Self-reported clinical pharmacy service provision in Austria: an analysis of both the community and hospital pharmacy sector-a national study.

Background With expansion of more advanced clinical roles for pharmacists we need to be mindful that the extent to which clinical pharmacy services are implemented varies from one country to another. To date no comprehensive assessment of number and types of services provided by either community or hospital pharmacies in Austria exists. Objective To analyse and describe the number and types of clinical pharmacy services provided in both community and hospital pharmacies, as well as the level of clinical pharmacy education of pharmacists across Austria. Setting Austrian community and hospital pharmacies. Method An electronic questionnaire to determine number and types of clinical pharmacy services provided was send to all chief pharmacists at all community (n = 1365) and hospital pharmacies (n = 40) across Austria. Besides current and future services provision, education and training provision were also assessed. Main outcome measure Extent of and attitude towards CPS in Austria. Results Response rates to the surveys were 19.1% (n = 261/1365) in community and 92.5% (n = 37/40) in hospital pharmacies. 59.0% and 89.2% of community and hospital pharmacies, respectively, indicated that the provision of clinical pharmacy services in Austria has increased substantially over the past 10 years. Fifty-one percent of community pharmacies reported to provide a medication review service, while 97.3% of hospitals provide a range of services. Only 18.0% of community pharmacies offer services other than medication review services at dispensing. Binary regressions show that provision of already established medication management is a predictor for the willingness of community pharmacists to extend the range of CPS (p < 0.01), while completed training in the area of clinical pharmacy is not (p > 0.05). More hospital than community pharmacists have postgraduate education in clinical pharmacy (17.4% vs 6.5%). A desire to complete postgraduate education was shown by 28.3% of community and 14.7% of hospital pharmacists. Lack of time, inadequate remuneration, lack of resources and poor relationship between pharmacists and physicians were highlighted as barriers. Conclusion Both community and hospital pharmacists show strong willingness to expand their service provision and will need continued support, such as improved legislative structures, more supportive resources and practice focused training opportunities, to further these services.

Successful treatment of cepacia syndrome with combination nebulised and intravenous antibiotic therapy.

We report the case of successful treatment of a 31-year-old lady with cystic fibrosis and an en-bloc liver-pancreas transplant, who developed cepacia syndrome on a background of chronic infection with the ET12 epidemic strain of Burkholderia cenocepacia. Combination therapy with nebulised and intravenous meropenem and tobramycin led to clinical improvement with a return to baseline function and complete resolution of the acute chest X-ray changes.

What lies beneath? Assessment of leg ulcers during acute hospital admission.

Chronic leg ulceration is a common condition often noted in patients during an acute hospital admission. We present the case of a patient in whom thorough examination and investigation of an incidentally noted ulcer revealed a serious, previously unexpected diagnosis of disseminated Merkel cell carcinoma. This article illustrates how important it is that medical staff are aware of the different patterns of an ulcer disease and are alert to atypical appearances. Acute admission, regardless of cause, represents an opportunity for full examination of all ulcers with a view to further investigation or specialist referral if needed. Such assessment can support the often overburdened community services and ensure appropriate investigation and treatment, particularly in the context of detecting malignancy.

A qualitative study of determinants of patient behaviour leading to an infection related hospital admission.

