Designated prescribing practitioners: a theory-based cross-sectional study of stakeholders' views on implementation of a novel pharmacy regulator mandated preceptorship model.

BACKGROUND: Scottish Government is increasing independent prescribers (IP) in community pharmacy (CP). A new preceptorship model using IPs as Designated Prescribing Practitioners (DPPs) has been introduced. AIM: To investigate stakeholder views of implementation of a novel regulator mandated IP course preceptorship model. METHOD: A theory-based online pre-piloted survey of stakeholders including e.g. directors of pharmacy, prescribing, education leads, policy & strategy leads and CPs. Questionnaire development used Consolidated Framework for Implementation Research (CFIR) and a DPP Competency Framework. Data were analysed descriptively and presented with mapping to CFIR constructs. RESULTS: Of ninety-nine responses 82.5% (80/97) responded 'yes' to '..abilities in reporting concerns..' and 53.1% (51/96) indicating 'no' to '..anticipated issues with clinical and diagnostic skills'. CFIR related facilitators included agreement that; there was tension for change with 84 (85%) indicating '….urgent need to implement role …', that incentives are likely to help (6566%) and small pilots would help (8588%). Barriers were evident related to 'unsure' responses about sufficiency of; DPP capacity (39/97, 40.2%), time (48/96, 50%) and support and resources (4445%) to undertake the role. Concerns were expressed with 81 (83%) in agreement or unsure that leadership commitment may be lacking and 48 (48.9%) were 'unsure' about availability of good training for the DPP role. CONCLUSION: There was DPP role positivity but expressed barriers and facilitators at policy, organisational and individual practitioner levels needing further consideration. Further research is warranted on uptake and embedding of the role.

Better long-term speech outcomes in stroke survivors who received early clinical speech and language therapy: What's driving recovery?

Establishing whether speech and language therapy after stroke has beneficial effects on speaking ability is challenging because of the need to control for multiple non-therapy factors known to influence recovery. We investigated how speaking ability at three time points post-stroke differed in patients who received varying amounts of clinical therapy in the first month post-stroke. In contrast to prior studies, we factored out variance from: initial severity of speaking impairment, amount of later therapy, and left and right hemisphere lesion size and site. We found that speaking ability at one month post-stroke was significantly better in patients who received early therapy (n = 79), versus those who did not (n = 64), and the number of hours of early therapy was positively related to recovery at one year post-stroke. We offer two non-mutually exclusive interpretations of these data: (1) patients may benefit from the early provision of self-management strategies; (2) therapy is more likely to be provided to patients who have a better chance of recovery (e.g., poor physical and/or mental health may impact suitability for therapy and chance of recovery). Both interpretations have implications for future studies aiming to predict individual patients' speech outcomes after stroke, and their response to therapy.

Patient's experience of psoriatic arthritis: a conceptual model based on qualitative interviews.

INTRODUCTION: Psoriatic arthritis (PsA) is a heterogeneous chronic inflammatory musculoskeletal disorder that manifests as peripheral arthritis, dactylitis, enthesitis and spondylitis. PsA results in significant burden that impacts quality of life of patients. We examined the signs, symptoms and impacts reported by patients with PsA, to characterise the patient experience of PsA and develop a conceptual model representing this patient experience. METHODS: Semi-structured interviews were conducted with patients with PsA recruited through the FORWARD databank. Spontaneous and probed signs, symptoms and impacts of PsA were assessed. Patients rated the disturbance of these concepts on their lives using a scale from 0 ('does not disturb') to 10 ('greatly disturbs'). Signs, symptoms and impacts reported by >80% of patients with a disturbance rating of ≥5 were defined as salient concepts. Recruitment continued until concept saturation was achieved. RESULTS: 19 patients with PsA were interviewed. The interviews elicited 42 symptoms of which 8 had not been identified in a previous literature review encompassing 15 relevant articles. The most salient signs and symptoms elicited in the interviews were joint pain, skin symptoms, stiffness, swollen/inflamed joints and fatigue all with moderate to high disturbance ratings (range: 5.5-7.8). The most salient impacts were sleep disturbance, physical disability, effects on daily activities and feelings of frustration with also moderate to high disturbance ratings (range: 6.1-7.4). CONCLUSIONS: The interviews highlighted the adverse impact PsA has on the patient's life and may inform on outcome variables or areas suitable to be assessed in PsA studies.

