Development of a model of medication review for use in clinical practice: Bristol medication review model.

BACKGROUND: Medication review is a core aspect of medicine optimisation, yet existing models of review vary substantially in structure and content and are not necessarily easy to implement in clinical practice. This study aimed to use evidence from the existing literature to identify key medication review components and use this to inform the design of an improved review model. METHODS: A systematic review was conducted (PROSPERO: CRD42018109788) to identify randomised control trials of stand-alone medication review in adults (18+ years). The review updated that by Huiskes et al. (BMC Fam Pract. 18:5, 2017), using the same search strategy implemented in MEDLINE and Embase. Studies were assessed using the Cochrane risk of bias tool. Key review components were identified, alongside relevant clinical and health service outcomes. A working group (patients, doctors and pharmacists) developed the model through an iterative consensus process (appraisal of documents plus group discussions), working from the systematic review findings, brief evidence summaries for core review components and examples of previous models, to agree on the main purpose of the review model, overarching model structure, review components and supporting material. RESULTS: We identified 28 unique studies, with moderate bias overall. Consistent medication review components included reconciliation (26 studies), safety assessment (22), suboptimal treatment (19), patient knowledge/preferences (18), adherence (14), over-the-counter therapy (13) and drug monitoring (10). There was limited evidence from studies for improvement in key clinical outcomes. The review structure was underpinned by patient values and preferences, with parallel information gathering and evaluation stages, feeding into the final decision-making and implementation. Most key components identified in the literature were included. The final model was considered to benefit from a patient-centred, holistic approach, which captured both patient-orientated and medication-focused problems, and aligned with traditional consultation methods thus facilitating implementation in practice. CONCLUSIONS: The Bristol Medication Review Model provides a framework for standardised delivery of structured reviews. The model has the potential for use by all healthcare professionals with relevant clinical experience and is designed to offer flexibility of implementation not limited to a particular healthcare setting.

Systematic review of self-management interventions for people with eczema.

Eczema is a common long-term condition, but inadequate support and information can lead to poor adherence and treatment failure. We have reviewed the international literature of interventions designed to promote self-management in adults and children with eczema. MEDLINE, MEDLINE in process, Embase, CINAHL and the Global Resource for EczemA Trials database were searched from their inception to August 2016, for randomized controlled trials. Two authors independently applied eligibility criteria, assessed risk of bias for all included studies and extracted data. Twenty studies (3028 participants) conducted in 11 different countries were included. The majority (n = 18) were based in secondary care and most (n = 16) targeted children with eczema. Reporting of studies, including descriptions of the interventions and the outcomes themselves, was generally poor. Thirteen studies were face-to-face educational interventions, five were delivered online and two were studies of written action plans. Follow-up in most studies (n = 12) was short term (up to 12 weeks). Only six trials specified a single primary outcome. There was limited evidence of effectiveness. Only three studies collected and reported outcomes related to cost and just one study undertook any formal cost-effectiveness analysis. In summary, we have identified a general absence of well-conducted and well-reported randomized controlled trials with a strong theoretical basis. Therefore, there is still uncertainty about how best to support self-management of eczema in a clinically effective and cost-effective way. Recommendations on design and conduct of future trials are presented.

Does case management for patients with heart failure based in the community reduce unplanned hospital admissions? A systematic review and meta-analysis.

OBJECTIVES: The aim of this systematic review of randomised controlled trials (RCTs) and controlled trials (non-RCTs, NRCTs) is to investigate the effectiveness and related costs of case management (CM) for patients with heart failure (HF) predominantly based in the community in reducing unplanned readmissions and length of stay (LOS). SETTING: CM initiated either while as an inpatient, or on discharge from acute care hospitals, or in the community and then continuing on in the community. PARTICIPANTS: Adults with a diagnosis of HF and resident in Organisation for Economic Co-operation and Development countries. INTERVENTION: CM based on nurse coordinated multicomponent care which is applicable to the primary care-based health systems. PRIMARY AND SECONDARY OUTCOMES: Primary outcomes of interest were unplanned (re)admissions, LOS and any related cost data. Secondary outcomes were primary healthcare resources. RESULTS: 22 studies were included: 17 RCTs and 5 NRCTs. 17 studies described hospital-initiated CM (n=4794) and 5 described community-initiated CM of HF (n=3832). Hospital-initiated CM reduced readmissions (rate ratio 0.74 (95% CI 0.60 to 0.92), p=0.008) and LOS (mean difference -1.28 days (95% CI -2.04 to -0.52), p=0.001) in favour of CM compared with usual care. 9 trials described cost data of which 6 reported no difference between CM and usual care. There were 4 studies of community-initiated CM versus usual care (2 RCTs and 2 NRCTs) with only the 2 NRCTs showing a reduction in admissions. CONCLUSIONS: Hospital-initiated CM can be successful in reducing unplanned hospital readmissions for HF and length of hospital stay for people with HF. 9 trials described cost data; no clear difference emerged between CM and usual care. There was limited evidence for community-initiated CM which suggested it does not reduce admission.

