Katie MacLure

MELAS syndrome with mitochondrial tRNA Leu[UUR] mutation: Correlation of clinical state, nerve conduction, and muscle 31P magnetic resonance spectroscopy during treatment with nicotinamide and riboflavin

We report a patient with mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes treated with riboflavin and nicotinamide for 18 months, during which time previously frequent encephalopathic spells ceased. To confirm clinical benefit, we withdrew treatment and monitored response with muscle 31P magnetic resonance spectroscopy (MRS) and sural nerve conduction studies. Of three prospectively chosen MRS variables, two changed coincidentally with clinical end points; phosphocreatine (PCr)/adenosine triphosphate recovery rates fell in parallel with sural nerve sensory amplitudes, and a drop in muscle bioenergetic efficiency (relationship of inorganic phosphate/PCr to the accelerating force of contracting muscle) coincided with development of encephalopathy. Investigations revealed a deficiency of respiratory complex I and mutation of the mitochondrial tRNALeu(UUR). We suggest that a defective cellular energy state in mitochondrial disease may be partially treatable and that changes seen in appropriate muscle spectroscopy studies may parallel improvement in brain and peripheral nerve function.

Educating nonmedical prescribers

The last decade has seen developments in nonmedical prescribing, with the introduction of prescribing rights for healthcare professionals. In this article, we focus on the education, training and practice of nonmedical prescribers in the UK. There are around 20 000 nurse independent prescribers, 2400 pharmacist supplementary/independent prescribers, several hundred allied health professional supplementary prescribers and almost 100 optometrist supplementary/independent prescribers. Many are active prescribers, managing chronic conditions or acute episodes of infections and minor ailments. Key aims of nonmedical prescribing are as follows: to improve patient care; to increase patient choice in accessing medicines; and to make better use of the skills of health professionals. Education and training are provided by higher education institutions accredited by UK professional bodies/regulators,namely, the Nursing and Midwifery Council, General Pharmaceutical Council, Health Professions Council and General Optical Council. The programme comprises two main components: a university component equivalent to 26 days full‐time education and a period of learning in practice of 12 days minimum under the supervision of a designated medical practitioner. Course content focuses on the following factors: consultation, decision making, assessment and review; psychology of prescribing; prescribing in team context; applied therapeutics; evidence‐based practice and clinical governance; legal, policy, professional and ethical aspects; and prescribing in the public health context. Nonmedical prescribers must practise within their competence, demonstrating continuing professional development to maintain the quality engendered during training. Despite the substantial progress, there are several issues of strategy, capacity, sustainability and a research evidence base which require attention to fully integrate nonmedical prescribing within healthcare.

Pharmacist prescribing in primary care: the views of patients across Great Britain who had experienced the service

Objective  To evaluate the views of patients across primary care settings in Great Britain who had experienced pharmacist prescribing.

Guidance to manage inappropriate polypharmacy in older people: systematic review and future developments.

ABSTRACT Introduction: Single disease state led evidence-based guidelines do not provide sufficient coverage of issues of multimorbidities, with the cumulative impact of recommendations often resulting in overwhelming medicines burden. Inappropriate polypharmacy increases the likelihood of adverse drug events, drug interactions and non-adherence. Areas covered: A detailed description of a pan-European initiative, ‘Stimulating Innovation Management of Polypharmacy and Adherence in the Elderly, SIMPATHY’, which is a project funded by the European Commission to support innovation across the European Union. This includes a systematic review of the literature aiming to summarize and review critically current policies and guidelines on polypharmacy management in older people. The policy driven, evidence-based approach to managing inappropriate polypharmacy in Scotland is described, with consideration of a change management strategy based on Kotter’s eight step process for leading sustainable change. Expert opinion: The challenges around promoting appropriate polypharmacy are on many levels, primarily clinical, organisational and political, all of which any workable solution will need to address. To be effective, safe and efficient, any programme that attempts to deal with the complexities of prescribing in this population must be patient-centred, clinically robust, multidisciplinary and designed to fit into the healthcare system in which it is delivered.

Promoting weight management services in community pharmacy: perspectives of the pharmacy team in Scotland

