AJP clinical update: Eye health

For most people our eyes provide around 80% of the information from our surroundings, and pharmacists are perfectly placed to help consumers maintain good eye health.

Clinical tips: Diabetes explained

For many people, diabetes can start insidiously, without people knowing or being aware that they have diabetes. Signs and symptoms can just start with something very benign, such as feeling more thirsty than usual, or that they are going to the bathroom more because they are drinking more fluids from being thirsty...

Clinical tips: Mental health and Christmas explained

Christmas is usually a time for celebration, being with family and friends, opening presents, stuffing yourself silly with food at Christmas lunch – then doing it all over again at dinner. However, this may not be the case for some people. Relationships with family may be strained, or there may have been the loss of a loved one or significant other...

Feedback and clinical practice improvement: A tool to assist workplace supervisors and students

In work integrated learning, students may report difficulties applying theory learned at university to clinical practice. One contributing factor may be students' inability to engage in meaningful reflection and self-correcting behaviours. This paper reports the evaluation of a tool, process and resources developed to assist students to reflect on feedback and engage in self-assessment. Students were assisted to develop self-assessment skills by reflecting on, and engaging with feedback from previous workplace experiences to develop goals, learning outcomes and strategies to improve performance with mostly positive results. A secondary aim was to identify common learning strategies or barriers that impacted on student outcomes. Four themes emerged from the qualitative data: 1) preparing for clinical learning; 2) relationships and engagement levels; 3) shared awareness, and; 4) developing clinical practice. Overall students felt the tool assisted them to narrow their attention on what needed to be improved. While supervisors believed the tool helped them to focus on specific needs of each student. Common barriers to clinical practice improvement related to a lack of opportunity in some settings, and lack of staff willingness to support students to achieve identified goals. Students and supervisors found the use of the tools beneficial and assisted students to demonstrate a greater understanding of how to apply feedback received to support their learning in the clinical environment.

Clinical Tips: Crohn's and Colitis

Inflammatory bowel disease (IBD) describes a group of chronic relapsing inflammatory conditions of the gastrointestinal tract (GIT), with Crohn’s disease and ulcerative colitis being the two most common. Ulcerative colitis affects the colon, with the inflammation limited to the colonic mucosal layers. In contrast, the full thickness of the gut wall can be inflamed in Crohn’s disease, and any part of the GIT can be affected – from the mouth to the anus, though the small and large intestine are most commonly involved...

Clinical tips: Food poisoning

Food poisoning is used to describe a range of illnesses caused by drinking or eating contaminated drink or food. Infectious pathogens include bacteria, viruses, parasites, or their toxins, though food poisoning can also be a result of eating poisonous plants e.g. some mushrooms, or animals e.g. puffer fish. Common symptoms include nausea, vomiting, watery diarrhoea, abdominal pain and cramps, and fevers, though these will vary depending on the causative pathogen or toxin. Symptoms can start within hours of eating contaminated food, or may begin days or weeks later. Most food poisoning is mild in nature, lasts for several hours to a few days, and generally resolves without treatment. However, some cases of food poisoning can also be extremely severe, with people requiring medical attention or admission to hospital...

Clinical tips: Actively supporting customers to make a significant lifestyle change for New Year

We have all made these New Year’s resolutions before ... to be healthier, to eat better, to look after ourselves more, to go to the gym more. Each year, we are adamant we will stick with these resolutions, but deep down, we all know most of us will have given up before February even arrives. So we have put together a few tips to help you actively support your customers to make a significant lifestyle change for the New Year. Healthy eating – it is important for your customers to have realistic expectations. It is all too easy to say they will stop eating junk food, and start ‘eating healthy’. Advising them that it is important to be realistic and starting with a few small measurable goals, such as aiming to eat two servings of fruits or five servings of vegetables each day, will work better in the long run. Small tweaks and modifications can add up to a major change quite quickly...

Clinical tips: The “12 days of Christmas” - surviving and preparing for Christmas as a retailer

“We wish you a Merry Christmas, and a Happy New Year” ... when the Christmas carols start playing in the pharmacy, it is a reminder the silly season has crept up on us. Christmas should be a time of celebration, fun and spending time with loved ones and families. However, if pharmacies are not prepared it can easily turn into the “nightmare before Christmas”. So to make sure everything runs smoothly like Santa’s schedule, we have compiled a few tips to help retailers survive and prepare for Christmas...

