What is impacting clinical pharmacists' participation in an interprofessional ward round: a thematic analysis of a national survey

The ward round (WR) is an important opportunity for interprofessional interaction and communication enabling optimal patient care. Pharmacists' participation in the interprofessional WR can reduce adverse drug events and improve medication appropriateness and communication. WR participation by clinical pharmacists in Australia is currently limited. This study aims to explore what is impacting clinical pharmacists' participation in WRs in Australian hospitals. A self-administered, anonymous national survey of Australian clinical pharmacists was conducted. This study describes the outcomes from qualitative questions which were analyzed thematically in NVivo-2020 according to Braun and Clarke's techniques. Five themes were constructed: "Clinical pharmacy service structure", "Ward round structure", "Pharmacist's capabilities", "Culture" and "Value". A culture supportive of pharmacist's contribution with a consistent WR structure and flexible delivery of clinical pharmacy services enabled pharmacists' participation in WR. Being physically "absent" from the WR due to workload, workflow, and self-perception of the need for extensive clinical knowledge can limit opportunities for pharmacists to proactively contribute to medicines decision-making with physicians to improve patient care outcomes. Bidirectional communication between the interprofessional team and the pharmacist, where there is a co-construction of each individual's role in the WR facilitates consistent and inter-dependent collaborations for effective medication management.

Innovations in pharmacovigilance studies of medicines in older people

Pharmacovigilance is defined by the World Health Organization as "the science and activities relating to the detection, assessment, understanding and prevention of adverse effects or any other medicine/vaccine related problem". Pharmacovigilance studies are critical for detecting and assessing adverse events of medicines that may not have been observed in clinical trials. This activity is especially important in older people who are often excluded from clinical trials as they have multiple chronic conditions and use multiple medicines for longer durations than the clinical trials. In this narrative review we describe innovative methods in pharmacovigilance studies of medicines in older people that leverage the increasing availability of digital health technologies, electronic health records and real-world health data to identify and quantify medication related harms in older people.

ution of the data and methods in real-world COVID-19 vaccine effectiveness studies on mortality: a oping eview protocol

BACKGROUND

Early evidence on COVID-19 vaccine efficacy came from randomised trials. Many important questions subsequently about vaccine effectiveness (VE) have been addressed using real-world studies (RWS) and have informed most vaccination policies globally. As the questions about VE have evolved during the pandemic so have data, study design, and analytical choices. This scoping review aims to characterise this evolution and provide insights for future pandemic planning-specifically, what kinds of questions are asked at different stages of a pandemic, and what data infrastructure and methods are used?

METHODS AND ANALYSIS

We will identify relevant studies in the Johns Hopkins Bloomberg School of Public Health VIEW-hub database, which curates both published and preprint VE RWS identified from PubMed, Embase, Scopus, Web of Science, the WHO COVID Database, MMWR, Eurosurveillance, medRxiv, bioRxiv, SSRN, Europe PMC, Research Square, Knowledge Hub, and Google. We will include RWS of COVID-19 VE that reported COVID-19-specific or all-cause mortality (coded as 'death' in the 'effectiveness studies' data set).Information on study characteristics; study context; data sources; design and analytic methods that address confounding will be extracted by single reviewer and checked for accuracy and discussed in a small group setting by methodological and analytic experts. A timeline mapping approach will be used to capture the evolution of this body of literature.By describing the evolution of RWS of VE through the COVID-19 pandemic, we will help identify options for VE studies and inform policy makers on the minimal data and analytic infrastructure needed to support rapid RWS of VE in future pandemics and of healthcare strategies more broadly.

ETHICS AND DISSEMINATION

As data is in the public domain, ethical approval is not required. Findings of this study will be disseminated through peer-reviewed publications, conference presentations, and working-papers to policy makers.

REGISTRATION

https://doi.org/10.17605/OSF.IO/ZHDKR.

Non-invasive parameters of autonomic function using beat-to-beat cardiovascular variations and arterial stiffness in hypertensive individuals: a systematic review

PURPOSE

Non-invasive, beat-to-beat variations in physiological indices provide an opportunity for more accessible assessment of autonomic dysfunction. The potential association between the changes in these parameters and arterial stiffness in hypertension remains poorly understood. This systematic review aims to investigate the association between non-invasive indicators of autonomic function based on beat-to-beat cardiovascular signals with arterial stiffness in individuals with hypertension.

METHODS

Four electronic databases were searched from inception to June 2022. Studies that investigated non-invasive parameters of arterial stiffness and autonomic function using beat-to-beat cardiovascular signals over a period of > 5min were included. Study quality was assessed using the STROBE criteria. Two authors screened the titles, abstracts, and full texts independently.

RESULTS

Nineteen studies met the inclusion criteria. A comprehensive overview of experimental design for assessing autonomic function in terms of baroreflex sensitivity and beat-to-beat cardiovascular variabilities, as well as arterial stiffness, was presented. Alterations in non-invasive indicators of autonomic function, which included baroreflex sensitivity, beat-to-beat cardiovascular variabilities and hemodynamic changes in response to autonomic challenges, as well as arterial stiffness, were identified in individuals with hypertension. A mixed result was found in terms of the association between non-invasive quantitative autonomic indices and arterial stiffness in hypertensive individuals. Nine out of 12 studies which quantified baroreflex sensitivity revealed a significant association with arterial stiffness parameters. Three studies estimated beat-to-beat heart rate variability and only one study reported a significant relationship with arterial stiffness indices. Three out of five studies which studied beat-to-beat blood pressure variability showed a significant association with arterial structural changes. One study revealed that hemodynamic changes in response to autonomic challenges were significantly correlated with arterial stiffness parameters.

CONCLUSIONS

The current review demonstrated alteration in autonomic function, which encompasses both the sympathetic and parasympathetic modulation of sinus node function and vasomotor tone (derived from beat-to-beat cardiovascular signals) in hypertension, and a significant association between some of these parameters with arterial stiffness. By employing non-invasive measurements to monitor changes in autonomic function and arterial remodeling in individuals with hypertension, we would be able to enhance our ability to identify individuals at high risk of cardiovascular disease. Understanding the intricate relationships among these cardiovascular variability measures and arterial stiffness could contribute toward better individualized treatment for hypertension in the future.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO ID: CRD42022336703. Date of registration: 12/06/2022.

A Digitally Enabled, Pharmacist service to detecT medicine harms in residential aged care (nursing home) (ADEPT): protocol for a feasibility study

INTRODUCTION

This feasibility study aims to develop and test a new model of practice in Australia using digital technologies to enable pharmacists to monitor early signs and symptoms of medicine-induced harms in residential aged care.

