Relationship between assertiveness in community pharmacists and pharmacist-initiated prescription changes.

BACKGROUND: Despite the usefulness of assertiveness by healthcare professionals in improving patient safety, few studies have evaluated the assertiveness of community pharmacists. Community pharmacists' assertiveness might be associated with pharmacist-initiated prescribing changes to improve medication safety. OBJECTIVES: Our objective was to examine which types of assertiveness-related self-expression are associated with community pharmacist-initiated prescribing changes while adjusting for possible confounding factors. METHODS: We conducted a cross-sectional survey in Japan between May and October 2022 in 10 prefectures. Community pharmacists belonging to a large pharmacy chain were recruited. The outcome variable was the frequency of community pharmacist-initiated prescription changes over 1 month. Community pharmacists' assertiveness was assessed using the Interprofessional Assertiveness Scale (IAS) and 3 sub-domains (nonassertive, assertive, and aggressive self-expression). Participants were classified into 1 of 2 categories based on medians. Demographic and clinical characteristics were compared by group with univariate analysis. A generalized linear model (GLM) was used to investigate the association between pharmacist-initiated prescription changes as an ordinal variable and pharmacists' assertiveness. RESULTS: Of 3346 community pharmacists invited, 963 were included in the analysis. Participants with high assertive self-expression scores had a significantly higher frequency of pharmacist-initiated prescription changes. There was no association between nonassertive or aggressive self-expression and pharmacist-initiated prescription changes. After adjustments, high assertive self-expression remained associated with a high frequency of community pharmacist-initiated prescription changes (odds ratio, 1.34; 95% confidence interval, 1.02-1.74; p = 0.032). CONCLUSIONS: Higher assertive self-expression among community pharmacists is associated with higher frequency of pharmacist-initiated prescription changes.

Disordered voluntary cough as freezing phenomenon in parkinsonism.

[Purpose] In patients with parkinsonism, the precise mechanism of impaired voluntary cough remains poorly understood. This study used the flow-volume curve to clarify whether disordered voluntary cough reflects the freezing phenomenon. [Subjects and Methods] Case 1 was a 58-year-old female who had been suffering from progressive supranuclear palsy-pure akinesia with gait freezing. Case 2 was a 59-year-old female who had advanced juvenile parkinsonism. The subjects were asked to take a deep inspiration to the total lung capacity and then cough more than five times through the face mask into the spirometer without intervening inspirations between the coughing efforts. [Results] Hesitation in cough initiation (case 2), decreased peak cough flow (case 1), and rounding of the first spike (cases 1 and 2) were observed. In addition, movements of the spike wave at a lower lung volume became progressively smaller and faster (cases 1 and 2). [Conclusion] These clinical manifestations in our patients are similar to those observed in the freezing phenomenon. However, to date, the concept of cough freezing has been underrecognized in clinical practice. From the present study, it could be hypothesized that the freezing phenomenon can occur in voluntary cough as well as in gait, speech, and writing.

Characteristics associated with freezing of gait in actual daily living in Parkinson's disease.

[Purpose] Parkinson's disease (PD) patients often freeze in actual daily living but seldom in clinical setting. This study aimed to identify the factors contributing to freezing of gait (FOG). [Subjects and Methods] The participants included 28 adults with PD. Principal component analysis was used to investigate the characteristics of 14 common FOG situations adopted from previous studies. Cluster analysis classified the subjects into four groups. Kruskal-Wallis test was performed to compare the PD Questionnaire-39 mobility dimension between the groups. [Results] The major variables of the first principal component in 14 FOG situations were unfamiliar places, unpredictable schedule changes, entering an automatic door, when another person suddenly crossed, and change in the walking surface. These situations were unrelated to the second principal component. Getting on/off a public transport and crowded places were major variables for the second principal component, and related to both the first and second principal components. Although fatigue was the most frequent FOG situation, not all principal components were influenced. The values of the PD Questionnaire-39 revealed significant differences between the groups. [Conclusion] Actual FOG situations may be categorized into (1) task complexity, (2) both task complexity and emotional factors, and (3) fatigue as decreased attentional resources.

