Medication review of children on long term medications:a review of the literature

INTRODUCTION: Children on long term medication may be under the care of more than one medical team including the patients GP. Children on chronic medication should be supported and their medications reviewed, especially in cases of polypharmacy. Medicines Use Reviews (MURs) were introduced into the pharmacy contract in 2005. The service was designed for community pharmacists to review patients on long term medication. The service specified that MURs were done on patients who can give consent and cannot be conducted with a parent or carer. Hence the service may be inaccessible to paediatric patients. This review aims to find studies that identify medication review services in primary care that cater for children on long term medication. METHODS: A literature search was conducted on 6th June 2015 using the keywords, ("Medication" or "review" or "Medication Review" or "Medicines use review" or "Medication use review" or "New Medicine Service") AND ("community pharmacy" OR "community pharmacist" OR "primary care" OR "General practice" OR "GP" OR "community paediatrician" OR "community pediatrician" OR "community nurse"). Bibliographic databases used were AMED, British Nursing Index, CINAHL, EMBASE, HMIC, MEDLINE, PsycINFO and Health Business Elite. Inclusion criteria were: paediatric specific medication review in primary care, for example by either a GP, community paediatrician, community nurse or community pharmacist. Exclusion criteria were studies of medication review in adults/unclear patient age and secondary care medication reviews. RESULTS: From the 417 articles, 6 relevant articles were found after abstract and full text review. 235 articles were excluded after title and abstract review (11 did not have full text in English); 96 were adult or non-age specified medication review/MUR/New Medicine Service studies; 63 referred to observational, evaluative studies of interventions in adults; 6 were non-paediatric specific systematic reviews and 17 were protocols, commentaries, news, and letters.The 6 relevant articles consisted of 1 literature review (published 2004), 3 research articles and 1 published protocol. The literature review[1] recommended that children's long term medication should be reviewed. The published protocol stated that the NMS minimum age for inclusion in the trial was for children aged over 13 years of age. The four studies were related to psychiatrists reviewing paediatric mental health patients in the USA, a pharmacist using Drug Related Problem to review patients in GP practices in Australia, a UK study based on an information prescription concept by providing children dispensed medications in community pharmacy with signposting them to health information and one GP practice based study observing pharmaceutical care issues in children and adults. CONCLUSION: The results show that there are currently no known studies on medication use reviews specific to children, whereas in adults, published evaluations are available. The terms of the MUR policy restrict children's access to the service and so more studies are necessary to determine whether children could benefit from such access.

The clinical assessment of systemic hypertension in optometric practice

This thesis sets out to examine in detail the condition of systemic hypertension (high Blood Pressure) in relation to optometric practice in the United Kingdom. Systemic hypertension, which is asymptomatic in the early stages, is diagnosed from the Blood Pressure (BP) measurement recorded by a sphygmomanometer and/or from the complications that have developed in target organs. Optometric practice based surveys revealed that diagnosed systemic hypertension was the most prevalent cardiovascular medical condition (20.5%). Measurement of BP of patients in this sample revealed that if an optometrist included sphygmomanometry into the sight examination then at least one patient each day would be referred for suspect systemic hypertension. Optometric opinion felt that the measurement of BP in optometric practice would advance the profession, being appreciated by both patients and General Practitioners (GPs), but was felt to be an unnecessary routine procedure. The present sight examination for the systemic hypertensive is similar to that of the normotensive patient, but may involve an altered fundus examination and a visual field test. The GPs were in favour of optometric BP measurement and a future role in the share care management of the systemic hypertensive. The application of a new pictorial grading scale for the grading of vascular changes associated with pre-malignant systemic hypertension was found to be both accurate and reliable. Clinical trial of the grading scale in optometric practice found positive correlations between BP and increasing severity of the retinal vascular features. The subtle pre-malignant vascular changes require reliable accurate detection and analysis to assist in the management of the systemic hypertensive patient. Vessel width was shown to decrease with increasing age. Image analysis of the A/V ratio, arteriolar tortuosity and focal calibre changes revealed a positive correlation to the patient's BP (p<0.001). The retinal vasculature is relatively stable longitudinally with only minor changes in response to early disease states. Age and elevated BP increased a patient's risk of developing systemic medical conditions over a two-year period. The application of the pictorial grading scale to optometric practice and training the optometrist in the use of sphygmomanometry would improve the management of the systemic hypertensive patient in optometric practice. Future advances in image analysis hold substantial benefits for the detection and monitoring of subtle vascular changes associated with systemic hypertension.

