Evaluating the effect of child home safety training upon three family support practitioner groups: a mixed-methods study

AIMS

Unintentional injuries in the home contribute substantially to preschool child morbidity and mortality. Practitioners such as health visitors, family mentors and children's centre staff are well-positioned to facilitate child injury prevention by providing home safety advice to families, and training may enhance their ability to do so. We aimed to assess the impact of child home safety training for these practitioners.

METHODS

An explanatory mixed-methods design was used. Practitioners completed questionnaires before, and up to 7 months after, receiving child home safety training and took part in interviews. Seventy-eight health visitors, 72 family mentors and 11 children's centre staff members completed questionnaires. Items were used to calculate scores on home safety knowledge, confidence to provide home safety advice and belief that child home safety promotion is important. Thematic analysis of interviews with seven health visitors and nine family mentors, open-ended responses to the questionnaires and an additional evaluation form was conducted to explore attendees' perceptions of the training and its impact. In addition, seven health visitors and six children's centre staff who had received no training were interviewed.

RESULTS

Knowledge was greater post-training than pre-training across all participants (p < .001). When practitioner groups were analysed separately, there were significant increases in family mentors' knowledge (p < .001) and belief (p = .016), and health visitors' confidence (p = .0036). Qualitative findings indicated that most training session attendees valued the training, believed their practice relating to child home safety had improved as a result, and felt further similar training sessions would be beneficial. Those who had not attended the sessions described a need for more child home safety training.

CONCLUSIONS

Delivering training to practitioners providing child home safety promotion to families with preschool children can enhance injury prevention knowledge, beliefs and confidence and positively impact on home safety promotion by practitioners.

Safety of direct oral anticoagulants (DOACs) vs. warfarin for people aged ≥ 75 years with atrial fibrillation: a cohort study

Introduction

Warfarin significantly reduces the risk of stroke in people with atrial fibrillation (AF), but historically has been underused in older people due to complicated dosage regimens. DOACs offer an attractive alternative to warfarin and were shown to be non-inferior in randomised controlled trials, however older people were underrepresented in these trials and there have been few studies investigating outcomes specifically in this high risk group (1).

Aim

To compare the risk of major, non-major, gastrointestinal, and intracranial bleeding between warfarin and DOACs in people aged ≥ 75 years with AF.

Methods

A cohort of patients aged ≥ 75 years with a diagnosis of AF was extracted from the Clinical Practice Research Datalink (CPRD). Patients could enter the study on the date of their first prescription for warfarin or a DOAC between 1/1/2013 and 27/12/2017. Patients were censored on the date of the outcome, death, or leaving the general practice. Switching between anticoagulants and unexposed periods were measured using prescription mapping. Crude and adjusted hazard rates of the risk of bleeding were calculated using a Cox proportional hazards model with oral anticoagulant prescribing as a time varying covariate.

Results

The cohort included 10,149 patients in the warfarin group and 10,237 in the DOAC group. The groups had similar characteristics and the average age was 81 in the warfarin group and 82 in the DOAC group. The table summarises the results. Whilst major and non-major bleeding was similar between all DOACs and warfarin, rivaroxaban was associated with higher risk and apixaban lower risk when analysed separately. Risk of gastrointestinal bleeding was higher with all DOACs and rivaroxaban than warfarin but apixaban was not significantly different. Few intracranial events occurred (n=131).

Conclusion

The results indicate that DOACs as a group are not significantly different to warfarin, however when analysed separately, apixaban may be safer. While the study relies on prescription data and hence it is not known if patients were taking the medications, the large cohort studied is representative of older people who are prescribed these medications in UK primary care.

Reference

(1) Mitchell A, Watson MC, Welsh T, McGrogan A. Effectiveness and safety of direct oral anticoagulants versus vitamin K antagonists for people aged 75 years and over with atrial fibrillation: A systematic review and meta-analyses of observational studies. Journal of Clinical Medicine. 2019; 8 (554).

