Intermediate Care: The Role of Medicines Management

Healthcare systems worldwide are facing an unprecedented demographic change as globally, the number of older people will triple to 2 billion by the year 2050. The resulting pressures on acute services have been instrumental in the development of intermediate care (IC) as a new healthcare model, which has its origins in the National Health Service in the UK. IC is an umbrella term for patient services that do not require the resources of a general hospital but are beyond the scope of a traditional primary care team. IC aims to promote timely discharge from hospital, prevent unnecessary hospital admissions and reduce the need for long-term residential care by optimizing functional independence. Various healthcare providers around the world have adopted similar models of care to manage changing healthcare needs. Polypharmacy, along with age-related changes, places older people at an increased risk of adverse drug events, including inappropriate prescribing, which has been shown to be prevalent in this population in other healthcare settings. Medicines management (the practice of maximizing health through optimal use of medicines) of older people has been discussed in the literature in a variety of settings; however, its place within IC is largely unknown. Despite IC being a multidisciplinary healthcare model, there is a lack of evidence to suggest that enhanced pharmaceutical involvement is core to the service provided within IC. This review article highlights the gap in the literature surrounding medicines management within IC and identifies potential solutions aimed at improving patient outcomes in this setting.

Understanding the Optimal Adsorption Energies for Catalyst Screening in Heterogeneous Catalysis

The fundamental understanding of the activity in heterogeneous catalysis has long been the major subject in chemistry. This paper shows the development of a two-step model to understand this activity. Using the theory of chemical potential kinetics with Bronsted-Evans-Polanyi relations, the general adsorption energy window is determined from volcano curves, using which the best catalysts can be searched. Significant insights into the reasons for catalytic activity are obtained.

Three-dimensional pure deflagration models with nucleosynthesis and synthetic observables for type ia supernovae

We investigate whether pure deflagration models ofChandrasekhar-mass carbon-oxygen white dwarf stars can account for one or more subclass of the observed population of Type Ia supernova (SN Ia) explosions. We compute a set of 3D full-star hydrodynamic explosion models, in which the deflagration strength is parametrized using the multispot ignition approach. For each model, we calculate detailed nucleosynthesis yields in a post-processing step with a 384 nuclide nuclear network. We also compute synthetic observables with our 3D Monte Carlo radiative transfer code for comparison with observations. For weak and intermediate deflagration strengths (energy release E {less-than or approximate} 1.1 × 10 erg), we find that the explosion leaves behind a bound remnant enriched with 3 to 10 per cent (by mass) of deflagration ashes. However, we do not obtain the large kick velocities recently reported in the literature. We find that weak deflagrations with E ~ 0.5 × 10 erg fit well both the light curves and spectra of 2002cx-like SNe Ia, and models with even lower explosion energies could explain some of the fainter members of this subclass. By comparing our synthetic observables with the properties of SNe Ia, we can exclude the brightest, most vigorously ignited models as candidates for any observed class of SN Ia: their B-V colours deviate significantly from both normal and 2002cx-like SNe Ia and they are too bright to be candidates for other subclasses.

Irradiation of water ice by C+ ions in the cosmic environment

We present a first principles molecular dynamics (FPMD) study of the interaction of low energy, positively charged, carbon (C+) projectiles with amorphous solid water clusters at 30 K. Reactions involving the carbon ion at an initial energy of 11 eV and 1.7 eV with 30-molecule clusters have been investigated. Simulations indicate that the neutral isoformyl radical, COH, and carbon monoxide, CO, are the dominant products of these reactions. All these reactions are accompanied by the transfer of a proton from the reacting water molecule to the ice, where it forms a hydronium ion. We find that COH is formed either via a direct, "knock-out", mechanism following the impact of the C+ projectile upon a water molecule or by creation of a COH_2^+ intermediate. The direct mechanism is more prominent at higher energies. CO is generally produced following the dissociation of COH. More frequent production of the formyl radical, HCO, is observed here than in gas phase calculations. A less commonly occurring product is the dihydroxymethyl, CH(OH)_2, radical. Although a minor result, its existence gives an indication of the increasing chemical complexity which is possible in such heterogeneous environments.

