Evaluation of a training programme for Pharmacist Independent Prescribers in a care home medicine management intervention.

BACKGROUND: The provision of independent prescribing rights for United Kingdom (UK) pharmacists has enabled them to prescribe within their area of competence. The aim of this study was to evaluate an evidence-based training programme designed to prepare Pharmacist Independent Prescribers (PIPs) to safely and effectively assume responsibility for pharmaceutical care of older people in care homes in the UK, within a randomised controlled trial. METHODS: The training and competency assessment process included two training days, professional development planning against a bespoke competency framework, mentor support, and a viva with an independent General Practitioner (GP). Data on the PIPs' perceptions of the training were collected through evaluation forms immediately after the training days and through online questionnaires and interviews after delivery of the 6-month intervention. Using a mixed method approach each data set was analysed separately then triangulated providing a detailed evaluation of the process. Kaufman's Model of Learning Evaluation guided interpretations. RESULTS: All 25 PIPs who received the training completed an evaluation form (N = 25). Post-intervention questionnaires were completed by 16 PIPs and 14 PIPs took part in interviews. PIPs reported the training days and mentorship enabled them to develop a personalised portfolio of competence in preparation for discussion during a viva with an independent GP. Contact with the mentor reduced as PIPs gained confidence in their role. PIPs applied their new learning throughout the delivery of the intervention leading to perceived improvements in residents' quality of life and medicines management. A few PIPs reported that developing a portfolio of competence was time intensive, and that further training on leadership skills would have been beneficial. CONCLUSIONS: The bespoke training programme was fit for purpose. Mentorship and competency assessment were resource intensive but appropriate. An additional benefit was that many PIPs reported professional growth beyond the requirement of the study. TRIAL REGISTRATION: The definitive RCT was registered with the ISRCTN registry (registration number ISRCTN 17,847,169 ).

Concerns, perceived need and competing priorities: a qualitative exploration of decision-making and non-participation in a population-based flexible sigmoidoscopy screening programme to prevent colorectal cancer.

OBJECTIVE: Optimising uptake of colorectal cancer (CRC) screening is important to achieve projected health outcomes. Population-based screening by flexible sigmoidoscopy (FS) was introduced in England in 2013 (NHS Bowel scope screening). Little is known about reactions to the invitation to participate in FS screening, as offered within the context of the Bowel scope programme. We aimed to investigate responses to the screening invitation to inform understanding of decision-making, particularly in relation to non-participation in screening. DESIGN: Qualitative analysis of semistructured in-depth interviews and written accounts. PARTICIPANTS AND SETTING: People from 31 general practices in the North East and East of England invited to attend FS screening as part of NHS Bowel scope screening programme were sent invitations to take part in the study. We purposively sampled interviewees to ensure a range of accounts in terms of beliefs, screening attendance, sex and geographical location. RESULTS: 20 screeners and 25 non-screeners were interviewed. Written responses describing reasons for, and circumstances surrounding, non-participation from a further 28 non-screeners were included in the analysis. Thematic analysis identified a range of reactions to the screening invitation, decision-making processes and barriers to participation. These include a perceived or actual lack of need; inability to attend; anxiety and fear about bowel preparation, procedures or hospital; inability or reluctance to self-administer an enema; beliefs about low susceptibility to bowel cancer or treatment and understanding of harm and benefits. The strength, rather than presence, of concerns about the test and perceived need for reassurance were important in the decision to participate for screeners and non-screeners. Decision-making occurs within the context of previous experiences and day-to-day life. CONCLUSIONS: Understanding the reasons for non-participation in FS screening can help inform strategies to improve uptake and may be transferable to other screening programmes.

Symptom appraisal and healthcare-seeking for symptoms suggestive of colorectal cancer: a qualitative study.