Pharmacist-led education-based antimicrobial stewardship interventions and their effect on antimicrobial use in hospital inpatients: a systematic review and narrative synthesis

BACKGROUND

Antimicrobial stewardship (AMS) programmes optimize antimicrobial use and address antimicrobial resistance. Pharmacists are often key agents of these programmes. The effectiveness of hospital-based AMS interventions when they are led by pharmacists, however, has not previously been reported.

AIM

To evaluate the effectiveness of pharmacist-led AMS interventions in improving antimicrobial use for hospital inpatients.

METHODS

Standard systematic review methods were used. The search strategies and databases used in a previous Cochrane review were applied. Studies that reported pharmacist-led AMS interventions were included. Narrative synthesis was used to report the findings. PRISMA guidelines were followed.

FINDINGS

From 6971 records retrieved and screened, 52 full-text articles were included. Most studies were undertaken in teaching hospitals (N = 45) and many were conducted in North America (N = 27). Most interventions targeted junior or ward physicians and lasted between one and six months. All studies evaluated educational interventions often in combination with other interventions and reported improvements 'in compliance with target AMS practice'. Greater compliance was achieved with multiple interventions. Pharmacist-led interventions reduced the duration of antimicrobial therapy without increasing mortality. No consistency of evidence was achieved in relation to interventions and reduced duration of hospital stay, nor infections due to antimicrobial resistance or occurrence of Clostridium difficile.

CONCLUSION

This is the first systematic review to evaluate the effectiveness of pharmacist-led AMS interventions in hospital inpatients. Education-based interventions were effective in increasing guideline compliance and reducing duration of antimicrobial therapy. Future hospital-based AMS programmes should consider the involvement of pharmacists to deliver and promote AMS interventions and programmes.

"We're really not ready for this": A qualitative exploration of community pharmacy personnel's perspectives on the pharmaceutical care of older people with sensory impairment

Background

In most developed countries there is an increasing ageing population living in the community with long-term conditions and sensory impairment (sight; hearing; dual impairment). Community pharmacy personnel are key providers of pharmaceutical care to this patient population.

Objective

This study explored community pharmacy personnel's experiences with providing pharmaceutical care for older people with sensory impairment.

Methods

Semi-structured telephone interviews were conducted with community pharmacy personnel across Scotland between 2015 and 2016.

Results

Thirty interviews were completed with community pharmacists (n = 17) and other pharmacy personnel (n = 13). Two overarching themes emerged: safety and communication. Interviewees reported patients' reluctance to disclose their impairment “patients are very good at hiding it” and had considerable safety concerns “it's a fear that they're going to take too much … accidentally taking the same medicine twice”. Difficulties in communication were cited “no matter what you do or how you label things, leaflets and telling people, things can go wrong”. Additionally, interviewees identified training needs to increase their disability awareness and to identify strategies to provide safe and reliable pharmaceutical care to this vulnerable group “We don't specifically have anything in place to deal with anyone with impairments of that kind”.

Conclusions

This is the first in-depth exploration of providing pharmaceutical care to older people with sensory impairment from the perspective of community pharmacy personnel. Strategies are needed to encourage older people to disclose their sensory impairment. Education and training are also needed to optimise the provision of pharmaceutical care to this vulnerable population.

A cohort study of influences, health outcomes and costs of patients' health-seeking behaviour for minor ailments from primary and emergency care settings

OBJECTIVES

To compare health-related and cost-related outcomes of consultations for symptoms suggestive of minor ailments in emergency departments (EDs), general practices and community pharmacies.

DESIGN

Observational study; prospective cohort design.

SETTING

EDs (n=2), general practices (n=6) and community pharmacies (n=10) in a mix of rural/urban and deprived/affluent areas across North East Scotland and East Anglia. Participants Adults (≥18 years) presenting between 09:00 and 18:00 (Monday-Friday) in general practices and 09:00-18:00 (Monday-Saturday) in pharmacies and EDs with ≥1 of the following: musculoskeletal pain; eye discomfort; gastrointestinal disturbance; or upper respiratory tract-related symptoms.

INTERVENTIONS

Participants completed three questionnaires: baseline (prior to index consultation); satisfaction with index consultation and follow-up (2 weeks after index consultation).

