Social Prescribing Competence among Community Pharmacists and Pharmacy Students in Norway

Background and aim: Social prescribing, which links patients to non-clinical services and involves general physicians, has been gaining traction. Community pharmacists, who are integral to primary healthcare, have untapped potential in social prescribing. This study explores social prescribing competence among Norwegian community pharmacists and pharmacy students. Method: A cross-sectional study utilizing an anonymous online questionnaire to collect quantitative data was conducted. Inspired by the limited relevant literature, the questionnaire was constructed, pilot-tested, and distributed in a one-week window within a Facebook group for Norwegian pharmacists. The questionnaire comprised 23 questions categorized into demographic details and competence assessment, covering general knowledge, attitude, and barriers/facilitators related to social prescribing. Statistical analyses were employed to determine the competence of the participants. Results: The online questionnaire collected data from 96 participants, primarily females (79.2%), aged 25-34 (40.6%), who were identified as community pharmacists (49.0%). Most (91.7%) worked in community pharmacies, with 31.3% having over 10 years of experience. Despite positive client relationships (93.8%), statistical analysis revealed no significant associations between competence and variables such as work experience, education, or gender. The custom scoring system yielded an average competence score of 1.98 on a 5-point scale, with attitudes and perceptions of participants scoring 3.82. Overall competence was calculated at 3.4, indicating a moderate level. Conclusions: The findings of this study reveal that the participants had limited knowledge regarding social prescribing, emphasizing the need for education. However, the participants showed strong enthusiasm for competence development. This groundwork paves the way for future investigations centered on pilot-testing strategies to boost social prescribing knowledge and engagement among Norwegian community pharmacists and pharmacy students.

Financial analysis of revision knee surgery at a tertiary referral centre as classified according to the Revision Knee Complexity Classification (RKCC)

BACKGROUND

Revision total knee arthroplasty (rTKA) can be complex, with greater costs to the treating hospital than primary TKA. A rTKA regional network has been proposed in England. The aim of this work was to accurately quantify current costs and reimbursement for the rTKA service and to assess whether costs are proportional to case complexity at a tertiary referral centre within the National Health Service (NHS).

METHODS

A review of all rTKA performed at our institution over two consecutive financial years (2017-2019) was performed. Cases were classified according to the Revision Knee Complexity Classification (RKCC) and by mode of failure; "infected" and "non-infected". Financial data was acquired through Patient-Level Information and Costing System (PLICS). The primary outcome was the financial difference between tariff and cost per episode. Comparisons between groups were analysed using analysis of variance and two-tailed unpaired t-test as appropriate.

RESULTS

159 patients underwent 188 rTKA procedures. Length of stay and cost significantly increased between complexity groups (p < 0.0001) and for infected revisions (p < 0.0001). All groups sustained a mean deficit but this significantly increased with revision complexity (from £1,903 to £5,269 per case) and for infected revisions. The total deficit to the Trust for the two-year rTKA service was £667,091.

CONCLUSIONS

The current level of NHS reimbursement are inadequate for centres that offer rTKA and should be more closely aligned to case complexity. An increase in the most complex rTKA at major revision centres will undoubtedly place an even greater strain on the finances of these units.

The cement spacer with multiple indentations: increasing antibiotic elution using a cement spacer 'teabag'

