'Really putting a different slant on my use of a glass of wine': patient perspectives on integrating alcohol into Structured Medication Reviews in general practice

BackgroundAlcohol is often overlooked in primary care even though it has wide-ranging impacts. The Structured Medication Review (SMR) in England is a new 'holistic' service designed to tackle problematic polypharmacy, delivered by clinical pharmacists in a general practice setting. Implementation has been protracted owing to the COVID-19 pandemic. This study explores early patient experiences of the SMR and views on the acceptability of integrating clinical attention to alcohol as another drug linked to their conditions and medicines, rather than as a standalone 'healthy living' or 'lifestyle' question.MethodSemi-structured interviews with a sample of 10 patients who drank alcohol twice or more each week, recruited to the study by five clinical pharmacists during routine SMR delivery.ResultsSMRs received were remote, brief, and paid scant attention to alcohol. Interviewees were interested in the possibility of receiving integrated attention to alcohol within a SMR that was similar to the service specification. They saw alcohol inclusion as congruent with the aims of a holistic medicines review linked to their medical history. For some, considering alcohol as a drug impacting on their medications and the conditions for which they were prescribed, introduced a new frame for thinking about their own drinking.ConclusionsIncluding alcohol in SMRs and changing the framing of alcohol away from a brief check with little meaningful scope for discussion, toward being fully integrated within the consultation, was welcomed as a concept by participants in this study. This was not their current medication review experience.

The reach and benefits of a digital intervention to improve physical activity in people with a musculoskeletal condition delivered during the COVID-19 pandemic in the UK.

AIM: To evaluate a digital intervention to improve physical activity in people in the UK with a musculoskeletal condition delivered during movement restrictions brought about because of the COVID-19 pandemic. METHOD: Service evaluation data collected from 26,041 participants over 5 months was assessed against national datasets to understand the reach and representativeness of the digital physical activity intervention. Measures to restrict the movement and interaction of people were in place during these 5 months. Cross-sectional data from 2752 participants across different stages of the 12-week programme assessed levels of physical activity and the components of behaviour as defined by the COM-B model (Capability, Opportunity, Motivation = Behaviour). Regression analysis investigated the relationship between programme stage and physical activity and the components of behaviour. RESULTS: In comparison to the UK population of people with a musculoskeletal condition, the intervention participants were over-represented by females, White, and inactive people. A cross-sectional analysis suggested that the number of participants regularly active increased by programme stage. Scores for the behavioural components of automatic and reflective motivation, physical and psychological capability, and physical opportunity were also improved by programme stage. CONCLUSION: The service evaluation suggests that the digital intervention, designed to improve physical activity in people with a musculoskeletal condition, could be beneficial during measures to restrict movement to slow the spread of infectious disease in those who are already motivated to become or stay active.

Waste COVID-19 Facemasks as an Auxiliary Iron Reductant in the Rotary Hearth Furnace

Non-recyclable waste disposable facemasks used to reduce transmission of the coronavirus SARS-CoV-2 have been milled into a form suitable for inclusion into the rotary hearth furnace as a way of reducing iron oxides in steelmaking by-products. Self-reducing briquettes were prepared of powdered Fe2O3, coal and facemask plastic and the stepwise reduction of iron oxide to metallic iron was studied thermogravimetrically and through atmospheric furnace experiments. The reduction efficiency of coal and coal treated with waste facemasks is comparable and the results suggest a synergistic effect where the pyrolysis products of plastic decomposition deposit as soot on Fe2O3 particles, supplying additional reductant to higher temperature reduction reactions. © 2023 American Institute of Physics Inc.. All rights reserved.

Frequency of reported thrombotic adverse events and clinical outcomes associated with three COVID-19 vaccines

Background: During the first quarter of 2021, several European countries suspended the use of the Oxford-AstraZeneca vaccine amid reports of blood clot events and the death of a vaccinated person. This was followed by several reports of fatalities related to pulmonary embolism and other thrombotic events including thrombocytopenia which has been referred to as vaccine-induced immune thrombotic thrombocytopenia (VITT). Aim(s): This study investigated the occurrence of thrombotic adverse events and their clinical outcomes of the three approved and most used COVID-19 vaccines namely Moderna, Pfizer and Oxford-AstraZeneca, using one of the largest spontaneous adverse events databases, namely EudraVigilance. Method(s): A retrospective descriptive analysis was conducted of spontaneous reports for Moderna, Pfizer and Oxford-AstraZeneca COVID-19 vaccines submitted to the EudraVigilance database in the period from 17 February to 14 June 2021. Result(s): There were 729,496 adverse events for the three vaccines, of which 3420 were thrombotic, mainly Oxford-AstraZeneca (n = 1988, 58 1%) followed by Pfizer (n = 1096, 32 0%) and Moderna (n = 336, 9 8%). As serious adverse events, there were 705 reports of pulmonary embolism for the three vaccines, of which 130 reports (18 4%) were for Moderna, 226 reports (32 1%) for Pfizer and 349 (49 5%) for Oxford-AstraZeneca vaccines. The occurrence of pulmonary embolism is significantly associated with a fatal outcome (p = < 0 001). Sixty-three fatalities were recorded (63/3420, 1.8%), of which Moderna (n = 6), Pfizer (n = 25) and Oxford-AstraZeneca (n = 32). Conclusion(s): Thrombotic adverse events reported for the three vaccines remains extremely rare with multiple causative factors reported elsewhere as precipitating these events. Practicing vigilance and proper clinical management for the affected vaccines, as well as continuing to report adverse events, are essential. More than 4 89 billion doses of different COVID-19 vaccines have been administered across the globe. On the basis of scientific evidence showing that benefit outweighs risk, people continue to be urged to accept the vaccination when offered.

