Development of an objective structured clinical examination (OSCE) to assess formulation and extemporaneous dispensing skills in MPharm undergraduates

Background: The use of Objective Structured Clinical Examination (OSCE) in Pharmacy has been explored; however this is the first attempt in Queen’s University School of Pharmacy, Belfast to assess students via this method in a module where chemistry is the main discipline.

Aims: To devise an OSCE to assess undergraduate ability to check extemporaneously dispensed products for clinical and formulation errors. This activity also aims to consider whether it is a viable method of assessment in such a science-based class, from a staff and student perspective.

Method: Students rotated around a number of stations, performing a check of the product, corresponding prescription and formulation record sheet detailing the theory behind the formulation. They were assessed on their ability to spot intentional mistakes at each one.

Results: Of the 79 students questioned, 95% indicated that OSCE made them aware of the importance of the clinical check carried out by the pharmacist. Nearly all of the undergraduates (72 out of 79) felt that OSCE made them aware of the type of mistakes that students make in class. Most (5 out of 7) of the academic team members strongly agreed that it made students aware of ‘point of dispensing’ checks carried out by pharmacists, in addition to helping them to prepare for their exam.

Conclusion: OSCE assesses both scientific and formulation skills, and has increased the diversity of assessment of this module, bringing with it many additional benefits for the undergraduates since it measures their ability to exercise professional judgement in a time- constrained environment and, in this way, mirrors the conditions many pharmacists work within.

Drugs affecting the renin-angiotensin system and survival from cancer: a population based study of breast, colorectal and prostate cancer patient cohorts

Background: Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are commonly prescribed to the growing number of cancer patients (more than two million in the UK alone) often to treat hypertension. However, increased fatal cancer in ARB users in a randomized trial and increased breast cancer recurrence rates in ACEI users in a recent observational study have raised concerns about their safety in cancer patients. We investigated whether ACEI or ARB use after breast, colorectal or prostate cancer diagnosis was associated with increased risk of cancer-specific mortality.

Methods: Population-based cohorts of 9,814 breast, 4,762 colorectal and 6,339 prostate cancer patients newly diagnosed from 1998 to 2006 were identified in the UK Clinical Practice Research Datalink and confirmed by cancer registry linkage. Cancer-specific and all-cause mortality were identified from Office of National Statistics mortality data in 2011 (allowing up to 13 years of follow-up). A nested case–control analysis was conducted to compare ACEI/ARB use (from general practitioner prescription records) in cancer patients dying from cancer with up to five controls (not dying from cancer). Conditional logistic regression estimated the risk of cancer-specific, and all-cause, death in ACEI/ARB users compared with non-users.

Results: The main analysis included 1,435 breast, 1,511 colorectal and 1,184 prostate cancer-specific deaths (and 7,106 breast, 7,291 colorectal and 5,849 prostate cancer controls). There was no increase in cancer-specific mortality in patients using ARBs after diagnosis of breast (adjusted odds ratio (OR) = 1.06 95% confidence interval (CI) 0.84, 1.35), colorectal (adjusted OR = 0.82 95% CI 0.64, 1.07) or prostate cancer (adjusted OR = 0.79 95% CI 0.61, 1.03). There was also no evidence of increases in cancer-specific mortality with ACEI use for breast (adjusted OR = 1.06 95% CI 0.89, 1.27), colorectal (adjusted OR = 0.78 95% CI 0.66, 0.92) or prostate cancer (adjusted OR = 0.78 95% CI 0.66, 0.92).

Conclusions: Overall, we found no evidence of increased risks of cancer-specific mortality in breast, colorectal or prostate cancer patients who used ACEI or ARBs after diagnosis. These results provide some reassurance that these medications are safe in patients diagnosed with these cancers.

Keywords: Colorectal cancer; Breast cancer; Prostate cancer; Mortality; Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers

Beta-blocker usage and breast cancer survival: a nested case-control study within a UK clinical practice research datalink cohort.

Background: To investigate the association between post-diagnostic beta-blocker usage and risk of cancer-specific mortality in a large population-based cohort of female breast cancer patients.

Methods: A nested case-control study was conducted within a cohort of breast cancer patients identified from cancer registries in England(using the National Cancer Data repository) and diagnosed between 1998 and 2007. Patients who had a breast cancer-specific death(ascertained from Office of National Statistics death registration data) were each matched to four alive controls by year and age at diagnosis. Prescription data for these patients were available through the Clinical Practice Research Datalink. Conditional logistic regression models were used to investigate the association between breast cancer-specific death and beta-blocker usage.

