An audit of responding to symptoms in community pharmacy

A two-stage audit of community pharmacists' service in response to symptoms was carried out using a previously piloted method. Pharmacists from up to 46 pharmacies completed questionnaires indicating the advice they thought should be given in each of 12 scenarios that could present to community pharmacies. The six scenarios with the highest consensus response were later enacted in the same pharmacies by researchers. Three were used in the first stage and three in the second. Meetings were held between the stages to discuss the results and suggest ways of improving them. The consensus advice, determined by the questionnaire responses, was given on only 27 per cent of all visits — 18 per cent in the first stage and 35 per cent in the second. This was mainly due to non-drug advice being omitted. “Appropriate” products were recommended in 90 per cent of first stage visits but only 74 per cent of second stage visits. “Acceptable” advice was provided in 75 per cent of all visits, with little difference between the two stages. Questioning of the researchers was “good” in 35 per cent of first stage visits and 43 per cent of second stage visits. Inadequate questioning was significantly related to inappropriate advice being given. Inappropriate advice was given on 25 per cent of all visits, with equal frequency by both pharmacists and assistants. Participating pharmacists identified many problems that could contribute to a less than ideal service but most were outside their control, such as television advertising of products and customer expectations. The use of protocols, implementation of staff training and the audit were considered to have had a positive effect on the response to symptoms service. Most participants considered that the method used was acceptable and suggested a similar method should be used on a regular basis to monitor the service.     

Carbon Localisation of Impalpable Mammographic Abnormalities

A prospective study was undertaken to assess the usefulness, safety and cost-effectiveness of stereotacti-cally guided carbon localisation of impalpable breast lesions. Fifty six lesions in 53 patients were iocalised by this method, some in combination with fine-needle aspiration and hookwire localisation. Some modification of the study was required due to ready acceptance of the technique by surgeons, who preferred carbon to hookwire localisation. The technique was proven to be safe and accurate, and highly acceptable to patients, referring clinicians and radiology staff. It is now the preferred procedure for localising impalpable breast lesions prior to excision biopsy.     

Urgent psychiatric transfers from prison in England and Wales: a prison perspective

Prisoners on remand are at high risk of mental illness. They have a high rate of suicide and a high incidence of psychotic illness. Provision does exist within the Mental Health Act (1983) for the emergency transfer of remanded prisoners by transfer order (section 48), but this facility is used to varying degrees throughout England and Wales. This is a retrospective case study of all patients transferred from Belrnarsh Prison under this emergency provision (S48) between April 1991 and March 1992. Twenty-two transfers were enacted (two patients on two separate occasions) during the trial period. Of these 22, 15 (68%) had a paranoid psychotic illness; 14/20 (70%) had committed serious violent offences; 14/22 (63%) were transferred to locked wards of general psychiatric hospitals; 5 (22%) went to regional secure units; 3 (14%) went to maximum secure hospitals. Rapid transfer to psychiatric hospital for all those offenders who are seriously psychiatrically ill is one of the main recommendations of a recent Department of Health/Home Office Report (Department of Health/Home Office, 1991). The existing provisions are shown to be an effective means to enact such emergency transfers. Many such transfers can be managed in the general psychiatric service.     

A Randomized, Double-Blind Comparison of Two Topical Anesthesic Formulations Prior to Electrodesiccation of Dermatosis Papulosa Nigra

BACKGROUND: Liposomal lidocaine 4% (L.M.X.4 cream, Ferndale Laboratories Inc., Ferndale, MI, USA) has been proposed as a more rapidly acting topical anesthetic than the eutectic mixture of lidocaine 2.5% and prilocaine 2.5% (EMLA cream, AstraZeneca LP, Wilmington, DE, USA) for venipuncture and laser procedures. However, their anesthetic efficacy has not been previously compared for electrosurgical destruction of superficial skin lesions. OBJECTIVE: To test the hypothesis that L.M.X.4 and EMLA differ in anesthetic efficacy when applied under occlusion for 30 minutes prior to electrodesiccation of papules of dermatosis papulosa nigra. METHODS: Forty adults were randomly assigned to treatment with either agent for 30 minutes under Tegaderm. The study drug was administered for an additional 30 minutes if the electrodesiccation of the first few papules was too painful. RESULTS: One subject treated with EMLA versus none treated with L.M.X.4 experienced complete anesthesia after a single 30-minute application. Nineteen of 20 (95%) subjects treated with EMLA versus 18 of 20 (90%) subjects treated with L.M.X.4 required only a single application (p = .49). Pain scores after the initial 30-minute application (scale: 0 = none to 10 = very severe) were EMLA 3.3 +/- 2.2 (mean +/- SD) versus L.M.X. 4 2.9 +/- 2.0 (p = .46). CONCLUSION: EMLA and L.M.X.4 provide comparable levels of anesthesia after a single 30-minute application under occlusion prior to electrodesiccation of superficial skin lesions.     