METHODS AND ANALYSIS

Thirty residents will be recruited from an aged care facility in South Australia. The study will be conducted in two phases. In phase I, the study team will work with aged care software providers and developers of digital technologies (a wearable activity tracker and a sleep tracking sensor) to gather physical activity and sleep data, as well as medication and clinical data from the electronic medication management system and aged care clinical software. Data will be centralised into a cloud-based monitoring platform (TeleClinical Care (TCC)). The TCC will be used to create dashboards that will include longitudinal visualisations of changes in residents' health, function and medicine use over time. In phase II, the on-site pharmacist will use the centralised TCC platform to monitor each resident's medicine, clinical, physical activity and sleep data to identify signs of medicine-induced harms over a 12-week period.A mixed methods process evaluation applying the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework will be used to assess the feasibility of the service. Outcome measures include service reach, changes in resident symptom scores (measured using the Edmonton Symptom Assessment System), number of medication adverse events detected, changes in physical activity and sleep, number of pharmacist recommendations provided, cost analysis and proportion of all pharmacists' recommendations implemented at 4-week, 8-week and 12-week postbaseline period.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the University of South Australia's Human Research Ethics Committee (205098). Findings will be disseminated through published manuscripts, conference presentations and reporting to the study funder.

TRIAL REGISTRATION NUMBER

ACTRN12623000506695.

Correlation of frailty assessment metrics in one-year follow-up of aged care residents: a sub-study of a randomised controlled trial

INTRODUCTION

Frailty is increasingly recognised as a dynamic syndrome, with multiple causes, dimensions and consequences. There is little understanding of how those frailty assessment metrics interact over time. The aim of this study was to describe the longitudinal correlation between five frailty metrics, namely multimorbidity, muscular strength, mood alterations, cognitive capacity, and functional capacity in a cohort study of aged care (nursing home) residents.

METHODS

248 aged care residents with Frailty Index at baseline of < 0.4 and no dementia were followed for 12 months. A multimorbidity score and an activity of daily living limitation score were created using individual items of the Frailty Index. Muscular strength was measured by grip strength. Cognitive capacity was measured using the Montreal Cognitive Assessment (MoCA) test. Mood alterations were measured using the anxiety/depression screening question from EQ-5D. We analysed the inter-individual correlation at baseline, association between baseline and future change, and within-individual correlation at baseline, 6 and 12 months.

RESULTS

Population analysis shows that metrics were not associated at baseline. All of the studied metrics at baseline were associated with change in 12 months, with the exception of anxiety/depression scores. Pairwise within-individual correlation was strong between MoCA and grip strength (0.13, p = 0.02) and activity of daily living (- 0.48, p < 0.001), and between activities of daily living and multimorbidity index (0.28, p < 0.001). No within-individual correlation was found between anxiety depression score and other metrics.

CONCLUSION

The results suggest an interdependence between comorbidities, physical capacity, cognition and activities of daily living in aged care residents. Comprehensive measurement of frailty-related metrics may provide improved understanding of frailty progression at later life stages.

Factors influencing pharmacists and pharmaceutical scientists' membership in professional organisations: an international survey

BACKGROUND

Professional organisations exist as international or national organisations, with each country establishing at least one national professional association. There remains a knowledge gap about factors that influence professional organisational involvement of pharmacists and pharmaceutical scientists. This study aims to explore the motivators and barriers of pharmacy professionals holding organisation membership from a global perspective.

METHODS

An online questionnaire was developed and disseminated between May and July 2021. The survey was open to all pharmacists and pharmaceutical scientists. The survey consisted of four sections; demographic information, questions about professional organisations, about the International Pharmaceutical Federation (FIP) and its impact on the members. Data were analysed descriptively.

RESULTS

A total of 1033 complete survey responses were received and included in the analysis. Of all respondents, 761 (73.7%) respondents were current members of a professional organisation and 272 (26.3%) were not members of any professional organisation. Overall, findings demonstrated networking, education, training and professional development opportunities as the main interests and anticipated activities, while the lack of clarity or need to join organisation, time, and financial constraints as the main barriers of pharmacy professionals holding membership. The majority of FIP members are satisfied with current FIP activities, and anticipate further networking opportunities, educational resources and grants made available to members.

CONCLUSIONS

Understanding the perceptions and needs, as well as factors that influence engagement of pharmacists and pharmaceutical scientists is the key to enhancing membership. Professional organisations are highly encouraged to strengthen and target activities according to the identified motivators and barriers.

Pharmacists as patient advocates: A series of case studies illustrating the impacts of a regular pharmacist service in residential aged care (nursing homes)

Background

Medicine-related problems are common in older people living in residential aged care facilities (RACFs). Recognising the significant medicine-related problems, the Australian government has announced a $345 million funding package to employ on-site pharmacists in RACFs starting in 2023. The new on-site pharmacists are to provide a range of clinical services to reduce medicine-related adverse events, promote quality use of medicines, and improve clinical governance and education. Underpinning these services, the authors argue that pharmacists play the critical role as resident advocates.

Objective

This study aims to demonstrate how pharmacists can enhance their advocacy responsibility within and beyond the clinical environment to not only reduce medicine-related adverse events but also improve residents' overall health and quality of life.

Methods

This study uses a case series methodology to demonstrate pharmacists' diverse roles in advocating for residents and their families. The case studies were based on participants enrolled in the Reducing Medicine-Induced Deterioration and Adverse Reactions (ReMInDAR) trial, a randomised controlled trial testing the effects of a regular pharmacist service across the Australian RACFs.

Results

Pharmacists' advocacy ranged from persistence in follow-up with a resident's general practitioner (GP) to ensure the GP was aware that a patient was experiencing bleeding and bruising while on an anticoagulant, to advocating for a new bed for a resident with peripheral oedema who had been sleeping in his chair due to fear of falling out of his current bed.

Conclusions

Our trial focussed on pharmacists serving as the residents' advocate to improve their overall health and quality of life, rather than just addressing a list of medicine-related problems. The pharmacist model used in the ReMInDAR trial supports pharmacists to work to their full scope of practice, helps guide the Australian government's new on-site pharmacist program, and serves as an exemplar pharmacist in aged care model internationally.

Clinical pharmacists' participation in ward rounds in hospitals: responses from a national survey

OBJECTIVES

The inclusion of clinical pharmacists in ward rounds (WRs) can reduce adverse drug events, improve communication and enable collaborative decision-making. The aim of this study is to investigate the level of and factors that influence WR participation by clinical pharmacists in Australia.

METHODS

An online administered, anonymous survey of clinical pharmacists in Australia was conducted. The survey was open to pharmacists aged ≥18 years, who had worked in an Australian hospital in a clinical role in the previous two weeks. It was distributed via The Society of Hospital Pharmacists of Australia and on pharmacist-specific social media threads. Survey questions related to the extent of WR participation and factors that influence WR participation. Cross-tabulation analysis was conducted to determine whether there was an association between WR participation and factors that influence WR participation.

KEY FINDINGS

Ninety-nine responses were included. The level of WR participation by clinical pharmacists in Australian hospitals was low, with only 26/67 (39%) pharmacists who had a WR in their clinical unit actually attending the WR in the previous 2 weeks. Factors that influenced WR participation included having recognition of the role of the clinical pharmacist within the WR team, support from pharmacy management and the broader interprofessional team, and having adequate time and expectation from pharmacy management and colleagues to participate in WRs.

