Community pharmacist's roles: nursing home staff and community pharmacists' views

Focal points

Causes of preventable drug-related hospital admissions: a qualitative study

OBJECTIVE

To explore the causes of preventable drug-related admissions (PDRAs) to hospital.

DESIGN

Qualitative case studies using semi-structured interviews and medical record review; data analysed using a framework derived from Reason's model of organisational accidents and cascade analysis.

PARTICIPANTS

62 participants, including 18 patients, 8 informal carers, 17 general practitioners, 12 community pharmacists, 3 practice nurses and 4 other members of healthcare staff, involved in events leading up to the patients' hospital admissions.

SETTING

Nottingham, UK.

RESULTS

PDRAs are associated with problems at multiple stages in the medication use process, including prescribing, dispensing, administration, monitoring and help seeking. The main causes of these problems are communication failures (between patients and healthcare professionals and different groups of healthcare professionals) and knowledge gaps (about drugs and patients' medical and medication histories). The causes of PDRAs are similar irrespective of whether the hospital admission is associated with a prescribing, monitoring or patient adherence problem.

CONCLUSIONS

The causes of PDRAs are multifaceted and complex. Technical solutions to PDRAs will need to take account of this complexity and are unlikely to be sufficient on their own. Interventions targeting the human causes of PDRAs are also necessary--for example, improving methods of communication.

Feasibility and benefits of implementing a Slimming on Referral service in primary care using a commercial weight management partner

OBJECTIVES

To assess participation in a costed Slimming on Referral service and identify factors associated with success.

STUDY DESIGN

Simple intervention offering participation in a new service to 100 eligible patients. The setting was two Derby general practices, one inner city and one suburban.

PARTICIPANTS

One hundred and seven patients (mean age 50 years) attending general practice for non-obesity reasons.

INCLUSION CRITERIA

BMI > or = 30, age > or = 18 years, not pregnant, no recent commercial weight management group membership, willingness to attempt weight loss.

METHODS

Patients were offered free attendance at a local Slimming World group for 12 consecutive weeks. Body weight and height were measured at baseline, and questionnaires established perceived health, motivation to lose weight, employment, concerns, responsibilities and well-being. Weight was measured at each group visit. The main outcome measures were: (1) changes in body weight at 12 and 24 weeks, (2) social and demographic factors associated with barriers to enrolment, continued attendance and successful weight loss.

RESULTS

Ninety-one (85%) patients attended a group, with 62 completing 12 weeks. Average weight loss in participants was 5.4 kg (6.4% baseline weight). Forty-seven then chose to self-fund, with 34 (37% original group) completing a further 12 weeks. Average weight loss over the total 24 weeks was 11.1 kg (11.3% baseline weight). Regular attendance was affected by income, financial concerns (independent of actual income), age, perceived importance of weight loss and initial weight loss success. Well-being of patients significantly improved between baseline and both 12 and 24 weeks.

CONCLUSIONS

Collaboration with an appropriate commercial weight management organization offers a feasible weight management option that is either similar to, or better than, other options in terms of attrition, efficacy and cost.

Thiazide diuretic prescription and electrolyte abnormalities in primary care

AIMS

Thiazide diuretics have a number of well-documented metabolic adverse effects. The aim of this study was to estimate the frequency of hyponatraemia and hypokalaemia amongst patients taking a thiazide diuretic in primary care.

METHODS

A computerized search of the electronic prescribing and laboratory records of six UK general practices was performed. Of the 32 218 adult patients identified, 3773 had received at least one prescription for a thiazide between the years 1990 and 2002.

RESULTS

Detailed prescribing data were available for 2942 patients of whom 951 (32.3%) had a recorded check of their electrolytes. One hundred and ninety-six (20.6%) had a sodium and/or potassium concentration below the normal range. The sodium distribution had a negative skew (-1.8) and in 130 (13.7%) patients was within the hyponatraemic range. Hypokalaemia was less common, occurring in 79 (8.5%) patients. Hyponatraemia was significantly associated with increased age; the odds ratio for developing hyponatraemia in patients over 70 years was 3.87 compared with those of < or = 70 years. Hypokalaemia was significantly associated with increased thiazide dose.

