2) product was prepared following the hospital's policy. The support needs in hospital pharmacy production were revealed as follows: (1) master formula, (2) quality assurance and quality control processes, (3) equipment, (4) standard references, (5) buildings, (6) personnel, (7) budget, (8) raw material suppliers, and (9) the coordination between the faculties of pharmaceutical sciences and hospitals. Conclusions: Approximately 60% of the respondents had pharmaceutical production in their hospitals. The greatest need for support was for a master formula to inform hospital-based pharmaceutical production. These findings provide essential information, especially for stakeholders, to understand the professional challenges and likely pharmaceutically related health service changes in the future.

Men's views of antidepressant treatment for depression, and their implications for community pharmacy practice

BACKGROUND

Men with depression can express and navigate their condition differently to women. Understanding this population's needs, and experiences, can help healthcare professionals better support these patients. There is a lack of knowledge in this area, and no studies have explored men's depression in the context of community pharmacy.

OBJECTIVES

Explore views of men around their medication for the treatment of depression and the role of community pharmacy in their treatment.

SETTING

United Kingdom (UK) primary care.

METHOD

Semi-structured in-depth interviews were conducted. Eligible participants were male, aged 18-65 years, and treating depression with antidepressants. Participants were recruited through 5 UK pharmacies (via the pharmacist or poster recruitment) and a UK University (poster recruitment). A thematic approach was used for analysis.

RESULTS

14 men aged 26-61 years, predominantly of white ethnicity were interviewed. Key themes were found. The theme 'Antidepressant's attributions to benefits' highlighted all men noticed benefits when taking antidepressants, but held uncertainty on what extent their antidepressants caused this. The themes 'Views of pharmacist's role influences engagement', and 'Influence of cognitive state upon healthcare interactions' demonstrated men were not inclined to discuss concerns with the community pharmacist. These men didn't see this as the pharmacist's role, nor had these men given cognitive space to evaluate their treatment beliefs or information needs. Yet the theme 'Reflection of support and information needs' shows men did have unmet information and support needs. This also links into the 'Hegemonic Masculinity and taking antidepressants' theme, where taking antidepressants could challenge ones masculinity.

CONCLUSION

Community pharmacists should create opportunities for men to engage in conversations around their antidepressants and wider support. Men, as a requisite for engagement, will need to see such interactions as within the community pharmacists' remit, and as part of a collaborative healthcare system.

Towards equity: a qualitative exploration of the implementation and impact of a digital educational intervention for pharmacy professionals in England

BACKGROUND

Patients belonging to marginalised (medically under-served) groups experience problems with medicines (i.e. non-adherence, side effects) and poorer health outcomes largely due to inequitable access to healthcare (arising from poor governance, cultural exclusion etc.). In order to promote service equity and outcomes for patients, the focus of this paper is to explore the implementation and impact of a new co-produced digital educational intervention on one National Health Service (NHS) funded community pharmacy medicines management service.

METHODS

Semi-structured interviews with a total of 32 participants. This included a purposive sample of 22 community pharmacy professionals, (16 pharmacists and 6 pharmacy support staff) all who offered the medicine management service. In order to obtain a fuller picture of the barriers to learning, five professionals who were unable to complete the learning were also included. Ten patients (from a marginalised group) who had received the service (as a result of the digital educational intervention) were also interviewed. Drawing on an interpretative analysis, Normalisation Process Theory (NPT) was used as a theoretical framework.

RESULTS

Three themes are explored. The first is how the digital learning intervention was implemented and applied. Despite being well received, pharmacists found it challenging completing and cascading the learning due to organisational constraints (e.g. lack of time, workload). Using the four NPT constructs (coherence, cognitive participation, collective action and reflexive monitoring) the second theme exposes the impact of the learning and the organisational process of 'normalisation'. Professional reflective accounts revealed instances where inequitable access to health services were evident. Those completing the intervention felt more aware, capable and better equipped to engage with the needs of patients who were from a marginalised group. Operationally there was minimal structural change in service delivery constraining translation of learning to practice. The impact on patients, explored in our final theme, revealed that they experience significant disadvantage and problems with their medicines. The medication review was welcomed and the discussion with the pharmacist was helpful in addressing their medicine-related concerns.

