Motivational interviewing to explore culturally and linguistically diverse people's comorbidity medication self-efficacy

Aims and objectives: To examine the perceptions of a group of culturally and linguistically diverse participants with the comorbidities of diabetes, chronic kidney disease and cardiovascular disease to determine factors that influence their medication self-efficacy through the use of motivational interviewing. Background: These comorbidities are a global public health problem and their self-management is more difficult for culturally and linguistically diverse populations living in English-speaking communities. Few interventions have been tested in culturally and linguistically diverse people to improve their medication self-efficacy. Design: A series of motivational interviewing telephone calls were conducted in the intervention arm of a randomised controlled trial using interpreter services. Methods: Patients with these comorbidities aged ≥18 years of age whose preference it was to speak Greek, Italian or Vietnamese were recruited from nephrology outpatient clinics of two Australian metropolitan hospitals in 2009. Results: The average age of the 26 participants was 73·5 years. The fortnightly calls averaged 9·5 minutes. Thematic analysis revealed three core themes which were attitudes towards medication, having to take medication and impediments to chronic illness medication self-efficacy. A lack of knowledge about medications impeded confidence necessary for optimal disease self-management. Participants had limited access to resources to help them understand their medications. Conclusion: This work has highlighted communication gaps and barriers affecting medication self-efficacy in this group. Culturally sensitive interventions are required to ensure people of culturally and linguistically diverse backgrounds have the appropriate skills to self-manage their complex medical conditions. Relevance to clinical practice: Helping people to take their medications as prescribed is a key role for nurses to serve and protect the well-being of our increasingly multicultural communities. The use of interpreters in motivational interviewing requires careful planning and adequate resources for optimal outcomes.

Initial medication adherence-review and recommendations for good practices in outcomes research: an ISPOR medication adherence and persistence special interest group report

Background: Positive associations between medication adherence and beneficial outcomes primarily come from studying filling/consumption behaviors after therapy initiation. Few studies have focused on what happens before initiation, the point from prescribing to dispensing of an initial prescription. Objective: Our objective was to provide guidance and encourage high-quality research on the relationship between beneficial outcomes and initial medication adherence (IMA), the rate initially prescribed medication is dispensed. Methods: Using generic adherence terms, an international research panel identified IMA publications from 1966 to 2014. Their data sources were classified as to whether the primary source reflected the perspective of a prescriber, patient, or pharmacist or a combined perspective. Terminology and methodological differences were documented among core (essential elements of presented and unpresented prescribing events and claimed and unclaimed dispensing events regardless of setting), supplemental (refined for accuracy), and contextual (setting-specific) design parameters. Recommendations were made to encourage and guide future research. Results: The 45 IMA studies identified used multiple terms for IMA and operationalized measurements differently. Primary data sources reflecting a prescriber's and pharmacist's perspective potentially misclassified core parameters more often with shorter/nonexistent pre- and postperiods (1-14 days) than did a combined perspective. Only a few studies addressed supplemental issues, and minimal contextual information was provided. Conclusions: General recommendations are to use IMA as the standard nomenclature, rigorously identify all data sources, and delineate all design parameters. Specific methodological recommendations include providing convincing evidence that initial prescribing and dispensing events are identified, supplemental parameters incorporating perspective and substitution biases are addressed, and contextual parameters are included.

Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol.

BACKGROUND: Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals' medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback METHODS/DESIGN: A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour. To assess sustainability of the intervention, at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained. This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events.

Psychiatric disorders, psychotropic medication use and falls among women: an observational study

BACKGROUND: Psychotropic agents known to cause sedation are associated with an increased risk of falls, but the role of psychiatric illness as an independent risk factor for falls is not clear. Thus, this study aimed to investigate the association between psychiatric disorders, psychotropic medication use and falls risk. METHODS: This study examined data collected from 1062 women aged 20-93 yr (median 50 yr) participating in the Geelong Osteoporosis Study, a large, ongoing, population-based study. Depressive and anxiety disorders for the preceding 12-month period were ascertained by clinical interview. Current medication use and falls history were self-reported. Participants were classified as fallers if they had fallen to the ground at least twice during the same 12-month period. Anthropometry, demographic, medical and lifestyle factors were determined. Logistic regression was used to test the associations, after adjusting for potential confounders. RESULTS: Fifty-six women (5.3%) were classified as fallers. Those meeting criteria for depression within the past 12 months had a 2.4-fold increased odds of falling (unadjusted OR = 2.4, 95% CI 1.2-4.5). Adjustment for age and mobility strengthened the relationship (adjusted OR = 2.7, 95% CI 1.4-5.2) between depression and falling, with results remaining unchanged following further adjustment for psychotropic medication use (adjusted OR = 2.7, 95% CI 1.3-5.6). In contrast, past (prior to 12-month) depression were not associated with falls. No association was observed between anxiety and falls risk. Falling was associated with psychotropic medication use (unadjusted OR = 2.8, 95% CI 1.5-5.2), as well as antidepressant (unadjusted OR = 2.4, 95% CI 1.2-4.8) and benzodiazepine use (unadjusted OR = 3.4, 95% CI 1.6-7.3); associations remained unchanged following adjustment for potential confounders. CONCLUSION: The likelihood of falls was increased among those with depression within the past 12 months, independent of psychotropic medication use and other recognised confounders, suggesting an independent effect of depression on falls risk. Psychotropic drug use was also confirmed as an independent risk factor for falls, but anxiety disorders were not. Further research into the underlying mechanisms is warranted.

