"We're really not ready for this": A qualitative exploration of community pharmacy personnel's perspectives on the pharmaceutical care of older people with sensory impairment.

BACKGROUND: In most developed countries there is an increasing ageing population living in the community with long-term conditions and sensory impairment (sight; hearing; dual impairment). Community pharmacy personnel are key providers of pharmaceutical care to this patient population. OBJECTIVE: This study explored community pharmacy personnel's experiences with providing pharmaceutical care for older people with sensory impairment. METHODS: Semi-structured telephone interviews were conducted with community pharmacy personnel across Scotland between 2015 and 2016. RESULTS: Thirty interviews were completed with community pharmacists (n = 17) and other pharmacy personnel (n = 13). Two overarching themes emerged: safety and communication. Interviewees reported patients' reluctance to disclose their impairment "patients are very good at hiding it" and had considerable safety concerns "it's a fear that they're going to take too much … accidentally taking the same medicine twice". Difficulties in communication were cited "no matter what you do or how you label things, leaflets and telling people, things can go wrong". Additionally, interviewees identified training needs to increase their disability awareness and to identify strategies to provide safe and reliable pharmaceutical care to this vulnerable group "We don't specifically have anything in place to deal with anyone with impairments of that kind". CONCLUSIONS: This is the first in-depth exploration of providing pharmaceutical care to older people with sensory impairment from the perspective of community pharmacy personnel. Strategies are needed to encourage older people to disclose their sensory impairment. Education and training are also needed to optimise the provision of pharmaceutical care to this vulnerable population.

The "Real Welfare" scheme: Identification of risk and protective factors for welfare outcomes in commercial pig farms in the UK.

From 2013-2016, animal-based measures were collected as part of the "Real Welfare" protocol adopted by the Red Tractor Pigs Assurance Scheme to assess the welfare in finisher pig herds in the UK. Trained veterinarians from 89 veterinary practices assessed 112,241 pens (hospital pens excluded) from 1928 farms using a multistage sampling protocol, and collected data about pig welfare, management and farm environment. Multivariable analyses were conducted for five main welfare outcomes: lameness, pigs requiring hospitalization, severe tail lesions, severe body marks and enrichment use ratio (number of active pigs interacting with the enrichment/total number of active pigs). Additionally, a multiple correspondence analysis (MCA) was conducted to analyse systematic patterns of variations of environmental characteristics and improve understanding of the connection between welfare outcomes and environment. The prevalence of the four welfare outcomes and the mean enrichment use ratio differed between pen types (P<0.05), with a higher mean prevalence of lame pigs (0.39%) but lower mean prevalence of pigs requiring hospitalization (0.07%), severe tail lesions (0.07%) and severe body marks (0.12%) in outdoor pens. In&outdoor pens had the highest mean prevalence of the measured outcomes (P<0.05). After adjusting for the farm, date and pen type, lameness, pigs requiring hospitalization and severe tail lesions were less prevalent in large pens (P<0.01), pens with substrates (P≤0.05) and pens fed with meal (P≤0.05), while enrichment use ratio was higher with substrates (P<0.001). Moreover, pigs requiring hospitalization and severe body marks were more prevalent in pens with powered ventilation (P<0.05). On the MCA graph, higher prevalences of lameness and pigs requiring hospitalization (>1, 5 and 10%) were located in the same direction as lower enrichment use ratio, liquid feed, trough feeding, floor feeding, restricted feed and in&outdoor pens. Results suggested that higher prevalences were not specifically connected to a particular system, but that all welfare outcomes were connected to several inappropriate features in the environment. This study highlights individual risk factors which can be considered to improve animal welfare, but also indicates the need to consider the environment as a whole because of potential factor combinations and confounds. Understanding of these requires a large scale database, which can be drawn from assessments carried out as part of farm assurance and support evidence-based advice and future formulation of standards for good practice.

The 'Real Welfare' scheme: benchmarking welfare outcomes for commercially farmed pigs.

Animal welfare standards have been incorporated in EU legislation and in farm assurance schemes, based on scientific information and aiming to safeguard the welfare of the species concerned. Recently, emphasis has shifted from resource-based measures of welfare to animal-based measures, which are considered to assess more accurately the welfare status. The data used in this analysis were collected from April 2013 to May 2016 through the 'Real Welfare' scheme in order to assess on-farm pig welfare, as required for those finishing pigs under the UK Red Tractor Assurance scheme. The assessment involved five main measures (percentage of pigs requiring hospitalization, percentage of lame pigs, percentage of pigs with severe tail lesions, percentage of pigs with severe body marks and enrichment use ratio) and optional secondary measures (percentage of pigs with mild tail lesions, percentage of pigs with dirty tails, percentage of pigs with mild body marks, percentage of pigs with dirty bodies), with associated information about the environment and the enrichment in the farms. For the complete database, a sample of pens was assessed from 1928 farm units. Repeated measures were taken in the same farm unit over time, giving 112 240 records at pen level. These concerned a total of 13 480 289 pigs present on the farm during the assessments, with 5 463 348 pigs directly assessed using the 'Real Welfare' protocol. The three most common enrichment types were straw, chain and plastic objects. The main substrate was straw which was present in 67.9% of the farms. Compared with 2013, a significant increase of pens with undocked-tail pigs, substrates and objects was observed over time (P0.3). The results from the first 3 years of the scheme demonstrate a reduction of the prevalence of animal-based measures of welfare problems and highlight the value of this initiative.

