A qualitative study of English community pharmacists’ experiences of providing lifestyle advice to patients with cardiovascular disease

Background - Cardiovascular disease (CVD) progression is modifiable through lifestyle behaviors. Community pharmacists are ideally placed to facilitate self-management of cardiovascular health however research shows varied pharmacist engagement in providing lifestyle advice. Objective - This study explored community pharmacists' experiences and perceptions of providing lifestyle advice to patients with CVD. Methods - Semi-structured interviews were conducted with fifteen pharmacists (1 supermarket; 7 multiple; 7 independent) recruited through multiple methods from community pharmacies across the Midlands, England. A thematic analysis was conducted using a Framework approach. Results - Pharmacists categorized patients according to their perceptions of the patients' ability to benefit from advice. Many barriers to providing lifestyle advice were identified. Confidence to provide lifestyle advice varied, with pharmacists most comfortable providing lifestyle advice in conjunction with conversations about medicines. Some pharmacists felt lifestyle advice was an integral part of their role whilst others questioned whether pharmacists should give lifestyle advice at all, particularly when receiving no remuneration for doing so. Conclusion - Pharmacists viewed providing lifestyle advice as important but identified many barriers to doing so. Lifestyle advice provision was influenced by pharmacists' perceptions of patients. Professional identity and associated role conflict appeared to underpin many of the barriers to pharmacists providing lifestyle advice. Pharmacists may benefit from enhanced training to: increase their confidence to provide lifestyle advice; integrate lifestyle advice with regular pharmaceutical practice and challenge their perceptions of some patients' receptiveness to lifestyle advice and behavior change. Changes to the way UK pharmacists are remunerated may increase the provision of lifestyle advice.

Parenting a child with chronic illness as they transition into adulthood:a systematic review and thematic synthesis of parents’ experiences

Objective - To understand how parents view and experience their role as their child with a long-term physical health condition transitions to adulthood and adult healthcare services. Methods - Five databases were systematically searched for qualitative articles examining parents’ views and experiences of their child’s healthcare transition. Papers were quality assessed and thematically synthesised. Results - Thirty-two papers from six countries, spanning a 17-year period were included. Long-term conditions were diverse. Findings indicated that parents view their child’s progression toward self-care as an incremental process which they seek to facilitate through up-skilling them in self-management practices. Parental perceptions of their child’s readiness, wellness, competence and long-term condition impacted on the child’ progression to healthcare autonomy. A lack of transitional healthcare and differences between paediatric and adult services served as barriers to effective transition. Parents were required to adjust their role, responsibilities and behaviour to support their child’s growing independence. Conclusion - Parents can be key facilitators of their child’s healthcare transition, supporting them to become experts in their own condition and care. To do so, they require clarification on their role and support from service providers. Practice Implications - Interventions are needed which address the transitional care needs of parents as well as young people.

Looking to the future : Predicting renal replacement outcomes in a large community cohort with chronic kidney disease

Peer reviewed

Looking to the future : Predicting renal replacement outcomes in a large community cohort with chronic kidney disease

Peer reviewed

Risk of fracture amongst patients with Parkinson's disease and other forms of parkinsonism

Acknowledgements We thank all the participants who took part, the research fellows (Kate Taylor, Robert Caslake, David McGhee, Angus Macleod) and nurses (Clare Harris, Joanna Gordon, Anne Hayman, Hazel Forbes) who helped assess the participants, and the study secretaries (Susan Kilpatrick, Pam Rebecca) and data management team (Katie Wilde, David Ritchie). The PINE study was funded by the BMA Doris Hillier award, Parkinson's UK, the RS McDonald Trust, NHS Grampian Endowments, SPRING and the BUPA Foundation. None of the funders had any influence in the study design, the collection, analysis and interpretation of the data, the writing of the report or the decision to submit the article for publication.

Looking to the future : Predicting renal replacement outcomes in a large community cohort with chronic kidney disease

Peer reviewed

Managing periodontal disease: the clinician's role and the patient's responsibility

This manuscript highlights the roles and responsibilities of the clinician and patient in the successful management of periodontal disease. Clinical relevance: This article highlights the variety of factors that need to be addressed for periodontal diseases to be successfully managed. Learning objective: The reader should understand the broad range of issues that require consideration for patients to be successfully managed for their periodontal problems.