CONCLUSIONS

Prescription of a thiazide diuretic in primary care is associated with a high frequency of hyponatraemia and hypokalaemia. Thiazides should be prescribed at low dose and the risk of hyponatraemia, especially in the elderly, should be considered and monitored for when prescribing these agents.

The role of livestock in the management of dryland salinity

Management of dryland salinity in Australia will require changes in the design and utilisation of plant systems in agriculture. These changes will provide new opportunities for livestock agriculture. In areas already affected by salt, a range of plants can be grown from high feeding value legumes with moderate salt tolerance through to highly salt tolerant shrubs. A hectare of these plants may support between 500 and 2000 sheep grazing days per year. The type of plants that can be grown and the subsequent animal production potential depend on a range of factors that contribute to the ‘salinity stress index’ of a site, including soil and groundwater salinity, the extent and duration of waterlogging and inundation, the pattern and quantity of annual rainfall, soil texture and chemistry, site topography and other site parameters. Where the salinity stress index is high, plant options will usually include a halophytic shrub that accumulates salt. High salt intakes by grazing ruminants depress feed intake and production. Where high and low salt feeds are available together, ruminants will endeavour to select a diet that optimises the overall feeding value of the ingested diet. In areas that are not yet salt affected but contribute to groundwater recharge, perennial pasture species offer an opportunity for improved water and salt management both on-farm and at the catchments. If perennial pasture systems are to be adopted on a broad scale, they will need to be more profitable than current annual systems. In the high rainfall zones in Victoria and Western Australia, integrated bioeconomic and hydrological modelling indicates that selection of perennial pasture plants to match requirements of a highly productive livestock system significantly improves farm profit and reduces groundwater recharge. In the low to medium rainfall zones, fewer perennial plant options are available. However, studies aiming to use a palette of plant species that collectively provide resilience to the environment while maintaining profitable livestock production may also lead to new options for livestock in the traditional cropping zone.

Tackling obesity in men -- preliminary evaluation of men-only groups within a commercial slimming organization

BACKGROUND

Over Slimming World's 36-year history men have always made up a small percentage of the slimming organization's membership. Past company research suggested that men would feel more comfortable in men-only groups rather than mixed. In 2002, Slimming World set a target to raise the awareness among men about the dangers of being overweight and made practical weight-management solutions more accessible through a national network of men's groups.

AIM

To evaluate men's weight loss within these 'men-only' groups.

METHODS

Data analysed included those men having attended a group for at least 8 weeks.

RESULTS

At the point of data collection average BMI had decreased from 35.9 to 32.5 kg m(-2). At least 5% weight loss was achieved in 90% of the sample. In those who had been members for 24 weeks 69% achieved a 10% weight loss. Shift working did not affect weight loss success.

CONCLUSION

This data shows that overweight and obese men attending Slimming World are successful at losing weight in this environment and can achieve recommended health-related weight loss targets. There should be a move to get away from the mis-perception that slimming groups are only for women and raise awareness of the commercial option to men.

Lineage differentiation of canine lymphoma/leukemias and aberrant expression of CD molecules

Multiparameter flow cytometry analysis and specific cluster differentiation (CD) molecules were used to determine the expression profiles of B- and T-cell antigens on lymph node preparations from 59 dogs with generalized or multisystemic lymphoma. Lymph node samples from 11 healthy dogs were labeled to validate the specificity of antibodies and to formulate guidelines for interpretation of the results obtained from lymphoma samples. In normal lymph nodes, T-lymphocytes expressing CD3, CD4, or CD8 beta represented 59+/-11%, 43+/-8%, or 16+/-5% of the total cells, whereas B-lymphocytes expressing either CD21 or surface IgM (IgM) represented 37+/-9% or 14+/-5%, respectively. Small lymphocytes could be distinguished from large lymphocytes by forward light scatter. Of the patient samples 29 different breeds were represented with Golden and Labrador retriever being the most common. The lymphoma samples segregated into three groups based on CD antigen expression. Thirty cases predominantly expressed one or more combinations of CD79a, IgM, and CD21 representing a B-cell lineage. Three B-cell cases also expressed the stem cell antigen, CD34. Sixteen cases expressed one or more combinations of CD3, CD4, and CD8 consistent with a T-cell lineage and CD3+CD4+CD8--phenotype was the most common. Thirteen cases showed a mixed expression profile for T- and B-cell antigens and in three cases CD14 was highly expressed. Clinical response was poorest for T-cell lymphomas. Leukemic states occurred in all three phenotypes; but mixed cell cases had the greatest proportion. Dual immunofluorescence staining confirmed co-expression of T-cell (CD3) and B-cell antigens (CD79a or CD21) on neoplastic lymphocytes of six mixed cell cases. In one mixed cell case, dual immunostaining identified lymphocyte populations that stained mutually exclusive for CD79a and CD3. Six mixed cell lymphomas tested by PCR showed clonality for rearranged antigen receptor. Four cases that were CD79a+CD3+ had TCRgamma chain gene rearrangements, whereas two cases that were CD3+CD8+CD21+ had Ig heavy chain rearrangement. One case expressing multiple CD molecules (CD3+CD8+CD21+CD14+) was PCR negative for both Ig and TCRgamma gene rearrangement and could not be classified into a B- or T-cell lineage. We show for the first time co-expression of B- and T-cell markers on lymphoma cells that had specific T- or B-cell gene rearrangements. These findings suggest that aberrant CD molecule expression is not an uncommon finding in canine lymphomas and is a useful diagnostic marker for malignancy.