CONCLUSIONS

The co-produced digital educational intervention increases pharmacy professionals' awareness and motivation to engage with marginalised groups. However structural barriers often hindered translation into practice. Patients reported significant health and medicine challenges that were going unnoticed. They welcomed the additional support the medication review offered. Policy makers and employers should better enable and facilitate ways for pharmacy professionals to better engage with marginalised groups. The impact of the educational intervention on patients' health and medicines management could be substantial if supported and promoted effectively.

P4404Prognostic value of novel nocturnal oxygen saturation metrics in patients with obstructive sleep apnoea and high cardiovascular event risk

Aim

To determine prognostic value of novel oximetry-derived metrics in patients with obstructive sleep apnoea (OSA) and high cardiovascular (CV) event risk.

Methods and results

Ancillary study of the Sleep Apnoea CV Endpoints (SAVE) randomised controlled trial, which investigated the effects of CPAP treatment on secondary CV event outcomes in 2687 participants with moderate-severe OSA and established CV disease. Associations between baseline characteristics, standard sleep and pulse oximetry-derived metrics, and CV outcomes were determined in Cox proportional hazards regression models stratified for treatment allocation. Metrics evaluated included: oxygen desaturation index, time below 90% oxygen saturation (SpO2), average SpO2across recordings (mean SpO2), across episodic desaturation events (desaturation SpO2), and baseline interpolated through episodic desaturation events (baseline SpO2); duration and desaturation/resaturation time ratio of episodic desaturation events; and mean and standard deviation of pulse rate. No SpO2 metric was associated with the composite outcome. Mean and baseline SpO2 were negatively associated with heart failure (hazard ratio [HR] 0.81, 95% confidence interval [CI] 0.69–0.95; P=0.009 and 0.78, 0.67–0.90; P=0.001, respectively) and myocardial infarction risk (0.86, 0.77–0.95; P=0.003 and 0.81, 0.73–0.90; P<0.001, respectively) and marginally positively associated with stroke risk (1.09, 1.00–1.20; P=0.065 and 1.13, 1.02–1.26; P=0.020, respectively). Desaturation duration and desaturation/resaturation time ratio, with established risk factors, predicted heart failure (area under the receiver-operating-characteristic curve 0.86, 95% CI 0.79–0.93).

Conclusions

Higher mean and baseline SpO2 were associated with reduced risk of heart failure and myocardial infarction, and small increases in stroke rate. Desaturation shape may have predictive utility for future CV events.

Clinical trial registration: clinicaltrials (NCT00738179).

Supporting the provision of pharmacy medication reviews to marginalised (medically underserved) groups: a before/after questionnaire study investigating the impact of a patient-professional co-produced digital educational intervention

OBJECTIVES

People who are marginalised (medically underserved) experience significant health disparities and their voices are often 'seldom heard'. Interventions to improve professional awareness and engagement with these groups are urgently needed. This study uses a co-production approach to develop an online digital educational intervention in order to improve pharmacy staffs' intention to offer a community pharmacy medication review service to medically underserved groups.

DESIGN

Before/after (3 months) self-completion online questionnaire.

SETTING

Community pharmacies in the Nottinghamshire (England) geographical area.

PARTICIPANTS

Community pharmacy staff.

INTERVENTION

Online digital educational intervention.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was 'behaviour change intention' using a validated 12-item survey measure. The secondary outcome measure was pharmacist self-reported recruitment of underserved groups to the medication review service.

RESULTS

All pharmacies in the Nottinghamshire area (n=237) were approached in June 2017 and responses were received from 149 staff (from 122 pharmacies). At 3 months (after completing the baseline questionnaire), 96 participants (from 80 pharmacies) completed a follow-up questionnaire, of which two-thirds (n=62) reported completing the e-learning. A before/after comparison analysis found an improving trend in all the five constructs of behaviour change intention (intention, social influence, beliefs about capabilities, moral norms and beliefs about consequences), with a significant increase in mean score of participants' 'beliefs about capabilities' (0.44; 95% CI 0.11 to 0.76, p=0.009). In the short-term, no significant change was detected in the number of patients being offered and the patient completing a medication review.

