An observational study examining the effects of a surgically induced inflammatory response on the distribution of morphine and its metabolites into cerebrospinal fluid.

PURPOSE: Morphine is administered intravenously for pain management in the perioperative period. The effect of the inflammatory response to surgery on morphine distribution across the blood-brain barrier (BBB) in humans was investigated. We hypothesized that a graded surgically induced, systemic inflammatory response alters cerebrospinal fluid (CSF) levels of morphine, morphine-3-glucuronide (M3G), and morphine-6-glucuronide (M6G) through a temporary reduction in BBB drug efflux transporter function. METHODS: We conducted a prospective pharmacokinetic study of the plasma and CSF distribution of the P-glycoprotein (PGP) substrate morphine in 33 patients undergoing open thoracic (n = 18) or endovascular (n = 15) aortic aneurysm repair. Morphine was administered with induction of anesthesia and in the intensive care unit. Plasma and CSF concentrations of interleukin (IL)-6, morphine, M3G, M6G, and albumin were measured prior to surgery (baseline), during surgery, and postoperatively every six hours until removal of the CSF drain. The area under the curve (AUC) was determined for plasma and CSF IL-6, morphine, M3G, and M6G concentrations vs time. The primary endpoint measures were the correlations between the morphine, M6G, and M3G AUC CSF/plasma ratios and systemic inflammation as quantified by the time-normalized IL-6 exposure, which was calculated for each individual by dividing the total exposure (AUC) by time (t). A Bonferroni corrected P < 0.017 indicated a significant correlation. RESULTS: Plasma and CSF IL-6 concentrations increased postoperatively. The median [interquartile range] IL-6 exposures were significantly higher in the open vs endovascular surgical group for plasma (105 [40-256] pg·mL-1 vs 29 [16-70] pg·mL-1, respectively; P = 0.013) and CSF (79 [26-133] pg·mL-1 vs 16 [9-80] pg·mL-1, respectively; P = 0.013). For the primary endpoint, the plasma IL-6 AUC/t did not correlate with the CSF accumulation of morphine (r = -0.009; P = 0.96) or M3G (r = 0.37; P = 0.04) when corrected for surgical procedure, age, and sex. There were insufficient data on CSF concentration to complete the primary analysis for M6G. CONCLUSION: Morphine distribution into the CSF was not significantly altered in patients undergoing thoracic aortic aneurysm repair. This suggests that BBB PGP function may not be affected by the perioperative inflammatory response. TRIAL REGISTRATION: www.clinicaltrials.gov , NCT 00878371. Registered 7 April 2009.

Using eHealth to improve health literacy among the patient population.

There is no denying the global influence of eHealth, in its various forms, on the health care system in the 21st Century. Health care professionals are often familiar with technological tools used to enhance health outcomes by assisting clinicians in meeting the needs of the patient population. In an age of social media, web-based information, and material available literally in an instant, it is crucial for nurses to use and proactively share their knowledge regarding accessing and finding credible sources of online health information with the patient population. By improving health literacy among consumers, self-sufficiency and competence can be developed and promoted to improve health outcomes, placing the patient in a participatory starring role of managing and improving his or her overall well-being.

Pharmacy students' experiences in provision of community pharmacy mental health services.

BACKGROUND: Little information is available describing the pharmacy student's experience working in community practice with people with lived experience of mental illness. Students' perspectives as observers, learners, technical staff and future pharmacists are important. OBJECTIVE: To gain a better understanding of the pharmacy student experience in community pharmacy-based service provision to people with lived experience of mental illness. METHODS: We conducted a qualitative study using interpretive description and application of the Theoretical Domains Framework. Focus groups were held with third- and fourth-year undergraduate pharmacy students from one Canadian university. RESULTS: Two student focus groups were held in the fall of 2012 with 11 students (7 third year and 4 fourth year), 6 women and 5 men, mean age 24.5 (range, 21 to 30) years, averaging 3.2 years (range, 2 weeks to 7 years) of cumulative, mostly part-time, community pharmacy experience. Three broad themes emerged from the pharmacy student experience: (1) business tension; (2) roles, responsibilities and relationships; and (3) stigma. Students discussed their own roles, responsibilities and relationships in a pluralistic identity experience (i.e., pharmacy student, technician, future pharmacist). Application of the Theoretical Domains Framework demonstrated numerous influences on behaviour. CONCLUSIONS: From the students' description of community pharmacy-based care of people with lived experience of mental illness, significant issues exist with current practices and behaviours. Advancing the role of pharmacists and pharmacy students to meet the needs of people with mental illness will require strategies to address multifactorial influences on behaviour.