A cross-sectional survey of the pharmacy workforce in general practice in Scotland.

BACKGROUND: In Scotland, there has been significant investment in pharmacy teams in general medical practices over recent years, aligned to current government policy. OBJECTIVES: To characterize the national pharmacy workforce including activities undertaken, perceived competence and confidence, as well as perception of integration of the intervention. METHODS: A cross-sectional survey of all pharmacists and pharmacy technicians in general practices. Survey items were demographics, activities undertaken and experiences. The NoMAD tool (Improving the Normalization of Complex Interventions) was included as a measure of perspectives of implementation. Post-piloting, a questionnaire link was sent to all pharmacists (n = 471) and pharmacy technicians (n = 112). A total NoMAD score was obtained by assigning 1 (strongly disagree) to 5 (strongly agree) to each item. RESULTS: Responses were received from 393 (83.4%) pharmacists and 101 (91.8%) pharmacy technicians. Three quarters of pharmacists (74.6%) and pharmacy technicians (73.3%) had been qualified for over 10 years. Two-thirds of pharmacists (68.4%) were independent prescribers, with three quarters (72.3%) currently prescribing. Respondents worked in a median of two practices and were providing a range of activities including medication/polypharmacy reviews, medicines reconciliation, prescribing efficiencies and training. Respondents reported high levels of competence and confidence (median 8, scale 0-10 highest). Median NoMAD total score (scale 20-100 highest, Cronbach's alpha 0.89) was 80 for pharmacists and 75 for pharmacy technicians, P ≤ 0.001. CONCLUSIONS: The general practice pharmacy workforce in Scotland is experienced, well-qualified and integrated within general practices, delivering a range of activities. These findings have implications for workforce planning and future education and training.

Does the obesity paradox predict functional outcome in intracerebral hemorrhage?

OBJECTIVEBeing overweight or mildly obese has been associated with a decreased risk of death or hospitalization in patients with cardiovascular disease. Similarly, overweight patients admitted to an intensive care unit (ICU) have improved survival up to 1 year after admission. These counterintuitive observations are examples of the "obesity paradox." Does the obesity paradox exist in patients with intracerebral hemorrhage (ICH)? In this study the authors examined whether there was an association between obesity and functional outcome in patients with ICH.METHODSThe authors analyzed 202 patients admitted to the neurological ICU (NICU) who were prospectively enrolled in the Columbia University ICH Outcomes Project between September 2009 and December 2012. Patients were categorized into 2 groups: overweight (body mass index [BMI] ≥ 25 kg/m2) and not overweight (BMI < 25 kg/m2). The primary outcome was defined as survival with favorable outcome (modified Rankin Scale [mRS] score 0-3) versus death or severe disability (mRS score 4-6) at 3 months.RESULTSThe mean age of the patients in the study was 61 years. The mean BMI was 28 ± 6 kg/m2. The mean Glasgow Coma Scale score was 10 ± 4 and the mean ICH score was 1.9 ± 1.3. The overall 90-day mortality rate was 41%. Among patients with a BMI < 25 kg/m2, 24% (17/70) had a good outcome, compared with 39% (52/132) among those with a BMI ≥ 25 kg/m2 (p = 0.03). After adjusting for ICH score, sex, do-not-resuscitate code status, and history of hypertension, being overweight or obese (BMI ≥ 25 kg/m2) was associated with twice the odds of having a good outcome compared with patients with BMI < 25 kg/m2 (adjusted odds ratio 2.05, 95% confidence interval 1.03-4.06, p = 0.04).CONCLUSIONSIn patients with ICH admitted to the NICU, being overweight or obese (BMI ≥ 25 kg/m2) was associated with favorable outcome after adjustment for established predictors. The reason for this finding requires further study.

