Oral anticoagulation in atrial fibrillation, the patients and physicians experiences of the consultation:a qualitative study

Background: Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF), however it is still underutilized and sometimes refused by patients. This project was divided in two inter-related studies. Study 1 explored the experiences that influence prescription of OAC by physicians. Study 2 explored the experiences which influence patients' decisions to accept, decline or discontinue OAC. Methods: Semi-structured individual interviews were conducted in both studies. In Study 1four sub-groups of physicians (n = 16) experienced with OAC in AF were interviewed: consultant cardiologists, consultant general physicians, general practitioners and cardiology registrars. In Study 2 three sub-groups of patients (n = 11) diagnosed with AF were interviewed; those who accepted, refused, and who discontinued warfarin. Results: Study 1: Two over-arching themes emerged from doctors' experiences: (1) communicating information and (2) challenges with OAC prescription for AF. Physicians still adopt a paternalistic approach to decision-making. They should instead motivate patients to take part in treatment discussions and choices should reflect the patient's needs and concerns. Physician education should focus more on communication skills, individualised care and time-management as these are critical for patient adherence. Continuous OAC education for AF should adopt a multi-disciplinary approach. Further, interpreters should also be educated on medical communication skills. Study 2: Three over-arching themes comprised patients' experiences: (1) the initial consultation, (2) life after the consultation, and (3) patients' reflections. Patient education during the initial consultation was critical in increasing patient's knowledge of OAC. On-going patient education is imperative to maintain adherence. Patients valued physicians' concern for their needs during decision-making. Patients who had experience of stroke were more receptive to education aimed towards stroke risk reduction rather than bleeding risk. Patients' perceptions of warfarin are also influenced by the media. Comment: Qualitative research is crucial in exploring barriers to treatment as it provides an excellent insight into patients' experiences of healthcare. A patient-centred approach should be adopted and incorporated into physicians' education. Education and patient involvement in the decision-making process is essential to promote treatment acceptance and long-term adherence

Diagnosis of type 2 diabetes:A qualitative analysis of patients' emotional reactions and views about information provision

Research about diagnosis of chronic illness indicates this is an emotional time for patients. Information provision is especially salient for diabetes management. Yet current orthodoxy suggests that too much information at the time of diagnosis is unhelpful for patients. In this study, we used in-depth interviews with 40 newly diagnosed type 2 diabetic (T2DM) patients in Scotland, to explore their emotional reactions about diagnosis, and their views about information provision at the time of diagnosis. Data were analysed using a thematic approach. Our results showed three main 'routes' to diagnosis: 'suspected diabetes' route; 'illness' route; and 'routine' route. Those within the 'routine' route described the most varied emotional reactions to their diagnosis. We found that most patients, irrespective of their route to diagnosis, wanted more information about diabetes management at the time of diagnosis. We suggest that practitioners would benefit from being sensitive to the route patients follow to diagnosis, and prompt, simple but detailed advice about T2DM management would be helpful for newly diagnosed patients. © 2004 Elsevier Ireland Ltd. All rights reserved.

A systematic review of treatments for atopic dermatitis

Atopic dermatitis is a very common inflammatory skin disease, particularly in children. A systematic review of randomised controlled trials of treatments for atopic dermatitis (AD) was carried out to assess how many trials exist, what they cover, what they do not cover, the research gaps, provide a 'blue print' for future Cochrane Reviews and assist those making treatment recommendations by summarising the available RCT evidence, using descriptive statistics. The Cochrane Collaboration systematic review process formed the basis of the methodology, from which over 4000 studies were located via electronic database searches and hand searching of journals. A total of 292 trials were finally included covering 9 treatment groups and over 48 individual treatments. There are lots of trials covering lots of interventions but gaps are evident. However, there is evidence of a benefit in the treatment of atopic dermatitis with topical corticosteroids, psychological approaches, UV light, ascomycin derivatives, topical tacrolimus and oral cyclosporin. Treatments that show limited evidence of a benefit include non-sedatory antihistamines, topical doxepin, the oral antibiotic Cefadroxil on clinically infected AD, the topical antibacterial Mupirocin on clinically uninfected AD, Chinese herbs, hypnotherapy and biofeedback, massage therapy, dietary manipulation, house dust mite reduction, patient education, emollients, allergen antibody complexes of house dust mite and thymic extracts. Treatments that show no evidence of benefit include sedatory antihistamines, oral sodium cromoglycate, oral antibiotics on clinically uninfected AD, topical antibacterials, topical antifungals, aromatherapy essential oils, borage oil, fish oil, evening primrose oil, enzyme-free clothes detergent, cotton clothing, house dust mite hyposensitisation, salt baths, topical coal tar, topical cyclosporin and platelet-activating-factor antagonist. When interpreting the conclusions of this thesis it is important to understand that lack of evidence does not equal lack of efficacy, particularly considering the interventions that are commonly in use today to treat atopic dermatitis that have not been subjected to RCTs, such as occlusive dressings, water softening devices and stress management among many others.

