Assessment and management of urinary tract infections in aged care facilities.

OBJECTIVES: To compare assessment and management of urinary tract infections (UTI) for residents in aged care facilities (ACF) with evidence-based infection criteria and recommended therapy. METHODS: A retrospective clinical audit was conducted for all short-course antibiotics (SCA) prescribed to treat presumed UTIs (p-UTIs). Surveillance, microbiological and dispensing data determined whether p-UTIs met the revised McGeer criteria for infection and the extent to which SCAs complied with guideline recommendations. RESULTS: Ten out of 74 (14%) p-UTIs were confirmed infections, that is met both the clinical and microbiological criteria for infection. Thirty-four out of 74 (46%) p-UTIs were classified as asymptomatic bacteriuria. The dose and frequency of the prescribed SCA were concordant with guideline recommendations for 87% and 85% of the courses, respectively; however, only 42% of the SCAs followed the recommended duration of therapy. CONCLUSION: Overdiagnosis of UTIs and consequent overprescribing of antibiotics, specifically extended duration, are consistent with similar studies.

We are all patient-centred now, aren't we? Lessons from new pharmacy graduates.

INTRODUCTION: Patient-centredness is considered integral to the delivery of modern healthcare. This qualitative, longitudinal study explored the meaning and development of the practice of pharmacy graduates, leading to a focus on patient-centredness. The approach adopted in this study aligned with the principles of hermeneutic phenomenology. METHODS: Twelve pharmacy graduates (seven females) from The University of Queensland were observed at work and interviewed about their experiences of pharmacy practice every six months for two years following graduation. RESULTS: These 12 graduates initially understood and enacted pharmacy practice in a range of ways. A distinguishing characteristic related to how patients/customers featured in their practice. For some, ensuring the efficient supply or administration of correct and safe medicines with instructions was the focus, with patients viewed as source and recipient of information. For others, the focus was communicating effectively with patients/customers to provide individualised advice to avoid medication-related problems. A third group focused on achieving a broader goal, to provide individualised care to optimise health outcomes from medicines. Initial understanding of patient-centredness remained largely unchanged for most participants over the two years, despite the passage of time and experience gained. CONCLUSIONS: This study calls into question an assumption of a common meaning for patient-centredness. The findings highlight the need to question and debate what patient-centredness means in contemporary pharmacy practice, rather than simply being an aspirational or theoretical concept. It is important that pharmacists and educators appreciate the centrality of understanding of practice for development, to optimally facilitate the development of patient-centred pharmacists.

The three dimensional structure of Bovine Salivary Protein 30b (BSP30b) and its interaction with specific rumen bacteria.

Bovine Salivary Protein 30b (BSP30b) is a member of the tubular lipid-binding (TULIP) superfamily that includes the human bactericidal/permeability-increasing proteins (BPI), lipopolysaccharide binding proteins (LBP) and palate, lung, and nasal epithelium carcinoma-associated proteins (PLUNC). BSP30b is most closely related to the PLUNC family and is predominantly found in bovine saliva. There are four BSP30 isoforms (BSP30a-d) and collectively, they are the most abundant protein component of bovine saliva. The PLUNC family members are proposed to be lipid binding proteins, although in most cases their lipid ligands are unknown. Here, we present the X-ray crystal structure of BSP30b at 2.0 Å resolution. We used a double methionine mutant and Se-Met SAD phasing to solve the structure. The structure adopts a curved cylindrical form with a hydrophobic channel formed by an α/ß wrap, which is consistent with the TULIP superfamily. The structure of BSP30b in complex with oleic acid is also presented where the ligand is accommodated within the hydrophobic channel. The electron density for oleic acid suggests that the ligand is only partially occupied in the binding site implying that oleic acid may not be the preferred ligand. GFP-tagged BSP30b binds to the surface of olive oil droplets, as observed under fluorescent microscopy, and acts as a surfactant consistent with its association with decreased susceptibility to bloat in cattle. Bacteria extracted directly from bovine rumen contents indicate that the GFP_BSP30b fusion protein binds to a small number of selected bacterial species in vivo. These results suggest that BSP30b may bind to bacterial lipids from specific species and that this abundant protein may have important biological roles via interacting with rumen bacteria during feeding and rumination.

From transitions to transformation - A study of pharmacists developing patient-centered communication skills.