CONCLUSIONS

Although increases in the numbers of patients being offered a medication review was not detected, the intervention has the potential to significantly improve pharmacy professionals' 'beliefs about capabilities' in the short-term. Wider organisational and policy barriers to engagement with marginasied groups may need to be addressed. Future research should focus on the interplay between digital learning and practice to better identify and understand effective practice change pathways.

A comparison of 6 osteoporosis risk assessment tools among postmenopausal women in Kuala Lumpur, Malaysia

Objectives

To compare and assess the performance of 6 osteoporosis risk assessment tools for screening osteoporosis in Malaysian postmenopausal women.

Methods

Six osteoporosis risk assessments tools (the Simple Calculated Osteoporosis Risk Estimation [SCORE], the Osteoporosis Risk Assessment Instrument, the Age Bulk One or Never Estrogen, the body weight, the Malaysian Osteoporosis Screening Tool, and the Osteoporosis Self-Assessment Tool for Asians) were used to screen postmenopausal women who had not been previously diagnosed with osteoporosis/osteopenia. These women also underwent a dual-energy X-ray absorptiometry (DXA) scan to confirm the absence or presence of osteoporosis.

Results

A total of 164/224 participants were recruited (response rate, 73.2%), of which only 150/164 (91.5%) completed their DXA scan. Sixteen participants (10.7%) were found to have osteoporosis, whilst 65/150 (43.3%) were found to have osteopenia. Using precision-recall curves, the recall of the tools ranged from 0.50 to 1.00, whilst precision ranged from 0.04 to 0.14. The area under the curve (AUC) ranged from 0.027 to 0.161. The SCORE had the best balance between recall (1.00), precision (0.04-0.12), and AUC (0.072-0.161).

Conclusions

We found that the SCORE had the best balance between recall, precision, and AUC among the 6 screening tools that were compared among Malaysian postmenopausal women.

A transition from the BPharm to the PharmD degree in five selected countries

This review focuses on the studies and opinions around issues of transition from the BPharm to the PharmD degree in the U.S., Japan, South Korea, Pakistan and Thailand.

The transition to the clinically orientated PharmD degree in many countries was seen to be a means of developing the profession. However, some countries have both clinically-oriented and pharmaceutical sciences-oriented PharmD programme that are designed to meet the needs of their countries. Each country created a different process to handle the transition to an all-PharmD programme, but mostly had the process of school accreditation mandated by the regulatory bodies. The main barrier to the transition in most of the countries was the issue of educational quality. A set of indicators is needed to measure and monitor the impact/outcome of the PharmD degree.

Each country has different needs due to the different contexts of health care systems and the scope of pharmacy practice. In order to increase their chances of benefiting from the new programme, academic leaders should critically assess their countries’ needs before deciding to adopt a PharmD programme.

A survey of smoking cessation training within UK pharmacy education

INTRODUCTION

Tobacco smoking is a significant public health problem, and remains the leading cause of preventable, premature death in the United Kingdom (UK). In order to reduce the burden of smoking in the UK, all healthcare professionals should be able to advise smokers how to quit and assist them to do so. The aim was to identify the extent of smoking cessation teaching and examination in UK pharmacy schools.

METHODS

A short survey of smoking cessation was sent to each Programme Director for all UK pharmacy schools (n = 29).

RESULTS

The survey achieved a response rate of 72%. All schools dedicated time teaching smoking cessation interventions, with 76% spending more than three hours, and 90% examining students on some aspect of smoking cessation. All schools taught about nicotine replacement therapy (NRT) and the role of behavioural support. At least 90% of schools taught about the role of the stop smoking services and opportunistic brief interventions, e.g., very brief advice (VBA). Only 14% covered practical delivery in clinical settings.

CONCLUSIONS

UK pharmacy schools are teaching and examining students on a wide range of smoking cessation interventions, including VBA. However, there was a lack of training reported on the management of mental health patients who smoke, and practical skills training. All schools should do more to ensure they are providing practical skills training to enable students to be adequately prepared for delivering smoking cessation support to all smokers, including vulnerable populations.

