Making community pharmacies psychologically informed environments: a pilot study to improve delivery of care for people with a drug problem

Introduction

Community pharmacies are key in the delivery of care to people who use drugs (PWUD), providing specialist harm reduction, and treatment interventions such as naloxone, Injecting Equipment Provision and opiate replacement treatment. PWUD are disproportionately burdened with mental ill-health and frequently report trauma history which impacts on engagement. A successful approach in the homeless sector, is that of Psychologically Informed Environments (PIE). The core elements of a PIE are: creating a space which engenders a sense of safety and wellbeing; reflective practice so staff can develop a shared model of working; training and support for staff; and considering the therapeutic aspects of service provision to vulnerable people (1).

Aim

This pilot study tested training pharmacy staff in applying a psychologically informed environments approach to improve the delivery of care to PWUD.

Methods

Three pharmacies were recruited from those with high involvement with PWUD. A range of location and type of pharmacy were included. Whole pharmacy teams were invited to an evening training session. Bespoke training was provided by clinical psychologists with PIE expertise.

Training was assessed by anonymous quantitative questionnaires using rating scales. Changes in the attitudes of staff were assessed by questionnaire before and 6 months after training. Descriptive statistics were applied. Qualitative interviews with staff at 6 months (planned for 3 months) explored what changes, were made after PIE training to adapt the delivery of care. The study used peer researcher-led telephone interviews for patient/client feedback on observed changes and experiences in participating pharmacies. Recruitment was via the three pharmacy teams due to covid restrictions. Thematic analysis was applied to qualitative data. Normalisation Process Theory provided a framework for assessing change.

Results

Three pharmacies (16 staff) participated. Training evaluation was positive; all participants rating training structure and delivery as very good or excellent. Covid-19 lockdowns restricted follow-up data collection which took place at six months rather than three. Attitude scores were positive (>0) for all participants at baseline (median 15.0) increasing to 20.0 at 6 months. This was not statistically significant (S=4, p=0.549).

Staff interviews revealed training had encouraged staff to reflect on communication and considered the impact of current practice which could be discriminatory e.g. their use of first names, use of private areas and level of explanation to people. The increased mental health challenges for patients from Covid-19 restrictions gave an opportunity for staff to apply their new skills to this patient group and others who were struggling with isolation, as staff across pharmacies noted mental health challenges for patients. Five patients from two pharmacies were interviewed but time delays in data collection meant changes in delivery of care were difficult to recall.

Conclusion

The study was limited by small sample size and covid-related delays. However, findings indicated that training whole pharmacy teams in PIE was well received and justifies a larger study. The approach allowed staff to reflect on practice and identify previous, potentially discriminatory practice. The importance of clear and compassionate communication was evident.

Reference

(1) Johnson R, Haigh R. Social psychiatry and social policy for the 21st century ‐ new concepts for new needs: the ‘psychologically‐informed environment.’ Ment Heal Soc Incl. 2010;14(4):30–5.

β-eye: A benchtop system for in vivo molecular screening of labeled compounds

Preclinical nuclear molecular imaging speeds up the mean time from synthesis to market, in drug development process. Commercial imaging systems have in general high cost, require high-cost service contracts, special facilities and trained staff. In the current work, we present β-eye, a benchtop system for in vivo molecular screening of labeled compounds with Positron Emission Tomography (PET) isotopes. The developed system is based on a dual-head geometry, offering simplicity and decreased cost. The goal of the design is to provide 2D, real-time radionuclide images of mice, allowing the recording of fast frames and thus perform fast kinetic studies, with spatial resolution of ∼2 mm. Performance evaluation demonstrates the ability of β-eye to provide quantitative results for injected activities lower than 1.5 MBq, which is adequate for pharmacodynamic studies in small mice.

