Medicine shortages--a study of community pharmacies in Finland

OBJECTIVES

To explore the frequency, the reasons behind, and the consequences of medicine shortages in Finnish community pharmacies.

METHODS

During the 27-day study period in the autumn of 2013, randomly selected pharmacies reported on medicines that were in short supply from orders made to wholesalers.

RESULTS

Altogether 129 (66%, n=195) pharmacies participated in the study, and the study material consisted of 3311 report forms. Of the study pharmacies, 79.8% had medicine shortages daily or almost daily. Medicines in short supply were most commonly medicines that affect the nervous system (30.8%) and the cardiovascular system (17.5%). The reason behind the shortage was reported to the pharmacies in 11.2% of the shortage cases. The medicine shortages caused problems for the pharmacies in 33.0% of the cases. In most cases (67.0%) the medicine shortages did not cause problems for the pharmacies, usually because a substitutable product was available (48.5%).

CONCLUSIONS

Medicine shortages are common in Finnish community pharmacies. Medicines in short supply were commonly used medicines. The reason behind the shortage was rarely told to the pharmacies. Medicine shortages caused problems for the pharmacies in one-third of all the shortage cases. These shortages may be significant for the customers or the pharmacies, as they cause customer dissatisfaction and increase the workload of the pharmacy staff.

Robot-assisted radical cystectomy with intracorporeal neobladder diversion: The Karolinska experience

Introduction:

The aim of this report is to describe our surgical technique of totally intracorporeal robotic assisted radical cystectomy (RARC) with neobladder formation.

Materials and Methods:

Between December 2003 and March 2013, a total of 147 patients (118 male, 29 female) underwent totally intracorporeal RARC for urinary bladder cancer. We also performed a systematic search of Medline, Embase and PubMed databases using the terms RARC, robotic cystectomy, robot-assisted, totally intracorporeal RARC, intracorporeal neobladder, intracorporeal urinary diversion, oncological outcomes, functional outcomes, and complication rates.

Results:

The mean age of our patients was 64 years (range 37-87). On surgical pathology 47% had pT1 or less disease, 27% had pT2, 16% had pT3 and 10% had pT4. The mean number of lymph nodes removed was 21 (range 0-60). 24% of patients had lymph node positive dAQ1isease. Positive surgical margins occurred in 6 cases (4%). Mean follow-up was 31 months (range 4-115 months). Two patients (1.4%) died within 90 days of their operation. Using Kaplan-Meier analysis, overall survival and cancer specific survival at 60 months was 68% and 69.6%, respectively. 80 patients (54%) received a continent diversion with totally intracorporeal neobladder formation. In the neobladder subgroup median total operating time was 420 minutes (range 265-760). Daytime continence and satisfactory sexual function or potency at 12 months ranged between 70-90% in both men and women.

Conclusions:

Our experience with totally intracorporeal RARC demonstrates acceptable oncological and functional outcomes that suggest this is a viable alternative to open radical cystectomy.

Host use of a hemiparasitic plant: no trade-offs in performance on different hosts

To examine putative specialization of a hemiparasitic plant to the most beneficial host species, we studied genetic variation in performance and trade-offs between performance on different host species in the generalist hemiparasite, Rhinanthus serotinus. We grew 25 maternal half-sib families of the parasite on Agrostis capillaris and Trifolium pratense and without a host in a greenhouse. Biomass and number of flowers of the parasite were the highest when grown on T. pratense. There were significant interactions between host species and R. serotinus seed-family indicating that the differences in performance on the two hosts and without a host varied among the families. However, we found no significant negative correlations between performance of R. serotinus on the host species or between performance on the two hosts and autotrophic performance. Thus, the genetic factors studied here are not likely to affect the evolution of specialization of R. serotinus to the most beneficial host.

