Physicians’ and pharmacies’ overview of patients’ medication. An analysis of fidelity coefficients

Background  

It is essential that pharmacies and prescribers have an overview of each patient’s medication in order to prevent drug interactions, unintentional co-prescribing, unnecessary polypharmacy and underprescribing. We have assessed this overview by measuring the ‘fidelity coefficient’, a measure of the extent to which a drug user has a preference for one prescriber or one pharmacy.     

Community pharmacists’ perceptions of leadership

BackgroundConcerns have been expressed regarding a “leadership crisis” in pharmacy. Previous research has identified potential barriers to pharmacists assuming leadership roles and signposted opportunities for further exploration of leadership issues in the profession related to psychological comfort with use of power.ObjectivesThis study explored community pharmacists’ perceptions of the effectiveness and impact of power leveraged by formal and informal pharmacy leaders.MethodsA theoretical framework based on Raven's 7 Sources of Power model was used to guide this research. Semi-structured interviews with community pharmacists in Ontario, Canada were undertaken, and data were coded and categorized using this framework.Findings29 pharmacists participated in this study. Participants in this study highlighted over-reliance on charismatic power, underuse of rewards and punishments, and general lack of effectiveness or impact in use of informational, expertise, positional, and relational powers amongst pharmacy leaders. Opportunities to broaden the power repertoire of pharmacy leaders, including leadership education, were identified as potentially valuable for individual leaders and the profession as a whole.ConclusionsEffectively leveraging power is important for leaders. This study has highlighted patterns of power use amongst community pharmacy leaders and identified opportunities for further research in this area and for continuing professional development for leaders.     

Accuracy of general practitioners’ readings of ECG in primary care

Background

The electrocardiogram (ECG) is a diagnostic test commonly used in daily Primary Care practice. General Practitioners (GP) often feel unsure about their interpretation of ECGs, so they engage external services to provide it.

Aim

To evaluate accuracy of ECG readings done by GPs by comparison with those done by a cardiologist as the gold standard.

Methods

We studied 195 ECGs collected consecutively during first semester of 2010 in an urban Health Centre of Portugal. Each ECG was read by each physician and inter-observer agreement was evaluated. After coding by Novacode, sensitivity and specificity of GP’s readings were calculated.

Results

Inter-observer agreement between GP readings was “good” with an intraclass correlation coefficient of 0.727 (CI 95%: 0.670–0.779). When compared with gold standard, GP achieved a “good” agreement with an intraclass correlation coefficient of 0.712 (CI 95%: 0.659–0.762). The overall accuracy of GP for detecting abnormalities was 81.0% (95%CI: 75.7–85.6%), with a sensitivity of 84.8% (95%CI: 77.3–90.6%) and a specificity of 77.5% (95%CI: 69.7–84.2%). For normal tests, accuracy was 79.9% (95%CI: 74.7–84.3). In the most prevalent classes of abnormalities, accuracy was higher than 90%.

Conclusion

GP showed good skills in reading ECGs in their practice of Primary Care. Better attention should be given to ischemic abnormalities present on ECGs. Key message: General Practitioners demonstrate good skills for reading the ECGs of patients on a primary care centre when compared to the gold standard defined by a cardiologist reading.     

Evaluation of memantine for the treatment of Alzheimer’s disease

Increasing evidence suggests that disturbances in glutamatergic activity play an important role in Alzheimer’s disease (AD). Excessive glutamate-mediated activation of NMDA receptors, for example, may contribute to the neuronal death that characterises AD. On the other hand, physiological activation of the NMDA receptor appears necessary for normal cognitive function. Therefore, compounds that finely modulate NMDA receptor activity hold promise as treatments for AD. Memantine (Namenda^?, Axura^®, Ebixa^®; Forest Laboratories, Inc., Merz Pharmaceuticals GmbH, H. Lundbeck A/S) is a low-moderate affinity, uncompetitive NMDA-receptor antagonist that appears to block pathological, but not physiological, activation of the NMDA receptor. Consequently, therapeutic doses of the drug are well-tolerated and do not seem to interfere with the acquisition or processing of cognitive information. Memantine has been shown to improve symptoms and reduce the rate of clinical deterioration among patients with moderate-to-severe AD and was approved in the US for this indication in October 2003. This review provides a brief rationale for the development of memantine as a therapy for AD, as well as an overview of the pharmacology, clinical efficacy, safety and tolerability of this novel therapeutic agent.     