Associations of obsessive-compulsive symptoms with clinical and neurocognitive features in schizophrenia according to stage of illness

This study aimed to investigate the association of obsessive-compulsive symptoms with clinical and neurocognitive features in patients with schizophrenia. This study enrolled 163 people with schizophrenia who were receiving risperidone monotherapy. Comorbid obsessive-compulsive symptoms were assessed using the Yale-Brown Obsessive-Compulsive Scale, and subjects with a score≥10 constituted the obsessive-compulsive symptom group (n=30, 18.4%). The learning index was significantly higher in patients with obsessive-compulsive symptoms than in those without such symptoms after adjusting for age, stage (early and chronic), duration of illness, and CDSS score. However, there was no significant interaction between obsessive-compulsive symptoms and stage of illness. Scores on Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, and Beck Depression Inventory were significantly higher in the obsessive-compulsive symptom group. In addition, the Subjective Well-being under Neuroleptic Treatment score was significantly lower in the obsessive-compulsive symptom group. In conclusion, comorbid obsessive-compulsive symptoms in patients with schizophrenia were associated with a higher learning ability without a significant interaction with stage of illness. However, schizophrenia patients with obsessive-compulsive symptoms had more severe psychotic and depressive symptoms and poorer quality of life.

Associations of obsessive-compulsive symptoms with clinical and neurocognitive features in schizophrenia according to stage of illness

This study aimed to investigate the association of obsessive-compulsive symptoms with clinical and neurocognitive features in patients with schizophrenia. This study enrolled 163 people with schizophrenia who were receiving risperidone monotherapy. Comorbid obsessive-compulsive symptoms were assessed using the Yale-Brown Obsessive-Compulsive Scale, and subjects with a score ≥ 10 constituted the obsessive-compulsive symptom group (n=30, 18.4%). The learning index was significantly higher in patients with obsessive-compulsive symptoms than in those without such symptoms after adjusting for age, stage (early and chronic), duration of illness, and CDSS score. However, there was no significant interaction between obsessive-compulsive symptoms and stage of illness. Scores on Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, and Beck Depression Inventory were significantly higher in the obsessive-compulsive symptom group. In addition, the Subjective Well-being under Neuroleptic Treatment score was significantly lower in the obsessive-compulsive symptom group. In conclusion, comorbid obsessive-compulsive symptoms in patients with schizophrenia were associated with a higher learning ability without a significant interaction with stage of illness. However, schizophrenia patients with obsessive-compulsive symptoms had more severe psychotic and depressive symptoms and poorer quality of life.

No evidence for mirror system dysfunction in schizophrenia from a multimodal TMS/EEG study

Dysfunctional mirror neuron systems have been proposed to contribute to the social cognitive deficits observed in schizophrenia. A few studies have explored mirror systems in schizophrenia using various techniques such as TMS (levels of motor resonance) or EEG (levels of mu suppression), with mixed results. This study aimed to use a novel multimodal approach (i.e. concurrent TMS and EEG) to further investigate mirror systems and social cognition in schizophrenia. Nineteen individuals with schizophrenia or schizoaffective disorder and 19 healthy controls participated. Single-pulse TMS was applied to M1 during the observation of hand movements designed to elicit mirror system activity. Single EEG electrodes (C3, CZ, C4) recorded brain activity. Participants also completed facial affect recognition and theory of mind tasks. The schizophrenia group showed significant deficits in facial affect recognition and higher level theory of mind compared to healthy controls. A significant positive relationship was revealed between mu suppression and motor resonance for the overall sample, indicating concurrent validity of these measures. Levels of mu suppression and motor resonance were not significantly different between groups. These findings indicate that in stable outpatients with schizophrenia, mirror system functioning is intact, and therefore their social cognitive difficulties may be caused by alternative pathophysiology.