Challenges in the Management of Geriatric Obesity in High Risk Populations.

The global prevalence of obesity in the older adult population is growing, an increasing concern in both the developed and developing countries of the world. The study of geriatric obesity and its management is a relatively new area of research, especially pertaining to those with elevated health risks. This review characterizes the state of science for this "fat and frail" population and identifies the many gaps in knowledge where future study is urgently needed. In community dwelling older adults, opportunities to improve both body weight and nutritional status are hampered by inadequate programs to identify and treat obesity, but where support programs exist, there are proven benefits. Nutritional status of the hospitalized older adult should be optimized to overcome the stressors of chronic disease, acute illness, and/or surgery. The least restrictive diets tailored to individual preferences while meeting each patient's nutritional needs will facilitate the energy required for mobility, respiratory sufficiency, immunocompentence, and wound healing. Complications of care due to obesity in the nursing home setting, especially in those with advanced physical and mental disabilities, are becoming more ubiquitous; in almost all of these situations, weight stability is advocated, as some evidence links weight loss with increased mortality. High quality interdisciplinary studies in a variety of settings are needed to identify standards of care and effective treatments for the most vulnerable obese older adults.

Adhésion au traitement antidiabétique oral chez les adultes atteints de diabète de type 2 : déterminants et interventions visant à l'améliorer

Introduction : Le diabète de type 2 est une maladie évolutive débilitante et souvent mortelle qui atteint de plus en plus de personnes dans le monde. Le traitement antidiabétique non-insulinique (TADNI) notamment le traitement antidiabétique oral (TADO) est le plus fréquemment utilisé chez les adultes atteints de cette maladie. Toutefois, plusieurs de ces personnes ne prennent pas leur TADO tel que prescrit posant ainsi la problématique d’une adhésion sous-optimale. Ceci entraîne des conséquences néfastes aussi bien pour les patients que pour la société dans laquelle ils vivent. Il serait donc pertinent d’identifier des pistes de solution à cette problématique. Objectifs : Trois objectifs de recherche ont été étudiés : 1) Explorer la capacité de la théorie du comportement planifié (TCP) à prédire l’adhésion future au TADNI chez les adultes atteints de diabète de type 2, 2) Évaluer l’efficacité globale des interventions visant à améliorer l’adhésion au TADO chez les adultes atteints de diabète de type 2 et étudier l’influence des techniques de changement de comportement sur cette efficacité globale, et 3) Évaluer l’efficacité globale de l’entretien motivationnel sur l’adhésion au traitement médicamenteux chez les adultes atteints de maladie chronique et étudier l’influence des caractéristiques de cette intervention sur son efficacité globale. Méthodes : Pour l’objectif 1 : Il s’agissait d’une enquête web, suivie d’une évaluation de l’adhésion au TADNI sur une période de 30 jours, chez des adultes atteints de diabète de type 2, membres de Diabète Québec. L’enquête consistait à la complétion d’un questionnaire auto-administré incluant les variables de la TCP (intention, contrôle comportemental perçu et attitude) ainsi que d’autres variables dites «externes». Les informations relatives au calcul de l’adhésion provenaient des dossiers de pharmacie des participants transmis via la plateforme ReMed. Une régression linéaire multivariée a été utilisée pour estimer la mesure d’association entre l’intention et l’adhésion future au TADNI ainsi que l’interaction entre l’adhésion passée et l’intention. Pour répondre aux objectifs 2 et 3, deux revues systématiques et méta-analyses ont été effectuées et rapportées selon les lignes directrices de PRISMA. Un modèle à effets aléatoires a été utilisé pour estimer l’efficacité globale (g d’Hedges) des interventions et son intervalle de confiance à 95 % (IC95%) dans chacune des revues. Nous avons également quantifié l’hétérogénéité (I2 d’Higgins) entre les études, et avons fait des analyses de sous-groupe et des analyses de sensibilité. Résultats : Objectif 1 : Il y avait une interaction statistiquement significative entre l’adhésion passée et l’intention (valeur-p= 0,03). L’intention n’était pas statistiquement associée à l’adhésion future au TADNI, mais son effet était plus fort chez les non-adhérents que chez les adhérents avant l’enquête web. En revanche, l’intention était principalement prédite par le contrôle comportemental perçu à la fois chez les adhérents [β= 0,90, IC95%= (0,80; 1,00)] et chez les non-adhérents passés [β= 0,76, IC95%= (0,56; 0,97)]. Objectif 2 : L’efficacité globale des interventions sur l’adhésion au TADO était de 0,21 [IC95%= (-0,05; 0,47); I2= 82 %]. L’efficacité globale des interventions dans lesquelles les intervenants aidaient les patients et/ou les cliniciens à être proactifs dans la gestion des effets indésirables était de 0,64 [IC95%= (0,31; 0,96); I2= 56 %]. Objectif 3 : L’efficacité globale des interventions (basées sur l’entretien motivationnel) sur l’adhésion au traitement médicamenteux était de 0,12 [IC95%= (0,05; 0,20); I2= 1 %. Les interventions basées uniquement sur l’entretien motivationnel [β= 0,18, IC95%= (0,00; 0,36)] et celles dans lesquelles les intervenants ont été coachés [β= 0,47, IC95%= (0,03; 0,90)] étaient les plus efficaces. Aussi, les interventions administrées en face-à-face étaient plus efficaces que celles administrées par téléphone [β= 0,27, IC95%=(0,04; 0,50)]. Conclusion : Il existe un écart entre l’intention et l’adhésion future au TADNI, qui est partiellement expliqué par le niveau d’adhésion passée. Toutefois, il n’y avait pas assez de puissance statistique pour démontrer une association statistiquement significative entre l’intention et l’adhésion future chez les non-adhérents passés. D’un autre côté, quelques solutions au problème de l’adhésion sous-optimale au TADO ont été identifiées. En effet, le fait d’aider les patients et/ou les cliniciens à être proactifs dans la gestion des effets indésirables contribue efficacement à l’amélioration de l’adhésion au TADO chez les adultes atteints de diabète de type 2. Aussi, les interventions basées sur l’entretien motivationnel améliorent efficacement l’adhésion au traitement médicamenteux chez les adultes atteints de maladie chronique. L’entretien motivationnel pourrait donc être utilisé comme un outil clinique pour soutenir les patients dans l’autogestion de leur TADO.