Center Variation is the Major Driver of Geographic Disparities in Access to Kidney Transplants Among Waitlisted Candidates

Purpose: The OPTN's monitoring of equity in access to deceased donor kidney (KI) transplants (tx) among waitlisted candidates has consistently found service area (DSA) of listing as the factor most independently associated with access disparities. We extracted center-level from DSA-level effects to better characterize geographic disparities in the COVID-19 and KAS 250NM circle eras. Method(s): Poisson tx rate regression, with random DSA and center effects, was applied to 3 period-prevalent cohorts (KAS: 2018-2019;KAS COVID Onset: 1/2020-3/2021;KAS250: 4/2021-9/2021) of active KI waiting list registrations using OPTN data. Risk-adjusted, population-weighted, factor-specific disparities were quantified as the Winsorized standard deviation (SDw) of log(tx rate) among registrations, holding other factors constant. Geographic disparity was also quantified by median incidence rate ratios (MIRR), interpreted as the median increase in tx rate if a candidate switched to a random, higher tx rate center or DSA. The association between donor supply to demand ratios (S/D;# deceased kidney donors / # prevalent WL candidates) and residual (after removing center effects) DSA effects was assessed with Spearman's rho. Result(s): Pre-COVID, variation in tx rates was markedly higher for centers (MIRR 1.72) vs. DSAs (MIRR 1.32). Under COVID, center-level MIRR rose to 1.94 and has remained high. The DSA-level MIRR fell to 1.20 in the early KAS250 era (Fig 1). As measured by population-weighted SDw, tx center (0.62) is the factor most associated with unintended disparities in the KAS250 era, with residual DSA-level variation (0.25) ranked 4th (Fig 2). Residual DSA effects were positively correlated (rho=0.55, p<0.001) with local S/D. Conclusion(s): DSA-level variation declined under KAS250, but disparities remain and are associated with differential local S/D. Tx center-level variation is the top driver of access disparities and may have been exacerbated by COVID. Further reductions in geographic disparities may be possible through allocation policy changes, although other interventions - such as reducing center variation in offer acceptance decisions and maximizing the recovery of potential deceased donors - may have greater impacts.

NatureScot research report 1289 - enjoying theoutdoors - monitoring the impact of coronavirus andsocial distancing - wave 3 survey results (September2021)

This report presents the findings from a further, third wave undertaken a year later, with fieldwork running from 7 to 21 September 2021 and respondents asked to focus their responses on the preceding 4 weeks from around mid-August 2021.

Exploring determinants of antimicrobial prescribing behaviour: a qualitative study using the Theoretical Domains Framework

Introduction Few qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals, and none has made reference to behavioural theories. An understanding of these determinants is required for the successful development and implementation of behaviour change interventions (BCIs) in this area. Aim To explore the determinants of clinicians’ antimicrobial prescribing behaviour, using the Theoretical Domains Framework (TDF;a framework of behavioural theories). Methods This work was part of a multi-phase explanatory, sequential mixed methods PhD programme of research. This qualitative part involved semi-structured, online (video) interviews via a videoconferencing software programme (Zoom) with clinicians (doctors and pharmacists) based in 12 Hamad Medical Corporation hospitals in Qatar. Clinicians were sampled purposively in strata of gender, profession, years of experience and area of practice. The interview schedule was developed based on a review of published literature (1), previous findings of quantitative research (2) and the TDF to ensure comprehensive coverage of key determinants (including barriers and facilitators) related to clinicians’ antimicrobial prescribing behaviour. Interviews were conducted from December 2020 to February 2021, audio-recorded, transcribed and independently analysed by two research team members using the TDF as an initial coding framework. Results Data saturation was achieved after interviewing eight doctors and eight pharmacists from a range of areas of practices and with a variety of experiences. A number of themes, linked to ten TDF domains, were identified as determinants of antimicrobial prescribing behaviour and these determinants were interrelated. In-depth analysis identified several barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. Main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources), gaps in the knowledge in relation to guidelines and appropriate prescribing (knowledge), restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity), uncomfortable antimicrobial prescribing decisions (memory, attention and decision processes), as well as professional hierarchies and poor multidisciplinary teamworking/relationships (social influences). “Sometimes, the barrier would be the ego of senior doctors who refuse our evidence-based recommendation and depend on their clinical judgement or experience” (Pharmacist 470, Cardiology). Key facilitators highlighted included guidelines compliance goals and intentions, and the beliefs of consequences of appropriate or inappropriate prescribing. Further education and training sessions, and some changes to guidelines, including accessibility were also considered essential. “We need to seriously consider getting an antibiotic guidelines app which is downloaded to clinicians’ mobile phones. The mobile app is handy, you can access it anytime even at the patient’s bedside” (Doctor 514, Microbiology). Conclusion This qualitative study, using a theoretically based approach, has identified that antimicrobial prescribing in hospitals is a complex process influenced by a broad range of behavioural determinants that described specific barriers and facilitators. The in-depth understanding of this complexity provided by this phase of the research may contribute to the design and development of theoretically based BCIs to improve clinicians’ antimicrobial prescribing. Limitations include data collected with online interviews due to the Covid-19 restrictions. This may have excluded some clinicians who did not feel comfortable with or have access to the technology required. References (1) Talkhan H, Stewart D, Mcintosh T, Ziglam H, Abdulrouf P, Al-Hail M et al. The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: systematic review. Journal of Antimicrobial Chemotherapy. 2020;75(9):2394-2410. (2) Talkhan H, Stewart D, McIntosh T, Ziglam H, Abdulrouf P, Al-Hail M et al. Using the Theoretical Domains Framework to investigate clinicians’ behavioural determinants of antimicrobial prescribing in Qatar. International Journal of Pharmacy Practice. 2021;29(1):i20-i22.