Exploring the influence of workplace supports and relationships on safe medication practice: a pilot study of Australian graduate nurses

BACKGROUND: Despite the growing awareness of the benefits of positive workplace climates, unsupportive and disruptive workplace behaviours are widespread in health care organisations. Recent graduate nurses, who are often new to a workplace, are particularly vulnerable in unsupportive climates, and are also recognised to be at higher risk for medication errors. OBJECTIVES: Investigate the association between workplace supports and relationships and safe medication practice among graduate nurses. DESIGN AND PARTICIPANTS: Exploratory study using quantitative survey with a convenience sample of 58 nursing graduates in two Australian States. METHODS: Online survey focused on graduates' self-reported medication errors, safe medication practice and the nature of workplace supports and relationships. RESULTS: Spearman's correlations identified that unsupportive workplace relationships were inversely related to graduate nurse medication errors and erosion of safe medication practices, while supportive Nurse Unit Manager and supportive work team relationships positively influenced safe medication practice among graduates. CONCLUSIONS: Workplace supports and relationships are potentially both the cause and solution to graduate nurse medication errors and safe medication practices. The findings develop further understanding about the impact of unsupportive and disruptive behaviours on patient safety and draw attention to the importance of undergraduate and continuing education strategies that promote positive workplace behaviours and graduate resilience.

Clozapine reverses schizophrenia-related behaviours in the metabotropic glutamate receptor 5 knockout mouse: association with N-methyl-d-aspartic acid receptor up-regulation

Abnormalities in glutamatergic signalling are proposed in schizophrenia in light of the schizophreniform psychosis elicited by NMDA antagonists. The metabotropic glutamate receptor 5 (mGluR5) interacts closely with the NMDA receptor and is implicated in several behavioural endophenotypes of schizophrenia. We have demonstrated that mice lacking mGluR5 have increased sensitivity to the hyperlocomotive effects of the NMDA antagonist MK-801. Mice lacking mGluR5 also show abnormal locomotor patterns, reduced prepulse inhibition (PPI), and deficits on performance of a short-term spatial memory task on the Y-maze. Chronic administration of the antipsychotic drug clozapine ameliorated the locomotor disruption and reversed the PPI deficit, but did not improve Y-maze performance. Chronic clozapine increased NMDA receptor binding ([3H]MK-801) but did not alter dopamine D2 ([3H]YM-09151), 5-HT2A ([3H]ketanserin), or muscarinic M1/M4 receptor ([3H]pirenzepine), binding in these mice. These results demonstrate behavioural abnormalities that are relevant to schizophrenia in the mGluR5 knockout mouse and a reversal of behaviours with clozapine treatment. These results highlight both the interactions between mGluR5 and NMDA receptors in the determination of schizophreniform behaviours and the potential for the effects of clozapine to be mediated by NMDA receptor regulation.
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Serotonin 1a receptor and associated G-protein activation in schizophrenia and bipolar disorder

Abnormalities in the serotonergic signalling system, including the serotonin 1a receptor, have been implicated in the pathogenesis of schizophrenia and bipolar 1 disorder. However, there is no consensus on whether the density of the serotonin 1a receptor and/or the activity of the G-proteins linking the receptor to the intracellular cascade are altered in these disease states. To address these issues, tissue obtained postmortem from four cortical regions was used to measure [3H] 8-hydroxy-2-(dipropylamino)tetralin hydrobromide (8-OH-DPAT) binding and 8-OH-DPAT-stimulated guanosine 5′-[γ-thio]triphosphate (GTPγS) binding to determine if either parameter is altered in schizophrenia or bipolar I disorder. There was an effect of diagnosis on the level of [3H] 8-OH-DPAT binding that may indicate a global change in the density of serotonin 1a receptors, although this effect did not reach significance in any individual brain region. The activation of serotonin 1a receptors did not differ significantly with diagnoses. However, in the outer cortical layers, there appeared to be a dissociation between the number of receptors available and the extent of ligand-induced GTPγS binding, suggesting considerable receptor reserve. In addition, comparing gender independent of diagnoses, a decrease in the levels of serotonin 1a receptors was observed in the cortex of female subjects. These data indicates that there may be subtle changes in serotonin 1a receptors across the cortex in schizophrenia or bipolar I disorder and suggests a gender discordance in receptor levels.