Results: Post-diagnostic use of beta-blockers was identified in 18.9% of 1435 breast cancer-specific deaths and 19.4% of their 5697 matched controls,indicating little evidence of association between beta-blocker use and breast cancer-specific mortality [odds ratio (OR) = 0.97,95% confidence interval (CI) 0.83, 1.13]. There was also little evidence of an association when analyses were restricted to cardio non-selective beta-blockers (OR = 0.90, 95% CI 0.69, 1.17). Similar results were observed in analyses of drug dosage frequency and duration, and beta-blocker type.

Conclusions: In this large UK population-based cohort of breast cancer patients,there was little evidence of an association between post-diagnostic beta-blocker usage and breast cancer progression. Further studies which include information on tumour receptor status are warranted to determine whether response to beta-blockers varies by tumour subtypes.

Older women living and coping with domestic violence

Although domestic violence is seen as a serious public health issue for women worldwide, international evidence suggests that women aged over 50 who are victims are suffering in silence because the problem is often ignored by health professionals. More UK research is needed to identify the extent of the problem, and services to meet the needs of older women. This study aims to bridge this gap by gaining a deeper understanding of how ‘older women’ cope with domestic violence and how it affects their wellbeing. Eighteen older women who were currently, or had been in an abusive relationship were recruited. Semi-structured interview schedules were used to discuss the personal nature of DV and its effects on wellbeing, ways of coping and sources of support. Findings suggest that living in a domestically violent context has extremely negative effects on older women’s wellbeing leading to severe anxiety and depression. Three-quarters of the women defined themselves as in ‘very poor’ mental and physical health and were using pathogenic coping mechanisms, such as excessive and long-term use of alcohol, prescription and non-prescription drugs and cigarettes. This negative coping increased the likelihood of these women experiencing addiction to drugs and alcohol dependence and endangered their health in the longer term. Our findings suggest that health professionals must receive appropriate education to gain knowledge and skills in order to deal effectively and support older women experiencing domestic violence.

Older Women Living with Domestic Violence: Coping Resources and Mental Health and Wellbeing

Background: Domestic violence represents a serious public health issue for women and their children worldwide. International evidence suggests that women aged over 50 who are victims of domestic violence are suffering in silence because the problem is ignored by professionals and policy makers. More UK research is needed to identify the extent of the problem, and services to meet the needs of older women.

Study aims: To bridge this gap by seeking to gain a deeper, systematic understanding of how ‘older women’ cope with domestic violence and how it effects their wellbeing, using a theoretical framework of ‘salutogenesis’ to consider coping resources used in lifelong abuse.

Methods: The study recruited a convenience sample of eighteen older women who are currently, or had been in an abusive relationship. A semi-structured interview schedule was used to discuss the personal nature, of domestic violence in their lives, and the pattern of abuse over time and its effects on their wellbeing, ways of coping and sources of support, barriers to reporting and accessing support, and experiences in seeking help.

Results: Living in a domestically violent context has extremely negative effects on older women’s wellbeing. Living with a perpetrator of long-term violence is predisposing these women to extremely negative health outcomes such as Post Traumatic Stress Disorder, anxiety and depression. Three-quarters of the women defined themselves as in poor mental health and were using pathogenic coping mechanisms, such as excessive and long-term use of alcohol, prescription and non-prescription drugs and cigarettes. This negative coping increased the likelihood of these women experiencing addiction to drugs and alcohol dependence and endangering their health and wellbeing in the longer term. Conclusions Public health interventions can work well from a ‘salutogenic’ perspective by finding ways to promote healthy behaviours that increase older women’s sense of wellbeing and coping. The application of this theoretical framework offers the potential for new knowledge to contribute to the discourse about wellbeing in older women dealing with domestic violence.