Medication reconciliation by a pharmacy technician in a mental health assessment unit

Background: Medication discrepancies are common when patients cross organisational boundaries. However, little is known about the frequency of discrepancies within mental health and the efficacy of interventions to reduce discrepancies. Objective: To evaluate the impact of a pharmacy-led reconciliation service on medication discrepancies on admissions to a secondary care mental health trust. Setting: In-patient mental health services. Methods: Prospective evaluation of pharmacy technician led medication reconciliation for admissions to a UK Mental Health NHS Trust. From March to June 2012 information on any unintentional discrepancies (dose, frequency and name of medication); patient demographics; and type and cause of the discrepancy was collected. The potential for harm was assessed based on two scenarios; the discrepancy was continued into primary care, and the discrepancy was corrected during admission. Logistic regression identified factors associated with discrepancies. Main outcome measure: Mean number of discrepancies per admission corrected by the pharmacy technician. Results Unintentional medication discrepancies occurred in 212 of 377 admissions (56.2 %). Discrepancies involving 569 medicines (mean 1.5 medicines per admission) were corrected. The most common discrepancy was omission (n = 464). Severity was assessed for 114 discrepancies. If the discrepancy was corrected within 16 days the potential harm was minor in 71 (62.3 %) cases and moderate in 43 (37.7 %) cases whereas if the discrepancy was not corrected the potential harm was minor in 27 (23.7 %) cases and moderate in 87 (76.3 %) cases. Discrepancies were associated with both age and number of medications; the stronger association was age. Conclusions: Medication discrepancies are common within mental health services with potentially significant consequences for patients. Trained pharmacy technicians are able to reduce the frequency of discrepancies, improving safety. © 2013 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie.

Technological enhancements to optometric clinical tests

A sizeable amount of the testing in eye care, requires either the identification of targets such as letters to assess functional vision, or the subjective evaluation of imagery by an examiner. Computers can render a variety of different targets on their monitors and can be used to store and analyse ophthalmic images. However, existing computing hardware tends to be large, screen resolutions are often too low, and objective assessments of ophthalmic images unreliable. Recent advances in mobile computing hardware and computer-vision systems can be used to enhance clinical testing in optometry. High resolution touch screens embedded in mobile devices, can render targets at a wide variety of distances and can be used to record and respond to patient responses, automating testing methods. This has opened up new opportunities in computerised near vision testing. Equally, new image processing techniques can be used to increase the validity and reliability of objective computer vision systems. Three novel apps for assessing reading speed, contrast sensitivity and amplitude of accommodation were created by the author to demonstrate the potential of mobile computing to enhance clinical measurement. The reading speed app could present sentences effectively, control illumination and automate the testing procedure for reading speed assessment. Meanwhile the contrast sensitivity app made use of a bit stealing technique and swept frequency target, to rapidly assess a patient’s full contrast sensitivity function at both near and far distances. Finally, customised electronic hardware was created and interfaced to an app on a smartphone device to allow free space amplitude of accommodation measurement. A new geometrical model of the tear film and a ray tracing simulation of a Placido disc topographer were produced to provide insights on the effect of tear film breakdown on ophthalmic images. Furthermore, a new computer vision system, that used a novel eye-lash segmentation technique, was created to demonstrate the potential of computer vision systems for the clinical assessment of tear stability. Studies undertaken by the author to assess the validity and repeatability of the novel apps, found that their repeatability was comparable to, or better, than existing clinical methods for reading speed and contrast sensitivity assessment. Furthermore, the apps offered reduced examination times in comparison to their paper based equivalents. The reading speed and amplitude of accommodation apps correlated highly with existing methods of assessment supporting their validity. Their still remains questions over the validity of using a swept frequency sine-wave target to assess patient’s contrast sensitivity functions as no clinical test provides the range of spatial frequencies and contrasts, nor equivalent assessment at distance and near. A validation study of the new computer vision system found that the authors tear metric correlated better with existing subjective measures of tear film stability than those of a competing computer-vision system. However, repeatability was poor in comparison to the subjective measures due to eye lash interference. The new mobile apps, computer vision system, and studies outlined in this thesis provide further insight into the potential of applying mobile and image processing technology to enhance clinical testing by eye care professionals.