MAIN OUTCOME MEASURES

Symptom resolution, quality of life, costs, satisfaction and influences on care-seeking behaviour.

RESULTS

377 patients participated, recruited from EDs (81), general practices (162) and community pharmacies (134). The 2-week response rate was 70% (264/377). Symptom resolution was similar across all three settings: ED (37.3%), general practice (35.7%) and pharmacy (44.3%). Mean overall costs per consultation were significantly lower for pharmacy (£29.30 (95% CI £21.60 to £37.00)) compared with general practice (£82.34 (95% CI £63.10 to £101.58)) and ED (£147.09 (95% CI £125.32 to £168.85)). Satisfaction varied across settings and by measure used. Compared with pharmacy and general practice use, ED use was significantly (p<0.001) associated with first episode and short duration of symptom(s), as well as higher levels of perceived seriousness and urgency for seeking care. Convenience of location was the most common reason for choice of consultation setting.

CONCLUSIONS

These results suggest similar health-related outcomes and substantially lower costs with pharmacy consultations for minor ailments. Effective strategies are now needed to shift demand for minor ailment management away from EDs and general practices to the community pharmacy setting.

Delivery of a national home safety equipment scheme in England: a survey of local scheme leaders

Aims:

Unintentional home injuries sustained by preschool children are a major cause of morbidity in the UK. Home safety equipment schemes may reduce home injury rates. In 2009, the Royal Society for the Prevention of Accidents was appointed as central coordinator of a two-year, £18m national home safety equipment scheme in England. This paper reports the findings from a national survey of all scheme leaders responsible for local scheme delivery.

Methods:

A questionnaire mailed to all local scheme leaders sought details of how the schemes were operated locally; barriers and facilitators to scheme implementation; evaluation of the local scheme and its sustainability.

Results:

A response rate of 73% was achieved. Health visitors and family support workers played a key role in both the identification of eligible families and performing home safety checks. The majority of local scheme leaders (94.6%) reported that they thought their local scheme had been successful in including those families considered ‘harder to engage’. Many scheme leaders (72.4%) reported that they had evaluated the provision of safety equipment in their scheme and over half (56.6%) stated that they would not be able to continue the scheme once funding ceased.

Conclusions:

Local schemes need support to effectively evaluate their scheme and to seek sustainability funding to ensure the future of the scheme. There remains a lack of evidence of whether the provision of home safety equipment reduces injuries in preschool children.

Educational strategies to promote evidence-based community pharmacy practice: a cluster randomised controlled trial

Focal points

A systematic review of the use of simulated patients and pharmacy practice research

Objective

The use of simulated patients to assess current practice, or to derive outcome measures for pharmacy practice research, has received much attention in recent years. A simulated patient is an individual who is trained to visit a pharmacy to enact a scenario testing specific behaviour of the pharmacist or pharmacy staff. The aim of this study was to provide a definitive review of the use of simulated patients as a methodological tool for pharmacy practice research.

Method

A systematic review was undertaken to identify all pharmacy practice studies that had used simulated patient methodology. The electronic databases searched to identify relevant studies were MEDLINE, EMBASE and CINAHL. Articles fulfilling all the following criteria were considered for inclusion in the review: primary reports of trials conducted in community pharmacy and drug store settings which used simulated patients to derive outcome measures. The review was not restricted by language or by country. The review was restricted to publications from 1976 to May 2005.

Key findings

In total, 56 full publications were retrieved for further examination, of which 46 studies were included in the review, including: nine randomised controlled trials, three controlled trials, 30 cross-sectional, two time-series and two ‘other’ studies. Ten publications were excluded: seven reviews, one laboratory-based study, one telephone survey and one study presented only as an abstract.

Conclusions

There has been steady growth in the use of simulated patient methodology over the past 30 years. Although simulated patients have received negative attention in the pharmaceutical media, they can be a rigorous and robust method of measuring practice if used appropriately. This review demonstrates the range of activities for which this method can be used, including the assessment of counselling and advice provision, the treatment of minor and major illness, and the assessment of the public health activities of pharmacy and drug store staff. Simulated patient methodology has been used in developing countries to a similar, if not greater extent, than the developed world, demonstrating its versatility and applicability to pharmacy practice research globally.