Right hemisphere structural adaptation and changing language skills years after left hemisphere stroke.

Stroke survivors with acquired language deficits are commonly thought to reach a 'plateau' within a year of stroke onset, after which their residual language skills will remain stable. Nevertheless, there have been reports of patients who appear to recover over years. Here, we analysed longitudinal change in 28 left-hemisphere stroke patients, each more than a year post-stroke when first assessed-testing each patient's spoken object naming skills and acquiring structural brain scans twice. Some of the patients appeared to improve over time while others declined; both directions of change were associated with, and predictable given, structural adaptation in the intact right hemisphere of the brain. Contrary to the prevailing view that these patients' language skills are stable, these results imply that real change continues over years. The strongest brain-behaviour associations (the 'peak clusters') were in the anterior temporal lobe and the precentral gyrus. Using functional magnetic resonance imaging, we confirmed that both regions are actively involved when neurologically normal control subjects name visually presented objects, but neither appeared to be involved when the same participants used a finger press to make semantic association decisions on the same stimuli. This suggests that these regions serve word-retrieval or articulatory functions in the undamaged brain. We teased these interpretations apart by reference to change in other tasks. Consistent with the claim that the real change is occurring here, change in spoken object naming was correlated with change in two other similar tasks, spoken action naming and written object naming, each of which was independently associated with structural adaptation in similar (overlapping) right hemisphere regions. Change in written object naming, which requires word-retrieval but not articulation, was also significantly more correlated with both (i) change in spoken object naming; and (ii) structural adaptation in the two peak clusters, than was change in another task-auditory word repetition-which requires articulation but not word retrieval. This suggests that the changes in spoken object naming reflected variation at the level of word-retrieval processes. Surprisingly, given their qualitatively similar activation profiles, hypertrophy in the anterior temporal region was associated with improving behaviour, while hypertrophy in the precentral gyrus was associated with declining behaviour. We predict that either or both of these regions might be fruitful targets for neural stimulation studies (suppressing the precentral region and/or enhancing the anterior temporal region), aiming to encourage recovery or arrest decline even years after stroke occurs.

Large scale implementation of a medicines reconciliation care bundle in NHS GGC GP practices.

Medicines reconciliation (MR) is an essential process for patient safety, promoting safer use of medicines with effective communication at the interface, particularly when patients are admitted and discharged from hospital. Much of the work on MR has been focussed in secondary care, however, the principles are equally important in primary care. The aim of the work was to test the Scottish Patient Safety in Primary Care (SPSP-PC) MR care bundle and consider scale up and spread across all NHS Greater Glasgow and Clyde (NHS GGC) GP practices. Care bundles are a quality improvement tool which can drive improvement by standardising processes to deliver optimum care. Pilot work and testing began with 5 GP practices in 2011 and was spread to over 200 practices by 2015/16. A care bundle compliance process measure was measured monthly, with practices sampling 10 patients per month. Practices could view their run charts in real time and identify which measures resulted in "non-compliance" and PDSA cycles were promoted to test and implement improvements. Data was collated at NHS GGC level with an aim of 95% compliance with the care bundle by March 2016. MR care bundle compliance started at 40% (5 practices reporting) in 2011 with final data in March 2016 demonstrating 92% compliance (192 practices reporting). A sustained "reliability" of 92-93% across >200 practices has been observed since January 2015. In conclusion, the bundle was implemented by 97% of NHS GGC GP practices and resulted in process improvements.

Impact of interventions to improve the quality of peer review of biomedical journals: a systematic review and meta-analysis.