The impact of COVID-19 on antimicrobial stewardship programme implementation in hospitals - an exploration informed by the Consolidated Framework for Implementation Research.

INTRODUCTION AND OBJECTIVES: The disruption of antimicrobial stewardship programmes (ASPs) caused by coronavirus disease 2019 (COVID-19) has been recognized but not explored in depth. This study used a theoretical, qualitative approach to understand the impact of COVID-19 on ASP implementation in hospitals. METHODS: Semi-structured online interviews, informed by the Consolidated Framework for Implementation Research (CFIR), were conducted with ASP team members and non-members in hospitals. Participants were recruited via purposeful and snowball sampling with interviews video recorded, transcribed and analysed independently by two researchers based on mapping against CFIR constructs. RESULTS: Thirty-one interviews were conducted across 11 hospitals. The following themes were identified: (i) increased complexity of ASP implementation and changes in prescribing behaviour influenced by COVID-19; (ii) adaptations, networking and cosmopolitanism to enhance integration of COVID-19 management into ASP services; and (iii) adaptations and networking to support continuity of the ASP implementation process. A disruption to pre-pandemic ASP activities was reported, with complexity of COVID-19 overwhelming the healthcare system. ASP team members and services showed an ability to adapt and repurpose roles to respond to the pandemic. Interventions included developing national guidelines for treatment of patients with COVID-19 and contributing to guideline management and monitoring. A gradual restoration of ASP activities was perceived. Technological adaptations and enhancements in networking were reported as positive impacts of the pandemic. CONCLUSION: Despite the initial disruption of ASP implementation caused by the pandemic, successful adaptation and evolution of ASP services reflects the high value and adaptability of ASP implementation in hospitals in the United Arab Emirates.

Equity in access to kidney transplants by race/ethnicity in the COVID-19 era

Purpose: The direct impact of the COVID-19 pandemic on minority populations has been well documented, and it is conceivable that disparities in access to kidney transplants by race and ethnicity have been exacerbated during the pandemic. Barriers to transplant may have emerged due to concerns about increased susceptibility to COVID-19 among racial/ethnic minorities. Methods: We examined quarterly trends in deceased donor kidney transplants per patient-year on the waiting list over time (1/2017-9/2020) among 4 major racial/ ethnic groups (White;Black;Hispanic;Asian). Unadjusted and adjusted Poisson regressions were used to estimate transplant rates pre-COVID-19 (1/2019-3/2020) and during COVID-19 (4/2020-9/2020). In addition to race/ethnicity, adjusted models included 17 factors such as blood type, CPRA, age, gender, diagnosis, and transplant center. Median KDPI was calculated among recipients. Results: For all 4 racial/ethnic groups, transplant rates rose steadily prior to COVID- 19, declined initially during the pandemic, and rebounded sharply in Jul-Sep '20. However, the decline was sharpest for Hispanic candidates, and the COVID-19-era rebound was greatest for White and Asian candidates (Fig 1). Relative to Whites, the transplant incidence rate ratio (IRR) declined in the COVID- 19 era for minorities (race by era interaction, p=0.0006, Fig 2a). Racial/ethnic transplant rate differences, and the race by era interaction, were both substantially attenuated in risk-adjusted modeling (Fig 2b). Median KDPI remained unchanged or improved during the pandemic for both White and minority recipients. Conclusions: Remarkably, the overall transplant rate surpassed pre-pandemic levels, as the transplant community has adapted remarkably well to the pandemic. But early COVID-19-era data suggest racial/ethnic disparities may have increased, particularly for Hispanic candidates. As the community continues to adapt and plan for the possibility of further pandemic impact, practices to ensure safe and equitable access to transplantation for vulnerable groups should be further developed and disseminated. (Table Presented).