Process and Outcome Evaluation of a Mindfulness-Based Cognitive Therapy Intervention for Cisgender and Transgender African American Women Living with HIV/AIDS

There is a need for evidence-based contextualized mental health interventions for persons living with HIV/AIDS. In the current study, the primary researcher conducted open trials with African American women living with HIV/AIDS (AAWLWHA) to examine the acceptability and feasibility of Project UPLIFT, a mindfulness-based cognitive therapy intervention that has demonstrated effectiveness in persons living with epilepsy. Women were recruited for a tele-delivered phone intervention group separated by gender identity, as well as participated in pre- and post-test assessments. Additionally, data on acceptability was collected. Both cis- and transgender women were highly satisfied with the intervention and demonstrated improvement in depressive and stress symptoms. The intervention seemed to be particularly feasible for cisgender women, though more qualitative mental health research may be warranted with transgender women. The current research has implications for the utility of mindfulness-based interventions such as UPLIFT, with AAWLWHA.

Endometrial development during the transition to menopause: preliminary associations with follicular dynamics

Objective: This study aimed to test the hypothesis that the development of functional luteal phase dominant follicles (LPDFs) is associated with increased endometrial growth as women transition to menopause.Methods: Endometrial thickness (ET), follicle development, and hormone production were characterized in ovulatory women of mid-reproductive age (MRA; 18-35 years, n = 10) and advanced reproductive age (ARA; 45-55 years, n = 16). Transvaginal ultrasonography was conducted every 1-3 days during one interovulatory interval to quantify ET and the diameters of follicles ≥2 mm. Blood was drawn at each visit to measure progesterone, estradiol, inhibin A, follicle stimulating hormone, and luteinizing hormone.Results: In the MRA group, ET was lower (8.87 vs. 10.1 mm) in women with typical versus no LPDFs, in association with greater luteal phase estradiol (91.1 vs. 48.8 ng/l). In the ARA group, luteal phase endometrial growth was greater (12.0 vs. 10.4 mm) in women with typical versus no LPDFs, in association with lower progesterone (10.7 vs. 13.8 μg/l; LPDF effect p < 0.1) and inhibin A (35.6 vs. 51.17 ng/l; p < 0.10).Conclusions: Preliminary findings suggest that ET may be increased in women who develop LPDFs, in association with reduced luteal phase progesterone and inhibin A, during the transition to menopause. Continued research is required to confirm these findings.

An in vivo demonstration of efficacy and acute safety of burst wave lithotripsy using a porcine model

Burst wave lithotripsy (BWL) is a new non-invasive method for stone comminution using bursts of sub-megahertz ultrasound. A porcine model of urolithiasis and techniques to implement BWL treatment has been developed to evaluate its effectiveness and acute safety. Six human calcium oxalate monohydrate stones (6-7 mm) were hydrated, weighed, and surgically implanted into the kidneys of three pigs. Transcutaneous stone treatments were performed with a BWL transducer coupled to the skin via an external water bath. Stone targeting and treatment monitoring were performed with a co-aligned ultrasound imaging probe. Treatment exposures were applied in three 10-minute intervals for each stone. If sustained cavitation in the parenchyma was observed by ultrasound imaging feedback, treatment was paused and the pressure amplitude was decreased for the remaining time. Peak negative focal pressures between 6.5 and 7 MPa were applied for all treatments. After treatment, stone fragments were removed from the kidneys. At least 50% of each stone was reduced to <2 mm fragments. 100% of four stones were reduced to <4 mm fragments. Magnetic resonance imaging showed minimal injury to the functional renal volume. This study demonstrated that BWL could be used to effectively fragment kidney stones with minimal injury.

Impact of stone characteristics on cavitation in burst wave lithotripsy

Non-invasive kidney stone treatments such as shock wave lithotripsy (SWL) and burst wave lithotripsy (BWL) rely on the delivery of pressure waves through tissue to the stone. In both SWL and BWL, the potential to hinder comminution by exciting cavitation proximal to the stone has been reported. To elucidate how different stones alter prefocal cavitation in BWL, different natural and synthetic stones were treated in vitro using a therapy transducer operating at 350 kHz (peak negative pressure 7 MPa, pulse length 20 cycles, pulse repetition frequency 10 Hz). Stones were held in a confined volume of water designed to mimic the geometry of a kidney calyx, with the water filtered and degassed to maintain conditions for which the cavitation threshold (in the absence of a stone) matches that from in vivo observations. Stone targeting and cavitation monitoring were performed via ultrasound imaging using a diagnostic probe aligned coaxially with the therapy transducer. Quantitative differences in the extent and location of cavitation activity were observed for different stone types-e.g., "softer" stones (natural and synthetic) that disintegrate into "dusty" fragments produced larger prefocal cavitation clouds. Future work will focus on correlation of such cavitation metrics with stone fragmentation.

