Community pharmacists' evolving role in Canadian primary health care: a vision of harmonization in a patchwork system

Canada's universal public health care system provides physician, diagnostic, and hospital services at no cost to all Canadians, accounting for approximately 70% of the 264 billion CAD spent in health expenditure yearly. Pharmacy-related services, including prescription drugs, however, are not universally publicly insured. Although this system underpins the Canadian identity, primary health care reform has long been desired by Canadians wanting better access to high quality, effective, patient-centred, and safe primary care services. A nationally coordinated approach to remodel the primary health care system was incited at the turn of the 21st century yet, twenty years later, evidence of widespread meaningful improvement remains underwhelming. As a provincial/territorial responsibility, the organization and provision of primary care remains discordant across the country. Canadian pharmacists are, now more than ever, poised and primed to provide care integrated with the rest of the primary health care system. However, the self-regulation of the profession of pharmacy is also a provincial/territorial mandate, making progress toward integration of pharmacists into the primary care system incongruent across jurisdictions. Among 11,000 pharmacies, Canada's 28,000 community pharmacists possess varying authority to prescribe, administer, and monitor drug therapies as an extension to their traditional dispensing role. Expanded professional services offered at most community pharmacies include medication reviews, minor/common ailment management, pharmacist prescribing for existing prescriptions, smoking cessation counselling, and administration of injectable drugs and vaccinations. Barriers to widely offering these services include uncertainties around remuneration, perceived skepticism from other providers about pharmacists' skills, and slow digital modernization including limited access by pharmacists to patient health records held by other professionals. Each province/territory enables pharmacists to offer these services under specific legislation, practice standards, and remuneration models unique to their jurisdiction. There is also a small, but growing, number of pharmacists across the country working within interdisciplinary primary care teams. To achieve meaningful, consistent, and seamless integration into the interdisciplinary model of Canadian primary health care reform, pharmacy advocacy groups across the country must coordinate and collaborate on a harmonized vision for innovation in primary care integration, and move toward implementing that vision with ongoing collaboration on primary health care initiatives, strategic plans, and policies. Canadians deserve to receive timely, equitable, and safe interdisciplinary care within a coordinated primary health care system, including from their pharmacy team

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Community pharmacists' evolving role in Canadian primary health care: a vision of harmonization in a patchwork system.

Canada's universal public health care system provides physician, diagnostic, and hospital services at no cost to all Canadians, accounting for approximately 70% of the 264 billion CAD spent in health expenditure yearly. Pharmacy-related services, including prescription drugs, however, are not universally publicly insured. Although this system underpins the Canadian identity, primary health care reform has long been desired by Canadians wanting better access to high quality, effective, patient-centred, and safe primary care services. A nationally coordinated approach to remodel the primary health care system was incited at the turn of the 21st century yet, twenty years later, evidence of widespread meaningful improvement remains underwhelming. As a provincial/territorial responsibility, the organization and provision of primary care remains discordant across the country. Canadian pharmacists are, now more than ever, poised and primed to provide care integrated with the rest of the primary health care system. However, the self-regulation of the profession of pharmacy is also a provincial/territorial mandate, making progress toward integration of pharmacists into the primary care system incongruent across jurisdictions. Among 11,000 pharmacies, Canada's 28,000 community pharmacists possess varying authority to prescribe, administer, and monitor drug therapies as an extension to their traditional dispensing role. Expanded professional services offered at most community pharmacies include medication reviews, minor/common ailment management, pharmacist prescribing for existing prescriptions, smoking cessation counselling, and administration of injectable drugs and vaccinations. Barriers to widely offering these services include uncertainties around remuneration, perceived skepticism from other providers about pharmacists' skills, and slow digital modernization including limited access by pharmacists to patient health records held by other professionals. Each province/territory enables pharmacists to offer these services under specific legislation, practice standards, and remuneration models unique to their jurisdiction. There is also a small, but growing, number of pharmacists across the country working within interdisciplinary primary care teams. To achieve meaningful, consistent, and seamless integration into the interdisciplinary model of Canadian primary health care reform, pharmacy advocacy groups across the country must coordinate and collaborate on a harmonized vision for innovation in primary care integration, and move toward implementing that vision with ongoing collaboration on primary health care initiatives, strategic plans, and policies. Canadians deserve to receive timely, equitable, and safe interdisciplinary care within a coordinated primary health care system, including from their pharmacy team.

Pupillary response: cognitive effort for breast cancer survivors.