BACKGROUND: The peer review process is a cornerstone of biomedical research. We aimed to evaluate the impact of interventions to improve the quality of peer review for biomedical publications. METHODS: We performed a systematic review and meta-analysis. We searched CENTRAL, MEDLINE (PubMed), Embase, Cochrane Database of Systematic Reviews, and WHO ICTRP databases, for all randomized controlled trials (RCTs) evaluating the impact of interventions to improve the quality of peer review for biomedical publications. RESULTS: We selected 22 reports of randomized controlled trials, for 25 comparisons evaluating training interventions (n = 5), the addition of a statistical peer reviewer (n = 2), use of a checklist (n = 2), open peer review (i.e., peer reviewers informed that their identity would be revealed; n = 7), blinded peer review (i.e., peer reviewers blinded to author names and affiliation; n = 6) and other interventions to increase the speed of the peer review process (n = 3). Results from only seven RCTs were published since 2004. As compared with the standard peer review process, training did not improve the quality of the peer review report and use of a checklist did not improve the quality of the final manuscript. Adding a statistical peer review improved the quality of the final manuscript (standardized mean difference (SMD), 0.58; 95 % CI, 0.19 to 0.98). Open peer review improved the quality of the peer review report (SMD, 0.14; 95 % CI, 0.05 to 0.24), did not affect the time peer reviewers spent on the peer review (mean difference, 0.18; 95 % CI, -0.06 to 0.43), and decreased the rate of rejection (odds ratio, 0.56; 95 % CI, 0.33 to 0.94). Blinded peer review did not affect the quality of the peer review report or rejection rate. Interventions to increase the speed of the peer review process were too heterogeneous to allow for pooling the results. CONCLUSION: Despite the essential role of peer review, only a few interventions have been assessed in randomized controlled trials. Evidence-based peer review needs to be developed in biomedical journals.

The role of admission timing in the outcome of intracerebral hemorrhage patients at a specialized stroke center.

INTRODUCTION: Admission at 'off times' has been suggested to result in increased risk of poor outcome. The utilization of high volume centers may be a potential remedy to this variability in care. OBJECTIVE: To assess the ability of a high volume center to mitigate variability in care due to timing of admission in a post hoc analysis of an observational study. METHODS: The medical records of 200 hypertensive intracerebral hemorrhage (ICH) patients admitted to the Neurological Intensive Care Unit (NICU) from 12 January 2009 to 4 April 2013 were identified and examined for variable outcome based on admission timing using the modified Rankin Scale (mRS). Multiple logistic regression was used to assess predictors of poor outcome, correcting severity of admission. RESULTS: Seventy-five admissions were recorded to have occurred on the weekend. The 3-month follow-up mRS of surviving patients was 3·78 in weekend admissions and 3·63 in weekday admissions (P  =  0·62). One hundred and seven night admissions occurred. The average mRS at 3 months of surviving patients was 3·56 in night admissions and 3·84 in daytime admissions (P  =  0·36). Thirteen patients were admitted in July. The 3-month mRS of surviving patients was 3·71 for July admissions and 3·38 for non-July admissions (P  =  0·58). Only ICH score was found to be a predictor of outcome on multivariate analysis (P < 0·001). CONCLUSIONS: No significant difference in the outcome of patients was identified regardless of time of admission. High volume centers may be less prone to temporal variability in care, though the existence of temporal variability in care at low volume centers is controversial.

Hemorrhagic complications of ventriculostomy: incidence and predictors in patients with intracerebral hemorrhage.