Using human error theory to explore the supply of non-prescription medicines from community pharmacies

BACKGROUND

The importance of theory in underpinning interventions to promote effective professional practice is gaining recognition. The Medical Research Council framework for complex interventions has assisted in promoting awareness and adoption of theory into study design. Human error theory has previously been used by high risk industries but its relevance to healthcare settings and patient safety requires further investigation. This study used this theory as a framework to explore non-prescription medicine supply from community pharmacies. The relevance to other healthcare settings and behaviours is discussed.

METHOD

A 25% random sample was made of 364 observed consultations for non-prescription medicines. Each of the 91 consultations was assessed by two groups: a consensus group (stage 1) to identify common problems with the consultation process, and an expert group (stages 2 and 3) to apply human error theory to these consultations. Paired assessors (most of whom were pharmacists) categorised the perceived problems occurring in each consultation (stage 1). During stage 2 paired assessors from an expert group (comprising patient safety experts, community pharmacists and psychologists) considered whether each consultation was compliant with professional guidelines for the supply of pharmacy medicines. Each non-compliant consultation identified during stage 2 was then categorised as a slip/lapse, mistake, or violation using human error theory (stage 3).

RESULTS

During stage 1 most consultations (n = 75, 83%) were deemed deficient in information exchange. At stage 2, paired assessors varied in attributing non-compliance to specific error types. Where agreement was achieved, the error type most often selected was "violation" (n = 27, 51.9%, stage 3). Consultations involving product requests were less likely to be guideline compliant than symptom presentations (OR 0.30, 95% CI 0.10 to 0.95, p = 0.05).

CONCLUSIONS

The large proportion of consultations classified as violations suggests that either pharmacy staff are unaware of professional guidelines and thus do not follow them (therefore these acts would not be violations), or that they knowingly violate the guidelines due to reasons that need further research. The methods presented here could be used in other healthcare settings to explore healthcare professional behaviour and to develop strategies to promote patient safety and effective professional practice.

Strong and complex electron-lattice correlation in optimally doped Bi2Sr2CaCu2O8+delta

We discuss the nature of electron-lattice interaction in optimally doped Bi_{2}Sr_{2}CaCu_{2}O_{8+delta} samples, using the isotope effect (IE) in angle resolved photoemission spectroscopy (ARPES) data. The IE in the ARPES linewidth and the IE in the ARPES dispersion are both quite large, implying a strong electron-lattice correlation. The strength of the electron-lattice interaction is "intermediate," i.e., stronger than the Migdal-Eliashberg regime but weaker than the small polaron regime, requiring a more general picture of the ARPES kink than the commonly used Migdal-Eliashberg picture. The two IEs also imply a complex interaction, due to their strong momentum dependence and their differing sign behaviors. In sum, we propose an intermediate-strength coupling of electrons to localized lattice vibrations via charge density fluctuations.

Potential of selective insecticides for managing Uraba lugens (Lepidoptera: Nolidae) on Eucalypts

The leaf skeletonizer Uraba lugens Walker (Lepidoptera: Nolidae), an Australian species, locally known as "gumleaf skeletonizer", is well established in New Zealand. This insect has the potential to become a serious pest of forestry and amenity eucalypts (Eucalyptus spp.) and is the focus of a long-term management program. The use of synthetic chemical or biological insecticides is one possible control method within an integrated control program. A series of dose-response trials were conducted using laboratory bioassays to test the efficacy of several insecticides against U. lugens: pyrethroids, spinosad, Bacillus thuringiensis kurstaki Berliner (Btk) and an insect growth regulator, Mimic. Pyrethroids and spinosad proved highly effective against U. lugens larvae, achieving 100% mortality after 3-6-d exposure. The performance of Btk was lower against gregarious skeletonizing larvae compared with solitary chewing larvae. When good coverage of the target foliage is achieved, >90% mortality is possible with Btk. Mimic performed poorly against U. lugens compared with other insecticides tested (<60% mortality). The Eucalyptus species on which larvae were feeding significantly altered insecticide efficacy. Treatments applied to Eucalyptus nitens (Deane & Maiden) Maiden had reduced efficacy compared with E. cinerea F. Muell. ex Benth. or E. fastigata Deane & Maiden. Cooler temperatures also reduced insecticide efficacy, presumably by decreasing movement and food consumption by U. lugens. Recommendations on spray applications to control U. lugens in New Zealand are given.