Randomised controlled multiple treatment comparison to provide a cost-effectiveness rationale for the selection of antimicrobial therapy in acne

OBJECTIVES

To determine the relative efficacy and cost-effectiveness of five of the most commonly used antimicrobial preparations for treating mild to moderate facial acne in the community; the propensity of each regimen to give rise to local and systemic adverse events; whether pre-existing bacterial resistance to the prescribed antibiotic resulted in reduced efficacy; and whether some antimicrobial regimens were less likely to give rise to resistant propionibacterial strains.

DESIGN

This was a parallel group randomised assessor-blind controlled clinical trial. It was a pragmatic design with intention-to-treat analysis. All treatments were given for 18 weeks, after a 4-week treatment free period. Outcomes were measured at 0, 6, 12 and 18 weeks.

SETTING

Primary care practices and colleges in and around Nottingham and Leeds, and one practice in Stockton-on-Tees, England.

PARTICIPANTS

Participants were 649 people aged 12--39 years, all with mild to moderate inflammatory acne of the face.

INTERVENTIONS

Study participants were randomised into one of five groups: 500 mg oral oxytetracycline (non-proprietary) twice daily (b.d.) + topical vehicle control b.d.; 100 mg oral Minocin MR (minocycline) once daily (o.d.) + topical vehicle control b.d.; topical Benzamycin (3% erythromycin + 5% benzoyl peroxide) b.d. + oral placebo o.d.; topical Stiemycin (2% erythromycin) o.d. + topical Panoxyl Aquagel (5% benzoyl peroxide) o.d. + oral placebo o.d., and topical Panoxyl Aquagel (5% benzoyl peroxide) b.d. + oral placebo o.d. (the active comparator group).

MAIN OUTCOME MEASURES

The two primary outcome measures were: (1) the proportion of patients with at least moderate self-assessed improvement as recorded on a six-point Likert scale, and (2) change in inflamed lesion count (red spots).

RESULTS

The best response rates were seen with two of the topical regimens (erythromycin plus benzoyl peroxide administered separately o.d. or in a combined proprietary formulation b.d.), compared with benzoyl peroxide alone, oxytetracycline (500 mg b.d.) and minocycline (100 mg o.d.), although differences were small. The percentage of participants with at least moderate improvement was 53.8% for minocycline (the least effective) and 66.1% for the combined erythromycin/benzoyl peroxide formulation (the most effective); the adjusted odds ratio for these two treatments was 1.74 [95% confidence interval (CI) 1.04 to 2.90]. Similar efficacy rankings were obtained using lesion counts, acne severity scores and global rating by assessor. Benzoyl peroxide was the most cost-effective and minocycline the least cost-effective regimen (ratio of means 12.3; difference in means -0.051 units/GBP, 95% CI -0.063 to -0.039). The efficacy of oxytetracycline was similar to that of minocycline, but at approximately one-seventh of the cost. For all regimens, the largest reductions in acne severity were recorded in the first 6 weeks. Reductions in disability scores using the Dermatology Quality of Life Scales were largest for both topical erythromycin-containing regimens and minocycline. The two topical erythromycin-containing regimens produced the largest reductions in the prevalence and population density of cutaneous propionibacteria, including antibiotic-resistant variants, and these were equally effective in participants with and without erythromycin-resistant propionibacteria. The clinical efficacy of both tetracyclines was compromised in participants colonised by tetracycline-resistant propionibacteria. None of the regimens promoted an overall increase in the prevalence of antibiotic-resistant strains. Systemic adverse events were more common with the two oral antibiotics. Local irritation was more common with the topical treatments, particularly benzoyl peroxide. Residual acne was present in most participants (95%) at the end of the study.