BACKGROUND: Pharmacists' communication with patients often focuses on technical aspects of advice giving, while limiting socio-emotional content. To develop pharmacists' patient-centered communication a learning and practice module integrating motivational interviewing (MI) was designed for an online postgraduate program, and its impact on their self-described practice evaluated. OBJECTIVES: To investigate whether training in patient-centered communication changes pharmacists' perceptions of communicating with patients, and how any changes in their communication style influenced interactions and relationships with patients. METHODS: A descriptive, qualitative study analyzing reflective journal entries detailing pharmacists' experiences of implementing patient-centered communication in practice was designed, evaluating reflections on initial patient interactions after training and 9-12 weeks later. Using the framework method of content and thematic analysis, an evaluation framework was devised that integrated communication, change and learning theories. Reflections were categorized within the framework as transitional (e.g. using good communication skills), transactional (e.g. using MI techniques, achieving reciprocity) or transformational (e.g. describing transformative learning, changing frames of reference in understanding of patient-centeredness). Differences between the first and last journal entries were evaluated and analyzed using descriptive statistics. RESULTS: Eighty-nine pharmacists provided two reflective journal entries for evaluation. Over 9-12 weeks, pharmacists described a change in their perspective of patient-centeredness, how they expanded the socio-emotional aspects of communication and succeeded in difficult conversations. When applying the thematic evaluation framework to initial journal entries, 38 (42%) of reflections fell within the transitional category, 51 (58%) were deemed transactional and none transformational. This changed to 10 (11%) transitional, 45 (51%) transactional and 34 (38%) transformational. Differences were observed between journal entries from pharmacists who studied completely online and those who also attended a workshop. CONCLUSION: Learning and practicing techniques of MI and person-focused communication changed many pharmacists' frames of reference in regards to patient-centeredness and their self-reported communication style with patients.

Certainty rating in pre-and post-tests of study modules in an online clinical pharmacy course - A pilot study to evaluate teaching and learning.

BACKGROUND: Graduate and post-graduate education for health professionals is increasingly delivered in an e-learning environment, where automated, continuous formative testing with integrated feedback can guide students' self-assessment and learning. Asking students to rate the certainty they assign to the correctness of their answers to test questions can potentially provide deeper insights into the success of teaching, with test results informing course designers whether learning outcomes have been achieved. It may also have implications for decision making in clinical practice. METHODS: A study of pre-and post-tests for five study modules was designed to evaluate the teaching and learning within a pharmacotherapeutic course in an online postgraduate clinical pharmacy program. Certainty based marking of multiple choice questions (MCQ) was adapted for formative pre- and post-study module testing by asking students to rate their certainty of correctness of MCQ answers. Paired t-tests and a coding scheme were used to analyse changes in answers and certainty between pre-and post-tests. A survey evaluated students' experience with the novel formative testing design. RESULTS: Twenty-nine pharmacists enrolled in the postgraduate program participated in the study. Overall 1315 matched pairs of MCQ answers and certainty ratings between pre- and post-module tests were available for evaluation. Most students identified correct answers in post-tests and increased their certainty compared to pre-tests. Evaluation of certainty ratings in addition to correctness of answers identified MCQs and topic areas for revision to course designers. A survey of students showed that assigning certainty ratings to their answers assisted in structuring and focusing their learning throughout online study modules, facilitating identification of areas of uncertainty and gaps in their clinical knowledge. CONCLUSIONS: Adding certainty ratings to MCQ answers seems to engage students with formative testing and feedback and focus their learning in a web-based postgraduate pharmacy course. It also offers deeper insight into the successful delivery of online course content, identifying areas for improvement of teaching and content delivery as well as test question design.

Beta-lactam allergy in adults with cystic fibrosis.

BACKGROUND: Allergic reactions to one or more beta-lactam antibiotic can pose a management problem in patients with cystic fibrosis (CF), and may limit antibiotic choice. METHOD: The aim of this study was to assess the prevalence of allergy to anti-pseudomonal beta-lactam antibiotics in an adult CF centre and to assess variables, which may contribute to the development of allergic reactions. A questionnaire-based interview and a review of medical records were performed. RESULTS: Of the 150 patients, 54 (36%) had allergic reactions to one or more beta-lactam antibiotics and 20 (19%) had allergic reactions to multiple beta-lactam antibiotics. The proportion of patients allergic to specific beta-lactam antibiotics varied from 10% to 26%. Rates of reactions were highest for penicillins and cephalosporins, intermediate for carbepenems and lowest for aztreonam. Of all reactions, 40% occurred within 24 h of the commencement of an individual antibiotic course. Patients with one or more beta-lactam allergic reactions had received greater cumulative exposure (p<0.0001), were older (p=0.016) and had lower lung function (p=0.037) than patients without a history of beta-lactam allergy. Cystic Fibrosis transmembrane regulator (CFTR) status, gender, peripheral blood eosinophil count and total IgE concentrations were not different in patients with allergic reactions. CONCLUSIONS: This study demonstrates that the prevalence of allergic reactions to beta-lactam antibiotics is high in adults with CF. Increasing age; cumulative exposure and decreasing FEV(1) were associated with the development of allergy.

