Uptake of a free coronary heart disease risk screening programme in community pharmacy: the Healthy Heart Assessment service

Introduction Health promotion (HP) aims to enhance good health while preventing ill-health at three levels of activity; primary (preventative), secondary (diagnostic) and tertiary (management).1 It can range from simple provision of health education to ongoing support, but the effectiveness of HP is ultimately dependent on its ability to influence change. HP as part of the Community Pharmacy Contract (CPC) aims to increase public knowledge and target ‘hard-to-reach’ individuals by focusing mainly on primary and tertiary HP. The CPC does not include screening programmes (secondary HP) as a service. Coronary heart disease (CHD) is a significant cause of morbidity and mortality in the UK. While there is evidence to support the effectiveness of some community pharmacy HP strategies in CHD, there is paucity of research in relation to screening services.2 Against this background, Alliance Pharmacy introduced a free CHD risk screening programme to provide tailored HP advice as part of a participant–pharmacist consultation. The aim of this study is to report on the CHD risk levels of participants and to provide a qualitative indication of consultation outcomes. Methods Case records for 12 733 people who accessed a free CHD risk screening service between August 2004 and April 2006 offered at 217 community pharmacies were obtained. The service involved initial self-completion of the Healthy Heart Assessment (HHA) form and measurement of height, weight, body mass index, blood pressure, total cholesterol and highdensity lipoprotein levels by pharmacists to calculate CHD risk.3 Action taken by pharmacists (lifestyle advice, statin recommendation or general practitioner (GP) referral) and qualitative statements of advice were recorded, and a copy provided to the participants. The service did not include follow-up of participants. All participants consented to taking part in evaluations of the service. Ethical committee scrutiny was not required for this service development evaluation. Results Case records for 10 035 participants (3658 male) were evaluable; 5730 (57%) were at low CHD risk (<15%); 3636 (36%) at moderate-to-high CHD risk (≥15%); and 669 (7%) had existing heart disease. A significantly higher proportion of male (48% versus 30% female) participants were at moderate- to-high risk of CHD (chi-square test; P < 0.005). A range of outcomes resulted from consultations. Lifestyle advice was provided irrespective of participants’ CHD risk or existing disease. In the moderate-to-high-risk group, of which 52% received prescribed medication, lifestyle advice was recorded for 62%, 16% were referred and 34% were advised to have a re-assessment. Statin recommendations were made in 1% of all cases. There was evidence of supportive and motivational statements in the advice recorded. Discussion Pharmacists were able to identify individuals’ level of CHD risk and provide them with bespoke advice. Identification of at-risk participants did not automatically result in referrals or statin recommendation. One-third of those accessing the screening service had moderate-to-high risk of CHD, a significantly higher proportion of whom were men. It is not known whether these individuals had been previously exposed to HP but presumably by accessing this service they may have contemplated change. As effectiveness of HP advice will depend among other factors on ability to influence change, future consultations may need to explore patients’ attitude towards change in relation to the Trans Theoretical Model4 to better tailor HP advice. The high uptake of the service by those at moderate-to-high CHD risk indicates a need for this type of screening programme in community pharmacy, perhaps specifically to reach men who access medical services less.

Genetic parameters and evaluations from single- and multiple-trait analysis of dairy cow fertility and milk production

Genetic parameters and breeding values for dairy cow fertility were estimated from 62 443 lactation records. Two-trait analysis of fertility and milk yield was investigated as a method to estimate fertility breeding values when culling or selection based on milk yield in early lactation determines presence or absence of fertility observations in later lactations. Fertility traits were calving interval, intervals from calving to first service, calving to conception and first to last service, conception success to first service and number of services per conception. Milk production traits were 305-day milk, fat and protein yield. For fertility traits, range of estimates of heritability (h(2)) was 0.012 to 0.028 and of permanent environmental variance (c(2)) was 0.016 to 0.032. Genetic correlations (r(g)) among fertility traits were generally high ( > 0.70). Genetic correlations of fertility with milk production traits were unfavourable (range -0.11 to 0.46). Single and two-trait analyses of fertility were compared using the same data set. The estimates of h(2) and c(2) were similar for two types of analyses. However, there were differences between estimated breeding values and rankings for the same trait from single versus multi-trait analyses. The range for rank correlation was 0.69-0.83 for all animals in the pedigree and 0.89-0.96 for sires with more than 25 daughters. As single-trait method is biased due to selection on milk yield, a multi-trait evaluation of fertility with milk yield is recommended. (C) 2002 Elsevier Science B.V. All rights reserved.

Tanniniferous Dichrostachys cinerea fruits do not require detoxification for goat nutrition: in sacco and in vivo evaluations

This study investigated the potential of Dichrostachys cinerea fruits as a protein supplement in semi-arid areas of Zimbabwe. The tanniniferous fruits were treated with aqueous solutions of polyethylene glycol (PEG) or sodium hydroxide (NaOH). Both treatments increased the soluble fraction, rate of degradation and effective degradability (ED) of nitrogen (N) in sacco. The PEG effects were higher than the NaOH effects (e.g. a 25% vs. 6% increase in effective N degradabilities, respectively). Five treatments were evaluated in a N-balance trial using Matebele goats: ground, PEG- or NaOH-treated D. cinerea fruits, a commercial protein supplement (CPS) and no supplement. Animals offered ground fruits or CPS retained most N (3.7 or 4.1 g N/day, respectively), while those offered NaOH- or PEG-treated fruits retained significantly less N (2.7 or 1.0 g/day, respectively). Unsupplemented animals were in negative N balance (-2.4 g/day). PEG treatment deactivated the tannins more than the NaOH treatment. PEG treatment resulted in excessive protein degradation in the rumen leading to high urine N loss. It is concluded that the D. cinerea fruits were beneficial for goat N-nutrition and that the tannins did not require inactivation. D. cinerea fruits can, therefore, replace the expensive commercial protein supplement. It is also suggested that the collection and grinding of fruits could be used as a management tool to control bush encroachment. (C) 2004 Elsevier B.V. All rights reserved.

The ethical challenges of ubiquitous healthcare

Ubiquitous healthcare is an emerging area of technology that uses a large number of environmental and patient sensors and actuators to monitor and improve patients’ physical and mental condition. Tiny sensors gather data on almost any physiological characteristic that can be used to diagnose health problems. This technology faces some challenging ethical questions, ranging from the small-scale individual issues of trust and efficacy to the societal issues of health and longevity gaps related to economic status. It presents particular problems in combining developing computer/information/media ethics with established medical ethics. This article describes a practice-based ethics approach, considering in particular the areas of privacy, agency, equity and liability. It raises questions that ubiquitous healthcare will force practitioners to face as they develop ubiquitous healthcare systems. Medicine is a controlled profession whose practise is commonly restricted by government-appointed authorities, whereas computer software and hardware development is notoriously lacking in such regimes.

Laughter in the Dark: ethical aspects of drama education

This chapter considers two questions. Firstly, in what ways might drama be an effective medium through which to explore difficult and sensitive issues that concern teenagers? And secondly, what ethical questions surround the use of drama to explore such issues? A practical workshop on teenage suicide is used as a platform for a discussion on the use and implications of different drama strategies and the role of humour as a critical lens and distancing device. The work of actual teenagers is used to illustrate the effectiveness of the techniques in both raising awareness and facilitating both critical and creative responses to the delicate issue explored in the workshop.