Community pharmacists' perspectives on assessing kidney function and medication dosing for patients with advanced chronic kidney disease: A qualitative study using the theoretical domains framework.

Background: The kidneys are responsible for the elimination of many drugs. Chronic kidney disease (CKD) is common, and medications may require adjustment to avoid adverse outcomes. Despite the availability of kidney drug dosing resources, people with CKD are at risk of inappropriate drug prescribing. Community pharmacists are in the ideal position to mitigate harm from inappropriate prescribing in this population. Methods: In this qualitative study, community pharmacists were interviewed on their perspective on kidney function assessment and dose adjustment in people with advanced CKD (estimated glomerular filtration rate <30 mL/min/1.73 m2). The theoretical domains framework for targeting behavioural change was used to inform the interview guide and analysis. Purposeful sampling was employed until data saturation. Semistructured virtual interviews were audio-recorded, transcribed verbatim and uploaded into NVIVO 12 Pro to facilitate thematic analysis. Deductive and inductive iterative coding approaches were employed to determine categories and themes. Results: Twelve pharmacists were interviewed, with a mean age of 42 years and 16 years of experience. Four themes comprising 10 categories were identified to influence kidney function assessment and dosing, including resources (information access, technology, references), environment (pharmacy infrastructure, practice setting), reflection (triggers, experience and training, collaboration) and leadership and governance (pharmacist role, advocacy). Feedback on an optimal CKD tool was collected, and enabling themes (categories) for implementation included knowledge and skills (education, training) and reflection (role, support, integration). Conclusions: Findings will inform the interventions needed to improve implementation of kidney assessment and dosing of high-risk medications in people with kidney impairment into community pharmacy practice. Can Pharm J (Ott) 2023;156:xx-xx.

The Management of the Symptomatic Patient With a Metal-on-Metal Hip Prosthesis.

Metal-on-metal (MoM) hip implants have gained popularity due to their greater stability and reduction in implant failure compare to metal-on-polyethylene prostheses. However, as well as carrying general risks of hip implantation, risks specifically associated with MoM implants have been well documented in recent years. Conditions such as pseudotumours or aseptic lymphocyte-dominated vasculitis-associated lesions are specific to MoM hip implants. In this review we discuss the typical patient presentation, the investigations that should be performed, the typical findings on various imaging modalities, and the treatment options of symptomatic patients with MoM hip arthroplasties.

St George Acute Care Team: the local variant of crisis resolution model of care.

OBJECTIVES: The objective of this study was to describe functioning and clinical activities of the St George Acute Care Team and how it compares to the typical crisis resolution model of care. METHODS: Descriptive data including demographics, sources of referral, type of clinical intervention, length of stay, diagnoses and outcomes were collected from records of all patients who were discharged from the team during a 10 week period. RESULTS: There were 677 referrals. The team's functions consisted of post-discharge follow-up (31%), triage and intake (30%), case management support (23%) and acute community based assessment and treatment (16%). The average length of stay was 5 days. The majority of patients were diagnosed with a mood (23%) or a psychotic (25%) disorder. Points of contrast to other reported crisis resolution teams include shorter length of stay, relatively less focus on direct clinical assessment and more telephone follow-up and triage. CONCLUSION: St George Acute Care Team provides a variety of clinical activities. The focus has shifted away from the original model of crisis resolution care to meet local and governmental requirements.

"Weird duality": learning from the experiences of students in university peer support roles during the COVID-19 pandemic.

Objectives: To explore university student peer supporter experiences in the pandemic context and with a specific focus on student mental health. Participants: The sample comprised 13 students from various peer support programs, providing academic, social and/or emotional support at a South-East England university. Methods: A two-phase qualitative design involved individual interviews and focus groups, followed by participant validation with a subset of participants. Results: Peer supporters identified an increased need peri-pandemic for mental health support. The accessibility was aided by students perceiving peer supporters to be approachable, but was undermined by concerns about peers' credibility. Supporter-supportee relationships were characterized by intimacy and mutuality, which were seen as conducive to authenticity, but caused challenges with respect to boundaries. Conclusions: Peer support is a complex activity, characterized by a sense of multiplicity and mutuality. Responsive supervision and dedicated training are necessary to manage these complexities amidst elevated student mental health needs.