Nonprofessionals’ perceptions of the causes of behavioral and substance addictions

We assessed nonprofessionals' perceptions of etiological explanations of behavioral and substance addictions in a nationwide sample. A total of 612 adults (51% male) residing in the United States were recruited using Mechanical Turk. Participants rated the perceived likelihood of seven psychosocial and biological etiologies for one of five randomly assigned types of “addiction” (i.e., alcohol, marijuana, heroin, gambling, or pornography). Significantly fewer participants rated social pressure a likely cause of addiction to pornography (31%) than to marijuana (53%), alcohol (55%), and heroin (64%); significantly fewer rated traumatic childhood events a likely cause of addiction to gambling (33%) and marijuana (36%) than to pornography (56%), heroin (57%), and alcohol (64%); significantly fewer rated the way a person was raised a likely cause of addiction to marijuana (37%) than to heroin (55%) and alcohol (65%); and significantly more rated genetics a likely cause of an addiction to alcohol (65%) than to pornography (26%), marijuana (33%), gambling (41%), and heroin (45%). The proportions who rated stressful circumstances and character problem as likely causes were not significantly associated with type of addiction. In addition, participants rated an average of three or four separate etiologies as likely causes of each target addiction. Our results suggest that lay individuals recognize the multi-determined nature of addictive disorders and rate some causes as more or less likely depending on the specific addictive substance or behavior.     

Relationship between adolescents’ and their parents’ attitudes toward medicines and awareness of the risk of medicines

Background When they reach adolescence, children begin to independently use medicine without their parents’ supervision, but parents usually still want to be involved in their drug therapy. Objective The aim of this study was to investigate how parental attitudes and awareness toward medicine relate to adolescents’ attitudes and awareness. Setting Twelve secondary schools in different regions of the Slovak Republic. Method Adolescents and parents responded to a questionnaire, and the answers were paired and analysed. Parental and adolescents’ attitudes toward medicines and awareness of the risk of medicines were measured using a five-point Likert scale. Main outcome measure The strength of the relationship between parents’ and their adolescent children’s level of agreement with statements about medicines. Results There were significant differences between parents? and adolescents’ mean Likert scores for statements about their attitudes toward medicines and their awareness of the risk of medicines (p?<?0.05). Parents and adolescents were not fully aware of the risks of cough medicine (73.5% and 76.1%), antihistamines (32.7% and 52.1%), painkillers (33.6% and 47%) and combining medicines (25.2% and 40.4%). More than half of the parents and adolescents had a positive perception of the effectiveness of medication and believed that taking medicine would not hurt adolescents. Parents’ and adolescents’ responses to the statements were directly proportional (r?=?0.94, p?<?0.001). Conclusion The analysis revealed a relationship between Slovakian adolescents’ and their parents’ attitudes and awareness toward medicine; it highlighted areas of adolescents’ and parents’ education about the proper use of medications.     

‘All suffering together’: student drinkers’ experiences of alcohol hangover

Background: There is a pervasive norm of drinking to intoxication among young people in many affluent countries, despite recent falls in overall alcohol consumption. Students’ accounts of their experiences of alcohol hangovers have not been explored in any depth, which is surprising given the high rates of heavy episodic drinking amongst this group. This study investigated student drinkers’ lay health beliefs about alcohol hangovers, considering the role of hangovers in student drinking culture and the implications for safer drinking initiatives.

Method: The present study involved a Thematic analysis of semi-structured individual interviews with 23 students aged 18 to 29 (8 women and 15 men) at a university in South West England about their thoughts, feelings and experiences regarding hangovers and drinking.

Results: Hangovers were relatively frequent events for most participants, associated with heavy drinking and producing unpleasant physical and psychological effects. Participants employed a range of strategies to minimise the effects of hangovers although very few considered reducing their alcohol consumption. A key negative aspect of hangovers involved low mood and social isolation, in contrast to the positive experience of shared collective suffering that strengthened social bonds in participants’ friendship groups.