Objectives To describe and understand the determinants of patients' behaviours surrounding admission to hospital for an acute infective episode Method Patients admitted to the infection or acute medicine admission units of a major Scottish teaching hospital and commenced on antibiotic therapy after admission were included. Semi-structured face-to-face interviews were conducted using a pre-piloted interview schedule guide that focused on gathering information about patient behaviours and experiences prior to admission to hospital with an acute infection. Interviews were audio-recorded, transcribed verbatim and analysed using the Framework Approach. Emerging themes were matched to the Theoretical Domains Framework of behavioural determinants. Results Twenty-one patients consented to participate and 18 transcripts were suitable for analysis. The most common infections were those of the skin, soft tissue and respiratory tract. From the patients' perspectives, behavioural determinants that appeared to impact their admission to hospital were principally their knowledge, beliefs of consequences, the environmental context and resources (mainly out-of-hours services), social influences and their own emotions. Determinants such as knowledge of the signs and symptoms, beliefs of consequences and environmental context were facilitators of health seeking behaviours. The main barriers were a lack of awareness of consequences of infection potentially leading to delayed admission impacting infection severity, stay in secondary care and resource utilisation. Conclusions This study has shown that any initial patient-centred intervention that is proposed to change patient behaviour needs to be based on behavioural determinants emerging in this research. The intervention may include aspects such as patient education on resources available out-of-hours and ways to access the healthcare system, education on recognising signs of infection leading to prompter treatment and positive reinforcement for patients who present with recurrences of infection.

A mixed methods investigation into the use of non-technical skills by community and hospital pharmacists.

BACKGROUND: Non-technical skills refer to the social and cognitive factors that may influence efficient and safe job performance. Non-technical skills are an important element of patient safety in a variety of health care disciplines, including surgery, anesthesia and nursing. However, the use of non-technical skills in pharmacy practice has not yet been fully assessed. OBJECTIVE: To examine attitudes toward, and use of, non-technical skills by pharmacy personnel. METHODS: A mixed methods approach was used: An attitude survey explored pharmacy personnel attitudes towards non-technical skills and inter-professional collaboration, with community and hospital pharmacy staff (n = 62). Qualitative interviews were then conducted using the critical incident technique, with community pharmacists (n = 11). RESULTS: The survey results demonstrated differences in the opinions of community and hospital pharmacists on three non-technical skill constructs: team structure, mutual support, and situation monitoring, with community pharmacists reporting significantly more positive attitudes about all three constructs. Both groups reported low levels of collaboration with primary care physicians. The interviews identified five non-technical skills as key elements of successful pharmacist performance from the interview transcripts: teamwork; leadership; task management; situation awareness; decision-making. CONCLUSION: The survey and interviews identified the non-technical skills that are important to pharmacists. This represents the first step towards the development of a behavioral rating system for training purposes that could potentially improve the non-technical skills of pharmacists and enhance patient safety.

Proteolytic cleavage of the fusion protein but not membrane fusion is required for measles virus-induced immunosuppression in vitro.

Immunosuppression induced by measles virus (MV) is associated with unresponsiveness of peripheral blood lymphocytes (PBL) to mitogenic stimulation ex vivo and in vitro. In mixed lymphocyte cultures and in an experimental animal model, the expression of the MV glycoproteins on the surface of UV-inactivated MV particles, MV-infected cells, or cells transfected to coexpress the MV fusion (F) and the hemagglutinin (H) proteins was found to be necessary and sufficient for this phenomenon. We now show that MV fusion-inhibitory peptides do not interfere with the induction of immunosuppression in vitro, indicating that MV F-H-mediated fusion is essentially not involved in this process. Proteolytic cleavage of MV F(0) protein by cellular proteases, such as furin, into the F(1)-F(2) subunits is, however, an absolute requirement, since (i) the inhibitory activity of MV-infected BJAB cells was significantly impaired in the presence of a furin-inhibitory peptide and (ii) cells expressing or viruses containing uncleaved F(0) proteins revealed a strongly reduced inhibitory activity which was improved following trypsin treatment. The low inhibitory activity of effector structures containing mainly F(0) proteins was not due to an impaired F(0)-H interaction, since both surface expression and cocapping efficiencies were similar to those found with the authentic MV F and H proteins. These results indicate that the fusogenic activity of the MV F-H complexes can be uncoupled from their immunosuppressive activity and that the immunosuppressive domains of these proteins are exposed only after proteolytic activation of the MV F(0) protein.

Measles virus-induced immunosuppression in vitro is independent of complex glycosylation of viral glycoproteins and of hemifusion.