Patients' versus general practitioners' assessments of pain intensity in primary care patients with non-cancer pain

Pain is a major cause for visiting a primary care physician. There are, however, few studies on the assessment of pain patients at the primary care level. The aim of this cross-sectional study was to investigate the concordance between general practitioners' (GPs') and patients' assessments of pain intensity and whether this assessment is influenced by the duration or intensity of pain. Seven hundred and thirty-eight patients aged 16 to 75 years, who were visiting a GP because of pain, participated. Both the patients and the GPs rated pain intensity using the horizontal 100 mm Visual Analogue Scale (VAS). Means and correlations were calculated using non-parametric tests. The VAS scales were arbitrarily divided into five grades (one unit = 20 mm) to investigate the concordance between GPs' and patients' assessments of pain intensity. Spearman 's correlation coefficient between GPs' and patients' assessments was 0.31 for non-chronic pain (of duration less than six months) and 0.20 for chronic pain. GPs evaluated graded pain intensity at least one unit lower than patients in 37% of the visits. In one-fifth of the visits (20.5%), the GP's rating was at least two units lower than the patient's rating. The more severe the pain as assessed by patients, the greater the non-concordance between patients' and GPs' assessments. There was considerable non-concordance between GPs' and patients' assessments of pain intensity. GPs tended to estimate their patients' pain intensity as clinically significantly lower than the patients themselves, particularly in chronic and severe pain.

Variability in prescribing for musculoskeletal pain in Finnish primary health care

OBJECTIVE

To assess primary care physicians' prescribing patterns for musculoskeletal pain in different diagnostic categories.

METHODS

The data were collected in 25 randomly selected health centres, in which a total of 28 physicians took part in the four-week study. Physicians recorded all the medicines they prescribed for patients visiting due to pain. Visits resulting in a diagnosis of musculoskeletal disease or injury were included in this study.

RESULTS

Analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs), were prescribed for 61% of the patients. NSAIDs were prescribed for 46%, topical analgesics for 15% and opioids for 4% of the patients. In general, ibuprofen was the most frequently prescribed drug but back and neck pains were most commonly treated with naproxen. No difference between patients' genders was observed in analgesic prescriptions. Prescribing was associated with patient's age, physician's view on priority of visit, diagnosis and intensity of pain. There was a large variation in prescribing patterns between individual physicians and between different areas of the country.

CONCLUSION

NSAIDs are the prevailing treatment for musculoskeletal pain in Finnish primary health care. Different drugs are favoured according to the diagnosis. The large variability in prescribing patterns cannot be explained solely by the characteristics of pain or patients.

Pain as a reason to visit the doctor: a study in Finnish primary health care

This study aims to demonstrate the prevalence of pain as a reason for seeing a physician in primary care. We also performed an analysis of the localization, duration and frequency of pains, as well as the diagnoses of patients having pain. A total of 28 physicians at 25 health centers in Finland collected the data, comprising 5646 patient visits. Pain was identified as the reason for 2237 (40%) of the visits. The most common localizations were in the lower back, abdomen and head. One-fifth of the pain patients had experienced pain for over six months. Analysis of the diagnoses revealed half of the pains to be musculoskeletal. Patients experienced considerable limitations in various activities of life due to pain. A quarter of the pain patients of active working age received sick leave. Our results confirm that pain is a major primary health care problem, which has an enormous impact on public health.

The feasibility of pain treatment at home after adenoidectomy with ketoprofen tablets in small children

In this study, we investigated the feasibility of pain treatment using ketoprofen 25 mg tablets (5 mg x kg(-1) x day(-1)) at home in children after daycase adenoidectomy. We also determined the adverse events and the incidence of postoperative bleeding during the first week after surgery. Initially, we studied 611 children aged 1-9 years. The study design was prospective, longitudinal, and open. The final data consisted of 555 (91%) children, and 522 children who received ketoprofen at home. The parents administered four (1-10, median with 10th and 90th percentiles) ketoprofen tablets to their children during the first week. A total of 20% of the parents experienced problems in administering tablets, and problems were three times more common in children under 48 months compared to older children. The main problems were swallowing difficulties and the unpleasant taste of the tablet. Neither serious adverse events, nor clinically significant bleeding occurred. Ketoprofen at the dose of 5 mg x kg(-1) x day(-1) proved to be a safe analgesic in children for short-term use after adenoidectomy.