CONCLUSIONS

This study highlights the need for ongoing interventions such as restructuring workflows and increasing the awareness of the role of a clinical pharmacist in WR to increase participation of pharmacists in this interprofessional activity.

Prevalence and Preventability of Adverse Medicine Events in a Sample of Australian Aged-Care Residents: A Secondary Analysis of Data from the ReMInDAR Trial

BACKGROUND

Aged care residents are vulnerable to the harmful effects of medicines; however, data on the prevalence and preventability of adverse medicine events in aged care residents are scarce.

AIM

To determine the prevalence and preventability of adverse medicine events in Australian aged care residents.

METHODS

A secondary analysis of data from the Reducing Medicine-Induced Deterioration and Adverse Reactions (ReMInDAR) trial was conducted. Potential adverse medicine events were identified and independently screened by two research pharmacists to produce a short-list of potential adverse medicine events. An expert clinical panel reviewed each potential adverse medicine to determine the likelihood that the event was medicine related (based on the Naranjo Probability Scale criteria). The clinical panel assessed preventability of medicine-related events using Schumock-Thornton criteria.

RESULTS

There were 583 adverse events due to medicines, involving 154 residents (62% of the 248 study participants). There was a median of three medication-related adverse events (interquartile range [IQR] 1-5) per resident over the 12-month follow-up period. The most common medication-related adverse events were falls (56%), bleeding (18%) and bruising (9%). There were 482 (83%) medication-related adverse events that were preventable, most commonly falls (66% of preventable adverse medicine events), bleeding (12%) and dizziness (8%). Of the 248 residents, 133 (54% of the cohort) had at least one preventable adverse medicine event, with a median of 2 (IQR 1-4) preventable adverse medicine events per resident.

CONCLUSION

In total, 62% of aged care residents in our study had an adverse medicine event and 54% had a preventable adverse medicine event in a 12-month period.

How are groups of early career pharmacists and pharmaceutical scientists contributing to global health and policy development: A cross-sectional survey

BACKGROUND

Early career pharmacists and pharmaceutical scientist groups (ECPGs) can make valuable contributions to addressing global health challenges and policy development. There is limited information describing their contribution to this topic. This study describes initiatives and activities related to global health and policy development led by ECPGs.

METHODS

An online questionnaire was disseminated between July and October 2020 through the International Pharmaceutical Federation Young Pharmacists Group (FIP YPG) mailing list and its social media network. The survey consisted of questions about ECPGs' involvement in global health and policy development activities. In addition to groups or organisations, the FIP YPG also invited individual pharmacists and pharmaceutical scientists to explore their needs and views on the role of the ECPGs, and themselves as individuals in global health. Data were analysed descriptively.

RESULTS

Thirty national ECPGs across six regions of the World Health Organisation (WHO) participated in the survey. Most of the initiatives led by ECPGs focused on health and wellbeing, quality of education and partnership. The most common activities were webinars, social events and partnerships with other organisations. In terms of global health challenges listed by the WHO, the most common initiatives led by ECPGs were related to medicines access and medicines safety. There was some involvement of early career pharmacists, pharmaceutical scientists, and ECPGs in the policy and regulation in their countries across various topics.

CONCLUSION

To the best of the authors' knowledge, this is the first global study exploring initiatives conducted by ECPGs. This study informed initiatives that have been implemented across regions, which could be useful for other ECPGs to initiate in their country according to their needs and priorities. Fostering engagement and collaboration between ECPGs is encouraged to provide opportunities and share learning across ECPGs, which could accelerate progress towards tackling global health challenges.

Using wrist-worn accelerometers to identify the impact of medicines with anticholinergic or sedative properties on sedentary time: A 12-month prospective analysis

INTRODUCTION

Studies have shown that use of medicines with sedative or anticholinergic properties is associated with a decline in physical function; however, the effects have not been quantified, and it is not known how and which specific physical movements are affected. This prospective study quantified the impact of a change in sedative or anticholinergic load over time on 24-hour activity composition.

METHODS

This study used data collected from a randomised trial assessing an ongoing pharmacist service in residential aged care. The 24-hour activity composition of sleep, sedentary behaviour, light-intensity physical activity, and moderate to vigorous physical activity was derived from 24-hour accelerometry bands. Mixed effect linear models were used to regress the multivariate outcome of 24-hour activity composition on medication load at baseline and at 12 months. A fixed effect interaction between trial stage and medication load was included to test for differing sedative or anticholinergic load effects at the two trial stages.

RESULTS

Data for 183 and 85 participants were available at baseline and 12 months respectively. There was a statistically significant interaction between medication load and time point on the multivariate outcome of 24-hour activity composition (sedative F = 7.2, p < 0.001 and anticholinergic F = 3.2, p = 0.02). A sedative load increase from 2 to 4 over the 12-month period was associated with an average increase in daily sedentary behaviour by an estimated 24 min.

CONCLUSION

As sedative or anticholinergic load increased, there was an increase in sedentary time. Our findings suggest wearable accelerometry bands are a possible tool for monitoring the effects on physical function of sedative and anticholinergic medicines.

TRIAL REGISTRATION

The ReMInDAR trial was registered on the Australian and New Zealand Trials Registry ACTRN12618000766213.

Wrist accelerometer temporal analysis as a prognostic tool for aged care residents: A sub‐study of the ReMInDAR trial

BACKGROUND

Objective measures for screening, prioritizing, and planning care for frail individuals are essential for appropriate aged care provision. This study evaluates metrics derived from actigraphy measures (captured by wrist accelerometer) as a digital biomarker to identify frail individuals at risk of adverse outcomes, including death, hospitalization, and cognitive decline.

METHODS

This was a secondary study using data from a randomized controlled trial assessing the effectiveness of an ongoing pharmacist service in residential aged care facilities. Three metrics are studied and compared: the Frailty Index, the daily time spent in light time activity, and the temporal correlation of the actigraphy signal, measured by detrended fluctuation analysis. The association between actigraphy-derived metrics at baseline and adverse events within 12 months (death, cognitive decline, and hospitalizations) was assessed using logistic regression.

RESULTS

Actigraphy records were available for 213 participants living in aged-care, median age of 85 years. Individuals with higher temporal correlation (activity is less random) were at lower risk of death (Standardized OR: 0.49; 95% CI 0.34, 0.7, p < 0.001) and hospitalization (Standardized OR: 0.57; 95% CI 0.42, 0.77, p < 0.001) in 12 months, but there was no difference in cognitive decline (Standardized OR: 1; 95% CI 0.74, 1.35, p = 0.98). The predictive model that included temporal correlation had an area under the curve of 0.70 (CI 0.60-0.80) for death and 0.64 (CI 0.54-0.72) for hospitalization.

CONCLUSION

Temporal correlation of the actigraphy signal from aged care residents was strongly associated with death and hospitalization, but not cognitive decline. Digital biomarkers may have a place as an objective, accurate, and low-cost patient metric to support risk stratification and clinical planning.

