Teresa M. Salgado

The relationship between transepidermal water loss and skin permeability

Transepidermal water loss (TEWL) is a measure of the steady-state water vapour flux crossing the skin to the external environment and it has been used extensively to characterise skin barrier function. We have previously hypothesised that in vivo TEWL is directly related to the reciprocal of the diffusional permeation pathlength through the stratum corneum (SC). The aim of the present paper is to validate experimentally this hypothesis. Ninety volunteers were recruited and TEWL and corneocyte surface areas were measured for six anatomic sites. The number of cell layers in the SC was calculated for each anatomic site in order to estimate the geometric pathlength for water efflux. Significant anatomic site variability was found for both TEWL and corneocyte surface area which were inversely correlated. A direct reciprocal relationship between TEWL and pathlength was determined, with TEWL values tending to zero when corneocytes are infinitely large. In general, skin sites with smaller corneocytes have fewer cell layers, with shorter permeation pathlengths and higher TEWL values. The results confirm our previous hypothesis and suggest that TEWL may be used to characterise the permeation routes for different anatomic sites.

Effectiveness of clinical pharmacy services: an overview of systematic reviews (2000–2010)

Background Multiple reviews have evaluated the impact of pharmacist-delivered patient care on health-related outcomes. However, it is unclear which of the pharmacist-delivered interventions in these services are the most effective. Aim of the review To gather the evidence of the impact of clinical pharmacy services on the medication use process or on patient outcomes using an overview of systematic reviews. Methods PubMed was searched to retrieve systematic reviews published between 2000 and 2010 that assessed the impact of clinical pharmacy services on the medication use process or patient outcomes. Two independent reviewers evaluated the study eligibility and one extracted the description and results of the services. The methodological quality of each review was assessed with the R-AMSTAR tool. Results Of the 343 potentially relevant records identified, 49 systematic reviews, comprising a total of 269 randomized controlled trials, met the selection criteria. Clinical pharmacy services that focused on specific medical conditions, such as hypertension or diabetes mellitus, revealed a positive impact of pharmacists’ interventions on patient outcomes. For other medical conditions, however, the results were inconclusive (e.g., dyslipidemia or thromboprophylaxis). Interventions that targeted medication adherence and assessed the impact of clinical pharmacy services in prescription appropriateness also produced inconclusive results because of the variability of methods used to assess both medication adherence and medication appropriateness. Conclusions Systematic reviews that assessed clinical pharmacy services targeting specific conditions were more conclusive given that the intervention was well defined, and the measured outcomes were unequivocal and tangible. Conversely, the results were inconclusive for interventions with a broader target and with monitoring parameters that were unclearly established or inconsistently assessed across studies. These findings emphasize the need to better define clinical pharmacy services and standardize methods that assess the impact of these services on patient health outcomes.

A Tool to Characterize the Components of Pharmacist Interventions in Clinical Pharmacy Services: The DEPICT Project

BACKGROUND The complexity of clinical pharmacy services usually leads to an inconsistent or even poor description of their interventions in scientific reports. To ensure comparability and reproducibility of the evidence, an in-depth description of pharmacist interventions is required. OBJECTIVE To validate a new tool called DEPICT (Descriptive Elements of Pharmacist Intervention Characterization Tool) to characterize clinical pharmacy services. METHODS We developed a 3-phase study. First, to create a theoretical framework, an overview of systematic reviews was performed in PubMed between 2000 and 2010. Then, an in-depth analysis of the included studies was carried out to identify a list of components in order to create the instrument. Finally, 2 independent raters separately applied the tool to a random sample of 28 randomized clinical trials extracted from the systematic reviews. Interrater agreement was evaluated using PABAK (prevalence-adjusted bias-adjusted κ) coefficient or intraclass correlation coefficient (ICC). RESULTS We included 49 systematic reviews in our overview. Analysis of these studies resulted in 58 intervention components, with 57 dichotomous variables and 1 discrete variable. These items resulted in a preliminary version of the instrument. The reliability analysis showed that 8 binary items of this version had a PABAK less than or equal to 0.60. These items were then excluded or modified, resulting in a final version of the tool, with 54 items organized into 12 domains. DEPICT showed an average PABAK of 0.85 (95% CI 0.81 to 0.88) and an ICC of 1.0. Twenty items presented a PABAK value between 0.61 and 0.80 (substantial agreement) and 33 had a value between 0.81 and 1.0 (almost perfect agreement). CONCLUSIONS DEPICT is a reproducible instrument for describing the components of pharmacist interventions performed as part of clinical pharmacy services. It allows retrospective analysis of published studies and can be used as a reference guide to report pharmacist interventions in future studies.