Changes in newspaper coverage of mental illness from 2008 to 2016 in England

AIMS

Since 2008 England's anti-stigma programme Time to Change has lobbied media outlets about stigmatising coverage and worked with them to promote accurate and non-stigmatising coverage. While this may have an impact on coverage and hence attitudes, it is also possible that coverage can change in response to improving attitudes, through the creation of a market demand for less stigmatising coverage. This study evaluates English newspaper coverage of mental health topics between 2008 and 2016.

METHOD

Articles covering mental health in 27 newspapers were retrieved using keyword searches on two randomly chosen days each month in 2008-2016, excluding 2012 and 2015 due to restricted resources. Content analysis used a structured coding framework. Univariate logistic regression models were used to estimate the odds of each hypothesised element occurring in 2016 compared with 2008 and Wald tests to assess the overall statistical significance of the year variable as the predictor.

RESULTS

The sample retrieved almost doubled between 2008 (n = 882) and 2016 (n = 1738). We found a significant increase in the proportion of anti-stigmatising articles (odds ratio (OR) 2.26 (95% confidence interval (CI) 1.86-2.74)) and a significant decrease in stigmatising articles (OR 0.62 (95% CI 0.51-0.75)). Reports on all diagnoses except for schizophrenia were more often anti-stigmatising than stigmatising.

CONCLUSIONS

This is the first clear evidence of improvement in coverage since the start of Time to Change. However, coverage of schizophrenia may be less affected by this positive shift than that of other diagnoses. The increase in the level of coverage identified in 2016 requires further investigation, as it may also influence public conceptualisation of what constitutes mental illness, attitudes to mental illness in general and/or specific diagnoses. While most anti-stigma programmes are not diagnosis specific, we suggest their evaluation would benefit from a diagnosis specific approach to allow fuller interpretation of their effects. This could include media analysis driven by hypotheses based on diagnoses to ascertain whether variations by diagnosis over time occur both in the nature and in the proportion of coverage.

Population differentiation between Australian and Chinese Helicoverpa armigera occurs in distinct blocks on the Z-chromosome

Over the last 40 years, many types of population genetic markers have been used to assess the population structure of the pest moth species Helicoverpa armigera. While this species is highly vagile, there is evidence of inter-continental population structure. Here, we examine Z-chromosome molecular markers within and between Chinese and Australian populations. Using 1352 polymorphic sites from 40 Z-linked loci, we compared two Chinese populations of moths separated by 700 km and found virtually no population structure (n = 41 and n = 54, with <1% of variation discriminating between populations). The levels of nucleotide diversity within these populations were consistent with previous estimates from introns in Z-linked genes of Australian samples (π = 0.028 vs. 0.03). Furthermore, all loci surveyed in these Chinese populations showed a skew toward rare variants, with ten loci having a significant Tajima's D statistic, suggesting that this species could have undergone a population expansion. Eight of the 40 loci had been examined in a previous study of Australian moths, of which six revealed very little inter-continental population structure. However, the two markers associated with the Cyp303a1 locus that has previously been proposed to be a target of a selective sweep, exhibited allele structuring between countries. Using a separate dataset of 19 Australian and four Chinese moths, we scanned the molecular variation distributed across the entire Z-chromosome and found distinct blocks of differentiation that include the region containing Cyp303a1. We recommend some of these loci join those associated with insecticide resistance to form a set of genes best suited to analyzing population structure in this global pest.

Structured Multi-Stakeholder Workshops to Advance a Global Transformative Roadmap for Pharmaceutical Workforce

In November 2016, the International Pharmaceutical Federation (FIP) endeavored to create an environment to foster a shared vision to lead a transformative pharmaceutical workforce roadmap. Three milestone documents were developed and presented at the Global Conference on Pharmacy and Pharmaceutical Education. Workshops with the key themes and connecting Pharmaceutical Workforce Development Goals (PWDG) were conducted and analyzed. This Note serves to summarize the key aspects of these workshops, reporting on the innovative approaches used to generate guidance for stakeholders regarding implementation.