A service evaluation of patient care relating toClostridioides difficile infection (CDI) in Oxford University Hospital NHS Foundation

Introduction

The bacterium Clostridioides difficile (C. difficile) frequently colonises the human intestine. In an adult who is healthy, this organism is relatively harmless. However, disruption of the normal gut flora, which is frequently brought on by the use of antibiotics, can result in Clostridioides difficile (C. difficile) infection (CDI). As a result, C. difficile can grow and produce a toxin that causes diarrhoea. Due to the ease with which C. difficile can be spread in healthcare environments, it is essential to recognise and treat CDI patients as soon as possible and in accordance with best practises.

Aim

This service evaluation aimed to explore and understand how adult inpatients presenting with diarrhoea where (CDI is suspected are managed according to Trust Clostridioides difficile guidelines.

Methods

Purposive sampling of up to 100 adult inpatients presenting with diarrhoea where C. difficile is suspected and the patient has been an in-patient for least 48 hours post sample request. A data collection tool was developed, pilot tested and used to collect patient data from the Oxford University Hospital's Electronic Prescribing Record. Data was analysed using descriptive statistics and the Functional Resonance Analysis Method (FRAM) that involved 1) Identifying and describing key functions relating to the management of patients 2) Identifying variability in performing key functions and 3) Determine the possibility of function resonance. Ethical approval was obtained from University of Reading.

Results

Fifty patient records were accessed. The results showed that many patients had a stool sample sent for review as soon as possible, a clinical review of their condition and where there was the absence of a strong suspicion or strong evidence of C. Difficile a delay in the initiation of empirical therapy. Documentation was an area with poor compliance to guidelines. 50 % had a Bristol stool chart completed before sample sent and after CDI suspected, 60 % had isolation of the patient documented, 47 % had placement of contact precautions documented, and 20 % had documentation of discontinuation of empirical therapy. A FRAM model was developed and a total of 14 functions were identified with three functions “Record Bristol stool charts”, “clinical review of the patient”, and “placement of contact precautions” being most connected to the other functions, demonstrating the significance of these functions in the management of patients who are suspected of having CDI.

Discussion/Conclusion

The three key tasks outlined by FRAM are important to ensure that provide patients with the best care. Understanding variability in how the functions identified in FRAM are performed is important to understand how work is performed in order to then design ways of working that benefits both patients and HCPs. Further work is required to explore this area.

Frailty trajectory over one year among residential aged care (nursing home) residents

Objectives

Large population-based studies examining frailty trajectory found a linear increase in frailty over time. The pattern in which frailty changes over time for an individual person is less well-described. We examined the frailty trajectory of older adults living in aged-care in Australia.

Materials and methods

This secondary study used data from a randomised controlled trial involving 39 aged-care facilities in Australia. The trial intervention was an on-going pharmacist-led intervention occurring every 8 weeks over 12 months aimed at preventing medicine-induced deterioration and adverse reactions. Frailty was assessed using the Frailty Index. Participants were categorised as non-frail, pre-frail and frail. Individual frailty trajectory over 12 months was visualised using the alluvial plot. Case notes were examined to explore reasons for any rapid transitions in frailty status.

Results

A total of 248 participants was included. At baseline, 40.3% were non-frail and 59.7% were pre-frail. The proportion of participants who were non-frail and pre-frail decreased over time; 15.7% were frail at 6 months and 23.4% were frail at 12 months. Overall, twenty different combinations of frailty transitions were identified over 12 months. Retrospective analysis of case notes suggest that death or transition from non-frail to frail was often preceded by hospitalisation, falls, medication change or clinically significant deterioration in grip strength or cognition.

Conclusion

The degree of frailty increased over time, but there were variations in the individual trajectories. Regular monitoring of events that precede changes in frailty status is needed to identify strategies to prevent further deterioration in residents’ conditions.

Correction: Lim et al. Patient-Reported Questionnaires to Identify Adverse Drug Reactions: A Systematic Review. Int. J. Environ. Res. Public Health 2021, 18, 11877

There was an error in the original publication [...].

Medicine-related problems: A recurrent issue among residents living in nursing homes

Aim: To examine the incidence and nature of medicine-related problems over time experienced by nursing home residents.

Method: We analyzed records collected in the Reducing Medicine-Induced Deterioration and Adverse Events (ReMInDAR) trial. The trial pharmacists provided services to reduce medicine-induced deterioration and adverse reactions for residents every 8-weeks over a year. The problems identified by the pharmacists were documented in reports and subsequently classified independently by research pharmacists using the D.O.C.U.M.E.N.T system. The number and type of problems at each service and time to develop a new problem post first session were assessed. All analyses were performed using R software (Version 4.1.1).

Results: The cohort was 115 nursing home residents who received 575 services. In the 12-months, a total of 673 medicine-related problems or symptom reports were identified in 112 residents. Most residents (75%) experienced a new medicine-related problem by the fourth month post the first assessment. After the first session, the proportion of residents with a new medicine-related problem or symptom report declined at each repeated pharmacy session (59% at visit 2 vs. 28% at visit 6, p &lt; 0.01).

Conclusion: Residents living in nursing homes frequently experience medicine-related problems. Our results suggest clinical pharmacist services performed every 4-months may have the potential to reduce the medicine-related problems in nursing homes.

Effect of an ongoing pharmacist service to reduce medicine-induced deterioration and adverse reactions in aged-care facilities (nursing homes): a multicentre, randomised controlled trial (the ReMInDAR trial)

Objective

To assess the effectiveness of a pharmacist-led intervention using validated tools to reduce medicine-induced deterioration and adverse reactions.

Design and setting

Multicenter, open-label parallel randomised controlled trial involving 39 Australian aged-care facilities.

Participants

Residents on ≥4 medicines or ≥1 anticholinergic or sedative medicine.

Intervention

Pharmacist-led intervention using validated tools to detect signs and symptoms of medicine-induced deterioration which occurred every 8 weeks over 12 months.

Comparator

Usual care (Residential Medication Management Review) provided by accredited pharmacists.

Outcomes

Primary outcome was change in Frailty Index at 12 months. Secondary outcomes included changes in cognition, 24-hour movement behaviour by accelerometry, grip strength, weight, adverse events and quality of life.

Results

248 persons (median age 87 years) completed the study; 120 in the interventionand, 128 in control arms. In total 575 pharmacist, sessions were undertaken in the intervention arm. There was no statistically significant difference for change in frailty between groups (mean difference: 0.009, 95% CI: −0.028, 0.009, P = 0.320). A significant difference for cognition was observed, with a mean difference of 1.36 point change at 12 months (95% CI: 0.01, 2.72, P = 0.048). Changes in 24-hour movement behaviour, grip strength, adverse events and quality of life were not significantly different between groups. Point estimates favoured the intervention arm at 12 months for frailty, 24-hour movement behaviour and grip strength.

Conclusions

The use of validated tools by pharmacists to detect signs of medicine-induced deterioration is a model of practice that requires further research, with promising results from this trial, particularly with regards to improved cognition.