CONCLUSIONS

The response of mild to moderate inflammatory acne to antimicrobial treatment in the community is not optimal. Only around half to two-thirds of trial participants reported at least a moderate improvement over an 18-week study period; extending treatment beyond 12 weeks increased overall benefit slightly. Around one-quarter dropped out when using such treatments, and 55% sought further treatment after 18 weeks. Topical antimicrobial therapies performed at least as well as oral antibiotics in terms of clinical efficacy. Benzoyl peroxide was the most cost-effective and minocycline the least cost-effective therapy for facial acne. The efficacy of all three topical regimens was not compromised by pre-existing propionibacterial resistance. Benzoyl peroxide was associated with a greater frequency and severity of local irritant reactions. It is suggested that the use of a combination of topical benzoyl peroxide and erythromycin gives less irritation and better quality of life. There was little difference between erythromycin plus benzoyl peroxide administered separately and the combined proprietary formulation in terms of efficacy or local irritation, except that the former was nearly three times more cost-effective. The data on cost-effectiveness, and outcomes in patients with resistant propionibacterial floras, did not support the first line use of minocycline for mild to moderate inflammatory acne of the face. Three priority areas for clinical research in acne are: defining end-points in acne trials (i.e. what is a satisfactory outcome?); developing and validating better patient-based measures for assessing treatment effects on facial and truncal acne; and exploring patient characteristics that may modify treatment effects (efficacy and tolerability).

Potential of current perennial plant-based farming systems to deliver salinity management outcomes and improve prospects for native biodiversity: a review

Existing perennial plant-based farming systems are examined within 4 climatic zones in southern Australia (western winter rainfall, south-eastern low to medium rainfall, south-eastern high rainfall and northern summer rainfall) to assess their potential to improve the management of dryland salinity. If profit is to be the primary driver of adoption, it appears that the available options (lucerne and other perennial pastures, farm forestry, saltland pastures and forage shrubs) will fall short of existing hydrological targets with the exception of the higher rainfall zones. In the 3 eastern zones, the need to preserve fresh water flows to permanent river systems places limitations on the use of perennial plants, while the higher proportion of regional groundwater flow systems increases response times and heightens the need for regional coordination of effort. In the western zone, the prevalence of local and intermediate ground water flow systems increases effectiveness of individual action. Research into new perennial land use systems has been characterised by an emphasis on water use over profit resulting from poor dialogue between paddock, farm and catchment scales. Exploring the water use implications of land use systems that are potentially viable at farm scale is a more promising approach than focusing on the opportunity cost of catchment scale intervention. Perennial plant-based farming systems present both threats and opportunities to native biodiversity. The major threat is the introduction of new environmental weeds. The opportunities are potential improvements in vegetative cover, food sources and habitat for the native biota, but only where nature conservation goals can influence the structural complexity, composition and location of new land use systems.

Randomised controlled trial of an occupational therapy intervention to increase outdoor mobility after stroke

OBJECTIVE

To evaluate an occupational therapy intervention to improve outdoor mobility after stroke.

DESIGN

Randomised controlled trial.

SETTING

General practice registers, social services departments, a primary care rehabilitation service, and a geriatric day hospital.

PARTICIPANTS

168 community dwelling people with a clinical diagnosis of stroke in previous 36 months: 86 were allocated to the intervention group and 82 to the control group.

INTERVENTIONS

Leaflets describing local transport services for disabled people (control group) and leaflets with assessment and up to seven intervention sessions by an occupational therapist (intervention group).