PURPOSE: The purpose of this cross-sectional comparative pilot study was to evaluate cognitive effort, indexed by pupillary response (PR), for breast cancer survivors (BCS) with complaints of cognitive dysfunction following chemotherapy. STUDY AIMS: Compare the cognitive effort employed by BCS to healthy controls (HC) during neuropsychological tests (NPT) for memory, sustained attention, verbal fluency, visuospatial ability, processing speed and executive function; and Investigate the relationship between PR-indexed cognitive effort and participants' self-report of cognitive function. METHODS: Self-report of cognitive function was collected from 23 BCS and 23 HC. PR was measured during NPT. Independent two-sample t tests or Wilcoxon rank sum tests were used to compare group scores. Between-group effect size (Cohen's d) was calculated for each outcome. Correlation between mean self-report scores and PR values, as well as 95% confidence intervals, was calculated. RESULTS: No group differences were demonstrated for NPT performance. BCS reported more issues with cognitive function than HC (p < .0001). A group effect for BCS was seen with PR-indexed cognitive effort for components of most NPT (p < .05). PR was correlated with most self-report measures of cognitive function (r = 0.33-0.45). CONCLUSIONS: PR sensitivity to cognitive effort across a variety of NPT and correlation with self-report of cognitive function was demonstrated. The portability, affordability, and "real-time" aspects of PR are attractive for potential use in the clinic setting to assess cognitive function. A larger study is needed to confirm these results. Prospective investigation of PR in BCS is needed to demonstrate sensitivity to cognitive function changes over time.

Informing antimicrobial stewardship: factors associated with inappropriate antimicrobial prescribing in primary care.

Background: Antimicrobial stewardship (AS) programs promote the optimal use of antimicrobials and safe patient care. With most antimicrobials prescribed in the ambulatory setting, establishing benchmark data is imperative to gauge the impact of future AS initiatives. Objectives: To determine the frequency of potentially inappropriate antimicrobial prescribing in primary care practices in Manitoba, Canada and to assess the association between potentially inappropriate antimicrobial prescribing and patient, prescriber and practice-related factors. Methods: A retrospective cohort study using the Manitoba Primary Care Research Network repository of de-identified Electronic Medical Records from consenting primary care practices. Descriptive statistics and logistic regressions detailed patients with bacterial or viral infections of interest and antimicrobial prescriptions. Results: Eighteen percent (n = 35 574) of primary care visits for common infections were associated with a potentially inappropriate antimicrobial prescription. Among antimicrobials prescribed to patients diagnosed with bacterial infections, 37.8% (n = 2168) had a potentially inappropriate antimicrobial prescribed and 19.6% (n = 1126) had an antimicrobial prescribed for a duration outside of guideline-based ranges. Female patients, younger age and less office visits were associated with potentially inappropriate antimicrobial prescribing for bacterial infections. Among physician visits for viral infection, 15.9% (n = 29 833) were associated with an antimicrobial prescription. Older patients, those with more comorbidity, more office visits and those who were seen in larger or rural practices, were associated with potentially inappropriate antimicrobial prescribing for viral infections. Conclusions: High frequency of potentially inappropriate antimicrobial prescribing, especially in certain patient populations, suggests the need for coordinated community-based AS programs to optimize prescribing and improve patient care.

Pharmacological response sensitization in nerve cell networks exposed to the antibiotic gentamicin.

Gentamicin is an aminoglycoside antibiotic that is used in clinical, organismic, and agricultural applications to combat gram-negative, aerobic bacteria. The clinical use of gentamicin is widely linked to various toxicities, but there is a void in our knowledge about the neuromodulatory or neurotoxicity effects of gentamicin. This investigation explored the electrophysiologic effects of gentamicin on GABAergic pharmacological profiles in spontaneously active neuronal networks in vitro derived from auditory cortices of E16 mouse embryos and grown on microelectrode arrays. Using the GABAA agonist muscimol as the test substance, responses from networks to dose titrations of muscimol were compared in the presence and absence of 100µM gentamicin (the recommended concentration for cell culture conditions). Spike-rate based EC50 values were generated using sigmoidal fit concentration response curves (CRCs). Exposure to 100µM gentamicin exhibited a muscimol EC50±S.E.M. of 80±6nM (n=10). The EC50 value obtained in the absence of gentamicin was 124±11nM (n=10). The 35% increase in potency suggests network sensitization to muscimol in the presence of gentamicin. Action potential (AP) waveform analyses of neurons exposed to gentamicin demonstrated a concentration-dependent decrease in AP amplitudes (extracellular recordings), possibly reflecting gentamicin effects on voltage-gated ion channels. These in vitro results reveal alteration of pharmacological responses by antibiotics that could have significant influence on the behavior and performance of animals.

An unexpected disruption of the atmospheric quasi-biennial oscillation.

One of the most repeatable phenomena seen in the atmosphere, the quasi-biennial oscillation (QBO) between prevailing eastward and westward wind jets in the equatorial stratosphere (approximately 16 to 50 kilometers altitude), was unexpectedly disrupted in February 2016. An unprecedented westward jet formed within the eastward phase in the lower stratosphere and cannot be accounted for by the standard QBO paradigm based on vertical momentum transport. Instead, the primary cause was waves transporting momentum from the Northern Hemisphere. Seasonal forecasts did not predict the disruption, but analogous QBO disruptions are seen very occasionally in some climate simulations. A return to more typical QBO behavior within the next year is forecast, although the possibility of more frequent occurrences of similar disruptions is projected for a warming climate.

Assessing prescribing of NSAIDs, antiplatelets, and anticoagulants in Canadian family medicine using chart review.