Innovation

Seven workshops with a uniform structure were developed. These were designed to improve communication, harmonise outcome-generation, and allow for aggregate analysis. A team of seven conducted each workshop, each team consisted of: a Chair, a facilitator, one rapporteur, and four speakers purposively selected from FIP member organisations and other key stakeholders with expertise for sharing a variety of perspectives. Guidelines and templates were developed for all roles and each team was briefed in advance.

Key findings

Approximately 200 personnel participated in the seven workshops, with around 20 country representatives per workshop, covering all six World Health Organisation regions. Three key aspects of workforce transformation, using the PWDGs, were explored in each workshop: drivers for implementation; challenges to implementation; and ways of encouraging implementation. Drivers for implementation mentioned were enhancing collaboration and engagement. Challenges to implementation were identified as variance in terminology. Several ways of encouraging implementation were acknowledged, such as communication strategies, advocating for workforce development and sharing best practices to foster partnerships.

Next steps

The unique format of the workshops, the innovative approach to include stakeholders across an array of settings and the parallel structure in all the seven workshops, aided in creating reliable findings. The achievability of the PWDGs depends on several factors. Engagement with stakeholders and engagement from and between professional associations are important factors to achieving workforce development goals.

A Coordinated Approach to Lung Cancer Screening in Canada

Background and context: Lung cancer screening with low-dose computed tomography is recommended by the Canadian Task Force on Preventive Health Care for individuals at high risk. While no organized lung cancer screening programs currently exist, several Canadian jurisdictions have begun to plan for program implementation with pilot programs, studies, or business cases. Aim: The Canadian Partnership Against Cancer (the Partnership) has supported lung cancer screening activities by initiating a series of projects to promote lung health in Canada. Strategy/Tactics: The Partnership responded to emerging evidence on lung cancer screening with the establishment of the Pan-Canadian Lung Cancer Screening Network (PLCSN) in 2012. The PLCSN brings together key stakeholders from across Canada to promote pan-Canadian collaboration and serves as a national platform for knowledge exchange. Program/Policy process: One of the first priorities of the PLCSN was the development of a consensus statement-based Lung Cancer Screening Framework for Canada in 2014. The Framework outlines key considerations for lung cancer screening programs, including screening eligibility, radiologic testing, pathology quality and reporting, diagnostic treatment and follow-up, and the inclusion of smoking cessation interventions. As the development of the Framework drew to completion, the second priority of the PLCSN was the development of national quality indicators for lung cancer screening. An initial set of ten national-level lung cancer screening quality indicators was developed for national reporting. Most recently, the PLCSN developed a list of five quality-related lung cancer screening questions that should be explored in advance of the widespread implementation of lung cancer screening programs. These considerations included eligibility, enrollment, smoking cessation, nodule management and the effect of lung cancer screening programs on projected lung cancer mortality. Other Partnership initiatives to promote lung health include health economic modeling for lung cancer screening and collecting data on evidence-based smoking cessation programs. Outcomes: These initiatives have aligned pan-Canadian lung cancer screening efforts to facilitate knowledge sharing and resource efficiency, standardization of data collection and reporting, and acceleration of lung cancer screening in Canada. As of January 2018, four provinces have completed business cases, one province has implemented a pilot study, and three trials are ongoing across the country. Partnership initiatives and resources were used by several jurisdictions to inform the development of lung health activities. What was learned: By initiating these activities in advance of organized lung cancer screening programs, the Partnership has contributed to the evidence base on best practices in lung cancer screening that will be necessary for successful program implementation.

Are we on the right track? Answers from a national survey of Thai graduates' perceptions during the transition to the 6-year PharmD program

PURPOSE

To serve the higher demands of pharmaceutical services, pharmacy education in Thailand has shifted from 5-year BPharm program to 6-year PharmD program with two specialization tracks: pharmaceutical care (PC) and industrial pharmacy (IP). This study aimed to compare the perceptions regarding professional competencies, pharmacy profession, and planned workplace between graduates with 5-year BPharm and 6-year PharmD and between those with PC and IP specialty.

METHODS

A cross-sectional national survey using a paper-pencil self-administered questionnaire was distributed to all new graduates attending the pharmacy licensure examination in March 2015.