MAIN OUTCOME MEASURES

Responses to postal questionnaires at four and 10 months: primary outcome measure was response to whether participant got out of the house as much as he or she would like, and secondary outcome measures were response to how many journeys outdoors had been made in the past month and scores on the Nottingham extended activities of daily living scale, Nottingham leisure questionnaire, and general health questionnaire.

RESULTS

Participants in the treatment group were more likely to get out of the house as often as they wanted at both four months (relative risk 1.72, 95% confidence interval 1.25 to 2.37) and 10 months (1.74, 1.24 to 2.44). The treatment group reported more journeys outdoors in the month before assessment at both four months (median 37 in intervention group, 14 in control group: P < 0.01) and 10 months (median 42 in intervention group, 14 in control group: P < 0.01). At four months the mobility scores on the Nottingham extended activities of daily living scale were significantly higher in the intervention group, but there were no significant differences in the other secondary outcomes. No significant differences were observed in these measures at 10 months.

CONCLUSION

A targeted occupational therapy intervention at home increases outdoor mobility in people after stroke.

Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema

OBJECTIVE

To determine whether a three day burst of a potent corticosteroid is more effective than a mild preparation used for seven days in children with mild or moderate atopic eczema.

DESIGN

Randomised, double blind, parallel group study of 18 weeks' duration.

SETTING

13 general practices and a teaching hospital in the Nottingham area.

PARTICIPANTS

174 children with mild or moderate atopic eczema recruited from general practices and 33 from a hospital outpatient clinic.

INTERVENTIONS

0.1% betamethasone valerate applied for three days followed by the base ointment for four days versus 1% hydrocortisone applied for seven days.

MAIN OUTCOME MEASURES

Primary outcomes were total number of scratch-free days and number of relapses. Secondary outcomes were median duration of relapses, number of undisturbed nights, disease severity (six area, six sign atopic dermatitis severity scale), scores on two quality of life measures (children's life quality index and dermatitis family impact questionnaire), and number of patients in whom treatment failed in each arm.

RESULTS

No differences were found between the two groups. This was consistent for all outcomes. The median number of scratch-free days was 118.0 for the mild group and 117.5 for the potent group (difference 0.5, 95% confidence interval -2.0 to 4.0, P=0.53). The median number of relapses for both groups was 1.0. Both groups showed clinically important improvements in disease severity and quality of life compared with baseline.

CONCLUSION

A short burst of a potent topical corticosteroid is just as effective as prolonged use of a milder preparation for controlling mild or moderate atopic eczema in children.

Fine-needle aspiration biopsy diagnosis of gastrointestinal stromal tumors using morphology, immunocytochemistry, and mutational analysis of c-kit

BACKGROUND

Differentiating gastrointestinal stromal tumors (GISTs) from other intramural mesenchymal tumors of the GI tract on fine-needle aspiration biopsies (FNABs) is difficult. Recent studies have shown that GISTs are immunophenotypically and genetically distinct. GISTs exhibit consistent immunohistochemical expression of CD-117 (KIT) and often express activating mutations of this protooncogene. The aim of the current study was to employ immunocytochemistry and mutational analysis of the c-kit gene to aid in the diagnosis of GISTs on FNAB.

METHODS

Five endoscopic ultrasound-guided FNABs of gastrointestinal spindle cell neoplasms performed at the Veterans Affairs Medical Center (VAMC) in Portland, Oregon, from 1998-1999 were reviewed. A panel of immunocytochemical stains was performed on each cellblock including CD-117 (KIT), smooth muscle actin (SMA), desmin, S-100, and CD34. Genomic DNA (gDNA) was extracted, and amplification of exons 9, 11, 13 and 17 of c-kit was performed by polymerase chain reaction (PCR) on CD-117 (KIT) and CD34 positive cases. Direct sequencing of amplicons identified the mutations.

RESULTS

Five patients were diagnosed with GISTs based on morphology and immunocytochemical positivity for CD-117 and CD34. PCR analysis of c-kit exon 11 revealed three cases with novel-sized PCR bands in addition to the expected wild-type-sized PCR product. Amplicons from these cases contained an in-frame deletion mutation. One of the two cases with wild-type-;sized exon 11 amplicons was found to be heterozygous for a point mutation producing an amino acid substitution (W557R). No mutations in exon 9, 11, 13, or 17 of c-kit were found in the remaining case.