The effect of helium accretion efficiency on rates of Type Ia supernovae: Double detonations in accreting binaries

he double-detonation explosion scenario of Type Ia supernovae (SNe Ia) has gained increased support from the SN Ia community as a viable progenitor model, making it a promising candidate alongside the well-known single degenerate and double degenerate scenarios. We present delay times of double-detonation SNe, in which a sub-Chandrasekhar mass carbon–oxygen white dwarf (WD) accretes non-dynamically from a helium-rich companion. One of the main uncertainties in quantifying SN rates from double detonations is the (assumed) retention efficiency of He-rich matter. Therefore, we implement a new prescription for the treatment of accretion/accumulation of He-rich matter on WDs. In addition, we test how the results change depending on which criteria are assumed to lead to a detonation in the helium shell. In comparing the results to our standard case (Ruiter et al.), we find that regardless of the adopted He accretion prescription, the SN rates are reduced by only ∼25 per cent if low-mass He shells (≲0.05 M⊙) are sufficient to trigger the detonations. If more massive (0.1 M⊙) shells are needed, the rates decrease by 85 per cent and the delay time distribution is significantly changed in the new accretion model – only SNe with prompt (<500 Myr) delay times are produced. Since theoretical arguments favour low-mass He shells for normal double-detonation SNe, we conclude that the rates from double detonations are likely to be high, and should not critically depend on the adopted prescription for accretion of He.

They’re not racist…’ Prejudice denial, mitigation and suppression in dialogue

Social scientific work on the suppression, mitigation or denial of prejudiced attitudes has tended to focus on the strategic self-presentation and self-monitoring undertaken by individual social actors on their own behalf. In this paper, we argue that existing perspectives might usefully be extended to incorporate three additional considerations. First, that social actors may, on some occasions, act to defend not only themselves, but also others from charges of prejudice. Second, that over the course of any social encounter, interactants may take joint responsibility for policing conversation and for correcting and suppressing the articulation of prejudiced talk. Third, that a focus on the dialogic character of conversation affords an appreciation of the ways in which the status of any particular utterance, action or event as 'racist' or 'prejudiced' may constitute a social accomplishment. Finally, we note the logical corollary of these observations - that in everyday life, the occurrence of 'racist discourse' is likely to represent a collaborative accomplishment, the responsibility for which is shared jointly between the person of the speaker and those other co-present individuals who occasion, reinforce or simply fail to suppress it.

Post-diagnostic prescriptions for low-dose aspirin and breast cancer-specific survival: a nested case-control study in a breast cancer cohort from the UK Clinical Practice Research Datalink

INTRODUCTION: Recent observational studies indicate that post-diagnostic use of aspirin in breast cancer patients may protect against cancer progression perhaps by inhibiting cyclooxygenase-2 dependent mechanisms. Evidence also supports a crucial role for interactions between tumour cells and circulating platelets in cancer growth and dissemination, therefore, use of low-dose aspirin may reduce the risk of death from cancer in breast cancer patients.

METHODS: A cohort of newly diagnosed breast cancer patients (1998 to 2006) were identified in the UK Clinical Practice Research Datalink (and confirmed by cancer registry linkage). Cancer-specific deaths were identified up to 2011 from Office for National Statistics mortality data. A nested case-control analysis was conducted using conditional logistic regression to compare post-diagnostic aspirin exposure using General Practice prescription data in 1,435 cases (breast cancer deaths) with 5,697 controls (matched by age and year of diagnosis).

RESULTS: After breast cancer diagnosis, 18.3% of cancer-specific deaths and 18.5% of matched controls received at least one prescription for low-dose aspirin, corresponding to an odds ratio (OR) of 0.98 (95% CI 0.83, 1.15). Adjustment for potential confounders (including stage and grade) had little impact on this estimate. No dose response relationship was observed when the number of tablets was investigated and no associations were seen when analyses were stratified by receipt of prescriptions for aspirin in the pre-diagnostic period, by stage at diagnosis or by receipt of prescriptions for hormone therapy.

CONCLUSIONS: Overall, in this large population-based cohort of breast cancer patients, there was little evidence of an association between receipt of post-diagnostic prescriptions for low-dose aspirin and breast cancer-specific death. However, information was not available on medication compliance or over-the-counter use of aspirin, which may have contributed to the null findings.