RESULTS

Of all 1,937 questionnaires distributed, 1,744 were returned and completed (90% response rate). Pharmacy graduates rated highest on their competencies in professional ethics, followed by PC services and system management. They rated low confidence in medication selection procurement and pharmaceutical industry competencies. The 6-year PharmD graduates showed higher confidence in ethics and professional pride than the 5-year BPharm graduates. Graduates with PC specialty rated higher perceived competency in PC, system management, primary care, and consumer protection domains, while the IP graduates were superior in IP and medication selection and procurement domains, and most graduates (PC and IP) intended to work mainly in a hospital or a community pharmacy. Hospital was preferred for the PC graduates, and the IP graduates were more likely to work in pharmaceutical industry, regulation and consumer protection, sales and marketing, and academia.

CONCLUSION

With some gaps still to be filled, the transition from 5-year BPharm to 6-year PharmD program with specialty tracks gave extra confidence to graduates in their specialty competencies and professional pride, leading to differences in preferred workplace. The findings of this study reflect that Thai pharmacy education continues to adjust to the needs of the society and the changing health care environments. Longitudinal monitoring to observe this transition is needed for both curriculum adjustment and competency of the graduates.

Power outages and refrigerated medicines: The need for better guidelines, awareness and planning

WHAT IS KNOWN AND OBJECTIVE

Vaccines and other pharmaceuticals are essential medical supplies that require continuous storage at specific temperatures to maintain viability. Power outages can lead to a break in the cold chain, resulting in the degradation of essential medicines.

COMMENT

After a power outage, the stability of vaccines and other medicines can be difficult to ascertain. Many public health guidelines therefore recommend discarding potentially compromised pharmaceuticals unless the cold chain can be guaranteed-a costly endeavour. There are government guidelines aimed at minimizing exposure to high temperatures in the event of a power outage; however, the usefulness of these guidelines is uncertain.

WHAT IS NEW AND CONCLUSION

The actual cost of vaccine and pharmaceutical loss due to a break in the cold chain is poorly studied and requires further research. Additional recommendations regarding the stability of specific medicines would also be a valuable resource.

The role of pharmacists in general practice: A realist review

BACKGROUND

The review was carried out to inform the evaluation of the clinical pharmacists in general practice pilot scheme, a world leading initiative to improve health care delivery in England. Around 500 pharmacists are already working in general practice as part of the pilot, launched in July 2015.

OBJECTIVES

The review attempts to explain the how pharmacists working in general practice is being implemented in the UK and beyond, what works well, what does not work so well and everything in-between.

METHODS

This realist review was conducted to the RAMESES standards. Studies were identified by searching three databases, Medline, Embase and Scopus. Additional papers were gathered from reference lists, Google searches and via the find similar citations feature.

RESULTS

A total of 83 papers and articles were initially identified from Medline (19), Embase (31) and Scopus (32). With close reading, the final review consisted of 43 papers relating to 38 studies. Most of the research was undertaken in the field of pharmacy practice and over half of the studies investigated the perspectives of different stakeholders using questionnaires or qualitative methods.

CONCLUSION

The pharmacist working in general practice is still a relatively new concept and further more in-depth research is still required. However, from this small number of studies, the common barriers and facilitators to the implementation can be identified. The review also lists mechanisms that will be needed to ensure the effective implementation of this initiative.

Exploring the role of advanced nurse practitioners in leadership

There have been several changes to healthcare services in the UK over recent years, with rising NHS costs and increasing demands on healthcare professionals to deliver high-quality care. Simultaneously, public inquiries have identified suboptimal leadership throughout the NHS, which has been linked to a lack of clear leadership across the healthcare professions. In nursing, the role of the advanced nurse practitioner is regarded as a solution to this leadership challenge. This article examines the background to the development of the advanced nurse practitioner role. It also explores the various factors that may affect nurse leadership and the role of the advanced nurse practitioner, including professional identity, gender, nursing's strategic influence, clinical outcomes, and recruitment and retention. The article concludes that while advanced nurse practitioners can positively influence clinical outcomes and cost efficiency, they must also be adequately prepared to undertake a leadership role.

