Experiences of community pharmacists in the United Kingdom on the provision of travel health services and associated educational requirements.

BACKGROUND: Travel health services play a critical role in public health. Previously, travel services were provided solely through GPs or private specialist clinics. In recent years, they have been available from community pharmacists in the UK. This study sought to understand the types of travel health services provided by community pharmacists and to establish the educational needs. METHOD: Qualitative interviews and focus groups explored current practices and educational needs in travel medicine. Thematic analysis of transcribed interviews and focus groups was conducted to understand how travel services are provided and the training undertaken by community pharmacists in delivering these services. RESULTS: Nine individual interviews and one focus group of seven additional pharmacists was conducted. Pharmacists considered that they provided a comprehensive service and undertook the necessary training for safe delivery. Pharmacists described a 'vaccine centric' approach to travel services, with aspects, such as management of chronic conditions, fitness/preparedness for travel, prevention and self-management of travel-related conditions considered to be of lower priority. This was reflected in the travel medicine education that they had received and their perception of future requirements. CONCLUSION: Whilst vaccination is a critical aspect of travel health medicine, taking a 'vaccine centric' approach represents a missed opportunity in public health. Future educational opportunities for pharmacists could include training that encourages a broader approach to travel health consultations, to include a co-created, structured, and holistic risk assessment for travellers and recommendations for appropriate prevention and management strategies for travellers prior to, during and after travel.

Characterisation of actions of p-menthane-3,8-diol repellent formulations against Aedes aegypti mosquitoes.

BACKGROUND: Characterisation of mosquito repellents using arm-in-cage tests are performed by assessing the 95% effective dose (ED95), half-life and complete protection time (CPT). This study fully characterizes these properties for p-menthane-3,8-diol (PMD), which has not been widely studied, and a long-acting formulation containing a PMD-vanillin composite. METHODS: A series of arm-in-cage tests against Aedes aegypti (Diptera: Culicidae) mosquitoes were devised using 6 volunteers to estimate CPT or 10 to estimate the ED95 and half-lives for three repellents: 20% N,N-diethyl-3-methylbenzamide (DEET), 30% PMD and a novel 30% PMD-vanillin formulation. Non-linear regression analysis was used to characterize the relationship between applied dose and CPT. RESULTS: PMD and DEET showed a very similar log dose relationship to CPT; however, the PMD-vanillin formulation exhibited a sigmoidal 'S-shaped' relationship. This resulted in a 1.5-fold higher CPT for PMD-vanillin compared with that of 20% DEET when applied at a dose of 1.6 mg/cm2, but little difference was observed at lower doses of 0.8-1 mg/cm2. The ED95 value for the 30% PMD and PMD-vanillin formulations were 0.25 and 0.24 mg/cm2, respectively, these being higher than that for 20% DEET (0.09 mg/cm2). The half-lives for 30% PMD and 20% DEET were similar (2.23 vs. 2.74 h), but longer for the PMD-vanillin formulations (3.8 h). CONCLUSIONS: A full characterisation for other repellent formulations, particularly those claiming extended longevity, should be conducted in order to identify differences at various applied doses.

Personalised Warfarin Dosing in Children Post-cardiac Surgery.

Warfarin dosing is challenging due to a multitude of factors affecting its pharmacokinetics (PK) and pharmacodynamics (PD). A novel personalised dosing algorithm predicated on a warfarin PK/PD model and incorporating CYP2C9 and VKORC1 genotype information has been developed for children. The present prospective, observational study aimed to compare the model with conventional weight-based dosing. The study involved two groups of children post-cardiac surgery: Group 1 were warfarin naïve, in whom loading and maintenance doses were estimated using the model over a 6-month duration and compared to historical case-matched controls. Group 2 were already established on maintenance therapy and randomised into a crossover study comparing the model with conventional maintenance dosing, over a 12-month period. Five patients enrolled in Group 1. Compared to the control group, the median time to achieve the first therapeutic INR was longer (5 vs. 2 days), to stable anticoagulation was shorter (29.0 vs. 96.5 days), to over-anticoagulation was longer (15.0 vs. 4.0 days). In addition, median percentage of INRs within the target range (%ITR) and percentage of time in therapeutic range (%TTR) was higher; 70% versus 47.4% and 83.4% versus 62.3%, respectively. Group 2 included 26 patients. No significant differences in INR control were found between model and conventional dosing phases; mean %ITR was 68.82% versus 67.9% (p = 0.84) and mean %TTR was 85.47% versus 80.2% (p = 0.09), respectively. The results suggest model-based dosing can improve anticoagulation control, particularly when initiating and stabilising warfarin dosing. Larger studies are needed to confirm these findings.