Animal and management factors influencing grower and finisher pig performance and efficiency in European systems: a meta-analysis.

A meta-analysis on the effects of management and animal-based factors on the performance and feed efficiency of growing pigs can provide information on single factor and interaction effects absent in individual studies. This study analysed the effects of such factors on average daily gain (ADG), feed intake (FI) and feed conversion ratio (FCR) of grower and finisher pigs. The multivariate models identified significant effects of: (1) bedding (P<0.01), stage of growth (P<0.001) and the interaction bedding×lysine (P<0.001) on ADG. ADG was higher on straw compared with no bedding (710 v. 605 g/day). (2) FI was significantly affected by stage of growth (P<0.01), bedding (P<0.01), group composition (P<0.05), group size (P<0.01), feed CP content (P<0.01), ambient temperature (P<0.01) and the interaction between floor space and feed energy content (P<0.001). Pigs housed on straw had a lower FI in comparison with those without (1.44 v. 2.04 kg/day); a higher FI was seen for pigs separated by gender in comparison with mixed groups (2.05 v. 1.65 kg/day); FI had a negative linear relationship with group size, the CP content of the feed and ambient temperature. (3) Stage of growth (P<0.001), feed CP (P<0.001) and lysine content (P<0.001), ambient temperature (P<0.001) and feed crude fibre (CF) content (P<0.01) significantly affected FCR; there were no significant interactions between any factors on this trait. There was an improvement in FCR at higher ambient temperatures, increased feed CP and lysine content, but a deterioration of FCR at higher CF contents. For ADG, the interaction of bedding×lysine was caused by pigs housed without bedding (straw) having higher ADG when on a feed lower in lysine, whereas those with bedding had a higher ADG when on a feed higher in lysine. Interaction effects on FI were caused by animals with the least amount of floor space having a higher FI when given a feed with a low metabolisable energy (ME) content, in contrast to all other pigs, which showed a higher FI with increased ME content. The meta-analysis confirmed the significant effect of several well-known factors on the performance and efficiency of grower and finisher pigs, the effects of some less established ones and, importantly, the interactions between such factors.

A meta-analysis to identify animal and management factors influencing gestating sow efficiency.

A meta-analysis on the effects of management and animal-based factors on the reproductive efficiency of gestating sows can provide information on single-factor and interaction effects that may not have been detected in individual studies. This study analyzed the effects of such factors on the number of piglets born alive per litter (BA), piglet birth weight (BiW) and weaning weight (WW), and number of piglets born alive per kilogram of sow feed intake during gestation (BA/FI). A total of 51 papers and 7 data sources were identified for the meta-analysis, out of which 23 papers and 5 sets of production data were useable (a total of 121 treatments). The information gathered included the dependent variables as well as information regarding animal, management, and feed characteristics. While a number of factors were individually significant, the multivariate models identified significant effects only of 1) floor type (P=0.003), sow BW at the end of gestation (P=0.002), and housing (stalls vs. loose; P=0.004) on BA; as floor type and housing were confounded, they were included in 2 separate models. The BA was higher on solid (12.1) in comparison to partly slatted (11.4) and fully slatted floors (10.2); 2) sow gestation environment (P=0.017) and gestation feed allowance (P=0.046) on BiW, with BiW of pigs higher for sows kept outdoors rather than indoors (1.75 versus 1.49 kg); 3) parity number (P=0.003) and feed intake during gestation (P=0.017) on WW; in addition there was an interaction between parity number×feed ME and parity number×feed CP content of feed during gestation on WW, with the positive effects of feed ME and CP contents seen during early rather than later parities; and 4) floor type (P=0.019) and feed crude fiber (P=0.003) for BA/FI with a greater number for those kept on solid floors (5.11) versus partially and fully slatted floors (4.07 and 4.05). The meta-analysis confirmed the significant effect of several well-known factors on the efficiency of gestating sows and, importantly, the interactions between these factors. In addition, the effects of some less established factors were noted, such as floor type. The results may contribute towards the improvement of efficiency of gestating sow systems by better understanding of the various factors that influence this.

Physical map covering a 2 Mb region in human xp11.3 distal to DX6849.