Studies in the marketing strategy of a U.K. producer of conveyor belts

Research was undertaken in the field of marketing strategy, its formulation and implementation in Dunlop Belting Division. Emphasis was placed on marketing channel strategy, but other strategies including product strategy were studied. The research has resulted in changes in management practice in the client organisation. The relevance of theories of company organisation, planning and strategy, and marketing channels was examined in the light of the research evidence. The technique of action-research was used to gain admittance to and effect change within the client organisation. Case study material was collected for subsequent analysis. The factors affecting marketing strategy formulation in the client organisation were studied. Both the external and the internal business environments were considered. The operation of the observed marketing channels was compared with channel theory. Market segmentation and penetration, and the selling and technical resources of the channels were analysed. Recommendations were made to (a) enlarge and resite the client's distribution unit to locate it centrally in England (b) use the resited unit to secure local advantage (c) obtain greater integration of field sales activities with and from the centre. A new ex-stock distribution unit was established. Improvements to the client's ex-stock marketing in Scotland were also recommended, including improvements to the Scottish distributor's stock control procedure, as well as to Dunlop-Distributor relationships at all levels. The influence of company organisation structure and formalised procedures and systems on the formulation of strategy were considered with respect to channel and product strategy, and other aspects of marketing. Conclusions were drawn that the action research resulted in successful implementation of .agreed changes in the client organisation; that theories of strategy formulation and planning, of the operation of decentralised companies, and of industrial market segmentation required modification; that the theory of marketing channels was found relevant and useful.

The influence of high contrast acuity and normalised low contrast acuity upon self-reported situation avoidance and driving crashes

The aim of this study was to determine the cues used to signal avoidance of difficult driving situations and to test the hypothesis that drivers with relatively poor high contrast visual acuity (HCVA) have fewer crashes than drivers with relatively poor normalised low contrast visual acuity (NLCVA). This is because those with poorer HCVA are well aware of their difficulties and avoid dangerous driving situations while those poorer NLCVA are often unaware of the extent of their problem. Age, self-reported situation avoidance and HCVA were collected during a practice based study of 690 drivers. Screening was also carried out on 7254 drivers at various venues, mainly motorway sites, throughout the UK. Age, self-reported situation avoidance and prior crash involvement were recorded and Titmus vision screeners were used to measure HCVA and NLCVA. Situation avoidance increased in reduced visibility conditions and was influenced by age and HCVA. Only half of the drivers used visual cues to signal situation avoidance and most of these drivers used high rather than low contrast cues. A statistical model designed to remove confounding interrelationships between variables showed, for drivers that did not report situation avoidance, that crash involvement decreased for drivers with below average HCVA and increased for those with below average NLCVA. These relationships accounted for less than 1% of the crash variance, so the hypothesis was not strongly supported. © 2002 The College of Optometrists.

Relationships, variety & synergy:the vital ingredients for scholarship in engineering education? A case study

This paper begins with the argument that within modern-day society, engineering has shifted from being the scientific and technical mainstay of industrial, and more recently digital change to become the most vital driver of future advancement. In order to meet the inevitable challenges resulting from this role, the nature of engineering education is constantly evolving and as such engineering education has to change. The paper argues that what is needed is a fresh approach to engineering education – one that is sufficiently flexible so as to capture the fast-changing needs of engineering education as a discipline, whilst being pedagogically suitable for use with a range of engineering epistemologies. It provides an overview of a case study in which a new approach to engineering education has been developed and evaluated. The approach, which is based on the concept of scholarship, is described in detail. This is followed by a discussion of how the approach has been put into practice and evaluated. The paper concludes by arguing that within today's market-driven university world, the need for effective learning and teaching practice, based in good scholarship, is fundamental to student success.

Targets and self monitoring in hypertension: randomised controlled trial and cost effectiveness analysis