Fijian farmers’ attitude and knowledge towards antimicrobial use and antimicrobial resistance in livestock production systems: a qualitative study

Introduction

Antimicrobial resistance (AMR) is a global health issue to humans and livestock (1). To mitigate AMR risks, responsible use of antimicrobials in livestock production systems have been advocated (1). Studies have demonstrated the patterns of antimicrobial use (AMU) in livestock production systems; however, there is limited information on the drivers of AMU. For successful antimicrobial stewardship (AMS), identifying the psychological (knowledge and attitude) and contextual drivers (environmental factors, economic status, and resource accessibility) for intervention is a crucial first step in the agri-food value chain. The theory of planned behaviour (TPB) has been used to understand behaviour influenced by a person’s intention, attitude, and knowledge; therefore, evaluating behaviour allows understanding of drivers that affect and shape the farmers’ intention and decisions (2).

Aim

To explore and understand the attitude and knowledge of Fijian livestock farmers on AMU and AMR.

Methods

Face to face one-to-one semi-structured qualitative interviews were conducted between September and November 2019 with Fijian livestock farmers and managers located in the Central and Western divisions of Viti Levu, Fiji. A sample of at least 20 participants from the cattle and poultry production systems was targeted and recruited using purposive and snowball sampling methods. TPB informed the development of the semi-structured interview guide. The interviews were audio-recorded and analysed inductively using Braun and Clarke’s reflexive thematic analysis and deductively using the TPB framework (results reported elsewhere). An interpretative approach underpinned the design and conduct of this study.

Results

Nineteen livestock farmers and managers took part in interviews. Our analysis generated four themes: 1) Uninformed use of antimicrobials and unaware of AMR, 2) Safeguarding livestock and generating income source as primary motivators for using medicine, 3) Medicine shortage resulting in hoarding and self-prescribing, and 4) Foreign farmers and veterinarians trusted over Fijian veterinarian and para-veterinarian knowledge. Livestock farmers did not differentiate amongst different types of medicine, including antimicrobials. Therefore, antimicrobials were unwittingly used and without an awareness of the risks of AMR. Medicines, including antimicrobials, were used to protect livestock and promote production for food and financial security. Farmers hoarded medicines and self-prescribed them on the farms. Farmers lacked confidence in the advice on livestock management, and medicine use, provided by Fijian veterinarians and para-veterinarians. They sought help online and from foreign farmers and veterinarians. No participant sought advice from pharmacists who are experts in medicine.

Conclusion

This study uncovered the first documented accounts of Fijian livestock farmers’ attitude and knowledge on AMU and AMR. AMS programmes promoting awareness and rational use of antimicrobials and resistance in Fijian livestock production is recommended. These programmes need to consider the social, economic, and environmental factors driving irrational medicine use by farmers. We acknowledge the views shared by participants may not be representative of all farmers in Fiji; however, we believe all participants provided in-depth insight into the current drivers of AMU. Future studies exploring the attitude and knowledge of Fijian veterinarians, para-veterinarians and pharmacists on AMU and AMR in livestock production can inform the design of AMS programmes that currently do not exist.

References

(1) WHO. Antimicrobial Resistance Geneva Switzerland: World Health Organization; 2021 [cited 2021 1 September]. Available from: http://www.who.int/en/news-room/fact-sheets/detail/antimicrobial-resistance.

(2) Ajzen I. The theory of planned behaviour. Organizational Behaviour and Human Decision Processes. 1991;50(2):179-211.

Association between mental illness and blood pressure variability: a systematic review

Background

Mental illness represents a major global burden of disease worldwide. It has been hypothesised that individuals with mental illness have greater blood pressure fluctuations that lead to increased cardiovascular risk and target organ damage. This systematic review aims to (i) investigate the association between mental illness and blood pressure variability (BPV) and (ii) describe methods of BPV measurements and analysis which may affect pattern and degree of variability.

Methods

Four electronic databases were searched from inception until 2020. The quality assessment was performed using STROBE criteria. Studies were included if they investigated BPV (including either frequency or time domain analysis) in individuals with mental illness (particularly anxiety/generalised anxiety disorder, depression/major depressive disorder, panic disorder and hostility) and without hypertension. Two authors independently screened titles, abstracts and full texts. A third author resolved any disagreements.

Results

Twelve studies met the inclusion criteria. Three studies measured short-term BPV, two measured long-term BPV and seven measured ultra-short-term BPV. All studies related to short-term BPV using ambulatory and home blood pressure monitoring found a higher BPV in individuals with depression or panic disorder. The two studies measuring long-term BPV were limited to the older population and found mixed results. Mental illness is significantly associated with an increased BPV in younger and middle-aged adults. All studies of ultra-short-term BPV using standard cardiac autonomic assessment; non-invasive continuous finger blood pressure and heart rate signals found significant association between BPV and mental illness. A mixed result related to degree of tilt during tilt assessment and between controlled and spontaneous breathing were observed in patients with psychological state.

Conclusions

Current review found that people with mental illness is significantly associated with an increased BPV regardless of age. Since mental illness can contribute to the deterioration of autonomic function (HRV, BPV), early therapeutic intervention in mental illness may prevent diseases associated with autonomic dysregulation and reduce the likelihood of negative cardiac outcomes. Therefore, these findings may have important implications for patients' future physical health and well-being, highlighting the need for comprehensive cardiovascular risk reduction.

Development of a web-based system to report medication-related adverse effects: a design and usability study (Preprint)

Background

Medicine use is the most common intervention in health care. The frequency with which medicines are used means medication-related problems are very common. One common type of medication-related problems is adverse drug events, which are unintended and harmful effects associated with use of medicines. Reporting of adverse drug events to regulatory authorities is important for evaluation of safety of medicines; however, these adverse effects are frequently unreported due to various factors, including lack of consumer-friendly reporting tools.

Objective

The aim of this study was to develop a user-friendly digital tool for consumers to report medication-related adverse effects.

Methods

The project consisted of 3 parts: (1) content development, including a systematic literature search; (2) iterative system development; and (3) usability testing. The project was guided by participatory design principles, which suggest involving key stakeholders throughout the design process. The first 2 versions were developed as a mobile app and were tested with end users in 2 workshops. The third version was developed as a web application and was tested with consumers who were taking regular medicines. Consumers were asked to complete a modified version of the mHealth app usability questionnaire (MAUQ), an 18-item questionnaire with each item scored using a 7-point Likert scale ranging from 0 (strongly disagree) to 7 (strongly agree). The MAUQ assessed 3 subscales including ease of use (5 items), interface and satisfaction (7 items), and usefulness (6 items). Continuous variables were reported as mean (SD) values, whereas categorical variables were presented as frequencies (percentages). Data analysis was conducted in Microsoft Excel.