Background Obesity has reached pandemic levels with more than 1.4 billion adults affected worldwide. While there is a need to systematically develop and evaluate community pharmacy based models of weight management, it is imperative to describe and understand the perspectives of pharmacy staff. In the UK, trained and accredited community pharmacy medicines counter assistants (MCAs) are commonly the front line staff involved in patient consultations and sale of over-the-counter medicines. Objective To explore the beliefs and experiences of pharmacists and MCAs in the North-East of Scotland on community pharmacy weight management. Setting All 135 community pharmacies in the North-East of Scotland. Method A qualitative approach of semi-structured telephone interviews with 31 pharmacists and 20 MCAs in the North-East of Scotland. The semi-structured interview schedule was developed with reference to key domains describing professional practice (i.e. awareness and knowledge, skills, practicalities, motivation, acceptance and beliefs) and contextualised with policy documents and published research on community pharmacy based weight management. Interviews were audio-recorded, transcribed and analysed thematically. Main outcome measure Pharmacists’ and MCAs’ beliefs and experiences with delivering weight management services in community pharmacy. Results There were mixed responses from pharmacists and MCAs around pharmacy based weight management services from positive views of providing the service in community pharmacy to those more reticent who would always favour patients visiting their physician. While all described similar services e.g. measurement of weight, healthy eating advice, supply of products, they acknowledged that support was often opportunistic at the request of customers, with little integration of other providers. Roles described varied from pharmacist only functions to any staff member. While pharmacists generally felt comfortable and confident, MCAs gave more diverse responses. Both Pharmacist and MCAs highlighted the need for a practice model which is systematically developed and suggested a scheme akin to the successful smoking cessation 12-week nicotine replacement therapy service already available in community pharmacies in Scotland. Conclusion Pharmacists and MCAs interviewed in this study reported their perceptions of benefits to providing community pharmacy based weight management as part of a wider public health function. They described services as opportunistic and customer driven based on ease of access. There was a notable variation in pharmacist and MCA training, reflected in their levels of comfort and confidence. There is a clear need to systematically develop and provide evidence of effectiveness and cost effectiveness for a pharmacy based practice model with key roles and functions for the full pharmacy team.

A systematic review of medical and non-medical practitioners’ views of the impact of ehealth on shared care

Purpose To explore medical and non-medical practitioners’ views of the impact of ehealth on shared care. Method A systematic review was conducted using a meta-narrative approach with publication search dates limited from 1 January 2005 to 28 February 2011 and English language only. Search results from the databases (ASLIB, EBSCO Host, Cochrane Library, Informa Healthcare, PsycNet, Sciverse Scopus, Zetoc) were independently reviewed and data extracted by two of the authors. The review included peer reviewed papers about medical and non-medical practitioners who provide ehealth supported shared care. Articles which focused solely on searching the internet or exchange of emails were excluded. Results Screening reduced the initial 327 papers identified to 12 which included three reviews, four qualitative, two mixed methods and three quantitative studies. Included studies collected data using combinations of questionnaires, case study, group/individual interviews, observation and extraction of data from records. Data were analysed using thematic, interpretive, analytic induction/constant comparative and statistical analysis methods. Practice settings were primary care, secondary care or both. The focus was on electronic records (7), telemedicine (2) or general ehealth implementation (3) predominantly from the perspective of doctors, nurses, IT developers, policy makers and managers plus one hospital pharmacist. The studies showed acceptance of ehealth technologies to support increasing levels of shared care but with cost effectiveness, level of resourcing and training questioned by respondents. Emerging themes across all study types were organisational, social and technical: resource and time implications, culture of the workplace and change management requirements; impact on patient consultation, extra workload, need for training suited to varying levels of IT literacy, usability, patient privacy and the practitioners role; systems incompatibility, technological inadequacies, need for shared definition and terminology. Conclusions Findings indicate acceptance of ehealth to support shared care but question anticipated efficiencies. Organisational, social and technical issues identified were similar to non-healthcare IT implementations and adoption of innovation theory. Evidence of medical and non-medical practitioners’ views of the impact of ehealth on shared care remains limited with further areas for pharmacy ehealth research identified.

A modified Delphi study to determine the level of consensus across the European Union on the structures, processes and desired outcomes of the management of polypharmacy in older people

Background Inappropriate use of multiple medicines (inappropriate polypharmacy) is a major challenge in older people with consequences of increased prevalence and severity of adverse drug reactions and interactions, and reduced medicines adherence. The aim of this study was to determine the levels of consensus amongst key stakeholders in the European Union (EU) in relation to aspects of the management of polypharmacy in older people. Methods Forty-six statements were developed on aspects of healthcare structures, processes and desired outcomes, with consensus defined at ≥ 80% agreement. Panel members were strategists (e.g. directors, leading clinicians and commissioners) from each of the 28 EU member states, with a target recruitment of five per member state. Three Delphi rounds were conducted via email, with panel members being provided with summative results and collated, anonymised comments at the commencement of Rounds 2 and 3. Results Ninety panel members were recruited (64.3% of target), with high participation levels throughout the three Delphi rounds (91.1%, 83.3%, 72.2%). During Round 1, consensus was obtained for 27/46 statements (58.7%), with an additional two statements in Round 2 and none in Round 3. Consensus was obtained for statements relating to: potential gain arising from polypharmacy management (3/4 statements); strategic development (7/7); change management (5/7) indicator measures (4/6); legislation (0/3); awareness raising (5/5); polypharmacy reviews (5/7); and EU vision (0/7). Analysis of free text comments indicated that the vision statements were too ambitious and not achievable by the specified timeframe of 2025. Conclusion Consensus was obtained amongst key EU strategists around many aspects of polypharmacy management in older people. Notably, no consensus was achieved in relation to statements relating to the need to alter legislation in areas of healthcare delivery, remuneration and practitioner scope of practice. While the vision for the EU by 2025 was considered rather ambitious, there is great potential and clear opportunity to advance polypharmacy management throughout the EU and beyond.

