Shared decision making and experiences of patients with long-term conditions: has anything changed?

BACKGROUND: Medication problems among patients with long-term conditions (LTCs) are well documented. Measures to support LTC management include: medicine optimisation services by community pharmacists such as the Medicine Use Review (MUR) service in England, implementation of shared decision making (SDM), and the availability of rapid access clinics in primary care. This study aimed to investigate the experience of patients with LTCs about SDM including medication counselling and their awareness of community pharmacy medication review services. METHODS: A mixed research method with a purposive sampling strategy to recruit patients was used. The quantitative phase involved two surveys, each requiring a sample size of 319. The first was related to SDM experience and the second to medication counselling at discharge. Patients were recruited from medical wards at St. George's and Croydon University Hospitals.The qualitative phase involved semi-structured interviews with 18 respiratory patients attending a community rapid access clinic. Interviews were audio-recorded and transcribed verbatim. Thematic analysis using inductive/deductive approaches was employed. Survey results were analysed using descriptive statistics. RESULTS: The response rate for surveys 1 and 2 survey was 79% (n = 357/450) and 68.5% (240/350) respectively. Survey 1 showed that although 70% of patients had changes made to their medications, only 40% were consulted about them and two-thirds (62.2%) wanted to be involved in SDM. In survey 2, 37.5% of patients thought that medication counselling could be improved. Most patients (88.8%) were interested in receiving the MUR service; however 83% were not aware of it. The majority (57.9%) were interested in receiving their discharge medications from community pharmacies. The interviews generated three themes; lack of patient-centered care and SDM, minimal medication counselling provided and lack of awareness about the MUR service. CONCLUSION: Although patients wanted to take part in SDM, yet SDM and medication counselling are not optimally provided. Patients were interested in the MUR service; however there was lack of awareness and referral for this service. The results propose community pharmacy as a new care pathway for medication supply and counselling post discharge. This promotes a change of health policy whereby community-based services are used to enhance the performance of acute hospitals.

Gastric emptying of solids and liquids for evaluation for gastroparesis.

BACKGROUND: Gastric emptying scintigraphy (GES) of solids is typically used to evaluate for gastroparesis. AIMS: The purpose of this study was to determine the value of simultaneously measuring gastric emptying of liquids and solids for assessing patients for delayed gastric emptying. METHODS: A total of 596 patients at our institution from September 2007 to January 2010 underwent GES with assessment of both solid and liquid gastric emptying. An EggBeaters® with jam sandwich meal radiolabeled with Tc-99 m was used for solid GES and water radiolabeled with In-111 for liquid GES. RESULTS: Inclusion criteria (no medications affecting gastric motility in 48 h prior to test; no prior gastric surgery) was met by 449 patients. Liquid gastric emptying was significantly correlated to solid gastric emptying: 30 min (r=0.652, P<0.001), 60 min (r=0.624, P<0.001) and 120 min (r=0.766, P<0.001). Interestingly, 60 patients, of which 57 were nondiabetic, had normal solid GES but delayed liquid emptying and represented 26% of the 228 patients with normal solid GES. Gastric retention of solids was mildly correlated with nausea, vomiting, loss of appetite, early satiety and feeling excessively full after meals. Gastric emptying of liquids was associated with early satiety and loss of appetite. CONCLUSIONS: Gastric emptying of liquids correlates well with gastric emptying of solids. When evaluating patients for gastroparesis, assessment of gastric emptying of liquids in addition to solids may help identify additional patients with delayed gastric emptying, particularly non-diabetic patients where 26% with normal solid emptying may have delayed emptying of liquids. Symptoms of gastroparesis, however, are primarily associated with delayed gastric emptying of solids.

Efficacy of cholesterol uptake inhibition added to statin therapy among subjects following a low-carbohydrate diet: a randomized controlled trial.

BACKGROUND: Low-carbohydrate diets are frequently used as part of weight-loss programs. These are typically associated with increased fat intake. Therefore, cholesterol absorption inhibition is a logical therapeutic strategy to lower low-density lipoprotein cholesterol (LDL-C) in subjects following a low-carbohydrate diet. However, the efficacy of cholesterol absorption inhibition added to statin therapy has not been studied in this common clinical setting. METHODS: We performed a randomized controlled trial to compare the effects of ezetimibe on LDL-C when added to simvastatin among subjects following a low-carbohydrate diet. We enrolled 65 subjects who were overweight or obese (body mass index 25-45 kg/m(2)) and had a moderately elevated LDL-C (130-190 mg/dL). During a 4-week diet run-in, subjects were instructed to restrict carbohydrate intake to <30 g/day. Subjects demonstrating adequate adherence to a low-carbohydrate diet (n = 58) were randomized to simvastatin (20 mg) or simvastatin (20 mg) plus ezetimibe (10 mg) for 8 weeks. RESULTS: Body weight decreased by 3.1% (95% CI 2.1%-4.0%, P < .0001), but the magnitude of weight change did not differ between the groups (P = .92). The LDL-C decreased by 32 mg/dL (95% CI 21-42 mg/dL) in the simvastatin arm and 60 mg/dL (95% CI 45-75 mg/dL) in the combined simvastatin-ezetimibe arm (P = .002). This corresponded to a 20.9% reduction (95% CI 14.5%-27.4%) in LDL-C on simvastatin alone, compared with a 37.4% reduction (95% CI 29.3%-45.6%) on simvastatin-ezetimibe (P = .002). A significant 15.8% reduction in triglycerides was observed among enrolled subjects, which did not differ between the groups. CONCLUSIONS: Among subjects following a low-carbohydrate diet, combined statin and cholesterol absorption inhibitor therapy is more effective than statin monotherapy for LDL-C lowering.

Comparison of human and porcine gastric clasp and sling fiber contraction by M2 and M3 muscarinic receptors.

To compare the gastroesophageal junction of the human with the pig, M(2) and M(3) receptor densities and the potencies of M(2) and M(3) muscarinic receptor subtype selective antagonists were determined in gastric clasp and sling smooth muscle fibers. Total muscarinic and M(2) receptors are higher in pig than human clasp and sling fibers. M(3) receptors are higher in human compared with pig sling fibers but lower in human compared with pig clasp fibers. Clasp fibers have fewer M(3) receptors than sling fibers in both humans and pigs. Similar to human clasp fibers, pig clasp fibers contract significantly less than pig sling fibers. Analysis of the methoctramine Schild plot suggests that M(2) receptors are involved in mediating contraction in pig clasp and sling fibers. Darifenacin potency suggests that M(3) receptors mediate contraction in pig sling fibers and that M(2) and M(3) receptors mediate contraction in pig clasp fibers. Taken together, the data suggest that both M(2) and M(3) muscarinic receptors mediate the contraction in both pig clasp and sling fibers similar to human clasp and sling fibers.