Implementation of a Patient Questionnaire in Community Pharmacies to Improve Care for Patients Using Combined Antithrombotic Therapy: A Qualitative Study.

For several indications or combinations of indications the use of more than one antithrombotic agent is required. The duration of combined antithrombotic therapy depends on indication and patient characteristics. This study investigated the use of an antithrombotic questionnaire tool that had been developed for pharmacists to detect patients with possible incorrect combined antithrombotic therapy. The objective of this study was to identify potential barriers and facilitators that could influence the implementation of the developed antithrombotic questionnaire tool in daily community pharmacy practice. A qualitative study was conducted at 10 Dutch community pharmacies in which the antithrombotic questionnaire tool had been used with 82 patients. Semi-structured interviews were conducted with pharmacy staff who used the antithrombotic questionnaire tool. The interview questions to identify barriers and facilitators were based on the Consolidated Framework for Implementation Research. The interview data were analysed using a deductive thematic analysis. Ten staff members from nine different pharmacies were interviewed. Facilitators for implementation were that the questionnaire was easily adaptable and easy to use, as well as the relative short duration to administer the questionnaire. A possible barrier for using the questionnaire was a lower priority for using the questionnaire at moments when the workload was high. The pharmacists estimated that the questionnaire could be used for 70-80% of the patient population and they thought that it was a useful addition to regular medication surveillance. The antithrombotic questionnaire tool can be easily implemented in pharmacy practice. To implement the tool, the focus should be on integrating its use into daily activities. Pharmacists can use this tool in addition to regular medication surveillance to improve medication safety in patients who use combined antithrombotic therapy.

Effect of lead position and orientation on electromagnetic interference in patients with bipolar cardiovascular implantable electronic devices.

Aims: Electromagnetic interferences (EMIs) with cardiovascular implantable electronic devices (CIEDs) are associated with potential risk for patients. Studies imply that CIED sensitivity setting and lead's tip-to-ring spacing determine the susceptibility of CIEDs with bipolar leads to electric and magnetic fields (EMFs); however, little is known about additional decisive parameters affecting EMI of CIEDs. We therefore investigated the influence of different patient-, device-, and lead-depending variables on EMIs in 160 patients. Methods and Results: We ran numerical simulations with human models to determine lead-depending variables on the risk of EMI by calculating the voltage induced in bipolar leads from 50/60 Hz EMF. We then used the simulation results and analysed 26 different patient-, device-, and lead-depending variables with respect to the EMI threshold of 160 CIED patients. Our analyses revealed that a horizontal orientation and a medial position of the bipolar lead's distal end (lead-tip) are most beneficial for CIED patients to reduce the risk of EMI. In addition, the effect of CIED sensitivity setting and lead's tip-to-ring spacing was confirmed. Conclusion: Our data suggest that in addition to the established influencing factors, a medial position of the lead-tip for the right ventricular lead as achievable at the interventricular septum and a horizontal orientation of the lead-tip can reduce the risk of EMI. In the right atrium, a horizontal orientation of the lead-tip should generally be striven independent of the chosen position. Still important to consider remains a good intrinsic sensing amplitude during implant procedure.

Electromagnetic interference with implantable cardioverter-defibrillators at power frequency: an in vivo study.

BACKGROUND: The number of implantable cardioverter-defibrillators (ICDs) for the prevention of sudden cardiac death is continuing to increase. Given the technological complexity of ICDs, it is of critical importance to identify and control possible harmful electromagnetic interferences between various sources of electromagnetic fields and ICDs in daily life and occupational environments. METHODS AND RESULTS: Interference thresholds of 110 ICD patients (1-, 2-, and 3-chamber ICDs) were evaluated in a specifically developed test site. Patients were exposed to single and combined electric and magnetic 50-Hz fields with strengths of up to 30 kV·m⁻¹ and 2.55 mT. Tests were conducted considering worst-case conditions, including maximum sensitivity of the device or full inspiration. With devices being programmed to nominal sensitivity, ICDs remained unaffected in 91 patients (83%). Five of 110 devices (5%) showed transient loss of accurate right ventricular sensing, whereas 14 of 31 (45%) of the 2- and 3-chamber devices displayed impaired right atrial sensing. No interference was detected in 71 patients (65%) within the tested limits with programming to maximum sensitivity, whereas 20 of 110 subjects (18%) exhibited right ventricular disturbances and 19 of 31 (61%) subjects exhibited right atrial disturbances. CONCLUSIONS: Extremely low-frequency daily-life electromagnetic fields do not disturb sensing capabilities of ICDs. However, strong 50-Hz electromagnetic fields, present in certain occupational environments, may cause inappropriate sensing, potentially leading to false detection of atrial/ventricular arrhythmic events. When the right atrial/right ventricular interferences are compared, the atrial lead is more susceptible to electromagnetic fields. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov/ct2/show/NCT01626261. Unique identifier: NCT01626261.