Unmet health needs in patients with coronary heart disease: implications and potential for improvement in caring services

BACKGROUND: Improving the quality of health care services requires tailoring facilities to fulfil patients' needs. Satisfying patients' healthcare needs, listening to patients' opinions and building a closer provider-user partnership are central to the NHS. Few published studies have discussed cardiovascular patients' health needs, but they are not comprehensive and fail to explore the contribution of outcome to needs assessment. METHOD: A comprehensive self-administered health needs assessment (HNA) questionnaire was developed for concomitant use with generic (Short Form-12 and EuroQOL) and specific (Seattle Angina Questionnaire) health-related quality of life (HRQL) instruments on 242 patients admitted to the Acute Cardiac Unit, Nottingham. RESULTS: 38% reported difficulty accessing health facilities, 56% due to transport and 32% required a travelling companion. Mean HRQOL scores were lower in those living alone (P < 0.05) or who reported unsatisfactory accommodation. Dissatisfaction with transport affected patients' ease of access to healthcare facilities (P < 0.001). Younger patients (<65 y) were more likely to be socially isolated (P = 0.01). Women and patients with chronic disease were more likely to be concerned about housework (P < 0.05). Over 65 s (p < 0.05) of higher social classes (p < 0.01) and greater physical needs (p < 0.001) had more social needs, correlating moderately (0.32 < r < 0.63) with all HRQL domains except SAQ-AS. Several HRQL components were highly correlated with the HNA physical score (p < 0.001). CONCLUSIONS: Patients wanted more social (suitable accommodation, companionship, social visits) and physical (help aids, access to healthcare services, house work) support. The construct validity and intra-class reliability of the HNA tool were confirmed. Our results indicate a gap between patients' health needs and available services, highlighting potential areas for improvement in the quality of services