The clinical effectiveness and cost-effectiveness of exercise referral schemes: A systematic review and economic evaluation

- Background Exercise referral schemes (ERS) aim to identify inactive adults in the primary-care setting. The GP or health-care professional then refers the patient to a third-party service, with this service taking responsibility for prescribing and monitoring an exercise programme tailored to the needs of the individual. - Objective To assess the clinical effectiveness and cost-effectiveness of ERS for people with a diagnosed medical condition known to benefit from physical activity (PA). The scope of this report was broadened to consider individuals without a diagnosed condition who are sedentary. - Data sources MEDLINE; EMBASE; PsycINFO; The Cochrane Library, ISI Web of Science; SPORTDiscus and ongoing trial registries were searched (from 1990 to October 2009) and included study references were checked. - Methods Systematic reviews: the effectiveness of ERS, predictors of ERS uptake and adherence, and the cost-effectiveness of ERS; and the development of a decision-analytic economic model to assess cost-effectiveness of ERS. - Results Seven randomised controlled trials (UK, n = 5; non-UK, n = 2) met the effectiveness inclusion criteria, five comparing ERS with usual care, two compared ERS with an alternative PA intervention, and one to an ERS plus a self-determination theory (SDT) intervention. In intention-to-treat analysis, compared with usual care, there was weak evidence of an increase in the number of ERS participants who achieved a self-reported 90-150 minutes of at least moderate-intensity PA per week at 6-12 months' follow-up [pooled relative risk (RR) 1.11, 95% confidence interval 0.99 to 1.25]. There was no consistent evidence of a difference between ERS and usual care in the duration of moderate/vigorous intensity and total PA or other outcomes, for example physical fitness, serum lipids, health-related quality of life (HRQoL). There was no between-group difference in outcomes between ERS and alternative PA interventions or ERS plus a SDT intervention. None of the included trials separately reported outcomes in individuals with medical diagnoses. Fourteen observational studies and five randomised controlled trials provided a numerical assessment of ERS uptake and adherence (UK, n = 16; non-UK, n = 3). Women and older people were more likely to take up ERS but women, when compared with men, were less likely to adhere. The four previous economic evaluations identified suggest ERS to be a cost-effective intervention. Indicative incremental cost per quality-adjusted life-year (QALY) estimates for ERS for various scenarios were based on a de novo model-based economic evaluation. Compared with usual care, the mean incremental cost for ERS was £169 and the mean incremental QALY was 0.008, with the base-case incremental cost-effectiveness ratio at £20,876 per QALY in sedentary people without a medical condition and a cost per QALY of £14,618 in sedentary obese individuals, £12,834 in sedentary hypertensive patients, and £8414 for sedentary individuals with depression. Estimates of cost-effectiveness were highly sensitive to plausible variations in the RR for change in PA and cost of ERS. - Limitations We found very limited evidence of the effectiveness of ERS. The estimates of the cost-effectiveness of ERS are based on a simple analytical framework. The economic evaluation reports small differences in costs and effects, and findings highlight the wide range of uncertainty associated with the estimates of effectiveness and the impact of effectiveness on HRQoL. No data were identified as part of the effectiveness review to allow for adjustment of the effect of ERS in different populations. - Conclusions There remains considerable uncertainty as to the effectiveness of ERS for increasing activity, fitness or health indicators or whether they are an efficient use of resources in sedentary people without a medical diagnosis. We failed to identify any trial-based evidence of the effectiveness of ERS in those with a medical diagnosis. Future work should include randomised controlled trials assessing the cinical effectiveness and cost-effectivenesss of ERS in disease groups that may benefit from PA. - Funding The National Institute for Health Research Health Technology Assessment programme.