N-Ethylmaleimide sensitive factor in the cortex of subjects with schizophrenia and bipolar I disorder

N-Ethylmaleimide sensitive factor (NSF) is a presynaptic protein that has been suggested to be differentially expressed in the cortex of schizophrenic subjects through both high-throughput proteomic and genomic screening studies. Thus, to expand upon these studies we measured NSF using Western blotting in four regions of the cortex (BA9, 10, 40 and 46), in a cohort comprising 20 schizophrenic subjects, 8 bipolar I disorder subjects, and 20 control subjects. There was no significant difference in NSF levels between diagnostic cohorts in any of the four cortical regions. These findings highlight the importance of validating findings from high-throughput screening studies and do not support changes in cortical NSF as being of significance in schizophrenia or bipolar 1 disorder.

Regionally specific changes in levels of cortical S100β in bipolar 1 disorder but not schizophrenia

Objective: To determine if levels of the glial-derived proteins S100β and glial acidic fibrillary protein (GFAP) and the pro- and antiapoptotic proteins p53 and Bcl-2 were altered in the cortex of subjects with schizophrenia or bipolar 1 disorder.
Method: Levels of S100β, GFAP, p53 and Bcl-2 were measured in cortex (Brodmann's Areas (BAs) 9, 10, 46 and 40) of control subjects and subjects with schizophrenia, bipolar 1 disorder and in the cortex of rats treated with haloperidol or lithium using protein-specific antibodies and western blot analysis.
Results: Levels of S100β were decreased in BA 9 and increased in BA 40 from subjects with bipolar 1 disorder. Levels of this protein were not altered in other CNS regions, in schizophrenia or in the cortex of rats treated with haloperidol or lithium. No changes in levels of the other three proteins were detected across diagnoses.
Conclusions: Regionally selective changes in cortical S100β may be associated with the pathology of bipolar 1 disorder and may reflect derangements in neuronal death or survival

A comparison of M1 and M4 muscarinic receptors in the thalamus from control subjects and subjects with schizophrenia

Having shown a decrease in muscarinic M1 receptors in Brodmann’s area (BA) 9 from subjects with schizophrenia we have extended our studies to determine if this receptor is decreased in the thalamus from the same cohort of subjects. Levels of Full-size image (<1 K)pirenzepine binding to and mRNA encoding for M1 and M4 receptors were measured throughout the thalamus. Levels of M1 and M4 receptor proteins were measured in the mediodorsal nucleus. Two-way ANOVA revealed a variance in Full-size image (<1 K)pirenzepine binding (F=4.69, d.f. = 1.190, P=0.03), but there was no significant change in radioligand binding in any thalamic region in schizophrenia. Neither levels of mRNA encoding the thalamic M1 or M4 receptor nor levels of M1 or M4 receptor protein in the mediodorsal nucleus differed between the schizophrenic and control subjects. We therefore conclude that the M1 and M4 receptor are not altered in the thalamus from subjects with schizophrenia. These data add weight to the hypothesis that changes in M1 receptors in selective regions of the CNS are associated with the pathology of schizophrenia.

Medication communication during handover interactions in specialty practice settings

AIMS AND OBJECTIVES: To investigate what and how medication information is communicated during handover interactions in specialty hospital settings. BACKGROUND: Effective communication about patients' medications between health professionals and nurses at handover is vital for the delivery of safe continuity of care. DESIGN: An exploratory qualitative design and observational study. METHODS: Participant observation was undertaken at a metropolitan Australian public hospital in four specialty settings: cardiothoracic care, intensive care, emergency care and oncology care. A medication communication model was applied to the data and thematic analysis was performed. RESULTS: Over 130 hours of observational data were collected. In total, 185 (predominately nursing) handovers were observed across the four specialty settings involving 37 nurse participants. Health professionals communicated partial details of patients' medication regimens, by focusing on auditing the medication administration record, and through the handover approach employed. Gaps in medication information at handover were evident as shown by lack of communication about detailed and specific medication content. Incoming nurses rarely posed questions about medications at handover. CONCLUSIONS: Handover interactions contained restricted and incomplete medication information. Improving the transparency, completeness and accuracy of medication communication is vital for optimising patient safety and quality of care in specialty practice settings. RELEVANCE TO CLINICAL PRACTICE: For nurses to make informed and rapid decisions regarding appropriate patient care, information about all types of prescribed medications is essential, which is communicated in an explicit and clear way. Jargon and assumptions related to medication details should be minimised to reduce the risk of misunderstandings. Disclosure of structured medication information supports nurses to perform accurate patient assessments, make knowledgeable decisions about the appropriateness of medications and their doses, and anticipate possible adverse events associated with medications. In addition, benefits of patient and family member contributions in communicating about medications at handover should also be considered.