OBJECT: Ventriculostomy--the placement of an external ventricular drain (EVD)--is a common procedure performed in patients with acute neurological injury. Although generally considered a low-risk intervention, recent studies have cited higher rates of hemorrhagic complications than those previously reported. The authors sought to determine the rate of postventriculostomy hemorrhage in a cohort of patients with intracerebral hemorrhage (ICH) and to identify predictors of hemorrhagic complications of EVD placement. METHODS: Patients with ICH who underwent EVD placement and had both pre- and postprocedural imaging available for analysis were included in this study. Relevant data were prospectively collected for each patient who satisfied inclusion criteria. Variables with a p < 0.20 on univariate analyses were included in a stepwise logistic regression model to identify predictors of postventriculostomy hemorrhage. RESULTS: Sixty-nine patients were eligible for this analysis. Postventriculostomy hemorrhage occurred in 31.9% of patients. Among all patients with intraparenchymal hemorrhage, the mean hemorrhage volume was 0.66 ± 1.06 cm(3). Stratified according to ventricular catheter diameter, patients treated with smaller-diameter catheters had a significantly greater mean hemorrhage volume than patients treated with larger-diameter catheters (0.84 ± 1.2 cm(3) vs 0.14 ± 0.12 cm(3), p = 0.049). Postventriculostomy hemorrhage was clinically significant in only 1 patient (1.4%). Overall, postventriculostomy hemorrhage was not associated with functional outcome or mortality at either discharge or 90 days. In the multivariate model, an age > 75 years was the only independent predictor of EVD-associated hemorrhage. CONCLUSIONS: Advanced age is predictive of EVD-related hemorrhage in patients with ICH. While postventriculostomy hemorrhage is common, it appears to be of minor clinical significance in the majority of patients.

The transcriptional regulatory network of proneural glioma determines the genetic alterations selected during tumor progression.

Proneural glioblastoma is defined by an expression pattern resembling that of oligodendrocyte progenitor cells and carries a distinctive set of genetic alterations. Whether there is a functional relationship between the proneural phenotype and the associated genetic alterations is unknown. To evaluate this possible relationship, we performed a longitudinal molecular characterization of tumor progression in a mouse model of proneural glioma. In this setting, the tumors acquired remarkably consistent genetic deletions at late stages of progression, similar to those deleted in human proneural glioblastoma. Further investigations revealed that p53 is a master regulator of the transcriptional network underlying the proneural phenotype. This p53-centric transcriptional network and its associated phenotype were observed at both the early and late stages of progression, and preceded the proneural-specific deletions. Remarkably, deletion of p53 at the time of tumor initiation obviated the acquisition of later deletions, establishing a link between the proneural transcriptional network and the subtype-specific deletions selected during glioma progression.

Alpha-7 nicotinic acetylcholine receptor agonists in intracerebral hemorrhage: an evaluation of the current evidence for a novel therapeutic agent.

Intracerebral hemorrhage (ICH) is the most deadly and least treatable subtype of stroke, and at the present time there are no evidence-based therapeutic interventions for patients with this disease. Secondary injury mechanisms are known to cause substantial rates of morbidity and mortality following ICH, and the inflammatory cascade is a major contributor to this post-ICH secondary injury. The alpha-7 nicotinic acetylcholine receptor (α7-nAChR) agonists have a well-established antiinflammatory effect and have been shown to attenuate perihematomal edema volume and to improve functional outcome in experimental ICH. The authors evaluate the current evidence for the use of an α7-nAChR agonist as a novel therapeutic agent in patients with ICH.

Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis.

OBJECT: Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions. METHODS: From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution's ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients' characteristics and outcomes of treatment were prospectively collected. RESULTS: The patients' median age was 43 years (range 30-55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5-9). The median ICH volume was 53 cm(3) (range 28-79 cm(3)), and the median midline shift was 7.6 mm (range 3.0-11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5-4.6 mm), and the median change in GCS score was +1 (range -3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9-11), the median modified Rankin Scale (mRS) score was 5 (range 5-5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17-27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4-5), and 2 were functionally independent (mRS Score 0-3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5-9, ICH volume 28-79 cm(3), age < 60 years) whose cases were managed nonoperatively (n = 5). CONCLUSIONS: Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.