Recovery after paediatric daycase herniotomy performed under spinal anaesthesia

In this prospective survey, recovery in hospital and at home was evaluated in 195 children aged 6 months to 10 years who had undergone herniotomy under spinal anaesthesia as a daycase procedure. Spinal anaesthesia was successful in most of the children, with only two patients being given general anaesthesia. Eighty-three percent of the children had pain at home and 19% had moderate or severe pain. Eighty-five percent of the children needed pain medication at home; the median dose of analgesics was 4 (1-9, 10th and 90th percentiles). Vomiting was noted in two of 195 children in hospital and in 10 of 192 children at home. Eleven children developed a mild position-dependent headache. Most of the children (183/191) recovered their normal daily activities during the first three postoperative days. We conclude that spinal anaesthesia is a safe and effective technique for paediatric herniotomy. Moreover, pain is common following herniotomy and children should be given analgesics for the first two or three postoperative days.

Self-medication with vaginal antifungal drugs: physicians' experiences and women's utilization patterns

BACKGROUND

In many countries, vaginal antifungal drugs have been released on over-the-counter (OTC) markets, yet little is known about women's management of their symptoms.

OBJECTIVES

The aim of this study was to judge the appropriateness of self-medication with vaginal antifungal drugs by examining utilization patterns and physicians' experiences of women's self-medication.

METHODS

An anonymous questionnaire survey was carried out in 20 pharmacies in Finland of women buying OTC vaginal antifungal drugs in 1997. Out of the 453 questionnaires distributed, 299 (66%) were returned. A survey of a random sample of gynaecologists (n = 169) and specialists in general practice (n = 288) was carried out in 1996. The response rate was 77%.

RESULTS

Nearly all women had used vaginal antifungal drugs previously, 49% during the previous 6 months. Most women did not report any difficulties with treatment, but 44% of women used the drug against recommendations. Half of the women had symptoms that are more likely to be related to infections other than Candida. Physicians had observed several disadvantages of self-treatment, with unnecessary use and use for the wrong indications being the most often reported. In all, 31% of gynaecologists and 16% of GPs reported that these adverse events had been clinically significant, with delay in the treatment of other infections being the most common problem.

CONCLUSION

The results raise concerns about inappropriate use and women's ability to self-diagnose correctly. Because vaginal antifungal drugs are likely to remain on OTC markets, two ways to address these concerns are for physicians and pharmacy personnel to provide spontaneous information and to have more informative advertisements on vaginal antifungal drugs.

Training of medical staff positively influences postoperative pain management at home in children

The aim of this study was to describe how parents manage their child's postoperative pain at home following day-case surgery. The incidence of pain, different analgesics used and problems related to administering medications were the main interests of the study. A postal questionnaire was sent to the parents of 275 children who were under 8 years of age and had undergone an ear, nose and throat (ENT) day-case operation. The questionnaire was sent to the parents a week after discharge from hospital. Altogether, the parents of 227 children answered the questionnaire (response rate 83%). The study was divided into two phases (preintervention and postintervention), and incorporated a training program for doctors and nurses between these two phases. The training program aimed to improve the treatment practices of postoperative pain in children. Seventy-eight per cent of the children in the preintervention study and 75% in the postintervention study experienced at least mild pain after discharge. The training program for doctors and nurses affected the home treatment practices of postoperative pain. The proportion of parents treating their children increased from 68% to 80% after the training program (p = 0.028). Many parents faced problems while treating their children; for example, 19% (n = 30) of the children refused to take their medicine, and suppositories were regarded to be an especially unpleasant dosage form. However, no serious adverse effects were reported. We conclude that due to the pain experienced at home by the great majority of children following day-case ENT operations, parents need information on how to manage their child's pain. A training program for doctors and nurses can improve the treatment of children's pain even at home. Since some children dislike suppositories, it would be worth considering the use of small tablets or mixtures instead.

Physicians' attitudes toward reclassifying drugs as over-the-counter

OBJECTIVES

Releasing prescription drugs over-the-counter (OTC) has been a trend in many Western countries. The purpose of this study was to find out about Finnish physicians' attitudes towards OTC switches and to find out whether transfer of drugs that are used in a doctor's own area of specialty increases negative attitudes toward release. For the latter purpose, gynecologists' perceptions about the availability of vaginal antifungal OTC drugs was studied.

METHODS

Postal questionnaire to a representative random sample of gynecologists (n = 169) and general practitioners (GPs) (n = 288) in six counties in Finland in 1996. After a reminder, the response rate was 77% (n = 341). Multivariate logistic regression models were used to explore the relationship of factors to attitudes toward OTC drugs.