Accelerometer based analysis of gait initiation failure in advanced juvenile parkinsonism: a single subject study.

[Purpose] This study used an accelerometer placed close to the center of gravity to quantitatively investigate whether unexpected gait initiation aggravates start hesitation (freezing of gait in gait initiation). [Subject and Methods] The subject was a 53-year-old female who had been suffering from juvenile parkinsonism since she was aged 21 years. An alternating-treatment design was used to compare acceleration characteristics under two gait initiation conditions, which were 1) deliberate gait initiation and 2) gait initiation on a sudden "go" verbal command (sudden gait initiation), in the "on" state of the medication cycle. [Results] In six out of eight sessions, a combination of reduced peak positive anterior accelerations and large power percentage in the high frequency band was consistently observed in the sudden gait initiation compared with deliberate gait initiation. In the other two sessions, although a large acceleration just after the "go" signal was observed, subsequent acceleration signals were blocked by sudden gait initiation. [Conclusion] The results suggest that, even in the "on" state, start hesitation is apparent without increased reliance on frontal cortical attentional mechanisms to compensate for impaired automaticity. In advanced juvenile parkinsonism, sudden gait initiation may be an effective paradigm as a provoking test for start hesitation.

Parkinsonian Symptomatology May Correlate with CT Findings before and after Shunting in Idiopathic Normal Pressure Hydrocephalus.

We aimed to investigate the characteristics of Parkinsonian features assessed by the unified Parkinson's disease rating scale (UPDRS) and determine their correlations with the computed tomography (CT) findings in patients with idiopathic normal pressure hydrocephalus (iNPH). The total score and the scores for arising from chair, gait, postural stability, and body hypokinesia in the motor examination section of UPDRS were significantly improved after shunt operations. Stepwise multiple regression analysis revealed that postural stability was the determinant of the gait domain score of the iNPH grading scale. The canonical correlation analysis between the CT findings and the shunt-responsive Parkinsonian features indicated that Evans index rather than midbrain diameters had a large influence on the postural stability. Thus, the pathophysiology of postural instability as a cardinal feature of gait disturbance may be associated with impaired frontal projections close to the frontal horns of the lateral ventricles in the iNPH patients.

Shunt-responsive parkinsonism and reversible white matter lesions in patients with idiopathic NPH.

BACKGROUND: Idiopathic normal pressure hydrocephalus (iNPH) is a potentially treatable dementia and gait disorder with abnormal CSF dynamics. OBJECTIVE: To investigate and characterize the changes in motor symptoms and CT and MRI features of iNPH before and after a shunt operation using specific evaluation criteria. METHODS: We studied 17 definitive iNPH patients, diagnosed according to the clinical guidelines of both the Japanese Society of NPH and the International NPH Consultant Group, with ventricular enlargement (Evan's index > 0.3) and narrowed CSF spaces at the high convexity on CT scan and /or MRI. The pre- and post-operative evaluation criteria for the gait and motor disturbances included the Japanese NPH Grading Scale-Revised (JNPHGSR), the Timed "Up and Go" test and the motor sections of the Unified Parkinson Disease Rating Scale. For cognitive impairments, the JNPHGSR, Mini Mental State Examination, Frontal Assessment Battery and Trail Making Test were used. White matter lesions were rated from the CT and/or MRI using a validated visual rating scale. RESULTS: All patients showed specific CT and MRI findings, consisting of diffusely-dilated Sylvian fissure, as well as narrowed CSF space at the high convexity. Fifteen patients (88%) showed white matter lesions on their CT or MRI images. These signs were ameliorated in all patients after the shunt operation. Evan's index and the mean total scores on the visual scale for white matter lesions also improved significantly. Clinically, the patients had frequent parkinsonism (71%), but relatively few had a history of either small-vessel diseases (29%), hypertension (41%) or diabetes (35%). All patients showed gait disturbances, and these symptoms, including postural instability and body bradykinesia, improved significantly after the operation. Over half also showed signs of cognitive impairment and urinary incontinence, and all such symptoms and signs improved significantly. CONCLUSION: iNPH often appears as a shunt-responsive type of parkinsonism and reversible white matter lesions among the geriatric population.