Commercial hybrids and mutant genotypes reveal complex protective roles for inducible terpenoid defenses in maize

Plant defense research is facilitated by the use of genome-sequenced inbred lines; however, a foundational knowledge of interactions in commercial hybrids remains relevant to understanding mechanisms present in crops. Using an array of commercial maize hybrids, we quantified the accumulation patterns of defense-related metabolites and phytohormones in tissues challenged with diverse fungal pathogens. Across hybrids, Southern leaf blight (Cochliobolus heterostrophus) strongly elicited specific sesqui- and diterpenoid defenses, namely zealexin A4 (ZA4) and kauralexin diacids, compared with the stalk-rotting agents Fusarium graminearum and Colletotrichum graminicola. With respect to biological activity, ZA4 and kauralexin diacids demonstrated potent antimicrobial action against F. graminearum. Unexpectedly, ZA4 displayed an opposite effect on C. graminicola by promoting growth. Overall, a negative correlation was observed between total analyzed terpenoids and fungal growth. Statistical analyses highlighted kauralexin A3 and abscisic acid as metabolites most associated with fungal suppression. As an empirical test, mutants of the ent-copalyl diphosphate synthase Anther ear 2 (An2) lacking kauralexin biosynthetic capacity displayed increased susceptibility to C. heterostrophus and Fusarium verticillioides. Our results highlight a widely occurring defensive function of acidic terpenoids in commercial hybrids and the complex nature of elicited pathway products that display selective activities on fungal pathogen species.

Community preparedness for highly pathogenic Avian influenza on Bali and Lombok, Indonesia

INTRODUCTION

The Asia-Pacific region is the likeliest location for the next significant outbreak of highly pathogenic avian influenza (HPAI). Indonesia has experienced HPAI H5N1 outbreaks in poultry and humans each year since 2003 and has had the highest case fatality rate for human cases. The purposes of this study were to capture the knowledge of avian influenza and of poultry-raising practices in two regions of Indonesia and to evaluate the impact and extent of activities undertaken to 2010 through the National Strategic Plan for Avian Influenza Control at the village level.

METHODS

A combination of quantitative and qualitative methods was used to investigate the multiple influences on behaviours, decisions and actions taken by poultry-raising households, and by villages and communities, regarding the threat of HPAI. Between June 2010 and May 2011 a structured survey of 400 households was conducted on Lombok and of 402 on Bali, inviting Sector 3 (small-scale independent commercial poultry farms) and Sector 4 (village household) poultry raisers to participate. Focus groups and in-depth interviews were convened with key stakeholders, including livestock and animal health and public health officials, community leaders and villagers.

RESULTS

From the focus group and in-depth interviews, it appears that the flow of information through the national HPAI control program has been efficient at the top levels (from national to provincial, then to districts and subdistricts). However, these findings show that effective transmission of information from subdistrict to rural village level and from village leaders to community members has been limited. The degree of community preparedness for HPAI on Bali and Lombok appears minimal. Knowledge of government activities was more extensive at Bali sites, while only limited government programs and activities occurred at the village level on Lombok. Activities conducted by government agencies from provincial to village level were limited in scope and need to be further developed to ensure safe poultry-handling practices and biosecurity measures. On both Bali and Lombok, community respondents knew the signs and symptoms of sick birds but did not differentiate well between HPAI and other bird diseases. On both islands, more than 60% of respondents were reluctant to report sudden deaths of poultry. The lack of a government compensation program for destroyed flocks contributed to this unwillingness to report.