Prostate cancer and supportive care: a systematic review and qualitative synthesis of men's experiences and unmet needs.

Prostate cancer is the second most common cancer in men worldwide, accounting for an estimated 1.1 million new cases diagnosed in 2012 (www.globocan.iarc.fr). Currently, there is a lack of specific guidance on supportive care for men with prostate cancer. This article describes a qualitative systematic review and synthesis examining men's experience of and need for supportive care. Seven databases were searched; 20 journal articles were identified and critically appraised. A thematic synthesis was conducted in which descriptive themes were drawn out of the data. These were peer support, support from partner, online support, cancer specialist nurse support, self-care, communication with health professionals, unmet needs (emotional support, information needs, support for treatment-induced side effects of incontinence and erectile dysfunction) and men's suggestions for improved delivery of supportive care. This was followed by the development of overarching analytic themes which were: uncertainty, reframing, and the timing of receiving treatment, information and support. Our results show that the most valued form of support men experienced following diagnosis was one-to-one peer support and support from partners. This review highlights the need for improved access to cancer specialist nurses throughout the care pathway, individually tailored supportive care and psychosexual support for treatment side effects.

Predicting and preventing avoidable hospital admissions: a review.

The strongest risk factors for avoidable hospital admission are age and deprivation but ethnicity, distance to hospital, rurality, lifestyle and meteorological factors are also important, as well as access to primary care. There is still considerable uncertainty around which admissions are avoidable. In terms of services to reduce admissions there is evidence of effectiveness for education, self-management, exercise and rehabilitation, and telemedicine in certain patient populations, mainly respiratory and cardiovascular. Specialist heart failure services and end-of-life care also reduce these admissions. However, case management, specialist clinics, care pathways and guidelines, medication reviews, vaccine programmes and hospital at home do not appear to reduce avoidable admissions. There is insufficient evidence on the role of combinations or coordinated system-wide care services, emergency department interventions, continuity of care, home visits or pay-by-performance schemes. This highlights the importance of robust evaluation of services as they are introduced into health and social care systems.

The health benefits of berry flavonoids for menopausal women: cardiovascular disease, cancer and cognition.

There is an increasing amount of research into the health benefits of berry flavonoids. Moreover, the consumption of flavonoid-rich food is on the increase; with women in particular showing a interest in eating a diet which may benefit their long-term health. The aim of this review was to examine the evidence for the benefits of berry flavonoids for cardiovascular health, cancer and cognition in the menopausal woman. Due to the limited amount of clinical data on this subject both in vitro and animal as well as human studies have been included. These data appear to support epidemiological studies that suggest cardiovascular benefits, cancer prevention and cognitive improvement from berry flavonoid consumption. However to date, it is not possible to be definitive about the specific berry type, preparation or regime which confers maximum benefits, or to give specific advice to menopausal women. Limited data from a combination of pre-clinical and clinical studies suggest that the addition of berry flavonoids to the diet has moderate effects on cardiovascular function in subjects at risk and potential preventative effects in oesophageal cancer. Evidence for cognitive benefits is limited to animal data but shows promise.

Grape flavonoids and menopausal health.

Grape flavonoids are members of a larger group of plant compounds called polyphenols. Epidemiological evidence relating to the traditional Mediterranean diet, which is high in polyphenols, derived from vegetables and red wine, suggests that dietary polyphenols are of benefit to health and reduce the incidence of cardiovascular disease. Overall, the evidence is promising for the benefit of grape flavonoids in the form of red wine, red grape juice and related preparations for cardiovascular risk factors. There are data to suggest a reduction in platelet activation, inflammation and low-density lipoprotein oxidation, and improvement of endothelial function with grape flavonoids. The evidence for grape flavonoids and renal function, cognition and cancer is less clear. However, it is important to note that much of this research has been carried out in animal and cell models; relatively little work has been done in humans and specifically on the health of menopausal women. There are no general safety concerns with ingestion of grape products. Obviously, consumption of red wine should be within recommended limits and it should be noted that grape juice has high sugar content. Grape flavonoids are also available as a supplement. In conclusion, it is likely that grape flavonoids do benefit the menopausal women. Further research is needed on the mode and dosage of application to maximize these benefits.

A review of the evidence for efficacy of complementary and alternative medicines in MS.