Computed tomographic evaluation of the thymus-does obesity affect thymic fatty involution in a healthy young adult population?

OBJECTIVE: To determine a relationship between increased body mass index (BMI) and fatty involution of the thymus in subjects aged between 20 and 30 years. METHODS: CT images of 94 patients aged between 20 and 30 years were reviewed. Quantitative thymic mean attenuation was recorded and qualitative thymic attenuation was assigned to 1 of 4 possible grades. BMI and subcutaneous fat thickness were documented. Correlations between thymic attenuation, and BMI and subcutaneous fat thickness were assessed using linear regression models. Differences in thymic attenuation in overweight vs normal weight patients were assessed using t-test and Pearson Χ2 analysis. RESULTS: Low mean thymic attenuation values were associated with higher patient BMI (p = 0.024). Normal weight patients had a mean quantitative thymic attenuation of 15.5 Hounsfield unit and overweight patients had a mean quantitative thymic attenuation of -16.4 Hounsfield unit (p = 0.0218). There was a significant association between increasing subcutaneous fat thickness and reduced mean quantitative thymic attenuation (p < 0.0001). There was also a significant difference in subcutaneous fat thickness when comparing qualitatively assessed thymic Grade 0 with grades 2 and 3 (p = 0.027 and 0.001 respectively); and Grade 1 with Grade 3 (p = 0.001). CONCLUSION: In patients between 20 and 30 years old, the degree of thymic fatty infiltration is related to BMI. Advances in knowledge: Multidetector CT can assess fatty involution of the thymus gland. This retrospective study demonstrates a relationship between BMI and thymus gland fatty involution. Subjects with increased subcutaneous fat have decreased mean thymus gland attenuation.

Balloon-assisted coil embolization (BACE) of a wide-necked renal artery aneurysm using the intracranial scepter C compliant occlusion balloon catheter.

BACKGROUND: True renal artery aneurysms (TRAA) are an uncommon pathology, with a prevalence of less than 1%. Treatment of TRAAs is generally recommended when the aneurysm sac equals or exceeds 2cms. Both wide-necked and main renal artery branch aneurysms represent a challenge for conventional endovascular coil embolization due to the risk of coil migration. MAIN BODY: Intra-procedural remodeling of the aneurysm neck using Balloon Assisted Coil Embolization (BACE) is considered a suitable alternative in challenging cases of visceral artery aneurysms. SHORT CONCLUSION: We describe the novel use of the Scepter C (MicroVention Terumo, Tustin, CA) compliant double lumen neurovascular occlusion balloon in the treatment of a wide-necked branch TRAA in a patient with a solitary kidney.

Endovascular Treatment of Wide-Necked Visceral Artery Aneurysms Using the Neurovascular Comaneci Neck-Bridging Device: A Technical Report.

INTRODUCTION: Visceral and renal artery aneurysms (VRAAs) are an uncommon clinical entity but carry a risk of rupture with associated morbidity and mortality. The rupture risk is particularly high when the aneurysms are large, of unfavourable morphology or in the setting of pregnancy and perioperative period. Endovascular approaches are now first line in the treatment of VRAA, but conventional techniques may be ineffective in excluding aneurysms with unfavourable anatomy such as those with wide necks or at arterial bifurcation points. The neurovascular Comaneci neck-bridging device is used to temporarily cover the neck of intracranial aneurysms without occluding forward arterial flow during endovascular coiling. We report the novel use of the Comaneci neck-bridging device for the treatment of complex peripheral VRAAs. MATERIALS AND METHODS: We describe the treatment of two patients with renal and splenic artery aneurysms demonstrating unfavourable anatomic morphology for conventional endovascular approaches. RESULTS: In the first patient, the renal artery aneurysm was situated at the intrarenal bifurcation of the main renal artery in the setting of a solitary kidney. In the second patient, the splenic artery aneurysm was situated close to the splenic hilum at the distal splenic arterial bifurcation. The Comaneci neck-bridging device was successfully used in both cases to assist coil embolisation with visceral preservation. CONCLUSIONS: The Comaneci neck-bridging device is potentially safe and effective for the treatment of peripheral VRAA with unfavourable anatomic characteristics that would have been deemed unsuitable for treatment using conventional techniques. LEVEL OF EVIDENCE: Level 4, Technical Report.