Multi-level wordline driver for robust SRAM design in nano-scale CMOS technology

In this paper, a multi-level wordline driver scheme is presented to improve 6T-SRAM read and write stability. The proposed wordline driver generates a shaped pulse during the read mode and a boosted wordline during the write mode. During read, the shaped pulse is tuned at nominal voltage for a short period of time, whereas for the remaining access time, the wordline voltage is reduced to save the power consumption of the cell. This shaped wordline pulse results in improved read noise margin without any degradation in access time for small wordline load. The improvement is explained by examining the dynamic and nonlinear behavior of the SRAM cell. Furthermore, during the hold mode, for a short time (depending on the size of boosting capacitance), wordline voltage becomes negative and charges up to zero after a specific time that results in a lower leakage current compared to conventional SRAM. The proposed technique results in at least 2× improvement in read noise margin while it improves write margin by 3× for lower supply voltages than 0.7 V. The leakage power for the proposed SRAM is reduced by 2% while the total power is improved by 3% in the worst case scenario for an SRAM array. The main advantage of the proposed wordline driver is the improvement of dynamic noise margin with less than 2.5% penalty in area. TSMC 65 nm technology models are used for simulations.

Gaussian pulse mixing by stacked semiconductor layers

The nonlinear scattering of two Gaussian pulses with different central frequencies incident at slant angles on the periodic stack of binary semiconductor layers has been modelled in the self-consistent problem formulation taking into account the dynamics of charges. The effects of the pump pulse length and central frequencies, and the stack physical and geometrical parameters on the properties of the emitted combinatorial frequency waveforms are analysed and discussed.

The uncritical realism of realist evaluation

This article is a response to Ray Pawson’s critique of critical realism, the philosophy of science elaborated by Roy Bhaskar. I argue with Pawson’s interpretation of critical realism’s positions on both natural and social science and his charges concerning its totalizing ontology, its arrogant epistemology and its naive methodology. The differences between critical realism and realist evaluation are not as significant as Pawson contends. The main differences between the two realisms lie in their approaches to the relationship between social structures and human agency, and between facts and values. I argue that evaluation scientists need to clearly distinguish structure and agency. They should also make their values explicit. The uncritical approach of realist evaluation, combined with its underplaying of the importance of agency, leaves it open to implication in the abuses of bureaucratic instrumentalism.

The Impact of Extension and Ecosystem Services on Smallholders’ Credit Constraint.

On formal credit markets, access to formal credit and reasonable credit terms of smallholder farmers
in rural sub-Saharan Africa is limited due to adverse selection. Financial institutions operating in
rural areas often cannot distinguish between borrowers (farmers) that are creditworthy and those that
are not, thus, allocate limited resource to agriculture to reduce credit risk. In the presence of limited business quality signaling by smallholder farmers, financial institutions shall demand for collateral and/or offer unfavorable contract terms. Moreover, agricultural productivity of rural sub-Saharan
Africa, dominated by subsistence or small-scale farmers, is also negatively impacted by the adverse
effect of climate change. A strategy that may make the farming practices of smallholder farmer’s
climate resilient and profitable may also improve smallholder farmer's access to formal credit. This
study investigates to what extent participating in ecosystem and extension services (EES) programs
signals business quality of smallholders, thus granting them credit accessibility. We collected data
on 210 smallholder farmers in 2013, comprising farmers that receive payments for ecosystem
services (PES) and farm management training from the International Small Group Tree Planting
Program (TIST) Kenya to test the aforementioned theory empirically. We use game theory,
particularly a screening and sorting model, to illustrate the prospects for farmers with EES to access
formal credit and to improve their credit terms given that they receive PES and banking services
training. Furthermore, the PES’ long term duration (10 – 30 years) generates stable cash-flow which
may be perceived as collateral substitute. Results suggest that smallholder farmers in the TIST
program were less likely to be credit constraint compared to non-TIST farmers. Distance to market,
education, livestock and farm income are factors that determine access to credit from microfinance
institutions in rural Kenya. Amongst farmers that have obtained loans, those keeping business records
enjoy more favorable formal credit conditions. These farmers were observed to pay ca. 5 percent less
interest rate in microfinance charges. For TIST farmers, this type of farm management practices may
be attributed to the banking services and other training they receive within the program. While the
availability of classical collateral (farmlands) and PES may reduce interest rate, the latter was found
to be statistically insignificant. This research underlines the importance of an effective extension
services in rural areas of developing countries and the need to improve gains from conservation
agriculture and ensuing PES. The benefits associated with EES and PES may encompass agricultural
financing.