Increasing child pedestrian and cyclist visibility: cluster randomised controlled trial

STUDY OBJECTIVE

Visibility aids have the potential to reduce child pedestrian and cyclist injury but scarce data exist relating to their use or to interventions for increasing visibility aid use among children. This cluster randomised controlled trial was designed to assess the use of free visibility aids one and eight weeks after their provision among primary school children in Nottingham, UK.

DESIGN

One class from each of 20 schools representing 377 children aged 7, 8, and 9 years old participated in the trial and were randomly assigned to treatment and control arms. Children in the intervention arm received two visibility aids, namely, a reflective and fluorescent slap wrap (an item that can be worn around an arm or trouser leg and is readily removed), and a reflective durable sticker in addition to educational material on the importance of being seen in the dark. Observers visited schools to observe use of reflective and fluorescent slap wraps, stickers, piping and patches on coats, and bags at baseline and at one and eight weeks after distribution of the visibility aids. The study used random effects logistic regression to calculate odds ratios (OR) and confidence intervals (CI).

MAIN RESULT

The results showed that children provided with free visibility aids were significantly more likely to use any visibility aid at one week (adjusted OR 59.5, 95% CI 18.5 to 191.0) and eight weeks (adjusted OR 5.9, 95% CI 3.4 to 10.4) after distribution than children in the control arm.

CONCLUSIONS

Providing free visibility aids and an educational booklet on road safety significantly increases use of visibility aids for up to eight weeks during the winter among primary school children. On the basis of an eight week follow up trial in Nottingham of 20 classes of children aged 7 to 9 years old, these results suggest that campaigns providing free visibility aids to primary school children should be encouraged.

Factors predicting the guideline compliant supply (or non-supply) of non-prescription medicines in the community pharmacy setting

BACKGROUND

The reclassification of prescription only medicines to pharmacy and general sales list medicines (also known as non-prescription medicines) provides the public with greater access to medicines that they can purchase for self-care. There is evidence that non-prescription medicines may be associated with inappropriate supply. This study investigated factors predicting evidence-based (guideline compliant) supply or non-supply of non-prescription medicines.

METHOD

Secondary analysis of results from a randomised controlled trial of educational interventions to promote the evidence based supply of non-prescription medicines. Ten actors made simulated patient (customer) visits to 60 community pharmacies using seven scenarios reflecting different types of presentations. The dependent variable was appropriate (guideline compliant) supply of antifungal medication for treatment of vaginal candidiasis.

RESULTS

No significant association was shown between guideline compliant behaviour and pharmacy type or location, or with the actor making the visit. The likelihood of guideline compliant outcome was significantly greater with symptom presentations than with condition or product presentations (p < 0.001). The likelihood of a guideline compliant outcome increased (a) as more information was exchanged (p < 0.001), (b) with the use of WWHAM (a mnemonic frequently used by medicine counter assistants during consultations for non-prescription medicines) (p < 0.001); (c) when specific WWHAM questions were used (including "description of symptoms" (p < 0.001) and "whether other medication was currently being used" (p < 0.001); and (d) in consultations involving solely pharmacists compared with those involving only medicine counter assistants (p = 0.017). After adjustment for presentation type, a significant association persisted between appropriate outcome and consultations with WWHAM scores of 2 and > or = 3, respectively.

CONCLUSIONS

The nature and extent of information exchange between pharmacy staff and customers has a strong influence on the guideline compliant supply of non-prescription medicines. Future interventions to promote the safe and effective use of non-prescription medicines should address the apparent deficit in communication between pharmacy staff in general, and medicine counter assistants in particular, which may reflect both pharmacy staff skills and customer expectations.