CONCLUSIONS

While the Indonesian government's planning efforts for HPAI are commendable, the plan has not been effective, as it depends on the cooperative actions of people with small rural farms who have not been consulted in the development of the plan, have not been adequately instructed on the nature of the plan, and perceive no benefits to themselves from prevention efforts. Context-appropriate mechanisms for communicating zoonotic risk and options for risk mitigation that do not result in net loss to poor households are also needed.

Genetic and molecular analyses of UniformMu transposon insertion lines

The UniformMu transposon population is a large public resource for reverse genetics and functional genomics of maize. Users access the collection of UniformMu genetic stocks that are freely distributed by the Maize Cooperation Stock Center using online tools maintained at MaizeGDB.org. Genetic and molecular analyses of UniformMu stocks (UFMu insertion lines) typically require development of genotyping assays that use a gene-specific polymerase chain reaction (PCR) to follow segregation of transposon insertions in genes of interest. Here we describe methods for accessing the resource and recommended protocols for genotyping of transposon insertion alleles.

Placebo-controlled trial of lubiprostone for constipation associated with Parkinson disease

OBJECTIVE

To evaluate the efficacy and tolerability of lubiprostone (Amitiza) for constipation in Parkinson disease (PD) in a double-blind, randomized, controlled study.

METHODS

Patients with PD and clinically meaningful constipation (constipation rating scale score > 10 [range: 0-28]) were recruited from 2 academic movement disorder centers to participate in the study. After enrollment, patients were initially followed for 2 weeks and then were randomly assigned 1:1 to lubiprostone, and the dose was titrated up to 48 μg/day. They returned 4 weeks later for a final assessment. Data included stool diaries and global impressions (co-primary endpoints), demographics, Unified Parkinson's Disease Rating Scale scores, constipation scale scores, visual analog scale (VAS) scores, a stool diary, and adverse events.

RESULTS

Fifty-four subjects (39 male, mean age 67.0 ± 10.1 years, and mean duration of PD 8.3 ± 5.4 years) were randomly assigned to lubiprostone or placebo. One patient in the drug group discontinued the study because of logistics, and one patient in the placebo group discontinued the study because of lack of efficacy. A marked or very marked clinical global improvement was reported by 16 of 25 (64.0%) subjects receiving drug vs 5 of 27 (18.5%) subjects receiving placebo (p = 0.001). The constipation rating scale (p < 0.05), VAS (p = 0.001), and stools per day in the diary (p < 0.001) all improved with drug compared with placebo. Adverse events with drug were mild, most commonly intermittent loose stools.

CONCLUSION

In this randomized controlled trial, lubiprostone seemed to be well tolerated and effective for the short-term treatment of constipation in PD.

Systemic sclerosis and bilateral lung transplantation: a single centre experience

Lung involvement is the leading cause of death in systemic sclerosis (SSc), but lung transplantation (LT) for systemic disease remains controversial. Our objective was to comprehensively evaluate post-LT outcomes for SSc compared to idiopathic pulmonary fibrosis (IPF). We retrospectively evaluated bilateral LT recipients (LTRs) with SSc or IPF at our centre between January 1, 2003 and December 31, 2007. The primary end-point was all-cause mortality at 1 yr post-LT. Secondary end-points included assessments of acute rejection (AR), pulmonary function, infection and chronic rejection. 14 patients with SSc and 38 patients with IPF underwent LT. Apart from a younger SSc cohort (53.2 versus 58.8 yrs; p = 0.02), the two groups were well matched. 1-yr all-cause mortality was no different between SSc (6.6%) and IPF (13.1%) groups, after adjusting for age (p = 0.62). Rates of (AR) ≥2 were significantly increased for the SSc compared with the IPF group (hazard ratio (HR) 2.91; p = 0.007). Other end-points, including chronic rejection, infection and pulmonary function, showed no differences. SSc LTRs experience similar survival 1 yr post-LT when compared to IPF. AR rates may be significantly higher in the SSc group. Longer follow-up is necessary to determine the effects of gastrointestinal dysfunction and AR on late allograft function in SSc LTR.