The role of complementary and alternative medicine for the management of MS symptoms lies in palliative care: this is borne out by the popularity of such therapies among people with MS. This article describes some of the major complementary and alternative therapies used to treat MS symptoms and whether their use is supported by evidence from randomized controlled trials. For the vast majority of complementary and alternative regimens researched, there are only one or two trials per therapy. Thus, it is difficult to recommend any specific modality. Several trials have investigated linoleic acid and its derivatives, magnetic field therapy and cannabis extracts. All three approaches appear to be of use in ameliorating MS symptoms but more research is needed. Other issues that should be considered by MS patients when taking a complementary or alternative therapy are discussed.

Relaxation therapies for asthma: a systematic review.

BACKGROUND: Emotional stress can either precipitate or exacerbate both acute and chronic asthma. There is a large body of literature available on the use of relaxation techniques for the treatment of asthma symptoms. The aim of this systematic review was to determine if there is any evidence for or against the clinical efficacy of such interventions. METHODS: Four independent literature searches were performed on Medline, Cochrane Library, CISCOM, and Embase. Only randomised clinical trials (RCTs) were included. There were no restrictions on the language of publication. The data from trials that statistically compared the treatment group with that of the control were extracted in a standardised predefined manner and assessed critically by two independent reviewers. RESULTS: Fifteen trials were identified, of which nine compared the treatment group with the control group appropriately. Five RCTs tested progressive muscle relaxation or mental and muscular relaxation, two of which showed significant effects of therapy. One RCT investigating hypnotherapy, one of autogenic training, and two of biofeedback techniques revealed no therapeutic effects. Overall, the methodological quality of the studies was poor. CONCLUSIONS: There is a lack of evidence for the efficacy of relaxation therapies in the management of asthma. This deficiency is due to the poor methodology of the studies as well as the inherent problems of conducting such trials. There is some evidence that muscular relaxation improves lung function of patients with asthma but no evidence for any other relaxation technique.

Which complementary and alternative therapies benefit which conditions? A survey of the opinions of 223 professional organizations.

UNLABELLED: With the increasing demand and usage of complementary/alternative medicine (CAM) by the general public, it is vital that healthcare professionals can make informed decisions when advising or referring their patients who wish to use CAM. Therefore they might benefit from advice by CAM-providers as to which treatment can be recommended for which condition. AIM: The primary aim of this survey was to determine which complementary therapies are believed by their respective representing professional organizations to be suited for which medical conditions. METHOD: 223 questionnaires were sent out to CAM organizations representing a single CAM therapy. The respondents were asked to list the 15 conditions they felt benefited most from their CAM therapy, the 15 most important contra-indications, the typical costs of initial and any subsequent treatments and the average length of training required to become a fully qualified practitioner. The conditions and contra-indications quoted by responding CAM organizations were recorded and the top five of each were determined. Treatment costs and hours of training were expressed as ranges. RESULTS: Of the 223 questionnaires sent out, 66 were completed and returned. Taking undelivered questionnaires into account, the response rate was 34%. Two or more responses were received from CAM organizations representing twelve therapies: aromatherapy, Bach flower remedies, Bowen technique, chiropractic, homoeopathy, hypnotherapy, magnet therapy, massage, nutrition, reflexology, Reiki and yoga. The top seven common conditions deemed to benefit by all twelve therapies, in order of frequency, were: stress/anxiety, headaches/migraine, back pain, respiratory problems (including asthma), insomnia, cardiovascular problems and musculoskeletal problems. Aromatherapy, Bach flower remedies, hypnotherapy, massage, nutrition, reflexology, Reiki and yoga were all recommended as suitable treatments for stress/anxiety. Aromatherapy, Bowen technique, chiropractic, hypnotherapy, massage, nutrition, reflexology, Reiki and yoga were all recommended for headache/migraine. Bowen technique, chiropractic, magnet therapy, massage, reflexology and yoga were recommended for back pain. None of the therapies cost more than l60 for an initial consultation and treatment. No obvious correlation between length of training and treatment cost was apparent. CONCLUSION: The recommendations by CAM organizations responding to this survey may provide guidance to health care professionals wishing to advise or refer patients interested in using CAM.

Rash after visiting Tucson.

Cactus dermatitis is a common problem among harvesters of cactus fruit. The smaller spines (glochidia) are responsible for most of the dermatitis. Easily separated from the body of the plant, the glochidia may be transferred to bystanders through contact with clothing or pets exposed to these cacti. Removal of the glochidia from the skin is key to treatment, and household glue may aid in this extraction.

Herbal medicines for asthma: a systematic review.