Ensuring consistent reporting of clinical pharmacy services to enhance reproducibility in practice: an improved version of DEPICT

RATIONALE, AIMS AND OBJECTIVES DEPICT (Descriptive Elements of Pharmacist Intervention Characterization Tool) was created in response to the frequently reported issue of poor intervention description across studies assessing the impact of clinical pharmacy activities. The aim of this study was to create an improved version of DEPICT (i.e. DEPICT 2) to better characterize clinical pharmacy services in order to ensure consistent reporting, therefore enhancing reproducibility of interventions in practice. METHOD A qualitative approach through a thematic content analysis was performed to identify components of pharmacist interventions described in 269 randomized controlled trials. A preliminary version of DEPICT 2 was applied independently by two authors to a random sample of 85 of the 269 RCTs and reliability determined by the prevalence-adjusted bias-adjusted kappa (PABAK) or the intraclass correlation coefficient (ICC). The final version of DEPICT 2 was compared against DEPICT 1. RESULTS The final version of DEPICT 2 comprised 146 items and 11 domains. The inter-rater agreement analysis showed that DEPICT presented good to optimal reproducibility, with a mean PABAK value of 0.87 (95% CI 0.85-0.89) and a mean ICC value of 0.88 (95% CI 0.62-1.14). The mean difference between items checked in the two versions (DEPICT 2 - DEPICT 1) was 10.58 (95% CI 9.55-11.61), meaning that approximately 11 more components were identified in the new version of DEPICT. CONCLUSIONS DEPICT 2 is a reliable tool to characterize components of clinical pharmacy services, which should be used to ensure consistent reporting of interventions to allow their reproducibility in practice.

Assessing the Implementability of Clinical Pharmacist Interventions in Patients With Chronic Kidney Disease: An Analysis of Systematic Reviews

Background: Pharmacy practice studies have been criticized for presenting poor intervention description, which has serious implications when attempting to replicate interventions elsewhere. Evidence of improved outcomes for patients with chronic kidney disease (CKD) following pharmacist intervention exist in the literature, but similar concerns with intervention description have been raised. Objective: To assess the implementability of evidence-based clinical pharmacist interventions in patients with CKD, based on the information contained in the published manuscripts. Methods: PubMed was searched to retrieve systematic reviews addressing the role of pharmacists in patients with CKD. Primary studies describing clinical pharmacy services in CKD were subsequently extracted. To describe and characterize pharmacists’ interventions, the DEPICT (Descriptive Elements of Pharmacist Intervention Characterization Tool) was applied. Studies were independently classified as “implementable” or “nonimplementable” by 2 authors, based on whether they could be easily implemented into practice using the description provided in the article. Finally, implementable interventions were grouped in different areas. Results: Five reviews were retrieved, and 39 original studies were analyzed. Of these, 59.0% were classified as nonimplementable. Among implementable interventions, 6 evidence-based areas of pharmacist interventions were identified: anemia, renal osteodystrophy, and cardiovascular risk factors management, medication appropriateness evaluation and medication reconciliation, patient education and compliance, and cost containment. Conclusions: Information contained in most articles reporting pharmacist interventions in CKD is not sufficient to ensure the implementation of the service in clinical practice. Pharmacy practice research articles should be written with the aim of improving clinical practice and not just showing the results of pharmacists’ interventions.

Exploring the role of renal pharmacists in outpatient dialysis centres: a qualitative study

Background Pharmacists’ involvement in outpatient dialysis centres in Australia is currently limited, despite the positive contribution of pharmacists to renal patients’ medication management and health outcomes outlined in the literature. An expanded role for pharmacists in this setting may be required as a consequence of the increasing burden of renal disease in the population. Objective To explore renal-specialised hospital pharmacists’ intentions to implement pharmacy services in outpatient dialysis centres. Setting Australian renal-specialised hospital pharmacists. Method Semi-structured interviews were conducted with a purposeful sample of renal pharmacists recruited through the Society of Hospital Pharmacists of Australia Renal Special Interest Group. The interview guide was developed based on the theory of planned behaviour. To identify behavioural intention, the three components of the theory—attitudes, subjective norm, and perceived behavioural control—were explored. The interviews were recorded, transcribed verbatim, and thematically content analysed following a qualitative approach. Main Outcome Measures Pharmacists’ views on their potential involvement and perceived ease or difficulty in implementing pharmacy services in outpatient dialysis centres. Results Thirteen renal pharmacists were interviewed until data saturation achievement. The following services for this setting were suggested: medication reconciliation, medication review, patient education, promotion of compliance, involvement in protocol development with subsequent anaemia/phosphate management. Pharmacists demonstrated positive attitudes towards the implementation of the services. Outcomes expected included benefits to patients, the renal team, and the pharmacy profession, as well as economic savings due to dose optimisation and improvement of patients’ adherence. Subjective norm was favourable meaning that nephrologists, nurses and patients were expected to be receptive towards future pharmacy services. Barriers pointed out for the implementation comprised: funding, hospital administrators’ approval, time and staff shortage, academic training, relationship with physicians, and attitudes of pharmacists, renal team, and patients. Facilitators mentioned by respondents included: having an interview room with access to information sources, consent from the team, access to patients’ profiles, and a full-time pharmacist with a clearly defined role. Conclusion Pharmacists showed positive attitudes, favourable subjective norm and strong perceived behavioural control, which originated a clear behavioural intention to develop pharmacy services in outpatient dialysis centres. The potential barriers and enablers outlined should be taken into account, as well as the holistic approach for the successful implementation of cognitive pharmacy services.