Educational strategies to promote evidence-based community pharmacy practice: a cluster randomized controlled trial (RCT)

BACKGROUND

Community pharmacists have increasing involvement in the self-management of minor illness as a result of the availability of a wider range of over-the-counter (OTC) medicines. We undertook a randomized controlled trial (RCT) to assess the effectiveness and efficiency of educational strategies to implement evidence-based guidelines for the sale of OTC anti-fungals in the community pharmacy setting.

OBJECTIVE

The aim of the study was to compare the effectiveness and efficiency of two guideline dissemination strategies in community pharmacy settings.

METHODS

A 2 x 2 factorial, cluster RCT was conducted with 60 community pharmacies in the Grampian region of Scotland. The interventions included dissemination of an evidence-based guideline for OTC management of vulvovaginal candidiasis (thrush) by postal dissemination (control), educational outreach visit or attendance at a continuing professional education session. Pre- and post-intervention simulated patient visits were made to participating pharmacies. The simulated patients completed assessment forms following each visit. The primary outcome was the appropriateness (based upon the guidelines) of sale or no sale of OTC anti-fungals.

RESULTS

There were no significant differences in the proportion of appropriate outcomes following educational outreach [odds ratio (OR) = 1.1; 95% confidence interval (CI) 0.52 to 2.45] or continuing professional education (OR = 0.88; 95% CI 0.41 to 1.91).

CONCLUSIONS

Neither strategy was effective in improving the appropriateness of OTC management of vulvovaginal candidiasis by community pharmacy staff. Further research is needed to identify barriers to guideline implementation and evidence-based practice in this setting.

Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush)

BACKGROUND

Anti-fungals are available for oral and intra-vaginal treatment of vulvovaginal candidiasis (thrush).

OBJECTIVES

The primary objective of this review was to assess the relative effectiveness of oral versus intra-vaginal anti-fungals for the treatment of uncomplicated vulvovaginal candidiasis. The secondary objectives of the review were to assess the cost-effectiveness, safety and patient preference of oral versus intra-vaginal anti-fungals.

SEARCH STRATEGY

The following sources were searched: The Cochrane Library (Issue 4, 1999), MEDLINE (January 1985 to May 2000), EMBASE (January 1980 to January 2000) and the Cochrane Collaboration Sexually Transmitted Disease Group Specialised Register of Controlled Trials. The reference lists of retrieved articles were reviewed manually. The manufacturers of anti-fungals available in the UK were contacted.

SELECTION CRITERIA

~Bullet~Randomised controlled trials published in any language. ~Bullet~Trials had to compare at least one oral anti-fungal with one intra-vaginal anti-fungal. ~Bullet~Women (aged 16 years or over) with uncomplicated vulvovaginal candidiasis. ~Bullet~The diagnosis of vulvovaginal candidiasis to be made mycologically (i.e. a positive culture and / or microscopy for yeast). ~Bullet~Trials were excluded if they solely involved subjects who were HIV positive, immunocompromised, pregnant, breastfeeding or diabetic. ~Bullet~The primary outcome measure was clinical cure.

DATA COLLECTION AND ANALYSIS

Duplicate scrutiny was performed of the titles and abstracts of the electronic search results. Full article formats of all selected abstracts were retrieved and independently assessed by two reviewers. Independent duplicate abstraction was performed by four reviewers. Disagreements regarding trial inclusion or data abstraction were resolved by discussion between the reviewers. Odds ratios were pooled using the random effects model. Chi-squared tests with a p-value of less than 0.1 indicated heterogeneity in the results.

MAIN RESULTS

Seventeen trials are included in the review, reporting 19 oral versus intra-vaginal anti-fungal comparisons. No statistically significant differences were shown between oral and intra-vaginal anti-fungal treatment for clinical cure at short term (OR 1.00 (95% CI, 0.72 to 1.40)) and long term (OR 1.03 (95% CI, 0.72 to 1.49)) follow-up. No statistically significant differences for mycological cure were observed between oral and intra-vaginal treatment at short term (OR 1.20(95% CI, 0.87 to 1.65)) or long term follow-up (OR 1.30 (95% CI, 0.99 to 1.71)). Two trials each reported one withdrawal from treatment due to an adverse reaction. Treatment preference data were poorly reported.