We investigated whether the indentation of bone cement spacers used in revision of infected joint arthroplasty with a MacDonald dissector increased the elution of antibiotic in vitro. A total of 24 cement discs containing either 0.17 g (0.88% w/w), 0.25 g (1.41% w/w), or 0.33 g (1.75% w/w) gentamicin of constant size were made. Of these, 12 were indented with the dissector. Each disc was immersed in ammonium acetate buffer in a sealed container, and fluid from each container was sampled at zero, one, three, six, 24, 48 and 72 hours and at one, and two weeks. The concentration of gentamicin in the fluid was analysed using high performance liquid chromatography mass spectrometry. The fluid sampled at 72 hours from the indented discs containing 0.17 g gentamicin (0.88% w/w) contained a mean of 113 mcg/ml (90.12 to 143.5) compared with 44.5 mcg/ml (44.02 to 44.90) in the fluid sampled from the plain discs (p = 0.012). In discs containing 0.33 g gentamicin (1.75% w/w), the concentration eluted from the indented discs at 72 hours was a mean of 316 mcg/ml (223 to 421) compared with a mean of 118 mcg/ml (100 to 140) from the plain discs (p < 0.001). At two weeks, these significant differences persisted. At nine weeks the indented discs eluted a greater concentration for all gentamicin doses, but the difference was only significant for the discs containing 0.17 g (0.88% w/w, p = 0.006). However if the area under the curve is taken as a measure of the total antibiotic eluted, the indented discs eluted more gentamicin than the plain discs for the 0.17 g (0.88% w/w, p = 0.031), the 0.25 g (1.41% w/w, p < 0.001) and the 0.33 g (1.75% w/w, p < 0.001) discs. When preparing antibiotic spacers for use in staged revision arthroplasty surgery we recommend indenting the spacer with a MacDonald dissector to increase the elution of antibiotic.

The callus fracture sign: a radiological predictor of progression to hypertrophic non-union in diaphyseal tibial fractures

We report a radiological sign which predicts progression to hypertrophic non-union for fractures of the tibial diaphysis. Radiographs of 46 tibial fractures were reviewed independently by four orthopaedic trauma surgeons and two musculoskeletal radiologists. Patients were identified from a database of tibial fractures managed with Ilizarov frame fixation. There were 23 fractures that progressed to non-union requiring further surgery. The controls were 23 fractures that had united without need for further surgery at 1-year follow-up. Radiographs selected were the first images taken following frame removal. All radiographs were anonymised and randomized prior to review. Presence of the callus fracture sign was identified in 16 radiographs of the fractures that progressed to non-union, and 7 of the united fracture group. Sensitivity is 69.6 %. Specificity is 91.4 %. Positive and negative predictive values are 88.9 and 75.0 %, respectively. These results compare favourably with computerised tomography for predicting non-union. Intra- and inter-observer reliability was good (κ = 0.68), and moderate (κ = 0.57), respectively. The callus fracture sign is a useful radiological predictor of progression to non-union and may represent insufficient mechanical stability at the fracture site.

Signalling of DNA damage and cytokines across cell barriers exposed to nanoparticles depends on barrier thickness

The use of nanoparticles in medicine is ever increasing, and it is important to understand their targeted and non-targeted effects. We have previously shown that nanoparticles can cause DNA damage to cells cultured below a cellular barrier without crossing this barrier. Here, we show that this indirect DNA damage depends on the thickness of the cellular barrier, and it is mediated by signalling through gap junction proteins following the generation of mitochondrial free radicals. Indirect damage was seen across both trophoblast and corneal barriers. Signalling, including cytokine release, occurred only across bilayer and multilayer barriers, but not across monolayer barriers. Indirect toxicity was also observed in mice and using ex vivo explants of the human placenta. If the importance of barrier thickness in signalling is a general feature for all types of barriers, our results may offer a principle with which to limit the adverse effects of nanoparticle exposure and offer new therapeutic approaches.

Comparison of Humalog Mix 50 with human insulin Mix 30 in type 2 diabetes patients during Ramadan

AIMS

To compare hypoglycaemic events, glycated haemoglobin (HbA1c) and changes in body weight in Muslim patients with Type 2 diabetes receiving Humalog Mix 50 and human Mixtard 30 twice daily during Ramadan fasting.

METHODS

Data were collected from Muslim patients with Type 2 diabetes attending primary care practices in North-West London, who were on Mixtard 30 insulin twice daily before Ramadan. Group 1 had their evening insulin changed to Humalog Mix 50 (n = 26) 2 weeks before Ramadan, i.e. taking Mixtard 30 at predawn meal and Humalog Mix 50 at the sunset meal during Ramadan. As the major proportion of the daily caloric intake was consumed at the sunset meal, the rationale of switching the evening dose from human Mixtard 30 to Humalog Mix 50 was to provide more rapid-acting insulin that has shorter time of onset and peak time for the large evening meal to improve the postprandial glucose control without increasing the risk of hypoglycaemia. Group 2 continued on Mixtard 30 twice daily (n = 26). All patients received structured education about how to identify and manage hypoglycaemia during Ramadan.

