Allopurinol use in a New Zealand population: prevalence and adherence.

Allopurinol is effective for the control of gout and its long-term complications when taken consistently. There is evidence that adherence to allopurinol therapy varies across population groups. This may exacerbate differences in the burden of gout on population groups and needs to be accurately assessed. The aim of this study was to describe the prevalence of allopurinol use in a region of New Zealand using community pharmacy dispensing data and to examine the levels of suboptimal adherence in various population groups. Data from all community pharmacy dispensing databases in a New Zealand region were collected for a year covering 2005/2006 giving a near complete picture of dispensings to area residents. Prevalence of allopurinol use in the region by age, sex, ethnicity and socioeconomic position was calculated. Adherence was assessed using the medication possession ratio (MPR), with a MPR of 0.80 indicative of suboptimal adherence. Multiple logistic regression was used to explore variations in suboptimal adherence across population groups. A total of 953 people received allopurinol in the study year (prevalence 3%). Prevalence was higher in males (6%) than in females (1%) and Maori (5%) than non-Maori (3%). The overall MPR during the study was 0.88, with 161 (22%) of patients using allopurinol having suboptimal adherence. Non-Maori were 54% less likely to have suboptimal allopurinol adherence compared to Maori (95% CI 0.30-0.72, p = 0.001). These findings are consistent with those from other studies nationally and internationally and point to the important role for health professionals in improving patient adherence to an effective gout treatment.

Too much and too little? Prevalence and extent of antibiotic use in a New Zealand region.

OBJECTIVES: Although antibiotic use in the community is a significant contributor to resistance, little is known about social patterns of use. This study aimed to explore the use of antibiotics by age, gender, ethnicity, socio-economic status and rurality. METHODS: Data were obtained on all medicines dispensed to ambulatory patients in one isolated town for a year, and data on antibiotics are presented in this paper. Demographic details were obtained from pharmacy records or by matching to a national patient dataset. RESULTS: During the study year, 51% of the population received a prescription for one or more antibiotics, and on average people in the region received 10.15 defined daily doses (DDDs). Prevalence of use was higher for females (ratio, 1.18), and for young people (under 25) and the elderly (75 and over), and the amount in DDDs/person/year broadly followed this pattern. Maori (indigenous New Zealanders) were less likely to receive a prescription (48% of the population) than non-Maori (55%) and received smaller quantities on average. Rural Maori, including rural Maori children, received few prescriptions and low quantities of antibiotics compared with other population groups. CONCLUSIONS: The level of antibiotic use in the general population is high, despite campaigns to try to reduce unnecessary use. The prevalence of acute rheumatic fever is high amongst rural Maori, and consequently treatment guidelines recommend prophylactic use of antibiotics for sore throat in this population. This makes the comparatively very low level of use of antibiotics amongst rural Maori children very concerning.

The Equity in Prescription Medicines Use Study: using community pharmacy databases to study medicines utilisation.

PURPOSE: Pharmacy dispensing databases provide a comprehensive source of data on medicines use free from many of the biases inherent in administrative databases. There are challenges associated with using pharmacy databases however. This paper describes the methods we used, and their performance, so that other researchers considering using pharmacy databases may benefit from our experiences. METHODS: Data were collected from all nine pharmacy dispensing databases in an isolated New Zealand town for the period October 2005-September 2006. Probabilistic record matching was used to link individuals across pharmacies. Patient addresses from the pharmacy data were geo-located to small areas so an area measure of socioeconomic deprivation could be assigned. Medicines were coded according to the ATC-DDD drug classification system. RESULTS: Data on 619,264 dispensings were collected. Record matching reduced an initial pool of individuals from 54,484 to 38,027. Socioeconomic deprivation ranks were assigned for 30,972 (93%) of the 33,375 unique addresses identified, or 36,048 (95%) of individuals. ATC codes were assigned to 613,490 (99%) of the dispensings, with DDDs assigned to 561,223 (91%). Overall, 93% of dispensing records had complete demographic and drug information. CONCLUSIONS: The methods described in this paper generated a rich dataset for medicines use research. These methods, while initially resource-intensive, can to a great extent be automated and applied to other locations, and will hopefully prove useful to other researchers facing similar challenges with using pharmacy databases. However, it is difficult to envisage these methods being viable on a long-term or national scale.