OBJECTIVES: Timely diagnosis of colorectal cancer is important to improve survival. This study explored symptom appraisal and help-seeking among patients referred to specialist services with symptoms of colorectal cancer. DESIGN: Qualitative in-depth interview study. SETTING AND PARTICIPANTS: Participants were recruited on referral to gastroenterology clinics (North East and East of England); interviews were conducted soon after referral. We purposively sampled participants to ensure a range of accounts in terms of age, sex, diagnosis and geographical location. METHODS: Data collection and analysis were underpinned by the Model of Pathways to Treatment. Framework analysis was used to explore the data within and across cases, focusing on patient beliefs and experiences, disease factors and healthcare influences. RESULTS: 40 participants were interviewed (aged 43-87 years, 17 women, 18 diagnosed with colorectal cancer). Patients diagnosed with and without colorectal cancer had similar symptom pathways. We found a range of interacting and often competing biopsychosocial, contextual and cultural influences on the way in which people recognised, interpreted and acted on their symptoms. People attempted to 'maintain normality' through finding benign explanations for their symptoms. Bodily changes were appraised within the context of usual bowel patterns, comorbidities and life events, and decisions to seek help were made in relation to expectations about the course of symptoms. The 'private nature' of colorectal cancer symptoms could affect both their identification and discussions with others including healthcare professionals. Within the context of the National Health Service, people needed to legitimise appropriate use of healthcare services and avoid being thought of as wasting doctors' time. CONCLUSIONS: Findings provide guidance for awareness campaigns on reducing stigma around appraising and discussing bowel movements, and the importance of intermittent and non-specific symptoms. Altering perceptions about the appropriate use of health services could have a beneficial effect on time to presentation.

Patient drawings of their melanoma: a novel approach to understanding symptom perception and appraisal prior to health care.

OBJECTIVE: This pilot study investigated the use of patient drawings to explore patient experiences of symptoms of melanoma prior to health care use. DESIGN: Patients (n = 63) with melanoma were interviewed within 10 weeks of diagnosis. Participants were asked to draw what their melanoma had looked like when they first noticed it, and to make additional drawings to depict changes as it developed. MAIN OUTCOME MEASURE: The size and features of the drawings were compared between participants and with clinical data (thickness of the melanoma; histological diameter; clinical photographs). RESULTS: Eighty-four percent of participants were able to produce at least one drawing. This facilitated discussion of their lesion and recall of events on the pathway to diagnosis. Common features of the drawings related to the view, presence of shading, inclusion of sections and the shape and border of the lesion. There was potential for disparity between the details in awareness resources and the perceptions of patients. The drawings resembled the clinical photographs and the size of the drawings was positively associated with the histological diameter, but did not differ according to tumour thickness. CONCLUSION: Asking patients to make drawings of their melanoma appears to be an acceptable, inclusive, feasible and insightful methodological tool.

Making sense of... photorefractive keratectomy.

The technique of photorefractive keratectomy (PRK) represents a major development in ophthalmology. Using lasers, PRK involves reshaping the cornea so that its refractive power is increased. Currently PRK can only be used to correct myopia and astigmatism, but hypermetropia may also be corrected by PRK in the near future.

The amino acid sequence of cytochrome c from the blowfly Lucilia cuprina.

The amino acid sequence of cytochrome c isolated from the sheep blowfly Lucilia cuprina has been determined by comparison of the compositions of the tryptic peptides to those predicted from the published sequences of cytochromes c from other insects. Cytochrome c from L. cuprina differs at a single residue when compared to cytochrome c from the screw worm fly Haematobia irritans, a species belonging to the same order as the blowfly. This substitution, proline for alanine, has been located at position 44 in the protein chain.

Genetics of lucilin, a storage protein from the sheep blowfly, Lucilia cuprina (Calliphoridae).

Lucilin, the main storage protein of larval fat body and hemolymph in the sheep blowfly, Lucilia cuprina, has been isolated as a series of trimers composed of subunits of 83,000 +/- 5%, daltons. Extensive electrophoretically detectable polymorphism of lucilin subunit patterns occurs in wild and laboratory populations of Lucilia; from four to nine bands are seen in any one individual. Evidence from genetic, electrophoretic, immunological, and structural studies suggests the existence of a series of 12 or more closely related structural loci (designated Luc-1 to Luc-12) which may have arisen through gene duplication. Codominant allelic variation has been found at several of these loci. Luc-1 and Luc-3, and probably the other structural loci of the series, are located on chromosome 2.

The effect of inhibitors in vivo on protein synthesis and the amino acid pool in the sheep blowfly, Lucilia cuprina.