CONCLUSIONS

Ancillary techniques such as immunocytochemistry and c-kit gene mutational analysis may aid in the diagnosis of GISTs on FNABs.

'Change to cup': an audit to determine parental awareness and practices in changing from bottle to cup

BACKGROUND

It is recommended that infants from the age of 6 months should be introduced to drinking from a cup and the use of a bottle should be actively discouraged after the age of 1 year. The number of young children using a feeder bottle after the age of 1 year is not known but it is recognized by health professionals as a 'growing' concern.

AIMS

To obtain local information about the number of children using a bottle past the age of 1 year, what fluids were being offered and to assess parental awareness about when a cup can be introduced.

METHODS

The study data was collected by questionnaire from 407 parents between June 1998 and January 1999. Socially disadvantaged groups were targeted for the sample group as well as care being taken to include a representative ethnic population.

RESULTS

Ninety-nine per cent of the study infants were below the age of 2 years, with the age range being 12-28 months. Thirty per cent were using only a cup/beaker, 8% of infants still used a bottle only, and 62% used both a bottle and a cup. Drinks/food other than milk and water had been offered from the bottle by 47% of respondents. More than 60% of the parents thought that the age at which the use of a bottle should be discontinued was older than that recommended. Only 18% thought a cup/beaker could be introduced as early as 6 months.

CONCLUSION

The results show that there is a need to actively encourage the use of a cup at an earlier age and to discourage the inappropriate and extended use of a feeder bottle. Barriers to change need to be addressed.

Unlicensed and off label prescribing of drugs in general practice

AIM

To determine the incidence and nature of unlicensed and off label prescribing of drugs for children in general practice.

METHODS

A retrospective analysis of all prescriptions for one year involving children (aged 12 years or under) from a single suburban general practice in the English Midlands. Prescribed drugs were categorised as licensed, unlicensed (without a product licence), or used in an off label way (outside the terms of their product licence).

RESULTS

During 1997 there were 3347 prescription items involving 1175 children and 160 different drugs. A total of 2828 (84. 5%) prescriptions were for licensed medicines used in a licensed way; 10 (0.3%) were for unlicensed medicines; and 351 (10.5%) were licensed medicines used in an off label way. For 158 (4.7%) the information was insufficient to determine licence status.

CONCLUSION

This is the first study to show that a significant number of drugs prescribed for children by general practitioners are off label and highlights the anomalies and inadequacies of drug information for prescribers.

Children are not goldfish--mark/recapture techniques and their application to injury data

OBJECTIVES

Mark/recapture (or capture-recapture) is a simple technique commonly applied to estimate the hypothetical total (including undercount) in a register composed of cases from two or more independent and separately incomplete case lists. This paper seeks to illustrate serious drawbacks in the use of the mark/recapture technique when applied to injuries.

SETTING AND SUBJECTS

Northumbrian children under 15 years of age who were seriously injured in motor vehicle accidents (MVAs) over a five year period ascertained from two data sources: police reports and hospital inpatient records.

METHODS

Individuals (n) appearing in both police (S) and hospital (H) case lists are identified using various matching criteria. The separate and combined influence of age, sex, and casualty class (cyclist, passengers, pedestrians) on the probability of such matching is estimated using multivariate techniques. The hypothetical total incidence of child MVA victims (N) is calculated from N = (S x H)/n.

MAIN OUTCOMES

Estimates of the incidences of "serious" injuries in MVAs under various conditions of stratification and matching. The overall procedure is tested for conformity with accepted criteria for valid use of mark/recapture.

RESULTS

About one third of the 1009 police and 836 hospital records could be exactly matched. There were significant variations in matching proportions by class of accident (pedestrian v passenger v cyclist). This selective recapture or "heterogeneity" was not affected by sex, but was independently influenced by the age of the child. Further uncertainty was introduced when matching criteria were slightly relaxed. Estimates of the total population of children with serious injuries vary accordingly from 1729 to 2743. A number of plausible reasons why these two data sources might not be unbiased or mutually independent samples of the total target population are proposed as explanations for this heterogeneity.

CONCLUSION

This typical example of two sample mark/recapture estimation in an epidemiological setting can be shown to violate virtually all the requirements for valid use of the technique. Very little can be deduced accurately about the scale or characteristics of an unobserved group by the use of mark/recapture applied to two overlapping health event registers.