Results

The content for the system was based on a systematic literature search and short-listing of questions, followed by feedback from project team members and consumers. Feedback from consumers in the 2 workshops were incorporated to improve the functionality, visual design, and stability of the third (current) version. The third version of the system was tested with 26 consumers. A total of 79% (N=307/390) of all responses on the MAUQ were scored 6 or 7, indicating that users generally strongly agree with the usability of the system. When looking at the individual domains, the system had an average score of 6.3 (SD 0.9) for “ease of use,” 6.3 (SD 0.8) for “interface and satisfaction,” and 5.2 (SD 1.4) for “usefulness.”

Conclusions

The web-based system for medicine adverse effects reporting is a user-friendly tool developed using an iterative participatory design approach. Future research includes further improving the system, particularly the usefulness of the system, as well as testing the scalability and performance of the system in practice.

The Extent of Medication-Related Hospital Admissions in Australia: A Review from 1988 to 2021

Introduction

Medication-related problems often lead to patient harm. This paper aims to review the Australian literature to determine the overall incidence, severity and preventability of medication-related hospital admissions, as well as providing a national estimate on their extent and cost.

Methods

The first part of the paper includes a literature search to identify studies that provided estimates of medication-related problems that caused hospital admissions. Incidence of medication-related hospital admissions, type of medication-related problem contributing to admission (e.g. adverse medicine reaction) and method used to estimate incidence (e.g. chart review) were extracted. Data on severity and preventability of the admissions were extracted where available. The second part of the paper involves use of methodological triangulation to estimate the extent and cost of medication-related hospital admission. Median estimates used to assess medication-related hospital admissions and the 2019–2020 national hospital admissions data were used to calculate the national estimate on the extent of medication-related hospital admission. Costs were also estimated.

Results

Seventeen studies provided estimates on the extent of medication-related hospital admissions as assessed using medication chart review. The median incidence of 2.5% (interquartile range [IQR] 0.6%) as a proportion of all hospital admissions suggests 275,000 hospital admissions annually in Australia are medication related. The median incidence of 9% (IQR 3.9%) of emergency admissions suggests that 270,000 admissions annually are medication related. Eight studies provided estimates of the extent of medication-related hospital admissions identified from administrative health data; the median incidence of 1.7% with an under-reporting rate of 82% suggests 280,000 hospital admissions annually are medication related. Triangulation of results suggests that at least 250,000 hospital admissions annually in Australia are medication related, with an estimated cost of 1.4 billion Australian dollars (AUD$). Five studies assessed severity, and nine studies assessed preventability. Preventability estimates suggest two-thirds of medication-related hospital admissions are potentially preventable.

Conclusions

We estimated that 250,000 hospital admissions in Australia are medication related, with an annual cost of AUD$1.4 billion to the healthcare system. Two-thirds of medication-related hospital admissions are potentially preventable.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-021-01144-1.

Patient-Reported Questionnaires to Identify Adverse Drug Reactions: A Systematic Review

Background: This systematic review aims to summarise available patient-reported questionnaires to detect adverse drug reactions (ADRs) that can be utilised by healthcare professionals in clinical practice and to summarise the psychometric properties (validity, reliability, and responsiveness) of the questionnaires. Methods: A systematic literature search was conducted using Medline, Pubmed, Embase, and Emcare databases to screen for articles published between January 2000 and July 2020. Data items regarding validity, reliability, and responsiveness were extracted independently by two authors. The methodological quality was assessed using the COSMIN (Consensus-Based Standards for the Selection of Health Measurement Instruments) checklist. Results: A total of 1563 unique article titles were identified after removing duplicates. Following shortlisting of relevant articles, 19 patient-reported ADR questionnaires were identified. Questionnaires most commonly focused on mental health medications (42.1%, n = 8), followed by general questionnaires applicable to any medication (21.1%, n = 4). Many questionnaires did not report assessing the validity and reliability of the measurement tool. For example, only 11 questionnaires (58%) mentioned assessing content validity, in addition to criterion or construct testing. Conclusion: This systematic review summarised the available patient-reported questionnaires that can be used in research and clinical practice to identify ADRs. Results of this systematic review highlight the need for more robust validity and reliability testing when developing patient-reported ADR questionnaires.

Third-generation modular mandible endoprosthesis in Macaca fascicularis

The aim of this study was to develop a third-generation modular mandible endoprosthesis that would experience less stress concentration at its stems compared to earlier generations, thereby minimizing micromotion and achieving long-term stability. In this three-piece modular design, different degrees of movement were incorporated between the endoprosthesis module interfaces. It was hypothesized that this unique feature would minimize stress concentration at the stems and hence promote osseointegration during the early phase of implantation. The endoprosthesis system was made of commercially pure grade 4 titanium, machined and surface-treated, then sterilized and implanted in segmental mandible defects of nine Macaca fascicularis. Clinical, radiological, histological, and histomorphometric evaluations were performed 4 months post-implantation. The endoprosthesis systems with a degree of movement incorporated, exhibited superior performance compared to the rigid system: 30.9-34.8 times higher percentage bone-implant contact (P< 0.0001) and 3.4-4.1 times higher percentage bone area (P<0.0001), with osseointegration noted at the posterior stems. However, fibrous tissue encapsulation was noted around the majority of the anterior stems in all groups. Although the degree of movement was favourable for improving bone healing and stability of the endoprosthesis system, more work needs to be done to investigate other strategies to further reduce loading on the endoprosthesis to achieve predictable osseointegration at the stems.

Effects of vitamin E on stroke: a systematic review with meta-analysis and trial sequential analysis

There are several previous studies on the association of vitamin E with prevention of stroke but the findings remain controversial. We have conducted a systematic review, meta-analysis together with trial sequential analysis of randomised controlled trials to evaluate the effect of vitamin E supplementation versus placebo/no vitamin E on the risk reduction of total, fatal, non-fatal, haemorrhagic and ischaemic stroke. Relevant studies were identified by searching online databases through Medline, PubMed and Cochrane Central Register of Controlled Trials. A total of 18 studies with 148 016 participants were included in the analysis. There was no significant difference in the prevention of total stroke (RR (relative risk)=0.98, 95% CI 0.92-1.04, p=0.57), fatal stroke (RR=0.96, 95% CI 0.77-1.20, p=0.73) and non-fatal stroke (RR=0.96, 95% CI 0.88-1.05, p=0.35). Subgroup analyses were performed under each category (total stroke, fatal stroke and non-fatal stroke) and included the following subgroups (types of prevention, source and dosage of vitamin E and vitamin E alone vs control). The findings in all subgroup analyses were statistically insignificant. In stroke subtypes analysis, vitamin E showed significant risk reduction in ischaemic stroke (RR=0.92, 95% CI 0.85-0.99, p=0.04) but not in haemorrhagic stroke (RR=1.17, 95% CI 0.98-1.39, p=0.08). However, the trial sequential analysis demonstrated that more studies were needed to control random errors. Limitations of this study include the following: trials design may not have provided sufficient power to detect a change in stroke outcomes, participants may have had different lifestyles or health issues, there were a limited number of studies available for subgroup analysis, studies were mostly done in developed countries, and the total sample size for all included studies was insufficient to obtain a meaningful result from meta-analysis. In conclusion, there is still a lack of statistically significant evidence of the effects of vitamin E on the risk reduction of stroke. Nevertheless, vitamin E may offer some benefits in the prevention of ischaemic stroke and additional well-designed randomised controlled trials are needed to arrive at a definitive finding. PROSPERO registration number: CRD42020167827.

