Pharmacist-led medication review in patients over 65: a randomized, controlled trial in primary care.

BACKGROUND: regular medication review has been recommended for those over 75 and those on multiple drug therapy. Pharmacists are a potential source of assistance in reviewing medication. Evidence of the benefits of this process is needed. OBJECTIVE: to study the effect of medication review led by a pharmacist on resolution of pharmaceutical care issues, medicine costs, use of health and social services and health-related quality of life. DESIGN: randomized, controlled trial. SETTING: general medical practices in the Grampian region of Scotland. SUBJECTS: patients aged at least 65 years, with at least two chronic disease states who were taking at least four prescribed medicines regularly. METHODS: pharmacists reviewed the drug therapy of 332 patients, using information obtained from the practice computer, medical records and patient interviews. In 168 patients, a pharmaceutical care plan was then drawn up and implemented. The 164 control patients continued to receive normal care. All outcome measures were assessed at baseline and after 3 months. RESULTS: all patients had at least two pharmaceutical care issues at baseline. Half of these were identified from the prescription record, the rest from notes and patient interview. Of all the issues, 21% were resolved by information found in notes and 8.5% by patient interview. General practitioners agreed with 96% of all care issues documented on the care plans in the intervention group. At the time of follow-up, 70% of the remaining care issues had been resolved in the intervention group, while only 14% had been resolved in the control group. There were no changes in medicine costs or health-related quality of life in either group. There were small increases in contacts with health-care professionals and slightly fewer hospital admissions among the intervention group than the control group. CONCLUSIONS: pharmacist-led medication review has the capacity to identify and resolve pharmaceutical care issues and may have some impact on the use of other health services.

An antimicrobial effect associated with rabbit primary aqueous humour.

Viability curves were recorded for a variety of bacteria suspended in rabbit primary aqueous humour. Controls included neat rabbit serum, dilute rabbit serum (1/50), dilute heat treated fetal bovine serum (1/50), and balanced salt solution. Rabbit aqueous humour was bactericidal in vitro for Staphylococcus aureus and Pseudomonas aeruginosa. Micrococcus spp, Streptococcus pneumoniae and Escherichia coli were not affected. The factor mediating the bactericidal effect survives filtration (0.2 micron porosity) and freezing in liquid nitrogen (-196 degrees C) but is labile when stored in air at temperatures of 4 degrees C, 25 degrees C, and 37 degrees C for 1 hour. The bactericidal effect was stable when aqueous humour was stored in an atmosphere of 5% CO2 at 37 degrees C for 3 hours. The antibacterial component in rabbit aqueous humour has yet to be identified.

Grampian Health Board's joint drug formulary.

OBJECTIVE: To develop a model for creating a joint general practice-hospital formulary, using the example of ulcer healing drugs. DESIGN: A joint formulary development group produced draft guidelines based on an earlier hospital formulary, which were sent to interested local general practitioners for consultation. Revised guidelines were then drawn up and forwarded to the health board's medicines committee for approval and distribution. SETTING: Grampian Health Board. SUBJECTS: Nine members of joint formulary development group plus local general practitioners who were invited to comment on a list of 11 ulcer healing drugs. MAIN OUTCOME MEASURE: Degree of coincidence of drugs selected by hospital doctors and general practitioners. RESULTS: The ulcer healing drugs selected by the panel of general practitioners and by hospital doctors were highly coincident. The cost of one day's treatment with drugs varied considerably between hospital and general practice--for example, one drug cost 46p in hospital and 1 pounds in general practice and another cost 1.26 pounds in hospital and 1.01 pounds in general practice. Overall, six drugs cost more in hospital and five cost more in general practice. CONCLUSIONS: A joint formulary for use in hospitals and general practice in a health board can be devised fairly simply by consultation as virtually the same drugs are used in both types of practice. It should influence the health board's expenditure on drugs and affect the choice of drugs when a patient is discharged from hospital or is referred to any hospital in the region.

Standardization of core data for practice annual reports: a pilot study.

To investigate the feasibility of a standardized practice annual report, nine general medical practices in Grampian region collected data over a four month trial period. The definitions for core data used were arrived at after considerable consultation and discussion. They were found to be workable indicators of practice activity enabling comparisons to be made between practices. Three practices reported that they were completing forms more accurately and that this had led to increased item of service income. The results from this study show smaller variations than have been previously reported and there is a case to be made for the pooling and collation of such defined core data. Analysis of this practice activity would provide the stimulus for further research.

Antibody-dependent cell-mediated cytotoxicity against IBR-infected bovine kidney cells by ruminant neutrophils: the role of lysosomal cationic protein.