RESULTS

The overall attitude toward the availability of OTC drugs was moderately positive but was more reserved toward those drugs only recently given OTC status. However, physicians were judged in many cases to be the most suitable source of information on OTC drugs. GPs working in health centers, more often than other physicians, found drugs suitable for self medication. Our hypothesis about gynecologists being against the release of vaginal antifungal drugs was not supported.

CONCLUSIONS

Physicians' views about OTC drugs are influenced by the current OTC status of the drug and by public discussion. The place of work has an important influence on these opinions, most likely reflecting the effect of case mix and patient load.

The effects of a hospital staff training program on the treatment practices of postoperative pain in children under 8 years

The widespread use of day case surgery for minor operations in children places increased emphasis on home care, parental responsibility and attention to suitable analgesia. This study evaluated a training program for doctors and nurses on postoperative analgesia in children by following up parental perceptions of pain relief after discharge. The main objective of our study was to determine the effects of a training program on treatment practices in the hospital and on the home care instructions provided. The study was carried out in two phases. A questionnaire was sent to parents of children aged under 8 years who had undergone a minor otorhinolaryngological operation (tonsillectomy, adenoidectomy, irrigation of maxillary sinus, insertion of grommets, or paracentesis) at the Day Case Unit in Kuopio University Hospital. The parents of 115 children returned the questionnaire in the preintervention study and those of 112 children in the postintervention study (response rates: 79% and 86% respectively). The training program for personnel (intervention) was organized between the two studies. It started with a one-hour lecture on postoperative pain and pain treatment in children, and the lecture was followed by two weeks of bedside teaching. The overall standard of pain treatment in the hospital was good. Most of the children had no pain or only mild pain on discharge (93% before the intervention and 90% after the intervention). The intervention had no effect on the likelihood of children receiving pain medication. Noticeable changes occurred in the selection of pain medicines and dosage forms, and in the increased number of home care instructions provided for parents. We conclude that the training program for both professional groups (doctors and nurses) can be beneficial in changing the treatment practice (especially the use of medicines and dosage forms). Such training programs also make it possible to emphasized the importance of proper instructions for home care and thus to improve the quality of information provided for parents.

The "questions to ask about your medicines" campaign. An evaluation of pharmacists' and the public's response

OBJECTIVES

The purpose of this study was to assess the impact of the WHO/EuroPharm Forum "Questions to Ask About Your Medicines" campaign on patient counseling in Finnish community pharmacies.

METHODS

The impact of the campaign was assessed by comparing the baseline findings with those at 3 months and 12 months after the implementation. The research methods involved observation of pharmacist-customer interactions, followed by personal interview of the customer.

RESULTS

The main positive outcome was the manner in which information was provided, as the counseling became more customized, more empathy was shown toward the customer, and haste was less obvious. The campaign did not increase the number of customers asking questions, with 6% asking at least one pharmacotherapeutic question throughout the campaign. Information was given mostly on the pharmacists' initiative, with approximately 40% receiving at least some oral counseling, mostly regarding how to use the medicine. Approximately 10% of the customers were provided with written information. No change was observed in the pharmacists' spontaneous provision of oral or written information.

CONCLUSIONS

The campaign was an attempt to set national and local standards for patient counseling in Finnish pharmacies. Further efforts are needed to change the content and availability of counseling.

Pain and activity disturbance after paediatric day case adenoidectomy

Over the past two decades outpatient surgery has become standard practice in paediatric surgery. Adenoidectomy is a common surgical procedure in children. In this prospective survey pain and pain-related outcomes such as sleep and activity disturbance were evaluated in 167 children aged 1-7 years who had undergone adenoidectomy as a day case in Kuopio University Hospital. The survey questionnaire consisted of 76 structured questions about pain, pain medication, adverse effects and daily activities during first week after the operation. Eighty-three per cent of children had pain at home and 17% of them had moderate or severe pain on a four point verbal rating scale. Eighty per cent of children used pain medication at home. Pain medication did not cause any major adverse effects. Over 90% of children were back to normal daily activities during the first three postoperative days and nearly all were able to drink during the whole postoperative period. We conclude that pain is a common problem after adenoidectomy in children but most of the children return to normal activities within three days.