Pharmacy Travel Health Services in Canada: Experience of Early Adopters.

Since 2007, community pharmacists in Canada have become increasingly involved in delivering Travel Health services, including the recommendation and administration of vaccines. This qualitative scoping survey examines some of the activities and opinions of those early pharmacist adopters delivering these services. A Survey Monkey free text questionnaire was emailed to pharmacists who were involved in delivering travel medicine services. 21 pharmacists responding represented seven Canadian provinces. Only 5 pharmacists estimated that they were seeing five or more patients a week on average. Amongst the challenges they faced the most quoted was lack of time when running a busy pharmacy (62%) a lack of prescribing authority, (52%), and lack of access to public health vaccines (52%). 'Word of mouth' was widely quoted as a means of developing the service, indicating a good patient satisfaction. Also expressed were the advantages of convenience in terms of being a 'one stop shop', ease of billing to insurance companies and convenient appointment times. There are a number of challenges which are still to be faced which may be resolved by further legislation allowing access to public health vaccines and more widespread prescribing rights. The relatively low level of consultations reported by some is of concern if those pharmacists are to maintain competence.

Pharmacy and Travel Medicine: A Global Movement.

This is the first special edition of a journal that has focused specifically on Pharmacy Practice and travel medicine [...].

Mosquito repellents for the traveller: does picaridin provide longer protection than DEET?

BACKGROUND: This review examines the published laboratory and field tests where the repellents DEET and picaridin have been compared for their efficacy as repellents against mosquitoes. The review is limited to an assessment of whether the duration of protection afforded by picaridin is similar to or better than DEET. METHOD: Identification and analysis of laboratory and field-based trials published in peer-reviewed journals that compared DEET to picaridin efficacy. RESULTS: Only eight field studies and three laboratory studies met the review criteria for inclusion and most were considered to be of high risk of bias and of lower quality when judged against evidence-based principles. Overall, the studies showed little potential difference between DEET and picaridin applied at the same dosage, with some evidence pointing to a superior persistence for picaridin. CONCLUSION: Applied dosage is one important variable in determining the persistence of a repellent experienced by users but the maximum concentration in current picaridin formulation is <30%w/v. Therefore, where only 30% DEET or lower concentrations are available, then on current evidence, it is reasonable to offer DEET or picaridin as a first choice. Where >50% DEET products are available then the protection time advantage associated with these formulations reasonably can be invoked to consider them as first choice repellents.

The Provision of Prescription-Only Medicines for Use on UK-based Overseas Expeditions.

Expedition teams without accompanying medical professionals traveling overseas from the UK frequently carry medical kits containing prescription-only medicines (POMs). Access to safe, basic POMs whilst on expedition is important, as the quality and availability of medicines in-country may not be acceptable, and delay in treatment may be hazardous. At present, there is no published guidance relating to drug acquisition and administration in these situations. In the UK, a number of different practices are currently in use, with uncertainty and medicolegal concerns currently hampering safe and efficient provision of POMs on overseas expeditions. A guideline is proposed for the management of prescription-only medications in an expedition setting.

Mosquito bite-avoidance attitudes and behaviors in travelers at risk of malaria.