A 2Mb contig was constructed of yeast artificial chromosomes (YACs) and P1 artificial chromosomes (PACs), extending from DXS6849 to a new marker EC7034R, 1Mb distal to UBE1, within the p11.3 region of the human X chromosome. This contig, which has on average four-fold cloned coverage, was assembled using 37 markers, including 13 new sequence tagged sites (STSs) developed from YAC and PAC end-fragments, for an average inter-marker distance of 55kb. The inferred marker order predicted from SEGMAP analysis, STS content and cell hybrid data is Xpter-EC7034R-EC8058R-FB20E11-DXS7804-D XS8308-(DXS1264, DXS1055)-DXS1003-UBE1-(UHX), PCTK1)-DXS1364-DXS1266-DXS337-SYN1-DXS6 849-cen. One (TC)n dinucleotide sequence from an end-clone was identified and found to be polymorphic (48% heterozygosity). The contig is merged with published physical maps both in the distal and in the centromeric direction of Xp, and provides reagents to aid in the DNA sequencing and the finding of genes in this region of the human genome.

Integration of 101 DNA markers across human Xp11 using a panel of somatic cell hybrids.

One hundred and one DNA markers previously assigned to the short arm of the human X chromosome were localized on a hybrid mapping panel consisting of ten radiation-reduced, and four classical somatic cell hybrids. Of the 101 DNA markers, 16 are genes, two are pseudogenes, 13 are expressed sequence tags, 32 are simple tandem repeats (STRs), four are restriction fragment length polymorphisms, one is a variable number of tandem repeats, and 33 are sequence tagged sites (STSs). Three of these markers, two STSs and one STR, were generated from the products of an inter-Alu PCR library of a radiation-reduced hybrid containing Xp11.4-->p11.22 as its only human DNA content. A second STR was isolated from a region-specific cosmid containing the gene ZNF21. The 101 DNA markers fell into 22 bins based on their retention on the hybrids of this panel, which, in combination with YAC contig data, could be further resolved into 24 bins. This hybrid map of Xp11 has an average resolution of approximately 0.8 Mb.

Therapy of hypercalcemia due to parathyroid carcinoma with intravenous dichloromethylene diphosphonate.

Dichloromethylene diphosphonate (Cl2MDP) a potent inhibitor of osteoclast-mediated bone resorption, lowers serum calcium in hypercalcemia associated wit malignancies and with primary hyperparathyroidism, and reduces excess calcium mobilization from bone in multiple myeloma and in Paget's disease. We have evaluated the effectiveness of intravenously administered Cl2MDP in five patients with parathyroid carcinoma, a disorder characterized by severe hypercalcemia, very high parathyroid hormone (PTH) levels, and marked osteoclast-mediated bone resorption. All patients had biopsy-proved metastatic parathyroid carcinoma and hypercalcemia which persisted after multiple surgical procedures and other attempts at management. During a three-day observation period, each patients continued to demonstrate stable or progressive hypercalcemia despite infusion with saline solution and furosemide. Cl2MDP was administered over 2 hours at 2.5 mg/kg on day 1 and 5 mg/kg on days 2 through 7. Response was noted in all five patients; there was a gradual decline in the average serum calcium from 16.0 +/- 1.1 mg/dl (SEM) to 11.1 +/- 0.9 mg/dl by the eighth day (p less than 0.01). There were concomitant reductions in urinary calcium excretion, from 798 +/- 153 mg/g creatinine to 350 +/- 96 mg/g creatinine (p less than 0.05) and in the urinary hydroxyproline excretion, from 155 +/- 38 mg/g creatinine to 94 +/- 29 mg/g creatinine (p less than 0.02). Serum PTH levels remained markedly elevated (460 +/- 141 micrograms eq/ml to 493 +/- 169 micrograms eq/ml). In three patients, all indices returned to pretreatment levels by 10 days after the last infusion. In two of these patients there was a response to retreatment with Cl2MDP with a fall in calcium from 16.9 +/- 0.5 mg/dl to 12.4 +/- 1.5 mg/dl. There was no response in one patient. No adverse reactions to Cl2MDP were observed. The decrease in serum calcium and concomitant declines in urinary calcium and hydroxyproline suggest that Cl2MDP can effectively inhibit the excessive bone resorption associated with parathyroid carcinoma.

Clinical and biochemical effects of EHDP in Paget's disease of bone: patterns of response to initial treatment and to long-term therapy.

Studies regarding the efficacy of EHDP in the treatment of Paget's disease of bone conducted at our institution are described. An initial placebo-controlled clinical trial established that doses of 5 mg/kg/day for 6 months produced symptomatic improvement and a 50% lowering of serum alkaline phosphatase and urinary hydroxyproline. A subsequent study indicated that the biochemical suppression was maintained during the ensuing 6 months without therapy. Current results of long-term intermittent EHDP treatment in 40 patients studied for 5-8 years demonstrate that a small minority of individuals experience a sustained remission after a single six-month course of therapy, while a majority require repeated courses of 5 mg/kg/day for 6 of every 12 months to maintain their initial improvement. Data are also presented describing the successful use of EHDP at a dose of 20 mg/kg/day for 1 of every 4 months in patients refractory to conventional low doses of therapy. The possible role of parathyroid hormone in the expression of Paget's disease is also discussed, and recommendations regarding the pharmacologic management of patients with this disorder are provided.