Antibody-dependent cell-mediated cytotoxicity (ADCC) of infectious bovine rhinotracheitis (IBR)-infected bovine kidney cells (MDBK) by neutrophils was demonstrated. Neutrophils from bovine and sheep mammary exudate and peripheral blood, and also from human peripheral blood, were all active in the presence of anti-IBR antibody. The component of the ruminant neutrophil granules which was responsible for cytotoxicity appeared to be cationic protein since purified cationic protein lysed the virus-infected cells and heparin inhibited cytotoxicity. Human neutrophil cytotoxicity to herpes simplex virus (HSV)-infected human Chang liver cells was also inhibited by heparin. Human neutrophil cytotoxicity to IBR-infected bovine kidney cells did not appear to be mediated by cationic protein since it was inhibited by the chelators of oxidative intermediates DMSO, thiourea, tryptophane, benzoate and mannitol, and not by heparin.

In vivo platelet activation with in vitro hyperaggregability to arachidonic acid in renal allograft recipients.

Renal allograft recipients were investigated to determine the extent and possible nature of in vivo platelet activation. In 92 allografted patients stable for more than 4 months' duration, intraplatelet serotonin in circulating platelets was depleted significantly. In a further 16 patients studied serially for 12 to 16 weeks following transplantation, intraplatelet serotonin fell abruptly within 4 days from transplantation to very low levels, and remained thus for 10 weeks, rising toward normal at about 12 weeks. Although some patients showed abrupt falls in intraplatelet serotonin coincident with acute rejection episodes, there was no difference in intraplatelet serotonin in seven patients whose grafts functioned well immediately and remained stable, and seven in whom repeated rejection led to graft loss within 3 months. Thus, these tests of platelet function do not permit diagnosis of rejection or prediction of graft outcome. Plasma platelet factor 4 (PF4) concentrations, in contrast, were normal in most patients during the first 6 weeks after grafting, then rose and remained abnormal up to 13 years following the allograft in the long-term stable graft recipients. This discrepancy suggests a different mode of platelet activation in the first few weeks after grafting from subsequent months. Despite universal depletion of intraplatelet amines and alpha-granule contents only four out of 14 early allograft recipients had an abnormal bleeding time, and platelet aggregation thresholds with adenosine-5'-diphosphate and collagen were not different from controls. However, thresholds for platelet aggregation with arachidonic acid were reduced significantly (P less than 0.01) and thromboxane B2 generation was increased in vitro. There was no correlation between depletion of intraplatelet serotonin and circulating platelet-agglutinating material, but nine of 17 biopsy specimens from rejecting allografts taken during the first 3 months showed extensive glomerular localization of platelet membrane antigens and PF4.

Intraglomerular localization of platelet related antigens, platelet factor 4 and beta-thromboglobulin in glomerulonephritis.

We examined renal biopsies from 121 patients with various forms of glomerulonephritis, using antisera against platelet membrane antigens, platelet factor 4, beta-thromboglobulin and fibrinogen using the indirect immunofluorescent technique. Eight biopsies were also studied by electron microscopy for recognizable platelets. Thirty-six of sixty-four (56%) biopsies from patients with severe forms of glomerulonephritis showed some intraglomerular platelet antigen, extensive fluorescence in seventeen (25%). Of forty-six patient with milder, usually non-progressive forms of nephritis, twenty (44%) were positive, but only four (9%) showed extensive fluorescence. Platelets were identified by electron microscopy within the capillary lumina equally in those with positive and negative results for platelet-related antigens. There was no correlation between the presence of fibrin and platelet-related material in the glomeruli, nor between the presence or extent of intraglomerular platelet antigen and simultaneous measurements of intraplatelet serotonin in circulating platelets. However, there was a strong correlation between presence, extent and distribution of platelet-related antigen and platelet factor 4 fluorescence. These studies provide further evidence for the involvement of platelets in some forms of glomerular disease.

Identification of nephritic factor as an immunoglobulin.

C3 nephritic factor (C3NeF) activity in sera from three patients with mesangiocapillary glomerulonephritis, one of whom had partial lipodystrophy, was found on chromatography to be associated with fractions containing IgG and no other detectable proteins. Immunoadsorption of IgG from these fractions with a highly purified anti-IgG removed the C3NeF, and the IgG, eluted after combination with the anti-IgG, retained C3NeF activity. In each case the isolated IgG with C3NeF activity was found to contain more than one subclass of IgG and both kappa and lambda chains, indicating that the immunoglobulin comprising C3NeF in these patients is heterogeneous and not monoclonal. The identification of C3NeF as an immunoglobulin suggests that it may be an autoantibody against antigenic determinants of complement components present in the C3 convertase of the alternative pathway.