Background Drug-related problems have been identified as a major contributor to emergency room visits, hospitalizations, and death. The most commonly implicated medications are nonsteroidal anti-inflammatory drugs (NSAIDs), antiplatelets, and anticoagulants. Considering a significant proportion of these harms are preventable, indicators to identify risky prescribing before they lead to harm have been developed. Objective To examine the prevalence and patterns of potentially inappropriate prescriptions (PIPs) in a primary care population who are using high-risk medications. Setting This study was performed within two multi-disciplinary family medicine teaching clinics in Winnipeg, Canada. Method A cross-sectional electronic/paper chart audit was conducted within two multi-disciplinary family medicine teaching clinics to evaluate the prevalence of 13 evidence-based high-risk prescriptions. Patients were included if they were prescribed an oral NSAID, antiplatelet, or an anticoagulant within the 12 month period between June 2012 and June 2013. Main outcome measure The proportion of PIPs associated with an increased bleeding risk for NSAIDs, antiplatelets, and anticoagulants. Results Of the 567 patients included in the review, 198 (35 %) patients had received at least 1 PIP in the past year. The most common PIP was the use of an oral NSAID with one or more GI risk factors without adequate gastro-protection. Only 34 (6 %) of these patients received a full medication review performed by a pharmacist. Although not statistically significant, patients who received a medication review had fewer inappropriate prescriptions (27 % with review, 35 % without). Conclusion Over one-third of the patients who were using high-risk medications were using them potentially inappropriately. Although pharmacists have been shown to reduce the amount of inappropriate prescribing, very few patients using these medications were referred to the pharmacist for a full medication review. These data suggest that there is opportunity for the identification and assessment of these patients when prescribing or dispensing these high-risk medications.

High risk use of OTC NSAIDs and ASA in family medicine: A retrospective chart review.

BACKGROUND: Complications associated with the use of NSAIDs, antiplatelet agents, and anticoagulants are among the top causes of preventable drug-related ER visits, hospitalizations and death. Although over-the-counter (OTC) NSAIDs and ASA also contribute to this preventable risk, it is unclear how well these medications are documented in primary care records. METHODS: A retrospective electronic and paper chart review was conducted to evaluate the prevalence of 13 evidence-based high-risk prescriptions and the contribution of OTC NSAIDs and ASA to these potentially inappropriate prescriptions (PIPs). RESULTS: Of the 148 patients included in the review, ASA was taken by 117 patients (79%) while OTC NSAIDs were taken by 36 (24%). OTC NSAIDs were never documented within the "medication" section of the electronic record, whereas ASA was documented in 65 (56%) cases. Eighty percent (118/148) taking either OTC NSAIDs or ASA were identified as having at least one PIP. CONCLUSION: OTC NSAIDs and ASA are widely available and are commonly taken without the knowledge of the prescriber. These medications contribute to the overall risk of bleeding. Review and documentation of OTC NSAIDs and ASA use should be part of all relevant patient encounters when prescribing NSAIDs, antiplatelets and anticoagulants.

Weakened stratospheric quasibiennial oscillation driven by increased tropical mean upwelling.

The zonal wind in the tropical stratosphere switches between prevailing easterlies and westerlies with a period of about 28 months. In the lowermost stratosphere, the vertical structure of this quasibiennial oscillation (QBO) is linked to the mean upwelling, which itself is a key factor in determining stratospheric composition. Evidence for changes in the QBO have until now been equivocal, raising questions as to the extent of stratospheric circulation changes in a global warming context. Here we report an analysis of near-equatorial radiosonde observations for 1953-2012, and reveal a long-term trend of weakening amplitude in the zonal wind QBO in the tropical lower stratosphere. The trend is particularly notable at the 70-hectopascal pressure level (an altitude of about 19 kilometres), where the QBO amplitudes dropped by roughly one-third over the period. This trend is also apparent in the global warming simulations of the four models in the Coupled Model Intercomparison Project Phase 5 (CMIP5) that realistically simulate the QBO. The weakening is most reasonably explained as resulting from a trend of increased mean tropical upwelling in the lower stratosphere. Almost all comprehensive climate models have projected an intensifying tropical upwelling in global warming scenarios, but attempts to estimate changes in the upwelling by using observational data have yielded ambiguous, inconclusive or contradictory results. Our discovery of a weakening trend in the lower-stratosphere QBO amplitude provides strong support for the existence of a long-term trend of enhanced upwelling near the tropical tropopause.

El Niño : Southern Oscillation Events and their associated midlatitude teleconnections 1531-1841

This paper reports on an investigation into the chronology of El Niño/Southern Oscillation (ENSO) events during the period from the arrival of Europeans in Perú in 1531 until the year 1841 when conventional barometricdata became available in the tropical regions. A number of probable ENSO events can be dated from anecdotal reports of significant rainfall in the coastal desert of northern Perú. In many of the years with anomalous Peruvian rainfall it is also possible to use various types pf proxy data to identify aspects of the global teleconnection patterns usually associated with tropical ENSO events(AU)