The effects of stepped sites and ruthenium adatom decoration on methanol dehydrogenation over platinum-based catalyst surfaces

A density functional theory study of methanol dehydrogenation over stepped Pt(2 1 1) surfaces without and with Ru modification was carried out to understand fuel catalytic reactions on Pt-based catalysts. Two main pathways of the CH3OH dehydrogenation were examined: the O–H pathway which was initiated by O–H bond scission to form the methoxy (CH3O) intermediate followed by sequential cleavage of C–H bonds to CO, and the C–H pathway which was initiated by C–H bond scission to form the hydroxymethyl (CH2OH) followed by two C–H bond cleavages to COH and then CO. Possible crossover reactions between the O–H and C–H pathways were also computed. Compared to flat Pt(1 1 1), stepped Pt(2 1 1) increases the adsorption energies of intermediates, making no significant contribution to decreasing the reaction barriers of most elementary steps involved, except in the first hydrogen scission. However, on the Ru-modified surface, a significant reduction was found in reaction barriers for the first step of the C–H bond scission and a number of further dehydrogenation steps crossing over to the O–H pathway, with the most facile paths identified. Our data reveals the complexity of methanol catalytic reaction processes at the atomic level and contributes to a fundamental understanding of fuel reactions on Pt-based catalysts.

Harmonic Generation from Relativistic Plasma Surfaces in Ultrasteep Plasma Density Gradients

Harmonic generation in the limit of ultrasteep density gradients is studied experimentally. Observations reveal that, while the efficient generation of high order harmonics from relativistic surfaces requires steep plasma density scale lengths (L-p/lambda <1), the absolute efficiency of the harmonics declines for the steepest plasma density scale length L-p -> 0, thus demonstrating that near-steplike density gradients can be achieved for interactions using high-contrast high-intensity laser pulses. Absolute photon yields are obtained using a calibrated detection system. The efficiency of harmonics reflected from the laser driven plasma surface via the relativistic oscillating mirror was estimated to be in the range of 10(-4)-10(-6) of the laser pulse energy for photon energies ranging from 20-40 eV, with the best results being obtained for an intermediate density scale length.

Large- and small-scale structure of the intermediate- and high-velocity clouds towards the LMC and SMC.

We employ Ca II K and Na I D interstellar absorption-line spectroscopy of early-type stars in the Large and Small Magellanic Clouds (LMC, SMC) to investigate the large- and small-scale structure in foreground intermediate- and high-velocity clouds (I/HVCs). Data include FLAMES-GIRAFFE Ca II K observations of 403 stars in four open clusters, plus FEROS or UVES spectra of 156 stars in the LMC and SMC. The FLAMES observations are amongst the most extensive probes to date of Ca II structures on ∼20 arcsec scales in Magellanic I/HVCs. From the FLAMES data within a 0 ∘.∘.∘.5 field of view, the Ca II K equivalent width in the I/HVC components towards three clusters varies by factors of ≥10. There are no detections of molecular gas in absorption at intermediate or high velocities, although molecular absorption is present at LMC and Galactic velocities towards some sightlines. The FEROS/UVES data show Ca II K I/HVC absorption in ∼60 per cent of sightlines. The range in the Ca II/Na I ratio in I/HVCs is from –0.45 to +1.5 dex, similar to previous measurements for I/HVCs. In 10 sightlines we find Ca II/O I ratios in I/HVC gas ranging from 0.2 to 1.5 dex below the solar value, indicating either dust or ionization effects. In nine sightlines I/HVC gas is detected in both H I and Ca II at similar velocities, implying that the two elements form part of the same structure.

“It’s very complicated”: a qualitative study of medicines management in intermediate care facilities in Northern Ireland

Background: Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery from illness and maximising independence. Older people are at increased risk of medication-related adverse events, but little is known about the provision of medicines management services in IC facilities. This study aimed to describe the current provision of medicines management services in IC facilities in Northern Ireland (NI) and to explore healthcare workers' (HCWs) and patients' views of, and attitudes towards these services and the IC concept. 