The influence of porosity changes in human epidermal membrane during iontophoresis on the permeability enhancement of a model peptide.

PURPOSE: We tested the hypothesis that the increases in the porosity of the skin during iontophoresis would not significantly increase the transport of peptides due to the small size of electrically induced pores. To investigate this mechanistically, we used human epidermal membrane under constant voltage conditions, applying the Nernst-Planck equation to the transport of a small ionic solute, tetraethylammonium bromide (TEAB), and a model peptide, luteinizing hormone releasing hormone. METHODS: Steady-state flux of the drugs was determined under passive conditions and also during iontophoresis using constant DC voltages applied across side-by-side diffusion cells. Electrical conductance measurements were used to monitor the porosity changes that occur during electrical field application. RESULTS: Porosity increases observed in the membrane substantially increased the permeability enhancement of the small ionic solute TEAB. The permeability enhancement was well described by Nernst-Planck model predictions after porosity changes in the membrane were taken into account. Enhancement of luteinizing hormone releasing hormone under identical conditions was much less than TEAB. The porosity increases induced by iontophoresis had little or no effect on the permeability enhancement of the larger molecule. CONCLUSIONS: These findings closely parallel those reports that have found electrically induced pores to be significantly smaller than preexisting pores in the human epidermal membrane. The data obtained also support the view that iontophoresis-induced pores, alone, may provide limited benefit for macromolecule transport across the skin.

Personal development planning: first-year Master of Pharmacy students' engagement with, and attitudes towards, reflective self-assessment.

OBJECTIVES: The aims of this study were to determine whether first-year Master of Pharmacy (MPharm) students would engage with an activity similar to pharmacists' continuing professional development, and to explore attitudes surrounding this task. METHODS: A paper version of the Royal Pharmaceutical Society of Great Britain's electronic template for recording continuing professional development was developed. Students were asked to use this paper version to record the planning, action and evaluation carried out while completing a written assignment. The records were assessed to determine any reflective self-assessment contained in the evaluation section, and whether this reflection related to the specified learning outcome and the planning and action stages. Six focus groups were run, during which the students discussed their reaction to completing these records. The study was carried out during the first semester with first-year undergraduate MPharm students in the School of Pharmacy and Pharmaceutical Sciences at the University of Central Lancashire in the UK. KEY FINDINGS: It was found that few students appeared to engage fully with the whole recording process. During focus-group sessions competence to self-assess was raised as an issue by students, and the value of the reflective process was questioned. Some students did recognize the value of undertaking and recording reflective self-assessment. CONCLUSIONS: It appears that undergraduate students need a more gradual introduction to the process of reflective self-assessment. We suggest that the findings are linked to students' previous education experience and conclude there is a need for students to be encouraged to take ownership of their undergraduate learning, to gain confidence in self-assessment and to increase the value they place on reflection.

Effect of permeation enhancer pretreatment on the iontophoresis of luteinizing hormone releasing hormone (LHRH) through human epidermal membrane (HEM).