1. The rates of detoxification of cycloheximide (33 mug/g fresh wt.), puromycin (167 mug/g fresh wt.) and actinomycin D (1 mug/g fresh wt.) were assessed in vivo on the basis of acid-insoluble [14C]leucine incorporation in the sheep blowfly, Lucilla cuprina; these were compared with quantitative estimates which took account not only of incorporation data but also of leucine pool size and turnover. Quantitatively, cycloheximide and puromycin were still at least 50% effective in inhibiting protein synthesis after 6.5 and 24.5h of exposure respectively, whereas values based only on incorporation data suggested that cycloheximide was 83% effective and puromycin completely ineffective after the respective periods. Quantitative estimates also showed that actinomycin D effectiveness increased with increasing exposure over 24.5h, in contrast with values based only on incorporation data, which suggested that it was completely ineffective after 24h.2. All inhibitors affected the dynamic state of the amino acid pool; there was a marked decrease in the rate of leucine-pool turnover as well as an increase in the half-life of leucine in the pool. 3. Inhibition of protein synthesis resulted in changes in leucine-pool size; the most pronounced increase occurred with cycloheximide and puromycin and the most pronounced decreases with actinomycin D. 4. Evidence is presented which suggests that proteolysis is functionally linked to protein synthesis, which determines its rate indirectly.

Aspects of the development of flight-muscle sarcosomes in the sheep blowfly, Lucilia cuprina, in relation to changes in the distribution of protein and some respiratory enzymes during metamorphosis.

1. Changes in the amounts and distribution of protein and respiratory enzymes have been estimated during the life cycle of the fly Lucilia cuprina. 2. The fully fed larva contains about 7mg. of protein, the pupa and newly emerged fly about 4mg., and the mature adult about 3mg. 3. There are two periods of incorporation of protein into particles at the expense of the soluble protein; the first, immediately after pupation, may store protein (0.5mg./insect) for use in adult development; the second, over the period of emergence, was due mainly to the development of the thoracic mitochondria of the adult (0.7mg./insect). 4. In the thorax, cytochrome c oxidase and the dehydrogenases for glycerophosphate, isocitrate (NAD-dependent), succinate and malate appeared initially in small particles (less than 1mu in diameter). 5. In adult development these enzymes were redistributed so that in the mature fly most of the activity was present in larger particles (1-10mu in diameter). 6. During this redistribution the specific activity (mul. of oxygen/hr./mg. of protein) of glycerophosphate dehydrogenase in the small particles was 690 at 1(1/2) days before emergence, 955 at emergence and 980 at 7 days after emergence; the corresponding values for the large particles were 164, 760 and 1220. 7. In the mature fly the highest specific activities (mul. of oxygen/hr./mg. of protein) estimated were: glycerophosphate dehydrogenase 1380, isocitrate dehydrogenase (NAD-dependent and requiring ADP and Mg(2+)) 408, succinate dehydrogenase 122, malate dehydrogenase 190, and cytochrome c oxidase 1360. 8. The results are considered in relation to the development of the flight-muscle sarcosomes.

The distribution of nicotinamide nucleotides during the life cycle of the blowfly Lucilia cuprina Wied.

1. Variations in the amounts and distribution of the nicotinamide coenzymes during the life cycle of the blowfly Lucilia cuprina have been investigated. 2. The concentrations of NAD and NADP declined to a minimum in mid-pupal life, then increased threefold from this to about 600 and 40mmumoles/g. fresh wt. respectively in the adult. 3. The NADH/NAD ratio was relatively constant (0.15) except in mid-pupal life (0.09); the NADPH/NADP ratio was lower (0.6) in larvae and mated adults than at other stages (0.90). 4. The increase in NAD content during development was greatest in the thorax, which finally contained about 75% of the total coenzyme. 5. Incorporation of NAD into the thoracic sarcosomes began about 2 days before ecdysis. Initially, most (77%) of the coenzyme was in particles 0.2-1mu in diameter, at a concentration of 11.1mmumoles/mg. of protein. During development there was a gradual appearance of NAD in larger particles (1-10mu) containing 2.8mmumoles/mg. of protein. 6. Similar but less marked changes occurred with NADP, which had a final concentration in the large particles of 0.01mmumole/mg. of protein.