OBJECTIVES: To assess whether blood pressure control in primary care could be improved with the use of patient held targets and self monitoring in a practice setting, and to assess the impact of these on health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences, and costs. DESIGN: Randomised controlled trial. SETTING: Eight general practices in south Birmingham. PARTICIPANTS: 441 people receiving treatment in primary care for hypertension but not controlled below the target of < 140/85 mm Hg. INTERVENTIONS: Patients in the intervention group received treatment targets along with facilities to measure their own blood pressure at their general practice; they were also asked to visit their general practitioner or practice nurse if their blood pressure was repeatedly above the target level. Patients in the control group received usual care (blood pressure monitoring by their practice). MAIN OUTCOME MEASURES: Primary outcome: change in systolic blood pressure at six months and one year in both intervention and control groups. Secondary outcomes: change in health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences of method of blood pressure monitoring, and costs. RESULTS: 400 (91%) patients attended follow up at one year. Systolic blood pressure in the intervention group had significantly reduced after six months (mean difference 4.3 mm Hg (95% confidence interval 0.8 mm Hg to 7.9 mm Hg)) but not after one year (mean difference 2.7 mm Hg (- 1.2 mm Hg to 6.6 mm Hg)). No overall difference was found in diastolic blood pressure, anxiety, health behaviours, or number of prescribed drugs. Patients who self monitored lost more weight than controls (as evidenced by a drop in body mass index), rated self monitoring above monitoring by a doctor or nurse, and consulted less often. Overall, self monitoring did not cost significantly more than usual care (251 pounds sterling (437 dollars; 364 euros) (95% confidence interval 233 pounds sterling to 275 pounds sterling) versus 240 pounds sterling (217 pounds sterling to 263 pounds sterling). CONCLUSIONS: Practice based self monitoring resulted in small but significant improvements of blood pressure at six months, which were not sustained after a year. Self monitoring was well received by patients, anxiety did not increase, and there was no appreciable additional cost. Practice based self monitoring is feasible and results in blood pressure control that is similar to that in usual care.

An evaluation of pharmacy education and pre-registration training

This thesis covers two major aspects of pharmacy education; undergraduate education and pre-registration training. A cohort of pharmacy graduates were surveyed over a period of four years, on issues related to undergraduate education, pre-registration training and continuing education. These graduates were the first-ever to sit the pre-registration examination. In addition, the opinions of pre-registration tutors were obtained on pre-registration training, during the year that competence-based assessment was introduced. It was concluded that although the undergraduate course provided a broad base of knowledge suitable for graduates in all branches of pharmacy, several issues were identified which would require attention in future developments of the course. These were: 1. the strong support for the expansion of clinical, social and practice-based teaching. 2. the strong support to retain the scientific content to the same extent as in the three-year course. 3. a greater use of problem-based learning methods. The graduates supported the provision of a pre-registration continuing education course to help prepare for the examination and in areas inadequately covered in the undergraduate course. There was also support for the introduction of some form of split branch training. There was no strong evidence to suggest that the training had been an application of undergraduate education. In general, competence-based training was well regarded by tutors as an appropriate and effective method of skill assessment. However, community tutors felt it was difficult to carry out effectively due to day-to-day time constraints. The assistant tutors in hospital pharmacy were found to have a very important role in provision of training, and should be adequately trained and supported. The study recommends the introduction of uniform training and a quality assurance mechanism for all tutors and assistants undertaking this role.

Patients' perceptions and experiences of transitions in diabetes care: a longitudinal qualitative study

Objective To examine patients' perceptions and experiences over time of the devolvement of diabetes care/reviews from secondary to primary health-care settings. Design Repeat in-depth interviews with 20 patients over 4 years. Participants and setting Twenty type 2 diabetes patients recruited from primary- and secondary-care settings across Lothian, Scotland. Results Patients' views about their current diabetes care were informed by their previous service contact. The devolvement of diabetes care/reviews to general practice was presented as a 'mixed blessing'. Patients gained reassurance from their perception that receiving practice-based care/reviews signified that their diabetes was well-controlled. However, they also expressed resentment that, by achieving good control, they received what they saw as inferior care and/or less-frequent reviews to others with poorer control. While patients tended to regard GPs as having adequate expertise to conduct their practice-based reviews, they were more ambivalent about nurses taking on this role. Opportunities to receive holistic care in general practice were not always realized due to patients seeing health-care professionals for diabetes management to whom they would not normally present for other health issues. Conclusions It is important to educate patients about their care pathways, and to reassure them that frequency of reviews depends more on clinical need than location of care and that similar care guidelines are followed in hospital clinics and general practice. A patients' history of service contact may need to be taken into account in future studies of service satisfaction.

Sex talk:discussion and meaning-making among religious young adults

Where does discussion about sex and sexuality take place for religious young adults? How well do religious young people feel they know the perspectives and debates within their religious tradition regarding sexuality? This chapter, based on a project which studied 18-25 year olds from a variety of religious traditions, will examine the context in which sexuality was discussed, giving particular attention to religious spaces, significant individuals (e.g. parents and friends) and popular media. The concluding section will also highlight some points for good practice, based on the perspectives of young people.

Semiparametric smooth-coefficient stochastic frontier model

This paper proposes a semiparametric smooth-coefficient (SPSC) stochastic production frontier model where regression coefficients are unknown smooth functions of environmental factors (ZZ). Technical inefficiency is specified in the form of a parametric scaling function which also depends on the ZZ variables. Thus, in our SPSC model the ZZ variables affect productivity directly via the technology parameters as well as through inefficiency. A residual-based bootstrap test of the relevance of the environmental factors in the SPSC model is suggested. An empirical application is also used to illustrate the technique.