BACKGROUND: Asthma is one of the most common chronic diseases in modern society and there is increasing evidence to suggest that its incidence and severity are increasing. There is a high prevalence of usage of complementary medicine for asthma. Herbal preparations have been cited as the third most popular complementary treatment modality by British asthma sufferers. This study was undertaken to determine if there is any evidence for the clinical efficacy of herbal preparations for the treatment of asthma symptoms. METHODS: Four independent literature searches were performed on Medline, Pubmed, Cochrane Library, and Embase. Only randomised clinical trials were included. There were no restrictions on the language of publication. The data were extracted in a standardised, predefined manner and assessed critically. RESULTS: Seventeen randomised clinical trials were found, six of which concerned the use of traditional Chinese herbal medicine and eight described traditional Indian medicine, of which five investigated Tylophora indica. Three other randomised trials tested a Japanese Kampo medicine, marihuana, and dried ivy leaf extract. Nine of the 17 trials reported a clinically relevant improvement in lung function and/or symptom scores. CONCLUSIONS: No definitive evidence for any of the herbal preparations emerged. Considering the popularity of herbal medicine with asthma patients, there is urgent need for stringently designed clinically relevant randomised clinical trials for herbal preparations in the treatment of asthma.

Complementary and alternative therapies for treating multiple sclerosis symptoms: a systematic review.

Multiple sclerosis (MS) is a chronic disease of the central nervous system without a known cure. Thus the role of complementary and alternative therapies (CATs) for the management of symptoms lies in palliative care and this is borne out by the popularity of these treatments amongst MS sufferers. This review is aimed at determining whether this use is supported by evidence of effectiveness from rigorous clinical trials. Database literature searches were performed and papers were extracted in a pre-defined manner. Twelve randomized controlled trials were located that investigated a CAT for MS: nutritional therapy (4), massage (1), Feldenkrais bodywork (1), reflexology (1), magnetic field therapy (2), neural therapy (1) and psychological counselling (2). The evidence is not compelling for any of these therapies, with many trials suffering from significant methodological flaws. There is evidence to suggest some benefit of nutritional therapy for the physical symptoms of MS. Magnetic field therapy and neural therapy appear to have a short-term beneficial effect on the physical symptoms of MS. Massage/bodywork and psychological counselling seem to improve depression, anxiety and self-esteem. The effectiveness for other CATs is unproven at this time. In all the CATs examined further investigations are needed in the form of rigorous large-scale trials.

Tea tree oil: a systematic review of randomized clinical trials.

AIM: Tea tree oil (TTO) is immensely popular for various topical applications. In vitro studies have repeatedly demonstrated that it has antibiotic activity. This article is an attempt to systematically review the evidence from randomised clinical trials for or against effectiveness of external TTO in dermatological conditions. METHODS: Six electronic databases were searched. Methodological quality was assessed by Jadad score. Data were extracted and validated in a standardised fashion by two independent reviewers. RESULTS: Only 4 trials were located. They suggest that TTO may be effective as a treatment of acne and fungal infections. The evidence is promising but by no means compelling. The adverse effects of TTO are usually mild and transient. They mainly consist of allergic reactions. CONCLUSIONS: It is concluded that, so far, there is no compelling evidence to show that TTO is efficacious in any dermatological condition. However, in view of promising findings, TTO deserves to be investigated more closely.

Angiotensin II activates MAPK and stimulates growth of human pulmonary artery smooth muscle via AT1 receptors.

To determine a potential role for the renin-angiotensin system in the growth of human pulmonary artery (PA) smooth muscle, we studied the localization of angiotensin (ANG) II-receptor subtypes by autoradiography in sections of human PA and in cultured PA smooth muscle cells (PASMCs) and examined the growth responses to ANG II in vitro. Specific 125I-labeled [Sar1,Ile8]ANG II binding was demonstrated within the pulmonary arterial media, but binding to cultured cells varied between isolates. Binding in tissues and cells was inhibited by the ANG II type 1 (AT1) receptor antagonist losartan but not by the type 2 (AT2) receptor antagonist PD-123319. Microautoradiographic studies indicated that cultured PASMCs exhibit heterogeneity with regard to ANG II binding sites. Addition of ANG II to serum-deprived PASMCs, exhibiting a relatively high level of 125I-[Sar1,Ile8]ANG II binding, led to a dose-dependent stimulation of DNA synthesis at 24 h and protein synthesis at 48 h. ANG II led to an increase in cell size without an increase in cell number. These effects were inhibited by losartan but not by PD-123319. In addition, ANG II led to rapid activation of mitogen-activated protein kinase (MAPK), and ANG II-stimulated DNA synthesis was inhibited by the specific inhibitor of MAPK PD-98059. We conclude that the AT1 receptor is expressed by human PASMCs in vivo and in vitro and is coupled to activation of MAPK and increased DNA and protein synthesis in vitro. These results are consistent with the hypothesis that ANG II may be involved in human pulmonary vascular remodeling.