The incidence and notification of measles in Australia

The incidence of measles in Australia in 1986 was estimated as 43 per 100,000 population, high by the standards of countries where immunization levels are high, low by the standards of countries where immunization levels are low. It is estimated that only 5 per cent of cases are notified in New South Wales, one of only 2 States which require notification. The reasons for this, its significance and a possible remedy are discussed.

Transplant glomerulopathy, late antibody-mediated rejection and the ABCD tetrad in kidney allograft biopsies for cause

To define the relative frequency of phenotypes of transplant glomerulopathy, we retrospectively reviewed the findings in 1036 biopsies for clinical indications from 1320 renal transplant patients followed in our clinics between 1997 and 2005. Transplant glomerulopathy, defined by double contours of glomerular basement membranes (D), was diagnosed in 53 biopsies (5.1%) from 41 patients (3.1%) at a median of 5.5 years post-transplant (range 3.8-381 months). In cases with D, we studied the frequency of circulating anti-HLA alloantibody (A), peritubular capillary basement membrane multilayering (B) and peritubular capillary C4d deposition (C). B was present in 48 (91%) of D biopsies. C4d staining by indirect immunofluorescence was detected in 18 of 50 D biopsies studied (36%). By Flow PRA Screening or ELISA, A was detected in 33 (70%) in 47 D cases with available sera, of which 28/33 or 85% were donor-specific. Class II (13/33) or class I and II (17/33) were more common than class I (3/33) antibodies. Thus 73% of transplant glomerulopathy has evidence of alloantibody-mediated injury (A and/or C), with ABCD and ABD being the common phenotypes in biopsies for cause. The remaining 27%, mostly BD, may be a different disease or a stage in which A and C are undetectable.

The function of RNAi in plant development

The morphological phenotype of mutations in genes required for posttranscriptional gene silencing (PTGS) or RNA interference (RNAi) in Arabidopsis demonstrates that this process is critical for normal development. One way in which RNAi contributes to gene regulation is through its involvement in the biogenesis of trans-acting small interfering RNAs (siRNAs). These endogenous siRNAs are derived from noncoding transcripts that are cleaved by a microRNA (miRNA) and mediate the silencing of protein-coding transcripts. Some protein-coding genes are also subject to miRNA-initiated transitive silencing. Several developmentally important transcription factors regulated by these silencing mechanisms have been identified.

The role of endoscopic sinus surgery in the diagnosis and treatment of metastatic orbital carcinoid tumors

Carcinoid tumor metastatic to the orbit is a rare occurrence. We report such a case in a patient with a carcinoid metastasis that was found in the medial rectus muscle. The diagnosis was established via a transnasal endoscopic approach. We also discuss the treatment of metastatic orbital carcinoid in the hope that we will increase awareness of the utility of transnasal endoscopy in facilitating both the diagnosis and treatment of posteromedial orbital pathology.

The Role of Endoscopic Sinus Surgery in the Diagnosis and Treatment of Metastatic Orbital Carcinoid Tumors

Carcinoid tumor metastatic to the orbit is a rare occurrence. We report such a case in a patient with a carcinoid metastasis that was found in the medial rectus muscle. The diagnosis was established via a transnasal endoscopic approach. We also discuss the treatment of metastatic orbital carcinoid in the hope that we will increase awareness of the utility of transnasal endoscopy in facilitating both the diagnosis and treatment of posteromedial orbital pathology.

Clinico-immunologic aspects of botulinum toxin type B treatment of cervical dystonia

In this multicenter study of 100 patients with cervical dystonia, we examined the immunogenicity of botulinum toxin type B (BTX-B) and correlated the clinical response with the presence of blocking antibodies (Abs) using a novel mouse protection assay. One-third of the patients who were negative for BTX-B Abs at baseline became positive for BTX-B Abs at last visit. Thus, the high antigenicity of BTX-B limits its long-term efficacy.