Developmental Toxicology Studies of Fluoxetine Hydrochloride Administered Orally to Rats and Rabbits

Pregnant Fischer 344 rats were given fluoxetine orally at doselevels of 0, 2, 5, or 12.5 mg/kg on Gestation Days (GD) 6–15;pregnant Dutch Belted rabbits were given 0, 2.5, 7.5, or 15mg/kg orally on GD 6–18. Cesarean sections were performedon rats and rabbits on GD 20 and 28, respectively. In rats,maternal toxicity was indicated at 12.5 mg/kg by depressionof weight gain and food consumption. Fetal viability, weight,and morphology were not affected at any dose level. Maternaland developmental No Observed Adverse Effect Levels (NOAELs)in the rat were 5 and 12.5 mg/kg, respectively. In rabbits,weight loss occurred at 2.5,7.5, and 15 mg/kg. Food consumptionwas also depressed at 7.5 and 15 mg/kg; abortions and maternalmortality occurred secondarily to anorexia and cachexia at 15mg/kg. Fetal viability, weight, and morphology were not affectedat any dose level. A NOAEL for maternal effects was not establishedin the rabbit; the NOAEL for developmental effects in the rabbitwas 15 mg/kg. Based on these data, fluoxetine did not exhibitany toxicity toward the developing rat or rabbit conceptus atdoses that were maternally toxic.     

Short-term outcome of mechanically ventilated infants weighing more than 2499 g at birth: A population based study*

Abstract: Very little data exist describing the neonatal outcome of infants of birthweight 2500 g or more who require mechanical ventilation. Our aim was to collect population-based data on such infants in New South Wales (NSW), and to monitor their neonatal morbidity, mortality to 1 year of age and the associated risk factors. The study group (NICUS infants) comprised all 341 infants weighing >2499 g who were admitted to the seven neonatal intensive care units in New South Wales and mechanically ventilated for 4 h or more between 1 January and 31 December, 1987. Two groups of infants emerged: those who were preterm and mostly had hyaline membrane disease, and term and post-term infants for whom the most common problem was ‘perinatal asphyxia’. The most important factors associated with dying were a birthweight of over 3499 g (OR = 2.6; CI 1.03–6.6) and a 1 min Apgar score <4 (OR = 4.8; C11.4–16.9). Study group mothers were significantly more likely than all NSW mothers to have had a spontaneous abortion in the previous pregnancy (P<0.01), a pre-existing medical condition or an obstetric complication in this pregnancy, or a Caesarean section for this delivery (P<0.001). This is the first population-based study of high-risk neonates without congenital anomalies to clearly document the worsening prognosis associated with a birthweight over 3499 g. Further research should be directed towards identifying prenatal and perinatal factors which might minimize the morbidity and mortality in this group of babies.     

Pilot Study to Enhance Start-up of a Multicenter Nutrition Intervention Trial

Multicenter trials are important for answering questions that require large numbers of subjects. Such trials require standardized implementation of behavioral change programs across diverse populations, regions, and staff. Researchers involved with the Trial of Nonpharmacologic Interventions in the Elderly conducted a 17-week pilot study of their most complex intervention (combined weight and sodium reduction) before actual start-up of the main study. This allowed staff to rehearse implementing the program and to identify and address intervention and standardization issues. Registered dietitians in 4 US communities recruited 28 participants for the pilot study, using eligibility criteria similar to those for the main trial. Participant evaluations reflected high satisfaction with the program materials and overall approach. Minor protocol changes suggested by results of the pilot study were made easily in time for start-up of the main study. Reductions in weight and sodium intake were less than targeted but were sufficient to suggest that the intervention would be effective under optimal conditions. This partial achievement of goals in the pilot study underscored the need to allow for a learning curve, for without it standardization and outcomes of the main study would be compromised. J Am Diet Assoc. 1998;98:322–325.