REVIEWER'S CONCLUSIONS

No differences exist in terms of the relative effectiveness (measured as clinical and mycological cure) of anti-fungals administered by the oral and intra-vaginal routes for the treatment of uncomplicated vaginal candidiasis. No definitive conclusion can be made regarding the relative safety of oral and intra-vaginal anti-fungals for uncomplicated vaginal candidiasis. The oral route of administration is the preferred route for anti-fungals for the treatment of vulvovaginal candidiasis. The decision to prescribe or recommend the purchase of an anti-fungal for oral or intra-vaginal administration should take into consideration: safety, cost and treatment preference. Unless there is a previous history of adverse reaction to one route of administration or contraindications: if women are purchasing their own treatment, they should be given full information about the characteristics and costs of treatment to make their own decision. If health services are paying the treatment cost, decision-makers should consider whether the higher cost of oral anti-fungal administration is worth the gain in convenience, if this is the patient's preference.

Community pharmacists' views and beliefs about the treatment of symptoms suggestive of vaginal thrush in community pharmacies

OBJECTIVE

To investigate the views and beliefs of community pharmacists about the benefits and disadvantages to the customer, pharmacy and pharmacist of treating women with symptoms suggestive of vaginal thrush.

DESIGN

Semi-structured interviews.

SETTING

Community pharmacists from within Grampian Primary Care NHS Trust.

OUTCOME MEASURES

Pharmacists' views and beliefs analysed using content analysis.

RESULTS

Of the 26 pharmacists contacted, 19 (73%) pharmacists from 16 pharmacies completed interviews. The pharmacists were generally positive towards the treatment of women with vaginal symptoms and perceived few disadvantages. Immediate access to treatment and rapid symptom relief were perceived to be the greatest advantages to the customer. The main problems were customer embarrassment, cost and the risk of masking a serious condition. Customer embarrassment was perceived to be influenced by lack of privacy and the gender of the member of staff involved in the consultation. Five pharmacists perceived vaginal thrush to be an infection that could be spread by sexual transmission.

DISCUSSION

There is a need to make pharmacists aware of the current evidence regarding the treatment of vaginal thrush, particularly the sexual partners of women with acute, uncomplicated thrush do not require treatment with an antifungal. The main difficulties that community pharmacists reported with the treatment of this condition were obtaining an accurate history and this was influenced by customer embarrassment. The gender of pharmacy staff and lack of private consultation facilities were suggested as factors that are associated with customer embarrassment and hence, the ability to obtain an accurate history.

Non-aspirin, non-steroidal anti-inflammatory drugs for osteoarthritis of the knee

OBJECTIVES

To determine whether there is a difference in the relative efficacy of individual non-steroidal anti-inflammatory drugs (NSAIDs) when used in the management of osteoarthritis (OA) of the knee.

SEARCH STRATEGY

We searched Medline (1966-1995) and Bids Embase (Jan-Dec, 1980-1995). The searches were limited to publications in the English language, and were last perfomed in November 1996. We used modified Cochrane Collaboration search strategy to identify all randomised controlled trials. The MeSH heading osteoarthritis was combined with the generic names of the 17 non-aspirin NSAIDs licensed in the UK for the management of OA in general practice. The search of Embase used the term "osteoarthritis" if present in the abstract, title or keywords, and was combined with the generic names of the 17 non-aspirin NSAIDs, only if they were mentioned in the title, abstract or keywords.

SELECTION CRITERIA

All double blind, randomised controlled trials, in the English language, comparing the efficacy of two non-aspirin NSAIDs in the management of osteoarthritis of the knee, were selected. Only trials with subjects aged 16 years and over, with clinical and/or radiological confirmation of the diagnosis of OA knee were included. Studies which compared one "trial" NSAID with one "reference" NSAID were included provided they were non-aspirin NSAIDs available in the UK and were licensed for the treatment of OA by general practitioners. Trials which were placebo-controlled and which also involved the comparison of two NSAIDs were also included.