Methods: Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with HCWs and patients from IC facilities in NI. 

Results: Interviews were conducted with 25 HCWs and 18 patients from 12 IC facilities in NI. Three themes were identified: 'concept and reality', 'setting and supply' and 'responsibility and review'. A mismatch between the concept of IC and the reality was evident. The IC facility setting dictated prescribing responsibilities and the supply of medicines, presenting challenges for HCWs. A lack of a standardised approach to responsibility for the provision of medicines management services including clinical review was identified. Whilst pharmacists were not considered part of the multidisciplinary team, most HCWs recognised a need for their input. Medicines management was not a concern for the majority of IC patients. 

Conclusions: Medicines management services are not integral to IC and medicine-related challenges are frequently encountered. Integration of pharmacists into the multidisciplinary team could potentially improve medicines management in IC.

A qualitative study of community pharmacists’ awareness of and involvement with intermediate care facilities

Rationale, aims and objectives: Intermediate care (IC) describes a range of services targeted at older people, aimed at preventing unnecessary hospitalisation, promoting faster recovery and maximising independence. The introduction of IC has created a new interface between primary and secondary care. Older people are known to be at an increased risk of medication-related problems when transferring between healthcare settings and pharmacists are often not included as part of IC multidisciplinary teams. This study aimed to explore community pharmacists’ (CPs) awareness of IC services and to investigate their views of and attitudes towards the medicines management aspects of such services, including the transfer of medication information.

Method: Semi-structured interviews were conducted, recorded, transcribed verbatim and analysed using a constant comparative approach with CPs practising in the vicinity of IC facilities in Northern Ireland, UK.

Results: Interviews were conducted with 16 CPs. Three themes were identified and named ‘left out of the loop’, ‘chasing things up’ and ‘closing the loop’. CPs felt that they were often ‘left out of the loop’ with regards to both their involvement with local IC services and communication across the healthcare interfaces. As a result, CPs resorted to ‘chasing things up’ as they had to proactively try to obtain information relating to patients’ medications. CPs viewed themselves as ideally placed to facilitate medicines management across the healthcare interfaces (i.e., ‘closing the loop’), but several barriers to potential services were identified.

Conclusion: CPs have limited involvement with IC services. There is a need for improvement of effective communication of patients’ medication information between secondary care, IC and community pharmacy. Increasing CP involvement may contribute to improving continuity of care across such healthcare interfaces, thereby increasing the person-centeredness of service provision.

Investigation into the effect of molybdenum-site substitution on the performance of Sr2Fe1.5Mo0.5O6-δ for intermediate temperature solid oxide fuel cells

In this paper, niobium doping is evaluated as a means of enhancing the electrochemical performance of a Sr₂Fe_1.5Mo_0.5O_6-δ (SFM) perovskite structure cathode material for intermediate temperature solid oxide fuel cells (IT-SOFCs) applications. As the radius of Nb approximates that of Mo and exhibits +4/+5 mixed valences, its substitution is expected to improve material performance. A series of Sr₂Fe_1.5Mo_0.5-xNb_xO_6-δ (x = 0.05, 0.10, 0.15, 0.20) cathode materials are prepared and the phase structure, chemical compatibility, microstructure, electrical conductivity, polarization resistance and power generation are systematically characterized. Among the series of samples, Sr₂Fe_1.5Mo_0.4Nb_0.10O_6-δ (SFMNb_0.10) exhibits the highest conductivity value of 30 S cm^-1 at 550°C, and the lowest area specific resistance of 0.068 Ω cm² at 800°C. Furthermore, an anode-supported single cell incorporating a SFMNb_0.10 cathode presents a maximum power density of 1102 mW cm^-2 at 800°C. Furthermore no obvious performance degradation is observed over 15 h at 750°C with wet H₂(3% H₂O) as fuel and ambient air as the oxidant. These results demonstrate that SFMNb shows great promise as a novel cathode material for IT-SOFCs.