Age-related macular degeneration patients' awareness of nutritional factors

Age-related macular degeneration (AMD) is the leading cause of visual impairment in older adults in the United Kingdom. This study sought to characterise AMD patients who seek the services of the Macular Society, and determine the level and source of their dietary knowledge. A questionnaire was designed, validated, and administered to 158 participants. The questions covered demographic data and knowledge of nutrition and supplementation. The mean age of participants was 79 years; 61% of them were female, and 27% were registered visually impaired. Only 55% of the participants thought diet was important for eye health, 63% felt that they had not received enough information about AMD. The participants reported that their information mainly came from non-professional support groups. Most participants identified healthy food, but could not say why, and were not able to identify carotenoid rich foods. The results of the study will inform design of education and dissemination methods regarding dietary information. © The Author(s) 2014.

Exploring attitudes towards dietary modification and nutritional supplementation in people with and without age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause for visual impairment and blindness registration in the developed world. Due to the large amounts of conflicting AMD research on the role of nutrition and antioxidant intake, it is difficult for patients and practitioners to determine which measures can be taken to slow down the disease progression. The aim of this research was to determine the beliefs and knowledge that patients with AMD have about nutrition, to identify whether their condition is preventing them from eating a healthy diet, and to discover what their diet consists of. For the initial study, 158 participants with AMD (mean age 79 ± 7.8 years) and 50 participants without AMD (mean age 67 ± 8 years) were recruited from the Macular Society helpline, or from optometric practice. Participants had a 25 minute telephone interview where a 36-question survey was completed. The survey elicited demographic information, and questions covered the knowledge that participants had on nutrition and their current diet. The results from this survey uncovered three major findings: 1) 100% of AMD participants felt that they do not have enough information and support from eye-care practitioners regarding nutrition, 2) AMD patients are confused over, and display a lack of knowledge of, which foods are beneficial for eye health and when and what nutritional supplements to take, evidenced by 65% of participants not taking the correct dosage 3) AMD patients are not eating enough nutrients that would be beneficial for their condition - consuming an average of 1.4mg of lutein and zeaxanthin rather than the recommended 10mg. A clinical decision-making aid was created as an intervention based upon these findings. The aim of the aid was to help eye-care practitioners give the correct nutritional advice to their patients. Founded on the AREDS 2 inclusion and exclusion criteria, practitioners are able to identify which patients could benefit from a nutritional supplement, and which patients could benefit from dietary modification. An evaluation of the aid with 72 qualified eye-care practitioners exhibited a statistically significant increase in confidence after using the aid for two weeks. An evaluation using 51 student optometrists showed a statistically significant increase in confidence and a statistically significant increase in appropriate management of patients after using the aid. This project has elicited findings that are significant for AMD patient education. It is hoped that through these studies, patients will receive consistent advice about the risk factors for AMD, the link between AMD and nutrition, and the importance of maintaining a healthy, well-balanced diet.

Dietary analysis and nutritional behaviour in people with and without age-related macular disease

Background and Aims: Consumption of antioxidant nutrients can reduce the risk of progression of age-related macular degeneration (AMD) - the leading cause of visual impairment in adults over the age of 50 years in the UK. Lutein and zeaxanthin (L&Z) are of particular interest because they are selectively absorbed by the central retina. The objectives of this study were to analyse the dietary intake of a group of AMD patients, assess their ability to prepare and cook healthy food, and to make comparisons with people not affected by AMD. Methods: 158 participants with AMD were recruited via the UK charity The Macular Society, and fifty participants without AMD were recruited from optometric practice. A telephone interview was conducted by trained workers where participants completed a 24 hour food diary, and answered questions about cooking and shopping capabilities. Results: In the AMD group, the average L&Z intake was low in for both males and females. Those able to cook a hot meal consumed significantly more L&Z than those who were not able. Most participants were not consuming the recommended dietary allowance of fibre, calcium, vitamin D and E, and calorific intake was also lower than recommendations for their age-group. The non-AMD group consumed more kilocalories and more nutrients than the AMD group, but the L&Z intake was similar to those with AMD. The main factor that influenced participant’s food choices was personal preference. Conclusion: For an ‘informed’ population, many AMD participants were under-consuming nutrients considered to be useful for their condition. Participants without AMD were more likely to reach recommended daily allowance values for energy and a range of nutrients. It is therefore essential to design more effective dietary education and dissemination methods for people with, and at risk of, AMD.

Pharmacy (ISSN 2226-4787):a journal of pharmacy education and practice

A journal of pharmacy education and practice is an international scientific open access journal on pharmacy education and practice, and is published by MDPI online quarterly. The practice of pharmacy is changing at an unprecedented rate as the profession moves from a focus upon preparation and supply of medicines to a clinical patient-facing role. While an understanding of the science related to medicines remains core to pharmacy education, the changes in practice are driving changes to the traditional methods of pharmacy education. This is reflected at an international level by major changes in the educational standards set by statutory regulators and by policy statements from bodies such as the World Health Organisation. These changes reflect an increasing trend to look at educational policy at a supra-national level, typified by the “Pharmine Project” led by the Association of European Faculties of Pharmacy.