Conclusions: Collective periods of shared suffering formed a valued aspect of participants’ hangover experiences, strengthening group identity and linking to the culture of heavy drinking. It is important to acknowledge positive as well as negative aspects of students’ views on hangovers in public health guidance on young adults’ alcohol consumption.     

Do pharmacists’ reports of adverse drug reactions reflect patients’ concerns?

Aim: The aim of the present study was to investigate whether the concerns patients express to a Drug Information Line about possible adverse drug reactions (ADRs) they have experienced, are sufficiently reflected by the ADR reports submitted by pharmacists to the Netherlands Pharmacovigilance Centre Lareb with regard to the type of ADRs and the drug groups involved.Methods: ADR-related questions patients addressed to the Dutch Drugs Information Line were compared with the ADR reports pharmacists sent in to Lareb in the same period. The similarities and differences between the characteristics of the suspected ADRs and the kinds of drugs mentioned were investigated, as well as the severity of the reported ADRs. To compare the two data sets and to establish whether significant differences were present, a logistic regression analysis was conducted on the reported drugs and ADRs.Results: Analysis of the content of the phone calls yielded 1168 (14.6%) calls concerning possible experienced ADRs. The suspected ADRs pharmacists reported to the Netherlands Pharmacovigilance Centre Lareb in the same period included 1734 reports. There were only slight differences between the queries patients put to the Drug Information Line regarding possible adverse drug reactions and the reports on suspected ADRs pharmacists submitted to the pharmacovigilance centre. With respect to possible ADRs in the psychiatric spectrum and ADRs associated with the use of antidepressants, there seems to be a deficiency in the reporting by pharmacists.Conclusion: The ADRs pharmacists report to the national pharmacovigilance centre reflect patients concerns about ADRs they experience in relation to the medication they are taking.     

‘Surfing the Silk Road’: A study of users’ experiences

IntroductionThe online drug marketplace called ‘Silk Road’ has operated anonymously on the ‘Deep Web’ since 2011. It is accessible through computer encrypting software (Tor) and is supported by online transactions using peer to peer anonymous and untraceable crypto-currency (Bit Coins). The study aimed to describe user motives and realities of accessing, navigating and purchasing on the ‘Silk Road’ marketplace.MethodsSystematic online observations, monitoring of discussion threads on the site during four months of fieldwork and analysis of anonymous online interviews (n = 20) with a convenience sample of adult ‘Silk Road’ users was conducted.ResultsThe majority of participants were male, in professional employment or in tertiary education. Drug trajectories ranged from 18 months to 25 years, with favourite drugs including MDMA, 2C-B, mephedrone, nitrous oxide, ketamine, cannabis and cocaine. Few reported prior experience of online drug sourcing. Reasons for utilizing ‘Silk Road’ included curiosity, concerns for street drug quality and personal safety, variety of products, anonymous transactioning, and ease of product delivery. Vendor selection appeared to be based on trust, speed of transaction, stealth modes and quality of product. Forums on the site provided user advice, trip reports, product and transaction reviews. Some users reported solitary drug use for psychonautic and introspective purposes. A minority reported customs seizures, and in general a displacement away from traditional drug sourcing (street and closed markets) was described. Several reported intentions to commence vending on the site.ConclusionThe study provides an insight into ‘Silk Road’ purchasing motives and processes, the interplay between traditional and ‘Silk Road’ drug markets, the ‘Silk Road’ online community and its communication networks.     

Pharmacy Students’ Knowledge of Black Box Warnings

Objective

To evaluate the progression of pharmacy students’ knowledge of black box warnings across 3 years of didactic training, and to determine how they stay current with new warnings.

Methods

A cross-sectional survey instrument was administered to pharmacy students in their first (P1), second (P2), and third (P3) professional years. The survey assessed student awareness of medications possessing a black box warning and familiarity with the warning content for 20 medications (15 with and 5 without warnings).

Results

Mean number of correct responses identifying the presence or absence of a black box warning among the 20 medications were 5.8 ± 3.3, 9.6 ± 4.0, and 14.8 ± 2.8 for the P1, P2, and P3 students, respectively. Knowledge of black box warning content was variable. Students were least aware of the warning content for stavudine and enoxaparin. Students were most familiar with the warning content for paroxetine and estrogen.