Newest Vital Sign as a proxy for medication adherence in older adults

OBJECTIVE To assess the utility of the Newest Vital Sign (NVS) as a proxy for medication adherence in community-dwelling older adults. DESIGN Descriptive cross-sectional study. SETTING 12 adult day care centers in the Lisbon metropolitan area, Portugal, between March and May 2009. PARTICIPANTS 100 white community-dwelling older adults. INTERVENTION Participants were administered the NVS, Single Item Literacy Screener (SILS), and self-reported Measure of Adherence to Therapy (MAT). MAIN OUTCOME MEASURES Health literacy and medication adherence. RESULTS The mean (±SD) age of the respondents was 73.3 ± 7.8 years and 71% were women. The NVS score was 0.81 ± 0.10 (of 6 possible points), and 95% of the respondents scored in the three lowest possible scores, indicating a notable floor effect. Age was found to be inversely correlated with NVS score (P = 0.003). The MAT score was 36.2 ± 4.7 (range 17-42). No statistically significant association between the NVS and level of education (P = 0.059 [Kruskal-Wallis]), gender (P = 0.700 [Mann-Whitney]), SILS (P = 0.167), or MAT (P = 0.379) was identified. CONCLUSION The utility of the NVS as a proxy for medication adherence in community-dwelling older adults is limited because of a floor effect that hinders its predictive power for medication adherence.

Characterization of the Medical Subject Headings thesaurus for pharmacy

PURPOSE The completeness and utility of pharmacy-oriented Medical Subject Headings (MeSH) relative to MeSH terminology pertaining to other healthcare professions (dentistry and nursing) are evaluated. METHODS The 2013 version of the MeSH thesaurus-the standard vocabulary used by the National Library of Medicine (NLM) to index articles in PubMed and MEDLINE-was searched for dentistry-, nursing-, and pharmacy-specific terms using a truncation strategy (search terms: nurs*, dent*, and pharm*); the hierarchical level of each term and the number of descendant terms (an indication of the granularity of the associated NLM-indexed content) were determined. PubMed searches were conducted to identify areas of the MeSH hierarchy containing dentistry- and nursing-specific terms but no equivalent pharmacy-specific term. RESULTS The search of the MeSH thesaurus identified 145 terms representing dentistry-specific activities and 94 and 26 terms specific to nursing and pharmacy practice, respectively. Analysis of the three sets of MeSH terms indicated that dentistry-oriented MeSH terms were generally situated more prominently within the MeSH hierarchy than terms for nursing- and pharmacy-oriented research; the MeSH terminology oriented toward nursing or dentistry practice was relatively more granular, allowing for increased specificity and power of information retrieval during PubMed and MEDLINE searches. Seventeen proposed new MeSH terms describing key areas of pharmacy practice were identified; the inclusion of these terms in the MeSH hierarchy could substantially expand and improve the retrievability of NLM-indexed literature. CONCLUSION Imbalances and gaps were found in MeSH coverage of pharmacy concepts and terminology relative to MeSH terminology specific to the nursing and dentistry professions.

Issues in the Medication Management Process in People Who Have Intellectual and Developmental Disabilities: A Qualitative Study of the Caregivers' Perspective

People who have intellectual and developmental disabilities (IDD) often rely on caregivers to assist in the medication management process. The aim of this study was to learn from caregivers, who are either family or support staff, what major issues arise throughout the process of managing medication and how these might be addressed. Problems identified by caregivers include (a) prescribers understanding of insurance and agency policies regarding medication utilization; (b) lack of continuity of care and accuracy of the medication record as well as clinical records;

Lack of harmonisation in the classification of renal impairment in European Summaries of Product Characteristics

We thank Fundacao para a Ciencia e a Tecnologia, Ministry of Education and Science, Portugal, for supporting this work (Doctoral Grant reference number SFRH/BD/43999/2008).