Assay to Detect Inhibitory Substances in Serum of Patients with Acute Liver Failure

Patients with acute liver failure accumulate toxic substances in the circulation which may impair recovery of hepatic function. The aim of this study was to test an in vitro assay to detect inhibitory substances in the serum of patients with acute liver failure. Human liver-derived HepG2 cells were incubated for 24h in 96 well plates (30,000 cells/well) with sera (10%) from 24 patients with acute liver failure due to paracetamol overdose or NANB hepatitis and 11 normal controls. DNA synthesis was determined from the incorporation of 3H-thymidine and cell viability by the metabolism of the tetrazolium dye MTS. HepG2 cells exposed to acute liver failure sera incorporated significantly less 3H-thymidine (median 30% of control, range 0.2–169%) than normal sera (100%, 76–133%, p=0.002). Cell viability was also reduced (75%, 33–112% vs 100%, 96–105%, p<0.00l). There was no correlation between these values and patient outcome or levels of plasma TNF-α or serum interferon-γ. The assay detected inhibitory substances in sera of patients with acute liver failure and could be used to monitor the use of liver support systems.

Exploring the current and future role of the pharmacists in osteoporosis screening and management in Malaysia

Background Several studies have found that pharmacists can assist in screening and prevention of osteoporosis by referring patients for bone mineral density scans and counselling on lifestyle changes. In Malaysia, screening osteoporosis in all elderly women is not mandatory due to its cost. One approach to address this gap is to develop a pharmacist-led osteoporosis screening and prevention program. However, there is a paucity of data on the perspectives of Malaysian pharmacists in this area. Objective To explore the perspective of stakeholders (policy makers, doctors, pharmacists, nurses and patients) towards the role of pharmacists in osteoporosis screening and management. Setting A primary care clinic located within a teaching hospital in Kuala Lumpur, Malaysia. Method Patients (n = 20), nurses (n = 10), pharmacists (n = 11), doctors (n = 10) and policy makers (n = 5) were individually interviewed using a semi-structured topic guide. Purposive sampling was used. Interviews were transcribed verbatim and analysed using thematic analysis. Main outcome measure Perspective of stakeholders on the current and future role of pharmacists. Results All participants perceived pharmacists to be suppliers of medication, although there was some recognition of roles in providing medication advice. Nonetheless, these stakeholders were eager for pharmacists to expand their non-dispensing roles towards counselling, creating awareness and screening of osteoporosis. Interviewed pharmacists referred to their current role as 'robotic dispensers' and unanimously agreed to spread out to osteoporosis management role. Conclusion Under stakeholders there is a willingness to expand the role of pharmacists in Malaysia to non-dispensing roles, particularly in osteoporosis screening and management.

Provision of pharmaceutical care by community pharmacists across Europe: Is it developing and spreading?

RATIONALE, AIMS, AND OBJECTIVES

Pharmaceutical care involves patient-centred pharmacist activity to improve medicines management by patients. The implementation of this service in a comprehensive manner, however, requires considerable organisation and effort, and indeed, it is often not fully implemented in care settings. The main objective was to assess how pharmaceutical care provision within community pharmacy has evolved over time in Europe.

METHOD

A cross-sectional questionnaire-based survey of community pharmacies, using a modified version of the Behavioural Pharmaceutical Care Scale (BPCS) was conducted in late 2012/early 2013 within 16 European countries and compared with an earlier assessment conducted in 2006.

RESULTS

The provision of comprehensive pharmaceutical care has slightly improved in all European countries that participated in both editions of this survey (n = 8) with progress being made particularly in Denmark and Switzerland. Moreover, there was a wider country uptake, indicating spread of the concept. However, due to a number of limitations, the results should be interpreted with caution. Using combined data from participating countries, the provision of pharmaceutical care was positively correlated with the participation of the community pharmacists in patient-centred activities, routine use of pharmacy software with access to clinical data, participation in multidisciplinary team meetings, and having specialized education.

CONCLUSIONS

The present study demonstrated a slight evolution in self-reported provision of pharmaceutical care by community pharmacists across Europe, as measured by the BPCS. The slow progress suggests a range of barriers, which are preventing pharmacists moving beyond traditional roles. Support from professional bodies and more patient-centred community pharmacy contracts, including remuneration for pharmaceutical care services, are likely to be required if quicker progress is to be made in the future.