Expression of the measles virus (MV) F/H complex on the surface of viral particles, infected cells, or cells transfected to express these proteins (presenter cells [PC]) is necessary and sufficient to induce proliferative arrest in both human and rodent lymphoid cells (responder cells [RC]). This inhibition was found to occur independent of apoptosis and soluble mediators excluded by a pore size filter of 200 nm released from either PC or RC. We now show that reactive oxygen intermediates which might be released by RC or PC also do not contribute to MV-induced immunosuppression in vitro. Using an inhibitor of Golgi-resident mannosidases (deoxymannojirimycin), we found that complex glycosylation of the F and H proteins is not required for the induction of proliferative arrest of RC. As revealed by our previous studies, proteolytic cleavage of the MV F protein precursor into its F1 and F2 subunits, but not of F/H-mediated cellular fusion, was found to be required, since fusion-inhibitory peptides such as Z-D-Phe-L-Phe-Gly (Z-fFG) did not interfere with the induction of proliferative inhibition. We now show that Z-fFG inhibits cellular fusion at the stage of hemifusion by preventing lipid mixing of the outer membrane layer. These results provide strong evidence for a receptor-mediated signal elicited by the MV F/H complex which can be uncoupled from its fusogenic activity is required for the induction of proliferative arrest of human lymphocytes.

Alzheimer's amyloid precursor protein-positive degenerative neurites exist even within kuru plaques not specific to Alzheimer's disease.

To clarify the relationship between amyloid formation and amyloid precursor protein (APP), the brain sections from eight patients with Alzheimer's disease (AD) and four with Gerstmann-Sträussler Syndrome (GSS) were investigated immunohistochemically by the double-immunostaining method. In AD, most APP-positive senile plaques belong to classical plaques or primitive plaques, whereas in diffuse plaques, APP-positive neuritic components are rarely observed. The authors documented that anti-APP-labeled degenerative neurites surrounding kuru plaques in all four GSS patients. These kuru plaques were verified by double immunostaining using anti-prion protein and anti-APP. The APP-positive structures in kuru plaques were almost identical with those seen in the classical plaques in AD. The authors concluded that APP-positive degenerative neurites are not an early event in the amyloid formation of senile plaques. It is therefore postulated that depositions of beta/A4 and prion proteins are primary events that may involve the surrounding microenvironment and result in the secondary formation of APP-positive degenerative neurites, not specific to AD.

Detection of psychological distress in patients with psoriasis: low consensus between dermatologist and patient.

BACKGROUND: Researchers have indicated that 30-40% of patients with psoriasis suffer significant psychological distress. For the appropriate clinical management of the patient with psoriasis it is important that dermatologists are able to recognize this distress. OBJECTIVES: To examine the level of agreement between dermatologists and patients with psoriasis as to the presence of clinically significant psychological distress. METHODS: Forty-three consultations between dermatologists and patients with psoriasis were assessed. Following the consultation two assessments were undertaken: the patients completed measures of anxiety and depression, and the consulting dermatologists recorded whether they believed the patient to be psychologically distressed and, if so, their subsequent action. At the end of the study, all dermatologists who participated completed the Jefferson Scale of Physician Empathy. RESULTS: Self-report questionnaires indicated that 37% and 12% of patients were identified as probable clinical cases for anxiety and depression, respectively. In general, the level of agreement between patient rating and dermatologist rating as to the presence of anxiety or depression was low (kappa statistic 0.24 and 0.26, respectively). Dermatologist empathy level did not appear to influence identification of distress. In only 39% of cases were the psychological difficulties of significantly distressed patients raised by dermatologists during the consultation. CONCLUSIONS: Agreement between dermatologists and patients with psoriasis regarding the presence of clinically significant psychological distress was low. When dermatologists did identify patients as being anxious and/or depressed, in the majority of cases no further action was taken following the consultation. This study highlights a number of areas for improvement in the psychological management of patients with psoriasis.