A cross-sectional assessment of the relationship between sedative medication and anticholinergic medication use and the movement behaviour of older adults living in residential aged care

Objectives

Medications with anticholinergic or sedative effects are frequently used by older people but can increase risk of falls and adverse events; however, less is known about their effect on movement behaviour. Here we examine the cross-sectional association between medication use and movement behaviour in older adults living in residential aged care.

Materials and Methods

Twenty-eight older adults living in residential aged care in metropolitan Australia participated. Medication data were collected from participants’ medical charts and sedative load and anticholinergic burden were determined. Seven-day movement behaviour was objectively assessed by a wrist-worn triaxial accelerometer. Raw accelerations were converted to sleep, sedentary time, and time in light, moderate, and moderate-to-vigorous physical activity. To explore the relationship between medication and movement behaviour, Spearman’s Rho correlations were conducted, as the data were not normally distributed.

Results

Analyses indicated that while anticholinergic burden was not associated with movement behaviour, sedative load was negatively correlated with a number of variables, accounting for 14% variance in moderate-to-vigorous physical activity (MVPA), and 17% in the bout length of MVPA (p < .02).

Conclusion

The findings of this study showed a negative association between sedative load, due to medicines, and an individual’s movement behaviour. The impact of this could be a reduction in the ability of this population to maintain or improve their functional mobility, which may overshadow any benefits of the medicine in some circumstances.

Reducing medicine-induced deterioration and adverse reactions (ReMInDAR) trial: study protocol for a randomised controlled trial in residential aged-care facilities assessing frailty as the primary outcome

INTRODUCTION

Many medicines have adverse effects which are difficult to detect and frequently go unrecognised. Pharmacist monitoring of changes in signs and symptoms of these adverse effects, which we describe as medicine-induced deterioration, may reduce the risk of developing frailty. The aim of this trial is to determine the effectiveness of a 12-month pharmacist service compared with usual care in reducing medicine-induced deterioration, frailty and adverse reactions in older people living in aged-care facilities in Australia.

METHODS AND ANALYSIS

The reducing medicine-induced deterioration and adverse reactions trial is a multicentre, open-label randomised controlled trial. Participants will be recruited from 39 facilities in South Australia and Tasmania. Residents will be included if they are using four or more medicines at the time of recruitment, or taking more than one medicine with anticholinergic or sedative properties. The intervention group will receive a pharmacist assessment which occurs every 8 weeks. The pharmacists will liaise with the participants' general practitioners when medicine-induced deterioration is evident or adverse events are considered serious. The primary outcome is a reduction in medicine-induced deterioration from baseline to 6 and 12 months, as measured by change in frailty index. The secondary outcomes are changes in cognition scores, 24-hour movement behaviour, grip strength, weight, percentage robust, pre-frail and frail classification, rate of adverse medicine events, health-related quality of life and health resource use. The statistical analysis will use mixed-models adjusted for baseline to account for repeated outcome measures. A health economic evaluation will be conducted following trial completion using data collected during the trial.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from the Human Research Ethics Committee of University of South Australia (ID:0000036440) and University of Tasmania (ID:H0017022). A copy of the final report will be provided to the Australian Government Department of Health.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Trials Registry ACTRN12618000766213.

USA Department of Defense audit of surgical antibiotic prophylaxis prescribing patterns in inguinal hernia repair

PURPOSE

Antibiotic prophylaxis in inguinal hernia repair (IHR) is contentious in literature and practice. In low-risk patients, for whom evidence suggests antibiotic prophylaxis is unnecessary, many surgeons still advocate for its routine use. This study surveys prescription patterns of Department of Defense (DoD) general surgeons.

METHODS

An anonymous survey was sent electronically to approximately 350 DoD general surgeons. The survey asked multiple-choice and free text answers about prescribing patterns and knowledge of current evidence for low-risk patients undergoing elective open inguinal hernia repair without mesh (OIHRWOM), open inguinal hernia repair with mesh (OIHRWM), or laparoscopic inguinal hernia repair (LIHR).

RESULTS

110 DoD general surgeons consented to participate. 58.6, 95 and 84.2% of surgeons always administer antibiotic prophylaxis in OIHRWOM, OIHRWM, and LIHR, respectively. 37.9, 70.9, and 63.2% of surgeons believe that it reduces rates of surgical site infection in OIHRWOM, OIHRWM, and LIHR, respectively. The most common reasons for empirically prescribing antibiotic prophylaxis include "I think the evidence supports it" (27 of 72 responses), "I would rather be conservative and safe" (15 of 72 responses), and "I am following my hospital/department guidelines" (9 of 72 responses). 11.8, 40.8, and 32.9% of surgeons believe current evidence supports antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively. 50, 18.4, and 22.4% of surgeons believe current evidence refutes antibiotic prophylaxis use in OIHRWM, OIHRWOM, and LIHR, respectively.

CONCLUSION

The survey results indicate that the majority of practicing DoD general surgeons still empirically prescribe surgical antibiotic prophylaxis in IHR despite more conflicting opinions that it has no meaningful effect or that current evidence does not supports its use.

Association of blood mercury levels with nonmelanoma skin cancer in the U.S.A. using National Health and Nutrition Examination Survey data (2003-2016)

BACKGROUND

Some studies have reported increased incidence or mortality of lung and brain cancers associated with occupations involving potential mercury exposure. Epidemiological evidence related to skin cancer is also limited.

OBJECTIVES

To investigate the association between blood mercury (Hg) levels and nonmelanoma skin cancer (NMSC).

METHODS

We used National Health and Nutrition Examination Survey data from 2003 to 2016. The exposures were blood total (tHg), inorganic (iHg) and methylmercury (MeHg). The outcome was a self-reported diagnosis of NMSC. We included participants aged ≥ 20 years who had information on blood mercury and sociodemographic factors. We conducted a logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risk of NMSC associated with quartiles of blood Hg, after adjusting for the sociodemographic factors and survey year.

RESULTS

The number of participants was 29 413; mean age was 49 years and 52% were female. Compared with those with a tHg ≤ 0·47 μg L^-1 (Q1), those with a tHg > 1·74 μg L^-1 (Q4) had nearly double the odds of NMSC (OR 1·79, 95% CI 1·19-2·71; P_trend = 0·004). Similarly, those in the highest quartile of MeHg (> 1·44 μg L^-1 ) had 1·7 times greater odds of NMSC (OR 1·74, 95% CI 1·13-2·70; P_trend = 0·01) than those in the lowest quartile (≤ 0·21 μg L^-1 ). iHg levels were nonsignificantly positively associated with NMSC (P_trend = 0·08).