Digital literacy knowledge and needs of pharmacy staff: A systematic review

Objective To explore the digital literacy knowledge and needs of pharmacy staff including pharmacists, graduate (pre-registration) pharmacists, pharmacy technicians, dispensing assistants and medicine counter assistants. Methods A systematic review was conducted following a pre-published protocol. Two reviewers systematically performed the reproducible search, followed by independent screening of titles/abstracts then full papers, before critical appraisal and data extraction. Full articles matching the search terms were eligible for inclusion. Exclusions were recorded with reasons. Kirkpatrick’s 4 level model of training evaluation (reaction, learning, behaviour and results) was applied as an analytical framework. Results Screening reduced the initial 86 papers to 5 for full review. Settings included hospital and community pharmacy plus education in Australia, Canada and the US. No studies of pharmacy staff other than pharmacists were identified. Main findings indicate that pharmacy staff lack digital literacy knowledge with minimal research evidenced at each level of Kirkpatrick’s model. Conclusions As a society, we acknowledge that technology is an important part of everyday life impacting on the efficiency and effectiveness of working practices but, in pharmacy, do we take cognisance, ‘that technology can change the nature of work faster than people can change their skills’? It seems that pharmacy has embraced technology without recognised occupational standards, definition of baseline skills or related personal development plans. There is little evidence that digital literacy has been integrated into pharmacy staff training, which remains an under-researched area.

Future perspectives on nonmedical prescribing.

Many countries have implemented nonmedical prescribing (NMP) and many others are scoping prescribing practices with a view to developing NMP. This paper provides a future perspective on NMP in light of findings of an umbrella review of aspects of NMP. This is followed by coverage of the Scottish Government strategy of pharmacist prescribing and finally, consideration of two key challenges. The review identified seven systematic reviews of influences on prescribing decision-making, processes of prescribing, and barriers and facilitators to implementation. Decision making was reported as complex with many, and often conflicting, influences. Facilitators of NMP included perceived improved patient care and professional autonomy, while barriers included lack of defined roles and resource pressures. Three systematic reviews explored patient outcomes that were noted to be equivalent or better to physician prescribing. In particular, a Cochrane review of 46 studies of clinical, patient-reported, and resource-use outcomes of NMP compared with medical prescribing showed positive intervention-group effects. Despite positive findings, authors highlighted high bias, poor definition and description of ‘prescribing’ and the ‘prescribing process’ and difficulty in separating NMP effects from the contributions of other healthcare team members. While evidence of benefit and safety is essential to inform practice, for NMP to be implemented and sustained on a large scale, there needs to be clear commitment at the highest level. The approach being taken by the Scottish Government to pharmacist prescribing implementation may inform developments in other professions and countries. The vision is that by 2023, all pharmacists providing pharmaceutical care will be pharmacist-independent prescribers. There are, however, challenges to implementing NMP into working practice; two key challenges are the need for sustainable models of care and evaluation research. These challenges could be met by considering the theoretical basis for implementation, and robust and rigorous evaluation.

The behaviors and experiences of the community pharmacy team on the provision of multi-compartment compliance aids

Background: Multi‐compartment compliance aids (MCAs) are repackaging systems for solid dosage form medicines. Acknowledging the lack of evidence that MCAs improve adherence or clinical outcomes, the Royal Pharmaceutical Society has expressed concern that MCAs have ‘become regarded as a panacea for medicines use’. Objectives: To determine the behaviors and experiences of the community pharmacy team around MCA provision. Methods: A cross‐sectional survey was conducted in 26 community pharmacies in the north east of Scotland. Survey items were grouped into: current activities in the provision of MCAs; potential influences on these activities; reports of patient experiences; and demographics. Data were analysed using descriptive and inferential statistics, and content analysis of responses to open questions. Principal component analysis (PCA) was performed on the items of potential influences on activities. Results: Data were collected from 136 community team members (median 4, range1–10 per pharmacy; 32.3% pharmacists). All were involved in some aspect of MCA provision and within the same pharmacy, several different staff positions were commonly involved in the same activity. PCA gave seven components; the lowest scores were obtained for the component of ‘others expecting me to provide MCAs’. Participants agreed that GPs, patients and their families, and carers expected them to provide MCAs. Positive experiences of MCA provision were in themes of promoting patient adherence, reducing patient stress and enhancing patient monitoring. Further negative experiences were in of lack of shared patient decision making, worsening adherence and generation of medicines waste, and dealing with changing medicines. MCAs were not always considered to be the most appropriate solution. Conclusion: While community pharmacy teams value MCAs, there may be issues around staff assignment to particular roles, expectations from others and reports of negative patient experiences. A systematic approach to MCA provision and monitoring involving the multidisciplinary health and social care team is warranted. HIGHLIGHTSA survey of behaviors and experiences of the community pharmacy team on multi‐compartment compliance aid provision.All 136 team members (1–10 per pharmacy; 32.3% pharmacists) were involved in some aspect of MCA provision.Participants agreed that GPs, patients and their families, and carers expected them to provide MCAs.MCAs were not always considered to be the most appropriate solution to medicines non‐adherence.