A gestão da pessoa com hipertensão arterial na unidade móvel de saúde

Enquadramento: A gestão da doença, designadamente da hipertensão arterial (HTA) através do apoio à auto-gestão, aconselhamento motivacional, acesso à informação resultam em maior adesão terapêutica. Objetivos: Identificar os fatores que determinam a adesão ao tratamento na pessoa com HTA numa amostra comunitária. Metodologia: Estudo transversal, descritivo-correlacional, com amostra de 235 hipertensos (63,8% do género feminino), idade média 75 ± 8,14 anos, 62,6% casados e a maioria com o 1.º ciclo de escolaridade. Recorremos ao questionário com variáveis sociodemográficas, dietéticas, clínicas, motivacionais, relacionadas com os profissionais e serviços de saúde, Escala de Apgar Familiar, Questionário de Dependência Alcoólica, Questionário Internacional de Atividade Física, Questionário de Determinação da Saúde Nutricional, Escala de Autocuidado com a Hipertensão, Questionário de Crenças Sobre a Doença, Escala de Crenças Acerca dos Medicamentos, Escala de Satisfação dos Utentes com os Cuidados de Enfermagem na Unidade Móvel de Saúde, Questionário abreviado da Perceção do Cliente sobre o Ambiente Terapêutico, Questionário de Autorregulação, Escala de Competência Percebida e Escala de Medida de Adesão aos Tratamentos para colheita de dados. Resultados: A pressão arterial estava controlada em 34,5% da amostra, 28,2% homens e 38% mulheres. A MAT revelou um mínimo de 3,86 e um máximo de 6 com uma média de 5,66±0,49. As variáveis preditoras da adesão foram: controlo pessoal (p=0,005), identidade (p=0,000), ambiente terapêutico (p=0,001), alimentação geral (p=0,041), atividade física (p=0,007) e toma de medicamentos (p=0,000). Conclusões: Compreender os fatores envolvidos na gestão do tratamento permite perceber como podem os enfermeiros contribuir para melhorar a adesão ao regime terapêutico. Palavras-chave: Hipertensão arterial, gestão da doença crónica, adesão ao tratamento e adultos.

Transforming Growth Factor-b1 polymorphism is not associated with chronic graft disease: evidence from a meta-analysis

Kidney transplantation has been recognised as the optimal treatment choice for most end stage renal disease patients and the increase of allograft survival rates is achieved through the refinement of novel immunosuppressive agents. Chronic Graft Disease (CGD) is a multifactorial process that likely includes a combination of immunological, apoptotic and inflammatory factors. The application of individualised immunosuppressive therapies will also depend on the identification of risk factors that can influence chronic disease. Despite being the subject of several independent studies, investigations of the relationship between transforming growth factor-b1 (TGF-b1) polymorphisms and kidney graft outcome continue to be plagued by contradictory conclusions.

Estágio realizado no Programa Comunitário PLE²NO

A OA é a doença reumática mais comum no ser humano e uma doença crónica com impacto elevado na sociedade. Tem repercussões na saúde, ao nível da funcionalidade, comprometendo a realização das atividades da vida diária e a qualidade de vida dos indivíduos. Uma das articulações mais afetada pela OA é a articulação do joelho. O tratamento eficaz requer a combinação de tratamentos farmacológicos e não farmacológicos. Os tratamentos não farmacológicos, principalmente o exercício e a educação do doente têm vindo a ganhar importância, no que se refere ao controlo dos sintomas. A realização do estágio curricular surge no programa comunitário PLE²NO. O programa é considerado uma opção não farmacológica no tratamento e controlo dos sintomas da Osteoartrose (OA) no joelho. Os principais objetivos do estágio no PLE²NO consistiram: aquisição de conhecimentos teóricos relacionados com OA e práticos com vista ao aperfeiçoamento da prescrição do exercício; aquisição de competências essenciais à ótima liderança e comunicação com as pessoas e instituições envolvidas; prescrição de exercício a indivíduos com OA no joelho; cativar e motivar as pessoas para a prática de exercício; e determinar a eficácia de um programa de 3 meses de educação e exercício nos sintomas, aptidão física e qualidade de vida dos idosos com OA no joelho. Na aptidão física verificaram-se diferenças significativas na capacidade aeróbia, flexibilidade e velocidade da marcha. Nos indicadores de saúde houve melhoria em praticamente todos os parâmetros avaliados: mobilidade, cuidados pessoais, dor/mal-estar e sintomas de ansiedade/depressão. Assim, esta intervenção revelou-se ser uma mais-valia para o tratamento não farmacológico da osteoartrose do joelho a médio prazo.