RESULTS

Group 1 had a mean HbA1c reduction of 0.48% (p = 0.0001) before and after Ramadan, whereas group 2 had a mean HbA1c increase of 0.28% (p = 0.007). Group 1 was associated with a small reduction of 0.04 (p = 0.81) in the mean number of hypoglycaemic events during Ramadan compared with before Ramadan, whereas group 2 was associated with an increase of 0.15 (p = 0.43), although these differences between the groups were not statistically significant following adjustment for baseline factors [LSM difference between groups = 0.135, p = 0.36, 95% confidence limits (-0.16, 0.43)].

CONCLUSION

Changing to humalog Mix 50 during Ramadan resulted in improvement in glycaemic control without increasing the incidence of hypoglycaemia.

Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with Type 2 diabetes who fast during Ramadan

BACKGROUND AND AIMS

During Ramadan, Muslims fast from dawn to dusk for one lunar month. The majority of Muslim diabetic patients are unaware of complications such as hypoglycaemia during fasting. The safety of fasting has not been assessed in the UK Muslim population with diabetes. The aim of this study was to determine the impact of Ramadan-focused education on weight and hypoglycaemic episodes during Ramadan in a Type 2 diabetic Muslim population taking oral glucose-lowering agents.

METHODS

We retrospectively analysed two groups. Group A attended a structured education programme about physical activity, meal planning, glucose monitoring, hypoglycaemia, dosage and timing of medications. Group B did not. Hypoglycaemia was defined as home blood glucose < 3.5 mmol/l.

RESULTS

There was a mean weight loss of 0.7 kg after Ramadan in group A, compared with a 0.6-kg mean weight gain in group B (P < 0.001). The weight changes observed were independent of the class of glucose-lowering agents used. There was a significant decrease in the total number of hypoglycaemic events in group A, from nine to five, compared with an increase in group B from nine to 36 (P < 0.001). The majority were in patients treated with short-acting sulphonylureas (group A-100%, group B-94%). At 12 months after attending the programme, glycated haemoglobin (HbA(1c)) reduction were sustained in group A.

CONCLUSIONS

Ramadan-focused education in diabetes can empower patients to change their lifestyle during Ramadan. It minimizes the risk of hypoglycaemic events and prevents weight gain during this festive period for Muslims, which potentially benefits metabolic control.

Survival of ceramic bearings in total hip replacement after high-energy trauma and periprosthetic acetabular fracture

Surgeons remain concerned that ceramic hip prostheses may fail catastrophically if either the head or the liner is fractured. We report two patients, each with a ceramic-on-ceramic total hip replacement who sustained high-energy trauma sufficient to cause a displaced periprosthetic acetabular fracture in whom the ceramic bearings survived intact. Simultaneous fixation of the acetabular fracture, revision of the cementless acetabular prosthesis and exchange of the ceramic bearings were performed successfully in both patients. Improved methods of manufacture of new types of alumina ceramic with a smaller grain size, and lower porosity, have produced much stronger bearings. Whether patients should be advised to restrict high-impact activities in order to protect these modern ceramic bearings from fracture remains controversial.

Vildagliptin therapy and hypoglycaemia in Muslim type 2 diabetes patients during Ramadan

AIMS

To compare hypoglycaemic events, glycated haemoglobin (HbA(1c)) and changes in bodyweight in metformin-treated Muslim patients with type 2 diabetes receiving adjunctive treatment with vildagliptin or gliclazide during Ramadan fasting.