Statin Use and Survival from Lung Cancer: A Population-Based Cohort Study

Background: Preclinical evidence from lung cancer cell lines and animal models suggest that statins could have anticancer properties. We investigated whether statin users had reduced risk of cancer-specific mortality in a population based cohort of lung cancer patients.
Methods: Newly diagnosed lung cancer patients, from 1998 to 2009, were identified from English cancer registry data and linked to the UK Clinical Practice Research Datalink, providing prescription records, and to Office of National Statistics mortality data up to 2012. Cox regression models were used to calculate hazard ratios (HR) for cancer-specific mortality and 95% confidence intervals (CIs) by statin use before and after diagnosis and to adjust these HRs for potential confounders.
Results: In 3,638 lung cancer patients, there was some evidence that statin use after diagnosis was associated with reduced lung cancer-specific mortality (adjusted HR=0.89, 95% CI 0.78, 1.02; P=0.09). Associations were more marked after 12 prescriptions (adjusted HR=0.81, 95% CI 0.67, 0.98; P=0.03) and when lipophilic statins were investigated (adjusted HR=0.81, 95% CI 0.70, 0.94; P=0.01) but were attenuated in some sensitivity analyses. Furthermore, in 11,051 lung cancer patients, statin use before diagnosis was associated with reduced lung cancer-specific mortality (adjusted HR=0.88, 95% CI, 0.83, 0.93; P<0.001).
Conclusions: There was some evidence that lung cancer patients who used statins, and particularly simvastatin, had reduced rates of cancer-specific mortality.
 Impact: These findings should first be confirmed in observational studies, but provide some support for conducting randomized controlled trials of simvastatin as adjuvant cancer therapy in lung cancer patients.

IMRT for image-guided single vocal cord irradiation

PURPOSE: We have been developing an image-guided single vocal cord irradiation technique to treat patients with stage T1a glottic carcinoma. In the present study, we compared the dose coverage to the affected vocal cord and the dose delivered to the organs at risk using conventional, intensity-modulated radiotherapy (IMRT) coplanar, and IMRT non-coplanar techniques.

METHODS AND MATERIALS: For 10 patients, conventional treatment plans using two laterally opposed wedged 6-MV photon beams were calculated in XiO (Elekta-CMS treatment planning system). An in-house IMRT/beam angle optimization algorithm was used to obtain the coplanar and non-coplanar optimized beam angles. Using these angles, the IMRT plans were generated in Monaco (IMRT treatment planning system, Elekta-CMS) with the implemented Monte Carlo dose calculation algorithm. The organs at risk included the contralateral vocal cord, arytenoids, swallowing muscles, carotid arteries, and spinal cord. The prescription dose was 66 Gy in 33 fractions.

RESULTS: For the conventional plans and coplanar and non-coplanar IMRT plans, the population-averaged mean dose ± standard deviation to the planning target volume was 67 ± 1 Gy. The contralateral vocal cord dose was reduced from 66 ± 1 Gy in the conventional plans to 39 ± 8 Gy and 36 ± 6 Gy in the coplanar and non-coplanar IMRT plans, respectively. IMRT consistently reduced the doses to the other organs at risk.

CONCLUSIONS: Single vocal cord irradiation with IMRT resulted in good target coverage and provided significant sparing of the critical structures. This has the potential to improve the quality-of-life outcomes after RT and maintain the same local control rates.

Precision Teaching in IV Fluid Prescribing and Patient Safety

OBJECTIVES: Precision Teaching (PT) has been shown to be an effective intervention to assess teaching method effectiveness and evaluate learning outcomes. SAFMEDS (Say All Fast Minute Every Day Shuffled) are a practice/assessment procedure within the PT framework to assist learning and fluency. We explored the effects of a brief intervention with PT, to impart high frequency performance in safe intravenous fluid prescription in a group of final year undergraduate medical students.
METHODS: 133 final year undergraduate medical students completed a multiple choice question (MCQ) test on safe IV fluid prescription at the beginning and end of the study. The control group (n= 76) of students were taught using a current standardized teaching method. Students allocated to the intervention arm of the study were additionally instructed on PT and the use of SAFMEDS. The study group (n = 57) received 50 SAFMEDS cards containing information on the principles of IV fluid prescription scenarios. These students were trained/tested twice per day for 1 minute.
RESULTS: Interim analysis showed that the study group displayed an improvement in fluency and accuracy as the study progressed. There was a statistically significant improvement in MCQ performance for the PT group compared with the control group between the beginning and end of the study (35% vs 15%).
CONCLUSION: These results suggest PT employing SAFMEDS is an effective method for improving fluency, accuracy and patient safety in intravenous fluid prescribing amongst undergraduate medical students.