Antibiotic desensitization in adults with cystic fibrosis.

OBJECTIVE: Allergic reactions to antibiotics occur in up to 30% of patients with cystic fibrosis (CF). Repeated antibiotic exposure and immune hyper-responsiveness increase the risk of allergic reactions and may limit antibiotic choice. Desensitization may allow the successful administration of an antibiotic despite previous allergy. We aimed to determine the success of antibiotic desensitization in patients with CF in an adult CF unit over a 7-year period. METHODOLOGY: A retrospective medical record review was performed on the 19 patients who had undergone antibiotic desensitization procedures. Data collected included drug allergy and intolerance profiles, nature of allergies, and the outcome of desensitization procedures. Desensitization procedures were performed in a ward setting according to published methods. RESULTS: Nineteen patients (13 females) reported 62 drug allergies with a mean of 3.3 per patient. Of the 71 desensitization procedures undergone by this group, 54 (76%) were successful. Fifteen of the 19 patients were allergic to two or more beta-lactam antibiotics. Over half of the patients were desensitized to more than one antibiotic. Nine different antibiotics were used in 31 different patient/drug combinations. A successful outcome was achieved in 18/31 (58%) combinations, with three requiring treatment for mild allergic reactions. Allergic reactions caused drug cessation in a total of 19 patient/drug combinations (three after initial successful desensitization and full courses of antibiotics). Over 50% of these reactions occurred on day 1. Desensitization failures were more common in patients with well-documented allergic reactions to a specific drug. CONCLUSION: This study demonstrates that multiple antibiotic allergies are common in adults with CF. Cross-reactivity between beta-lactam antibiotics may limit antibiotic choice for the treatment of pulmonary exacerbations. Antibiotic desensitization allows safe and successful treatment in the ward setting of many patients with previous allergies to an antibiotic. In many patients symptoms of allergy still occur and result in cessation of the antibiotics. Use of corticosteroids and antihistamines may improve the success rate of desensitization procedures.

Nebulised dornase alpha: adherence in adults with cystic fibrosis.

BACKGROUND: Dornase alpha improves sputum clearance and pulmonary function in patients with moderate bronchiectasis and cystic fibrosis (CF). Several studies have demonstrated variable adherence to treatment regimens in patients with CF. We aimed to compare self-reported adherence with computer based dispensing records of dornase alpha. METHOD: Direct interview of adherence to dornase alpha was compared with pharmacy-dispensing records during a 12-month period. The reasons for dornase alpha usage, and change in lung function in three groups of patients were compared (group 1 (n=42): positive trial, continuing therapy; group 2 (n=13): positive trial, ceased therapy; group 3 (n=22): negative trial). Ninety patients with CF were surveyed. Patients who had ceased dornase alpha provided reasons for drug cessation. Lung function and anthropometric data were collected prior to dornase alpha treatment and at 3 years. Health care professionals rated adherence to therapy. RESULTS: Of the 42 patients on dornase alpha, the average utilisation was 197 days (54%). From dispensing records, 24% of patients were classified as good adherence, 46% as moderate adherence and 30% as poor adherence. Eighty-two percent claimed to use dornase alpha therapy more than 20 days/month, whereas dispensing records showed that only 24% of collected sufficient drug supplies. Health professionals' assessment of adherence of therapy was often incorrect and an overestimation was more common than underestimation. The change in FEV(1) 3 years after trial was not significantly different between groups. There was a negative correlation between initial response to dornase alpha and baseline FEV(1) (r=-0.44, P=0.001), however, initial response was not related to the change in FEV(1) over 3 years (r=0.20, P=0.16). CONCLUSION: There is variability in adherence to dornase alpha in adults with CF and patient self-reporting is likely to over-estimate drug collection from the pharmacy. Further study of the long-term effects of dornase alpha is required. To date, proven interventions to enhance adherence are limited and require investigation in CF.