INTRODUCTION: Mosquito bite prevention is an important strategy to reduce the risk of contracting malaria and advice on the methods available should be offered in pre-travel consultations. This study examines the attitudes of a cohort of UK travelers to the various bite-avoidance strategies and the extent to which they are practiced when visiting malaria-endemic areas. METHOD: This was a retrospective cohort study of UK travelers above 18 years of age returning from malaria-endemic areas. Those who agreed to participate were emailed a Web-based questionnaire on their return to the UK. The questionnaire consisted of items relating to attitudes to bite-avoidance measures and malaria and the use of bite-avoidance measures while away. RESULTS: One hundred and thirty-two travelers completed the questionnaire representing a 51% response rate. Frequent use of repellents (69%) was higher than covering the arms (49%) and legs (56%), or using insecticide vaporizers (16%), sprays (24%), and bed nets (32%). Those under the age of 30 tended to use bite avoidance less frequently. Gender, purpose, and duration of travel were also found to influence the use of particular measures. A reliable 17-point attitude to the bite-avoidance questionnaire (Cronbach's alpha = 0.70) was constructed and a subscale score indicated that attitudes influenced the use of repellents. CONCLUSION: The use of measures to avoid mosquito bites on retiring and covering arms and legs needs to be further emphasized to travelers. The attitude scales described could be a useful tool in practice and research into this area.

Choice of and adherence to prophylactic antimalarials.

BACKGROUND: There were 1,370 cases of imported malaria and six fatalities in the UK in 2008, the majority of which were due to chloroquine-resistant Plasmodium falciparum. Poor adherence to prescribed regimens is known to be an important factor in these cases. METHOD: An observational study utilizing questionnaires both pre- and post-travel was conducted to assess the adherence behavior of UK travelers undertaking trips of less than 28 days duration, who were prescribed one of three antimalarials recommended to prevent P falciparum malaria (atovaquone plus proguanil, doxycycline, or mefloquine) in travel clinics in England and Scotland. The primary objectives of the study were to assess travelers' perceptions of, and self-reported adherence to antimalarial medication. A secondary objective was to examine the reasons for the choice of antimalarial therapy from the perspective of prescriber and traveler. RESULTS: For the primary end point of self-reported adherence specified as the proportion of antimalarial tablets prescribed that were actually taken, statistically significantly higher adherence overall and post-travel was seen with atovaquone plus proguanil compared with doxycycline. It was not possible to calculate the statistical significance of comparisons with mefloquine, but adherence to mefloquine appeared similar to or better than doxycycline and similar to atovaquone plus proguanil for categorical adherence. Effectiveness, side effects, previous experience of antimalarials, and dosing convenience were the main determinants of both travelers and practitioner's choice of antimalarial. The practitioner's recommendation was highly important for 63% of travelers. CONCLUSION: A shorter post-travel regimen has a significant impact on adherence to antimalarial prophylaxis. A reassessment of the risk by travelers on returning home may be a major contributor to this poor adherence.

Pharmacist supplementary prescribing: a step toward more independence?

BACKGROUND: Supplementary prescribing (SP) is a drug therapy management model implemented in the United Kingdom since 2003. It is a voluntary partnership between an independent prescriber; a supplementary prescriber, for example, nurse or pharmacist; and the patient, to implement an agreed patient-specific clinical management plan (CMP). OBJECTIVE: To investigate pharmacist prescribers' views and experiences of the early stages of SP implementation. METHODS: A qualitative, longitudinal study design was used. A purposive, maximum variability sample of 16 pharmacist supplementary prescribers, trained in Southern England, participated. Eleven were hospital pharmacists, owing to the overrepresentation of hospital pharmacists in the first cohort. Two semistructured interviews were conducted with each participant, at 3 and 6 months after their registration as prescribers. The Framework approach was used for data collection, management, and analysis. RESULTS: Three typologies of pharmacists' experiences were identified: "a blind alley", "a stepping stone" and "a good fit". Despite some delays in its implementation, SP was seen as a step forward. Some participants also believed that it improved patient care and pharmacists' integration in the health care team and increased their job satisfaction. However, there was a concern that SP, as first implemented, was bureaucratic and limited pharmacists' freedom in their decision making. Hence, pharmacists were more supportive of the then imminent introduction of a pharmacist independent prescribing (IP) role. CONCLUSIONS: Despite challenges, the SP role represented a step forward for pharmacists in the United Kingdom. It is possible that pharmacist SP can coexist with IP in the areas suitable for CMP use. Elsewhere, SP is likely to become more of a "stepping stone" to an IP role than the preferred model for pharmacist prescribing. Future research needs to objectively assess the outcomes of pharmacist SP, preferably in comparison with IP, to inform decision making among pharmacists regarding the adoption of such an innovative role.

Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis.

We set out to determine the effects of pharmacist-led medication review in older people by means of a systematic review and meta-analysis covering 11 electronic databases. Randomized controlled trials in any setting, concerning older people (mean age > 60 years), were considered, aimed at optimizing drug regimens and improving patient outcomes. Our primary outcome was emergency hospital admission (all cause). Secondary outcomes were mortality and numbers of drugs prescribed. We also recorded data on drug knowledge, adherence and adverse drug reactions. We retrieved 32 studies which fitted the inclusion criteria. Meta-analysis of 17 trials revealed no significant effect on all-cause admission, relative risk (RR) of 0.99 [95% confidence interval (CI) 0.87, 1.14, P = 0.92], with moderate heterogeneity (I(2) = 49.5, P = 0.01). Meta-analysis of mortality data from 22 trials found no significant benefit, with a RR of mortality of 0.96 (95% CI 0.82, 1.13, P = 0.62), with no heterogeneity (I(2) = 0%). Pharmacist-led medication review may slightly decrease numbers of drugs prescribed (weighted mean difference = -0.48, 95% CI -0.89, -0.07), but significant heterogeneity was found (I(2) = 85.9%, P < 0.001). Results for additional outcomes could not be pooled, but suggested that interventions could improve knowledge and adherence. Pharmacist-led medication review interventions do not have any effect on reducing mortality or hospital admission in older people, and can not be assumed to provide substantial clinical benefit. Such interventions may improve drug knowledge and adherence, but there are insufficient data to know whether quality of life is improved.

Application of insect repellents by travelers to malaria endemic areas.

The use of insect repellents applied to the skin is always encouraged in those visiting malaria endemic areas. There are a number of factors contributing to the efficacy of insect repellents in the field and an important factor contributing to their longevity relates to the applied dose. This study investigated the dose of insect repellent that travelers might normally apply to the skin. Subjects were asked to apply a product they had purchased to the arms and neck, and the dose applied (mg/cm(2)) was calculated. The study was conducted using three different populations; 74 travelers to malaria endemic areas visiting pharmacies to purchase repellents before they left the UK, 23 travelers on safari in India, and 24 on safari in Kenya. There was a significant difference in the mean applied arm dose of product (mg/cm(2)) [p < 0.001, analysis of variance (ANOVA)]; UK 1.15 (SD 0.29), India 0.96 (SD 0.23), and Kenya 1.34 (SD 0.54). Higher concentrations were achieved on the neck area. Few of the participants in the field trial used long-sleeved shirts at night. Even using 50% wt/vol repellent products, 32% in the Kenya and 25% in the India, study achieved a dose of active ingredient less than 0.5 mg/cm(2). These pilot studies would indicate that travelers tend to apply below the optimal concentration of active ingredient of repellent as might be suggested by mathematical models.

Inhaler technique in Turkish people with poor English: a case of information discrimination?