Conclusion

Students’ awareness and understanding of black box warnings was proportional to their educational progression, but their knowledge level was inconsistent across drug groups.     

Targeting the Progression of Parkinson’s Disease

By the time a patient first presents with symptoms of Parkinson’s disease at the clinic, a significant proportion (50-70%) of the cells in the substantia nigra (SN) has already been destroyed. This degeneration progresses until, within a few years, most of the cells have died. Except for rare cases of familial PD, the initial trigger for cell loss is unknown. However, we do have some clues as to why the damage, once initiated, progresses unabated. It would represent a major advance in therapy to arrest cell loss at the stage when the patient first presents at the clinic. Current therapies for Parkinson’s disease focus on relieving the motor symptoms of the disease, these unfortunately lose their effectiveness as the neurodegeneration and symptoms progress. Many experimental approaches are currently being investigated attempting to alter the progression of the disease. These range from replacement of the lost neurons to neuroprotective therapies; each of these will be briefly discussed in this review. The main thrust of this review is to explore the interactions between dopamine, alpha synuclein and redox-active metals. There is abundant evidence suggesting that destruction of SN cells occurs as a result of a self-propagating series of reactions involving dopamine, alpha synuclein and redox-active metals. A potent reducing agent, the neurotransmitter dopamine has a central role in this scheme, acting through redox metallo-chemistry to catalyze the formation of toxic oligomers of alpha-synuclein and neurotoxic metabolites including 6-hydroxydopamine. It has been hypothesized that these feed the cycle of neurodegeneration by generating further oxidative stress. The goal of dissecting and understanding the observed pathological changes is to identify therapeutic targets to mitigate the progression of this debilitating disease.Key Words: Parkinson’s disease, pathology, redox chemistry, metallo- chemistry, review, iron.     

The safety of istradefylline for the treatment of Parkinson’s disease

Introduction: Antagonism of the A_2A receptor improves motor behavior in patients with Parkinson’s disease (PD), according to results of clinical studies which confirm findings of previous experimental research. The xanthine derivative, istradefylline, has the longest half-life out of the available A_2A receptor antagonists. Istradefylline easily crosses the blood–brain barrier and shows a high affinity to the human A_2A receptor.

Areas covered: This narrative review aims to discuss the safety and tolerability of istradefylline against the background of the currently available drug portfolio for the treatment of PD patients.

Expert opinion: Istradefylline was safe and well tolerated in clinical trials, which have focused on l-DOPA-treated PD patients. The future of istradefylline as a complementary drug for modulation of the dopaminergic neurotransmission also relies on its potential to act like an l-DOPA plus dopamine agonist sparing future treatment alternative and to reduce the risk of predominant l-DOPA-related onset of motor complications in addition to its direct ameliorating effect on motor symptoms. Dopamine-substituting drugs may dose-dependently produce systemic side effects, particularly onset of hypotension and nausea by peripheral dopamine receptor stimulation. Istradefylline does not interfere with these peripheral receptors and therefore shows a good safety and tolerability profile.     

An evaluation of pixantrone for the treatment of non-Hodgkin’s lymphoma

ABSTRACT

Introduction: The overall prognosis for patients with relapsed or refractory aggressive non-Hodgkin’s lymphomas is poor. Only a minority of patients are able to receive autologous stem cell transplantation. Patients not transplant-eligible or patients relapsing after transplantation have an urgent need for effective treatment options. Pixantrone is the only compound approved in Europe for this situation.

Areas covered: This review describes the clinical development of pixantrone, starting with phase I trials up to phase III trials in order to define the role of pixantrone in treatment algorithms. The effectiveness of pixantrone is considered in relation to alternative therapeutic options. Furthermore, the similarities and differences between pixantrone and anthracyclines is highlighted, with a special focus on the mode of action and on cardiotoxicity.

Expert opinion: Pixantrone is a valuable treatment option in relapsed and refractory aggressive lymphomas, with documented disease responses, manageable toxicities and clear distinctions to anthracyclines. Additional studies are needed to evaluate the role of pixantrone in combination with other compounds, especially with upcoming targeted therapies, and to confirm the effectiveness of pixantrone in other lymphoma subtypes, e.g. follicular lymphomas.