METHODS

Data were collected from Muslim patients with type 2 diabetes attending primary care practices in North West London, whose HbA(1c) was > 8.5% despite treatment with metformin 2 g daily before Ramadan and who received gliclazide 160 mg twice daily (n = 26) or vildagliptin 50 mg twice daily (n = 26) in addition to metformin. Hypoglycaemic events, HbA(1c) and weight were recorded 2 weeks before and 10 days after the Ramadan fast. All patients received education about how to identify and manage hypoglycaemia during Ramadan.

RESULTS

During Ramadan, at least one hypoglycaemic event (defined as blood glucose < 3.5 mmol/l with or without symptoms) was recorded in two patients receiving vildagliptin (7.7%) and 16 patients receiving gliclazide [61.5%; difference between groups -53.8%, 95% confidence interval (CI) -74.9 to -26.3, p < 0.001]. Vildagliptin was associated with a reduction in the mean number of hypoglycaemic events during Ramadan compared with before Ramadan, whereas gliclazide was associated with an increase (least squares mean difference between groups -0.66, 95% CI -1.20 to -0.13, p = 0.0168). Both gliclazide and vildagliptin were associated with similar reductions in HbA(1c) and a small, but insignificant, increase in weight.

CONCLUSIONS

Appropriate treatment adjustments can lead to improved diabetes management during Ramadan, with avoidance of significant weight gain and improved glucose control without hypoglycaemia. The addition of vildagliptin to metformin therapy during Ramadan in Muslim patients with type 2 diabetes was associated with a reduction in the incidence of hypoglycaemia.

Pseudonits in dreadlocked hair: a louse-y case of nits

We report a case of pseudonits in dreadlocked hair, with prominent hair roots of shed hair closely resembling Pediculosis humanus capitis infestation.

Spinal dysraphism in an elderly patient

Spinal dysraphisms are diagnosed more frequently at birth or in infancy. We report a spinal malformation compatible with lipomyeloschisis in an elderly patient presenting with symptoms and signs of myelopathy. Magnetic resonance imaging revealed an intraspinal mass continuous with a subcutaneous lipoma. Three-dimensional computed tomography reconstructions better showed the spinal dysraphism; dermal sinus was also evident. Neuroimaging can define the precise diagnosis also in elderly patients presenting with myelopathy and can provide valuable structural details.

Gender differences and practice implications of risk factors for frequent hospitalization for heart failure in an urban center serving predominantly African-American patients

To identify the clinical correlates of recurrent heart failure hospitalization in a large urban hospital serving predominately African-American patients, and to provide further insight into modifiable risks for heart failure readmissions, a retrospective period prevalence review of the records of all adult patients admitted with a primary diagnosis of heart failure (International Classification of Diseases-9 code 428.0) between January and December 1995 was performed. The main outcome was the number of heart failure hospitalizations over 12 months. Twelve hundred patients were identified. Mean age was 64 +/- 16 years, 94% were black, 57% were women, and 40% were > or = 65 years old. Ninety-eight percent had a history of systemic hypertension and 55% had uncontrolled hypertension. Other comorbidities were left ventricular (LV) hypertrophy (64%), coronary artery disease (52%), and tobacco abuse (28%). Sixty-five percent of patients were on angiotensin-converting enzyme (ACE) inhibitors, 51% on calcium antagonists, and 8% on beta blockers. Most patients had suboptimal dosing of ACE inhibitors and there was inappropriate use of calcium antagonists in 56% of patients with moderate or severe systolic dysfunction. Diabetes mellitus and echocardiographic wall motion abnormality were independently associated with frequent admissions for women but not for men. Medication-related increase in heart failure hospitalization was seen for calcium antagonists in patients with severe LV dysfunction (odds ratio 2.24, 95% confidence intervals 1.0 to 5.03; p <0.03). Uncontrolled hypertension, underdosing of ACE inhibitors, and overuse of calcium antagonists in patients with significant LV dysfunction are potential targets for intervention.

Charcot-Marie-Tooth disease type 2 with restless legs syndrome

In a series of 44 consecutive patients with Charcot-Marie-Tooth disease (CMT), we found restless legs syndrome (RLS) in 10 of 27 CMT type 2 (CMT2) patients (37%) and in none of 17 CMT type 1 patients (p = 0.004). In the CMT2 patients, RLS was associated with positive sensory symptoms (10/10 versus 10/17; p = 0.026). This finding supports the view that a disorder of sensory input plays a role in the pathogenesis of RLS. Symptomatic treatment may benefit these patients.