OBJECTIVES: (a) To compare metered dose inhaler (MDI) technique in users with poor English and fluent English, (b) to evaluate two interventions: a translated patient information leaflet (PIL) plus support from an translator (PIL + verbal) and a multimedia touch screen system (MTS) using video clips and own-language instruction. METHODS: (a) Inhaler technique was videotaped and key steps rated blind for 105 fluent English-speakers (FE) and 69 Turkish-speakers with poor English (EP). (b) The EP group was randomised to receive information by MTS (n = 34) or PIL + verbal (n = 35). Inhaler technique was videotaped before and after information. MAIN OUTCOME MEASURES: (a) Global inhaler technique; (b) breathing-in time; (c) co-ordination of inspiration and inhaler actuation. RESULTS: Global technique, co-ordination and breath-holding were all significantly worse in MDI users with poor English. Only 17% of that group had adequate technique compared to over half (62%) of FE. The EP group were significantly less likely than the FE group to report ever seeing the practice nurse about their asthma. After information, global technique was rated as improved in 50% of the MTS group compared to 28% of those given a translated PIL. A further six people (17%) in the PIL group improved after subsequent verbal advice in their own language. Both information methods significantly increased inhaler shaking and mouthpiece checking, but co-ordination only improved in a small number of people. CONCLUSIONS: The study suggests that Turkish-speaking MDI users with poor English may be disadvantaged in terms of access to medicines information in the UK. The acceptability of pharmacy-based support services for this, and other specific language groups should be explored. Multimedia offers an alternative to a translator for brief explanations, particularly for first-time users, but improving poor co-ordination requires individualised "hands on" teaching from health professionals.

Medical supplies for travelers to developing countries.

BACKGROUND: There has been little research to date on the use of medicines and first aid supplies by travelers. In some developing countries such products may be difficult to obtain, and there is the danger that substandard medicines may be purchased. As space for medical supplies in the luggage of many individuals, particularly backpackers, may be restricted, it is important to identify correctly those items most likely to be needed. OBJECTIVES: The aim of this study was to survey a cohort of travelers from the UK visiting a variety of destinations in developing countries, regarding the medical supplies taken and used during their trip. METHOD: Travelers visiting a specialist travel pharmacy in London, UK were recruited consecutively into the study. Only those planning to visit destinations in South America, Asia, Africa or the Middle East for < or = 2 weeks and returning to the UK were included. Participants were handed a questionnaire to be posted back when they returned to the UK, asking them to note those items that they included in the kit, those actually used, and any others obtained while they were away. All subjects had consulted the pharmacist concerning the medical kit appropriate for their trip. RESULTS: Two hundred and ninety-nine travelers volunteered to take part, of whom 127 returned the postal questionnaire. Analgesics and medication for the treatment of diarrhea were most likely to be used, but many types of wound dressing were unlikely to be required. Twenty individuals (16%) required antibiotics, with eight people purchasing them while they were away. Thirty-two (31%) individuals did not use insect repellents despite traveling to potentially malaria-endemic countries. Only seven subjects purchased any other items while they were away. CONCLUSION: The items most likely to be required by travelers to developing countries are analgesics, treatments for diarrhea, antiseptics and sticking plasters. The provision of antibiotics to certain travelers is probably justified.

Providing information on metered dose inhaler technique: is multimedia as effective as print?

BACKGROUND: Metered dose inhalers (MDIs) are not easy to use well. Every MDI user receives a manufacturer's patient information leaflet (PIL). However, not everyone is able or willing to read written information. Multimedia offers an alternative method for teaching or reinforcing correct inhaler technique. OBJECTIVE: The aim of this study was to compare the effects of brief exposure to the same key information, given by PIL and multimedia touchscreen computer (MTS). METHODS: A single-blind randomized trial was conducted in 105 fluent English speakers (53% female; 93% White) aged 12-87 years in London general practices. All patients had had at least one repeat prescription for a bronchodilator MDI in the last 6 months. Inhaler technique was videotaped before and after viewing information from a PIL (n = 48) or MTS (n = 57). Key steps were rated blind using a checklist and videotape timings. The main outcome measures were a change in (i) global technique; (ii) co-ordination of inspiration and inhaler actuation; (iii) breathing-in time; and (iv) information acceptability. RESULTS: Initially, over a third of both groups had poor technique. After information, 44% (MTS) and 19% (PIL) were rated as improved. Co-ordination improved significantly after viewing information via MTS, but not after PIL. Breathing-in time increased significantly in both groups. Half the subjects said they had learned 'something new'. The MTS group were more likely to mention co-ordination and breathing. CONCLUSIONS: Short-term, multimedia is as least as effective as a good leaflet, and may have advantages for steps involving movement. MTS was acceptable to all age groups. The method could be used more widely in primary care.