CONCLUSIONS

We found that higher blood tHg and MeHg levels were associated with a higher prevalence of NMSC. Linked Comment: Taylor. Br J Dermatol 2020; 183:413-414.

A review of efferent cholinergic synaptic transmission in the vestibular periphery and its functional implications

It has been over 60 years since peripheral efferent vestibular terminals were first identified in mammals, and yet the function of the efferent vestibular system remains obscure. One reason for the lack of progress may be due to our deficient understanding of the peripheral efferent synapse. Although vestibular efferent terminals were identified as cholinergic less than a decade after their anatomical characterization, the cellular mechanisms that underlie the properties of these synapses have had to be inferred. In this review we examine how recent mammalian studies have begun to reveal both nicotinic and muscarinic effects at these terminals and therefore provide a context for fast and slow responses observed in classic electrophysiological studies of the mammalian efferent vestibular system, nearly 40 years ago. Although incomplete, these new results together with those of recent behavioral studies are helping to unravel the mysterious and perplexing action of the efferent vestibular system. Armed with this information, we may finally appreciate the behavioral framework in which the efferent vestibular system operates.

Nursing teamwork in the care of older people: A mixed methods study

Healthcare is increasingly complex and requires the ability to adapt to changing demands. Teamwork is essential to delivering high quality care and is central to nursing. The aims of this study were to identify the processes that underpin nursing teamwork and how these affect the care of older people, identify the relationship between perceived teamwork and perceived quality of care, and explore in depth the experience of working in nursing teams. The study was carried out in three older people's wards in a London teaching hospital. Nurses and healthcare assistants completed questionnaires (n = 65) on known dynamics of teamwork (using the Nursing Teamwork Survey) together with ratings of organisational quality (using an adapted AHRQ HSPS scale). A sample (n = 22; 34%) was then interviewed about their perceptions of care, teamwork and how good outcomes are delivered in everyday work. Results showed that many care difficulties were routinely encountered, and confirmed the importance of teamwork (e.g. shared mental models of tasks and team roles and responsibilities, supported by leadership) in adapting to challenges. Perceived quality of teamwork was positively related to perceived quality of care. Work system variability and the external environment influenced teamwork, and confirmed the importance of team adaptive capacity. The CARE model shows the centrality of teamwork in adapting to variable demand and capacity to deliver care processes, and the influence of broader system factors on teamworking.

Analysis of anticholinergic and sedative medicine effects on physical function, cognitive function, appetite and frailty: a cross-sectional study in Australia

OBJECTIVE

To test the association between use of medicines with anticholinergic or sedative properties and physical function, cognitive function, appetite and frailty.

DESIGN, SETTING AND PARTICIPANTS

This cross-sectional study analysed baseline data collected as part of the Australian Longitudinal Study of Ageing, a population-based cohort of 2087 participants aged 65 years or over living in South Australia.

MAIN OUTCOME MEASURES

Physical function was measured at baseline using measures including hand grip strength, walking speed, chair stands, activities of daily living and instrumental activities of daily living (IADL). Cognitive function was measured using Mini-Mental State Examination. Appetite was measured using Center for Epidemiologic Studies Depression question 2. Frailty was measured using frailty index. The association between use of anticholinergics or sedatives and physical or cognitive function, appetite, or frailty was assessed using analysis of covariance and ordinal or binary logistic regression.

RESULTS

Almost half of the population were using anticholinergics or sedatives (n=954, 45.7%). Use of anticholinergics was significantly associated with poorer grip strength, slower walking speed, poorer IADL and poorer appetite. Use of sedatives was significantly associated with poorer grip strength, slower walking speed and poorer IADL. We found no significant association between medicine use and cognitive function. Users of anticholinergics or sedatives were significantly more likely to be frail compared with non-users.

CONCLUSION

Use of medicines with anticholinergic or sedative properties is significantly associated with poorer physical function, poorer appetite and increased frailty. Early identification of signs and symptoms of deterioration associated with medicine use is particularly important in older people so that worsening frailty and subsequent adverse events are prevented.

Impact of myocardial infarction on intraventricular vortex and flow energetics assessed using computational simulations

Flow energetics have been proposed as early indicators of progressive left ventricular (LV) functional impairment in patients with myocardial infarction (MI), but its correlation with individual MI parameters has not been fully explored. Using electro-fluid-structure interaction LV models, this study investigated the correlation between four MI parameters: infarct size, infarct multiplicity, regional enhancement of contractility at the viable myocardium area (RECVM), and LV mechanical dyssynchrony (LVMD) with intraventricular vortex and flow energetics. In LV with small infarcts, our results showed that infarct appearance amplified the energy dissipation index (DI), where substantial viscous energy loss was observed in areas with high flow velocity and near the infarct-vortex interface. The LV with small multiple infarcts and RECVM showed remarkable DI increment during systole and diastole. In correlation analysis, the systolic kinetic energy fluctuation index (E') was positively related to ejection fraction (EF) (R²  = 0.982) but negatively correlated with diastolic E' (R²  = 0.970). Diastolic E' was inversely correlated with vortex kinetic energy (R²  = 0.960) and vortex depth (R²  = 0.876). We showed an excessive systolic DI could differentiate infarcted LV with normal EF from healthy LV. Strong flow acceleration, LVMD, and vortex-infarct interactions were predominant factors that induced excessive DI in infarcted LVs. Instead of causing undesired flow turbulence, high systolic E' suggested the existence of energetic flow acceleration, while high diastolic E' implied an inefficient diastolic filling. Thus, systolic E' is not a suitable early indicator for progressive LV dysfunction in MI patients, while diastolic E' may be a useful index to indicate diastolic impairment in these patients.

Making global river ecosystem health assessments objective, quantitative and comparable

Assessing and comparing global river ecosystem health in an objective and quantitative way remains a major challenge. In this study the widely-used semi-quantitative methods Rapid Biological assessment Protocols (RBPs) was used to determine the health of rivers. The findings were then compared to the results derived from our new UAV (Unmanned aerial vehicles) orthophotographic imagery method. This method quantitatively and objectively assesses river ecosystem health. As a comparison, our method was used to quantitatively measure distance and areas of a range of hydrological and biological attributes thus improving the accuracy of distance- and area-related indices, consequently avoiding subjective errors in these estimations that is fraught in methods like the RBPs. To strengthen the objectivity of the assessment the weights of these indices were objectively determined using the entropy weighting method. This new method was then tested using 9551 UAV orthophotographs taken over six field campaigns. It performed satisfactorily, showing that in our study area the health status of mountain rivers was the best with the highest score of 0.94 out of 1.0. Temporally, the health of the river was better in summer (0.65) compared with that in autumn (0.40). Changes in river ecosystem health were driven by variations in biology and water quality. In contrast the outputs of RBPs, especially in relation to distance and area indices, had ~ 20% uncertainty due to visual errors and subjectivity in estimations by observers. The UAV orthophotographic imaging method proposed in this study can improve the ability to compare the health of rivers across different periods and regions throughout the globe.