Sarcoid neuromyopathy with selective involvement of the intramuscular nerves

A 35-year-old man affected with pulmonary sarcoidosis had a 12-year history of fatigue and pain in the limbs, with normal neurological examination, except for diffusely absent deep tendon reflexes. Muscle biopsy samples showed multiple noncaseating granulomas, most prominent around the intramuscular nerves, with predominance of CD4+ cells. Intramuscular nerve bundles surrounded by granulomas were immunolabelled with laminin alpha1, alpha2, beta1 and gamma1 chain, and collagen IV. Sural nerve biopsy samples were normal. This patient showed a unique histopathological pattern of sarcoid neuromyopathy characterized by distribution of granulomas or infiltrating cells around intramuscular nerve fibers. The clinical picture, restricted to nonspecific symptoms of fatigue and myalgia, and loss of deep tendon reflexes, correlated well with the selective localization of sarcoid lesions in contiguity with the intramuscular nerves. To our knowledge, this peculiar clinico-pathological correlation has not been reported previously.

Cryoglobulinaemic neuropathy manifesting with restless legs syndrome

In a series of 12 patients with essential mixed cryoglobulinaemia (EMC) and peripheral neuropathy as main feature of the disease, restless legs syndrome (RLS) was a major manifestation in four women, aged 55-65 years. In one patient RLS was a presenting manifestation of the disease, and in another patient the diagnosis of EMC was made investigating RLS and polyneuropathy, although prior rheumatological symptoms were retrospectively recognized. All patients with RLS had symmetrical sensory polyneuropathy, but non-RLS patients had also other forms of peripheral neuropathy, and symmetrical sensory polyneuropathy only in two of eight cases (P=0.03). Neurophysiological study showed that sensory action potentials of the sural nerve were more often inelicitable in non-RLS patients (six of eight) than in RLS patients (none of three). Sural nerve biopsy had no distinctive features in three RLS patients, with regard to other patients with cryoglobulinaemic neuropathy. RLS seems not uncommon in cryoglobulinaemic neuropathy, and significantly associated with symmetrical sensory polyneuropathy, whereas patients with other subtypes of cryoglobulinaemic neuropathy do not develop RLS; thus, a disorder of the sensory inputs may be important in the pathogenesis of RLS. The occurrence of RLS, especially in middle-aged women, should prompt investigations for peripheral neuropathy focusing on cryoglobulinaemic neuropathy.

Low-grade non-Hodgkin B-cell lymphoma presenting as sensory neuropathy

Low-grade non-Hodgkin B-cell lymphoma was found during the evaluation of 3 aged patients with predominantly sensory neuropathy of mild to moderate severity. Presenting manifestations were sensory ataxia and right ulnar mononeuropathy in a 75-year-old man, and painful dysesthesias of the legs in two 78-year-old women. A neurophysiological study showed mainly axonopathic alterations. M-protein was present in all cases (Ig-kappa in two, triclonal gammopathy IgG(kappa)/IgM(kappa)/IgM-gamma in one). The male patient had IgM antisulfatide antibody in high titer, whereas the other 2 patients had cryoglobulinemia (type II and type III, respectively). Our report emphasizes the occurrence of mild polyneuropathy as presenting manifestation of low-grade non-Hodgkin lymphoma, different from the clinicopathological entity of neurolymphomatosis, in which severe nerve damage occurs in association with manifest lymphoma, related to nerve infiltration by lymphomatous cells. Alternative pathogenetic mechanisms, such as antibody-mediated nerve damage, or vasa nervorum changes caused by cryoglobulin, may be implicated in our cases. Non-Hodgkin lymphoma should be considered in the diagnostic evaluation of polyneuropathy of unknown cause, especially in patients with paraproteinemia and/or cryoglobulinemia.