Prevalence of chronic diseases in private healthcare sector of South Africa: A threat to public health

Purpose: To evaluate the prevalence of patients suffering from registered chronic disease list (CDL) conditions in a section of the South African private health sector from 2008 - 2012. Methods: This study was a retrospective analysis of the medicine claims database of a nationally (South African) representative Pharmacy Benefit Management (PBM) company data between 2008 and 2012. Statistical analysis was used to analyse the data. Descriptive analysis was performed to calculate the prevalence of CDL conditions for the entire population, and stratified by age and gender. However, MIXED linear modelling was used to determine changes in the average number of CDL conditions per patient, adjusted for age and gender from 2008 - 2012. Results: An increase of 0.20 in chronic diseases was observed from 2008 - 2012 in patients having any CDL condition, with an average of 1.57 (1.57 - 1.58, 95 % CI) co-morbid CDL conditions in 2008 and 1.77 (1.77 - 1.78, 95 % CI) in 2012. This increase in average number of CDL conditions per patient between 2008 and 2012 was statistically significant (p < 0.05), but with no large practical significance (d < 0.8). Conclusion: Prevalence of patients with CDL conditions along with risk of co-morbidity has been increasing with time in the private health sector of South Africa. Risk of increased co-morbidity with age and among different genders was prevalent.

Public health implications of dietary fiber intake to reduce the cost of chronic diseases

Objective: To assess the epidemiological evidence on dietary fiber intake and chronic diseases and make public health recommendations for the population in Romania based on their consumption. Populations that consume more dietary fiber from cereals, fruits and vegetables have less chronic disease. Dietary Reference Intakes recommend consumption of 14 g dietary fiber per 1,000 kcal, or 25 g for adult women and 38 g for adult men, based on epidemiologic studies showing protection against cardiovascular disease, stroke, hypertension, diabetes, obesity, metabolic syndrome, gastrointestinal disorders, colorectal -, breast -, gastric -, endometrial -, ovarian - and prostate cancer. Furthermore, increased consumption of dietary fiber improves serum lipid concentrations, lowers blood pressure, blood glucose leads to low glycemic index, aids in weight loss, improve immune function, reduce inflammatory marker levels, reduce indicators of inflammation. Dietary fibers contain an unique blend of bioactive components including resistant starches, vitamins, minerals, phytochemicals and antioxidants. Dietary fiber components have important physiological effects on glucose, lipid, protein metabolism and mineral bioavailability needed to prevent chronic diseases. Materials and methods: Data regarding diet was collected based on questionnaires. We used mathematical formulas to calculate the mean dietary fiber intake of Romanian adult population and compared the results with international public health recommendations. Results: Based on the intakes of vegetables, fruits and whole cereals we calculated the Mean Dietary Fiber Intake/day/person (MDFI). Our research shows that the national average MDFI was 9.8 g fiber/day/person, meaning 38% of Dietary Requirements, and the rest of 62% representing a “fiber gap” that we have to take into account. This deficiency predisposes to chronic diseases. Conclusions and recommendations:The poor control of relationship between dietary fiber intake and chronic diseases is a major issue that can result in adverse clinical and economic outcomes. The population in Romania is at risk to develop such diseases due to the deficient fiber consumption. A model of chronic diseases costs is needed to aid attempts to reduce them while permitting optimal management of the chronic diseases. This paper presents a discussion of the burden of chronical disease and its socio-economic implications and proposes a model to predict the costs reduction by adequate intake of dietary fiber.