Response: Special communication: Letters to the Editor-in-Chief [Vigorous exercise in clinical practice: balancing risks and benefits]

The effects of different exercise intensities on health have been investigated in several studies in recent years, in which some authors showed greater benefits for vigorous exercise (6) while others did not find any differences (8). An important issue regarding these conflicting results could be the fact that only a few of the studies controlled the effects of different exercise intensities for the overall volume of physical activity, making the evaluation of the available data difficult.

Classifying patients by their characteristics and clinical presentations; the use of latent class analysis

In this article, we introduce the general statistical analysis approach known as latent class analysis and discuss some of the issues associated with this type of analysis in practice. Two recent examples from the respiratory health literature are used to highlight the types of research questions that have been addressed using this approach.

Development and psychometric properties of the DCDDaily: a new test for clinical assessment of capacity in activities of daily living in children with developmental coordination disorder

Objective To develop the DCDDaily, an instrument for objective and standardized clinical assessment of capacity in activities of daily living (ADL) in children with developmental coordination disorder (DCD), and to investigate its usability, reliability, and validity. Subjects Five to eight-year-old children with and without DCD. Main measures The DCDDaily was developed based on thorough review of the literature and extensive expert involvement. To investigate the usability (assessment time and feasibility), reliability (internal consistency and repeatability), and validity (concurrent and discriminant validity) of the DCDDaily, children were assessed with the DCDDaily and the Movement Assessment Battery for Children-2 Test, and their parents filled in the Movement Assessment Battery for Children-2 Checklist and Developmental Coordination Disorder Questionnaire. Results 459 children were assessed (DCD group, n = 55; normative reference group, n = 404). Assessment was possible within 30 minutes and in any clinical setting. For internal consistency, Cronbach’s α = 0.83. Intraclass correlation = 0.87 for test–retest reliability and 0.89 for inter-rater reliability. Concurrent correlations with Movement Assessment Battery for Children-2 Test and questionnaires were ρ = −0.494, 0.239, and −0.284, p < 0.001. Discriminant validity measures showed significantly worse performance in the DCD group than in the control group (mean (SD) score 33 (5.6) versus 26 (4.3), p < 0.001). The area under curve characteristic = 0.872, sensitivity and specificity were 80%. Conclusions The DCDDaily is a valid and reliable instrument for clinical assessment of capacity in ADL, that is feasible for use in clinical practice.

Diabetic charcot neuroarthropathy of the hand: Clinical course, diagnosis, and treatment options

During the treatment of diabetic Charcot neuroarthropathy (CN) of the foot in two young patients, we discovered atypical alterations of their hands with loss of strength and paresthesia combined with atypical and nonhealing bone alterations and instability. Whereas CN of the foot is a serious and well-known complication of diabetes, CN of the hand is only mentioned in four articles (1–4).

A randomised controlled clinical trial of a post-discharge, nurse-led educational intervention to reduce anxiety and enhance self-efficacy in percutaneous coronary intervention (PCI) patients within the first week post-discharge: A pilot study

This research investigated the efficacy of a post-discharge nurse-led clinic, for patients who underwent a cardiovascular interventional procedure in Australia. A randomised controlled clinical trial measured the effects of the clinic on patient confidence to self-manage and minimise psychological distress given the strong link between anxiety, depression and coronary heart disease. Hospitalisation for the procedure is short and stressful, and patients may wait up to 7-64 days for post-discharge review. This study provides preliminary quantitative and qualitative evidence that nurse-led clinics undertaken within the first week post-percutaneous coronary intervention may fill a much-needed gap for patients during a potentially vulnerable period.

perCues: Trails of persuasion for ambient intelligence

The realization of the ambient intelligence (AmI) vision will have a profound impact on our everyday lives and society. AmI applied in contexts like homes or public spaces will not only affect individual users but influence entire groups of users. The question is how we can apply such technologies to persuade groups and individual users. Our approach is to design AmI environments by borrowing a concept which works very well in biological and social systems: Collective Intelligence (CI). The intelligence of a group surpasses the individual intelligences and leads to improved problem solving capabilities of individuals and groups. From nature we borrow examples of cues in the environment to stimulate goal directed collective intelligence (perCues). The application of perCues in AmI environments helps to persuade users to reach a common goal like decreasing environmental pollution. Adopting CI for AmI we blaze a trail for the design of persuasive AmI environments.