Effects of 17beta-estradiol on blood-brain barrier disruption during focal cerebral ischemia in younger and older rats

This study was performed to compare the effects of 17beta-estradiol on blood-brain barrier disruption in focal cerebral ischemia between younger and older rats. Younger (three-month-old) and older (24-month-old) ovariectomized female Fischer 344 rats were studied. In one half of each age group, a 500 microg 17beta-estradiol 21-day release pellet and in another half, a vehicle pellet was implanted 21 days before the experiments. One hour after middle cerebral artery occlusion, the transfer coefficient (Ki) of 14C-alpha-aminoisobutyric acid and the volume of 3H-dextran distribution were determined to examine the degree of blood-brain barrier disruption. In all four groups, the Ki in the ischemic cortex was higher than in the corresponding contralateral cortex. There was no significant difference in the Ki in both cortices among the groups. The volume of dextran distribution of the ischemic cortex was only greater than in the corresponding contralateral cortex in the older 17beta-estradiol-treated group, and the volume of that group was greater than the younger 17beta-estradiol-treated group (4.00 +/- 1.29 VS. 2.13 +/- 0.88 ml/100 g). After analyzing the difference in Ki between the ischemic cortex and the contralateral cortex in each animal, the difference was significantly greater in the older 17beta-estradiol-treated rats than the older vehicle-treated rats (3.40 +/- 2.10 VS. 1.26 +/- 1.44 microl/g/min). In the younger rats, however, 17beta-estradiol did not significantly affect the difference. Our data showed that 17beta-estradiol treatment failed to attenuate the BBB disruption in the cerebral ischemic cortex in the older or younger Fischer 344 rats. However, our data also suggest the possibility that 17beta-estradiol could aggravate the BBB disruption in older rats.

Chaos in orbits due to disk crossings

We study orbits of halo stars in simple models of galaxies with disks and halos to see if the cumulative effects of the sudden changes in acceleration that occur at disk crossings can induce chaos. We find that they can, although not in all orbits and not in all potentials. Most of the orbits that become chaotic stay relatively close to the disk and range widely in the radial direction. Heavier disks and increased halo flattening both enhance the extent of the chaos. A limited range of experiments with a three-component model of the Milky Way with an added central bulge finds that many chaotic disk-crossing orbits can be expected in the central regions, and that prolateness of the halo is much more effective than oblateness in generating chaos.

Effects of 17beta-estradiol on blood-brain barrier disruption in focal ischemia during GABA(A) receptor inhibition

We performed this study to determine whether gamma-aminobutyric acid (GABA(A)) receptor inhibition could reverse the effect of 17beta-estradiol on blood-brain barrier (BBB) disruption in focal cerebral ischemia. Young ovariectomized rats were implanted with a 500 microg 17beta-estradiol 21-day release pellet or with a vehicle pellet 21 days before the experiments. Forty-five minutes after middle cerebral artery (MCA) occlusion, half of each group was infused with bicuculline (a GABA(A) receptor antagonist) 1 mg/kg/min for 2 min followed by 0.1 mg/kg/min up to the end of experiments. The other half was infused with the same volume of normal saline. The transfer coefficient (Ki) of 14C-alpha-aminoisobutyric acid and the volume of 3H-dextran distribution (70,000 Daltons) were determined to measure the degree of BBB disruption one hour after MCA occlusion. In the control vehicle-treated animals, the Ki in the ischemic cortex (7.2 +/- 2.6 microl/g/min) was higher than in the contralateral cortex (2.5 +/- 1.4 microl/g/min). After bicuculline infusion, the Ki in the ischemic cortex increased (10.6 +/- 5.4 microl/g/min) although the increase was not statistically significant. In the 17beta-estradiol treated animals, the Ki in the ischemic cortex (3.8 +/- 1.6 microl/g/min) was lower than control vehicle-treated rats. With bicuculline infusion, the Ki in the ischemic cortex (14.5 +/- 6.8 microl/g/min) was markedly increased. In the non-ischemic cortex, there was no significant difference in Ki among the experimental groups. The volume of dextran distribution was not significantly different between the experimental groups in the ischemic or non-ischemic cortex. Our data suggests that part of the reason for the decreased BBB disruption in the focal ischemic area after 17beta-estradiol treatment could be due to the interaction between GABA(A) receptors and 17beta-estradiol.