DATA COLLECTION AND ANALYSIS

The methodological design of each study was scored according to a pre-determined system. The three main outcome measures of pain, physical function and patient global assessment were chosen based on the core set agreed upon by OMERACT (Outcome Measures in Rheumatology Clinical Trials). These were used to determine the power of each trial. The equivalency of NSAID doses was calculated using the percentage of the recommended maximum daily dose. Sample size estimates for the detection of clinically relevant changes in outcome measures used in the assessment of OA knee were used for power calculations. These calculations were performed to determine whether the trials were of a sufficient size to detect clinically relevant differences which were statistically significant. The calculations incorporate estimates of standard deviation, and minimum, median and maximum differences (delta) between drugs which are deemed to be clinically important. The number of "withdrawals due to lack of efficacy" was also selected as an outcome measure for this review. The Peto odds ratio and 95% confidence intervals were calculated where possible. The results of studies which compared the same trial and reference NSAIDs were combined where possible.

MAIN RESULTS

Of the 1151 trials identified by the search strategy, 22 involved knee osteoarthritis only. Sixteen of these trials fulfilled the inclusion criteria and were entered in the review. Eight NSAIDs were represented in these trials. Etodolac was represented in 11 trials. The reference NSAID in these trials was piroxicam (n=3), naproxen(n=3), diclofenac (n=3), indomethacin (n=1), and, nabumetone (n=1). The reported methodological design of the trials was poor, with a median score of 3 (out of a maximum of 8). The results of the trials comparing the same trial and reference NSAIDs were pooled for the outcome "withdrawal due to lack of efficacy". For the comparison, etodolac vesus piroxicam, the odds ratio favoured etodolac i.e. patients receiving etodolac were less likely to withdraw due to lack of efficacy. The dose of etodolac used in each of these three studies, however, was greater than the corresponding dose of piroxicam (based on percentage maximum daily dose). The significance of these results is therefore questionable. For the comparisons etodolac versus diclofenac, and etodolac versus naproxen, there were no clear differences betw

Salicornia bigelovii Torr.: An Oilseed Halophyte for Seawater Irrigation

The terrestrial halophyte, Salicornia bigelovii Torr., was evaluated as an oilseed crop for direct seawater irrigation during 6 years of field trials in an extreme coastal desert environment. Yields of seed and biomass equated or exceeded freshwater oilseed crops such as soybean and sunflower. The seed contained 26 to 33 percent oil, 31 percent protein, and was low in fiber and ash (5 to 7 percent). The oil and meal were extracted by normal milling equipment, and the oil was high in linoleic acid (73 to 75 percent) and could replace soybean oil in chicken diets. The meal had antigrowth factors, attributed to saponins, but could replace soybean meal in chicken diets amended with the saponin antagonist, cholesterol. Salicornia bigelovii appears to be a potentially valuable new oilseed crop for subtropical coastal deserts.

Chemical Control of Nematodes on Flue-cured Tobacco in Brazil, Canada, United States, and Zimbabwe

A survey was conducted in four major flue-cured tobacco producing countries to determine use of nematicides for control of plant-parasitic nematodes on flue-cured tobacco. Included in the survey were scientists from Brazil, Canada, the United States, and Zimbabwe. Nematicides were used on 60-95% of the flue-cured tobacco crop in these regions. The choice of fumigant and nonfumigant nematicides, however, varied greatly as influenced by the edaphic factors, nematode species, and other pests present. The major nematicides, application methods, and efficacy evaluation systems used in these countries were addressed.

Mesenteric ischemia: nutritional impact and capturing the golden operative moment

Chronic thrombotic mesenteric ischemia is a well-described but infrequently encountered disease in the practice of clinical vascular surgery. Viewing it as a three-stage process and tailoring the management to this concept will help to achieve maximal success in prompt diagnosis, appropriate revascularization, and resection when needed. Aggressive intravenous nutritional support will help bolster these patients against the complications and mortality associated with management for each stage, while helping to restore the deficits engendered preoperatively by the disease itself.

Congenital Absence of the Vagina

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