A 2 x 2 factorial design was performed to determine the effect of a permeation enhancer (oleic acid/propylene glycol), iontophoresis (2 V), and the combination of the two treatments on the permeation enhancement of a model peptide, LHRH (luteinizing hormone releasing hormone), through human epidermal membrane (HEM). In parallel studies, TEAB (tetraethylammonium bromide, a small ionic solute) and sucrose (an electroosmotic flow marker) were also investigated. Structural changes in the HEM were monitored via conductance measurements, differential scanning calorimetry (DSC), and infrared (IR) spectroscopy experiments. LHRH enhancement due to enhancer in combination with iontophoresis (I + E; 29.5 times passive permeability, P), was greater than during iontophoresis alone (I; 14.3) and enhancer treatment alone (E; 3.5). I + E had an additive effect of I and E, indicating the mechanisms of action of the individual enhancement strategies were likely to be located at different sites in the skin. Also, no synergistic enhancement was observed with I + E for either TEAB or sucrose. For TEAB, permeability enhancement due to I (approximately 1400) was much higher than that due to E (14.9), and no additive effect could be detected. For sucrose, E had no effect on either passive or iontophoretic permeability, eliminating the possibility that electroosmosis could explain increases in LHRH permeability. Evidence of synergy between E and I was found, with conductance measurements indicating that I + E synergistically increased the membrane permeability to conducting ions (Na+ and Cl-). It appears these pathways were not available for transport for the solutes used in the current study. DSC and IR investigations showed significant changes in stratum corneum lipid structure following E treatment but not following I. These findings probably arise from the localized action of iontophoresis compared with the bulk action of enhancer. In summary, increased LHRH delivery through HEM in vitro can be achieved using an enhancer in combination with iontophoresis.

Moral development of first-year pharmacy students in the United Kingdom.

OBJECTIVE: To investigate the moral development of pharmacy students over their first academic year of study at a university in the United Kingdom. METHODS: Pharmacy students completed Defining Issues Test (DIT) at the start of their first year (phase 1) and again at the end of their first year (phase 2) of the program. RESULTS: Pharmacy students (N=116) had significantly higher moral reasoning at the beginning of their first year than by the end of it. Scores differed by students' gender and age; however, these findings differed between phase 1 and phase 2. CONCLUSION: First-year pharmacy students in the United Kingdom scored lower on moral reasoning than did pharmacy students in the United States and Canada.

Equity in statin use in New Zealand.

INTRODUCTION: Preventive medications such as statins are used to reduce cardiovascular risk. There is some evidence to suggest that people of lower socioeconomic position are less likely to be prescribed statins. In New Zealand, Maori have higher rates of cardiovascular disease. AIM: This study aimed to investigate statin utilisation by socioeconomic position and ethnicity in a region of New Zealand. METHODS: This was a cross-sectional study in which data were collected on all prescriptions dispensed from all pharmacies in one city during 2005/6. Linkage with national datasets provided information on patients' age, gender and ethnicity. Socioeconomic position was identified using the New Zealand Index of Socioeconomic Deprivation 2006. RESULTS: Statin use increased with age until around 75 years. Below age 65 years, those in the most deprived socioeconomic areas were most likely to receive statins. In the 55-64 age group, 22.3% of the most deprived population received a statin prescription (compared with 17.5% of the mid and 18.6% of the least deprived group). At ages up to 75 years, use was higher amongst Maori than non-Maori, particularly in middle age, where Maori have a higher risk of cardiovascular disease. In the 45-54 age group, 11.6% of Maori received a statin prescription, compared with 8.7% of non-Maori. DISCUSSION: Statin use approximately matched the pattern of need, in contrast to other studies which found under-treatment of people of low socioeconomic position. A PHARMAC campaign to increase statin use may have increased use in high-risk groups in New Zealand.

Empathy levels in first- and third-year students in health and non-health disciplines.

OBJECTIVE: To compare empathy scores between health professions students (pharmacy and nursing) and non-health professions (law) students and between first- and third-year students. METHODS: The Jefferson Scale of Physician Empathy-Student Version was completed by 282 students. RESULTS: Nursing and pharmacy students had significantly more empathy than did law students. Third-year pharmacy students scored higher on empathy than did first-year pharmacy students, whereas the converse was true for nurses. There was no significant difference in empathy between first- and third-year law students. Across the study years, empathy increased among pharmacy students, decreased among nurses, and remained the same among law students. Women scored higher on empathy than did males. CONCLUSIONS: Empathy scores among university students vary depending on discipline and year of study.

Poisoning due to water hemlock.