Proof in the pedagogic pudding? The challenges of promoting evidence-based teaching practice in a research-focused institution

Drawing upon the findings of a mixed methodological study, this paper critically analyses the cultural, pedagogical, and organisational issues encountered by academics and support staff working within a newly established Centre for Learning Innovation and Professional Practice tasked with facilitating a new teaching-focused policy in a previously research-led institution. The aim of this policy is to assure that, across the institution, teaching is given the same priority and kudos as research. Focusing specifically staff perceptions of the impact of the new policy on various aspects of academic life including, pedagogic practice, student support, staff training, and organisational management, the paper critically addresses the cultural and attitudinal challenges of change management (Kotter, 1996) within a ‘grey-brick’ university. In doing so it makes a significant contribution to current academic theory and debate in the areas of pedagogic practice and organisational management.

Strategic human resource management:building research-based practice

Strategic Human Resource Management: Building Research-Based Practice is a challenging and engaging student-focussed text written by a team of world-class researchers and experienced HRM tutors at Aston University. It is ideal for students taking a HRM or Strategic HRM module at postgraduate and upper-undergraduate level. Structured around contemporary and emerging issues this critical text is designed to encourage students to think analytically about Strategic HRM and builds real-world practice on the basis of solid research evidence. With a unique and thought-provoking range of contents that explores the links between Strategic HRM, Strategic Management and Organisational Behaviour, this text connects theory, research evidence and real-world practice. It also provides examples and case studies covering a variety of organisations, cultures and contexts, with access to the latest in leading-edge thinking. The text also includes integrated consideration of Strategic HRM in an international context, including coverage of emerging markets such as China and India.

Doing business in India:building research-based practice

In response to the increasing interest in the growth and developments in the Indian economy, and the dynamic nature of the rapidly changing Indian business environment, this textbook is designed to provide a comprehensive guide to doing business in the Indian context. Written by academic experts in their respective fields, this book is divided into three parts: the Indian business context, conducting business in India, and India and the world. Key information is presented on a wide range of topics, including: •Both the shortcomings and opportunities associated with the Indian business environment •The economic development model in India •Critical skills for negotiation and incentives for foreign investors, including case studies of Italian companies that have entered the Indian market in different ways •Business culture in India, including particular customs and etiquette In addition to the pedagogical features, each chapter contains a set of key issues, and there is also a list of useful websites covering a wide range of business needs. This book introduces students to business in India, and will be also be of use to investors, organisations and managers who are already doing business, or intend to start one, in India.

From art for arts sake to art as means of knowing:a rationale for advancing arts-based methods in research, practice and pedagogy

This paper advances a philosophically informed rationale for the broader, reflexive and practical application of arts-based methods to benefit research, practice and pedagogy. It addresses the complexity and diversity of learning and knowing, foregrounding a cohabitative position and recognition of a plurality of research approaches, tailored and responsive to context. Appreciation of art and aesthetic experience is situated in the everyday, underpinned by multi-layered exemplars of pragmatic visual-arts narrative inquiry undertaken in the third, creative and communications sectors. Discussion considers semi-guided use of arts-based methods as a conduit for topic engagement, reflection and intersubjective agreement; alongside observation and interpretation of organically employed approaches used by participants within daily norms. Techniques span handcrafted (drawing), digital (photography), hybrid (cartooning), performance dimensions (improvised installations) and music (metaphor and structure). The process of creation, the artefact/outcome produced and experiences of consummation are all significant, with specific reflexivity impacts. Exploring methodology and epistemology, both the "doing" and its interpretation are explicated to inform method selection, replication, utility, evaluation and development of cross-media skills literacy. Approaches are found engaging, accessible and empowering, with nuanced capabilities to alter relationships with phenomena, experiences and people. By building a discursive space that reduces barriers; emancipation, interaction, polyphony, letting-go and the progressive unfolding of thoughts are supported, benefiting ways of knowing, narrative (re)construction, sensory perception and capacities to act. This can also present underexplored researcher risks in respect to emotion work, self-disclosure, identity and agenda. The paper therefore elucidates complex, intricate relationships between form and content, the represented and the representation or performance, researcher and participant, and the self and other. This benefits understanding of phenomena including personal experience, sensitive issues, empowerment, identity, transition and liminality. Observations are relevant to qualitative and mixed methods researchers and a multidisciplinary audience, with explicit identification of challenges, opportunities and implications.