A 1-year follow-up of prescribing patterns of analgesics in primary health care

The prescription of analgesics and anti-inflammatory drugs (analgesics) was studied using computerized patient records from a Finnish health centre with a population base of some 27,000 inhabitants. A random sample of every fifth patient visiting the health centre in 1986 was chosen. This study sample consisted of 4,577 patients with 17,021 physician contacts and altogether 14,035 prescriptions during the 1-year follow-up: of these analgesics comprised 14.8%. The proportion of the study population who received at least one analgesic prescription was 23 +/- 1.2% (95% CI). The use of physician contacts as a base revealed 10.7 +/- 0.5% (95% CI) of the contacts with an analgesic prescription. The exposure to analgesics among males increased with age from 17% for those aged 15-34 years to 34% for those aged 75 years or more. Among women, exposure to analgesics increased from 17% (15-34 years) to 41% (75 years or more). Most of patients who received analgesic prescriptions were incidental users (one or two analgesic prescriptions per year). Only 4% of women and 3% of men were categorized as heavy users of analgesics (seven or more analgesic prescriptions per year). The proportion of heavy users increased with age and was highest in the oldest age-group (75 years or more). In order to make informed policy judgements about drug use in society, we need routine sales statistics and patient-specific drug-use data such as those presented in this paper.

Consumption of analgesics and anti-inflammatory drugs in the nordic countries between 1978-1988

Comparative wholesale statistics from the five Nordic countries show an increase of 15-42% in the total consumption of analgesics and anti-inflammatory drugs (including antirheumatics) in the period 1978-1988. Denmark had the highest total consumption (112 DDD/1000 inhab/day in 1988) and Norway had the lowest (61 DDD/1000 inhab/day). Iceland and Finland, with the highest increases in total consumption (45% and 35%), overtook Norway in the early to mid 1980's. Division of total consumption into subgroups showed that Denmark had the highest consumption of analgesics (90 DDDs) and that Finland and Iceland had the lowest figure. The latter countries, however, had the highest consumption of nonsteroidal anti-inflammatory drugs (NSAID), 35 and 30 DDDs, respectively, in 1988. The increase in NSAID consumption was 57% in Finland and 54% in Iceland, while Denmark had only an 18% increase. The new NSAIDs introduced in the 1970's appear to have increased the overall consumption of pain relievers in the Nordic countries, especially in Finland and Iceland.

Corneal endothelium after photocoagulation in diabetic patients

The corneal endothelium was photographed through a wide-field specular microscope in 38 eyes, in 20 successive diabetic outpatients receiving laser therapy because of underlying proliferative or background retinopathy. Areas of 100 individual endothelial cells from each central cornea were analysed using a digitizer. No statistically significant correlations were observed between mean cell areas or standard deviations of mean and total amount of previous laser energy received. Laser therapy or the type of diabetes did not seem to cause statistically significant changes in the endothelial cell areas examined.

Corneal endothelium in herpetic keratouveitis

The corneal endothelium underwent changes in 15 patients with unilateral herpetic keratouveitis. Study with both noncontact and wide-field specular microscopes showed that six patients had mild and nine patients severe keratouveitis. Transient endothelial changes indicating endotheliitis were observed in all eyes affected by severe keratouveitis. In three cases nonreflecting areas were observed with the specular microscope one to two days earlier than the conventional signs of anterior uveitis. This finding suggests direct herpes simplex virus invasion into endothelial cells that could be followed by an inflammatory cell attack against the endothelium. The eyes that had experienced severe keratouveitis showed marked pleomorphism of the endothelial cells and a 15% lower central endothelial cell density on average than the healthy fellow eyes. In the eyes with mild keratouveitis, the endothelial mosaic showed only a 1.4% lower endothelial cell density.

Herpetic endothelial keratitis. A case report

Corneal endothelial reaction on a 60-year-old male with acute anterior uveitis following typical dendritic keratitis was studied by bio- and specular microscopes. The epithelial dendritic ulcer of the left cornea healed within 10 days with topical trifluorothymidin treatment. Six weeks later the same eye became red and painful and anterior uveitis was diagnosed. Changes in the endothelium suggested that endothelitis was also present. The non-reflecting black endothelial areas were documented as a new sign, by specular microscopy. The black areas disappeared in 3 days with topical trifluorothymidin and corticosteroid treatment. The pathomechanism of these transient black areas is discussed.