INTRODUCTION: Water hemlock, which encompasses a range of species divided across two genera (Cicuta and Oenanthe), are regarded as being among the most poisonous plants both in North America and in the United Kingdom. Despite their toxicity, the literature consists almost entirely of case reports. AIM: The aim of this review is to summarize this literature by covering all aspects of taxonomy and botanical characterization, principal toxins, basic pharmacology including mechanisms of toxicity, and the clinical features, diagnosis, and management of poisoning. MECHANISMS OF TOXICITY: The principal toxins, cicutoxin and oenanthotoxin, belong to a group of C17 conjugated polyacetylenes. They act as (noncompetitive) gamma-aminobutyric acid antagonists in the central nervous system (CNS), resulting in unabated neuronal depolarization that can lead to seizures. Ingestion of even a small amount of plant matter may result in severe intoxication. FEATURES: After ingestion, the patient is most likely to experience CNS stimulatory effects including seizures that, in the absence of aggressive supportive care, can result in death. Other features include nausea, vomiting, diarrhea, tachycardia, mydriasis, rhabdomyolysis, renal failure, coma, respiratory impairment, and cardiac dysrhythmias. MANAGEMENT: Treatment consists mainly of prompt airway management and seizure control, plus decontamination if achieved early and after stabilization. In the event of renal failure, the use of hemodialysis has been employed successfully. CONCLUSIONS: The ingestion of water hemlock can lead to serious complications that may be fatal. Prognosis is good, however, if prompt supportive care is provided.

How many antibiotic prescriptions are unsubsidised in New Zealand?

AIMS: To determine the proportion of prescriptions for antibiotics which were unsubsidised, in one town in one year, and to use this to develop a model which could be used to estimate the number of unsubsidised prescriptions. METHODS: Data on all prescriptions for antibiotics during 2002 were extracted from pharmacy computers in one town. Data were obtained from PharmHouse database on all subsidised prescriptions from the town pharmacies during 2002. (The PharmHouse database is a subset of the New Zealand Health Information System database and contains records of all the claims for medicines dispensed within New Zealand.) These were compared and the proportion of unsubsidised prescriptions for each antibiotic calculated. Weighted linear regression was used to develop a model of the relationship between the percentage of each drug subsidised, and patient and prescription characteristics obtainable in PharmHouse. RESULTS: 64.4% of antibiotic dispensings in the study town were subsidised, and therefore captured by the PharmHouse database. The proportion varied substantially between different antibiotics. For particular drugs, the proportion of drugs unsubsidised could be predicted by the price of the drug, the number of days it was prescribed for, and the number of patients aged under six who received subsidised prescriptions. CONCLUSIONS: Previous studies using PharmHouse data are likely to have significantly underestimated the extent of drug use. Further research is needed on whether this model can help to estimate the extent of unsubsidised prescriptions.

Demographic variation in the use of antibiotics in a New Zealand town.

AIMS: To describe the use of antibiotics in one New Zealand town, and to investigate relationships between antibiotic use and gender, age, and socioeconomic status. METHODS: Data from dispensing computers in all community pharmacies in the town were extracted. All dispensings of antibiotics to residents in the town were identified. Discrete individuals were identified and, where possible, linked with data on gender, age and the socioeconomic status (NZDep) of the area in which they lived. RESULTS: 42% of residents in the town received one or more dispensing of antibiotics in 2002. These people, on average, received 2.1 dispensings. Children received antibiotics more often than adults, females more than males and there was a strong relationship between socioeconomic status and antibiotic dispensings. CONCLUSIONS: Rates of antibiotic use in the community are strongly influenced by age, gender and socioeconomic status.

Capturing data on medicines usage: the potential of community pharmacy databases.

AIMS: The initial aim of the research projects was to examine the geographic distribution, patronage patterns, and loyalty of prescription clients around individual community pharmacies. A second aim was to explore the geographical and socioeconomic variation in the use of prescription medicines and prescribing trends both between and within therapeutic classes. METHODS: Geographic Information Systems (GIS) technology (including the tabulating, geocoding, and mapping functions) was used to analyse the information that is held in community pharmacy databases. RESULTS: These studies demonstrated the use of this technology to show variation in local use of prescription medicines, at both an individual level and a population level, through the analysis of data already held in community pharmacy databases. CONCLUSION: The use of GIS technology and pre-existing community pharmacy databases enables improved data capture on the prescription--and medication-related behaviour of health-service consumers.