Challenges in the provision of natural medicines by community pharmacists in East Java Province, Indonesia.

OBJECTIVES: Community pharmacist has been widely known as a health professional who can be easily accessed to provide medicines and reliable medicine information. However, this was not always in the case of dispensing natural medicines. Several international studies revealed that community pharmacists were less likely to deliver natural medicines accompanied with detailed information. Therefore, this study aimed to investigate factors influencing Indonesian community pharmacists in the supply of, delivery of, and provision of information about natural medicines. METHODS: A qualitative study with purposively selected community pharmacists in four areas (district or municipality) in East Java Province was designed. In-depth, semi-structured interviewed were conducted using a Capability-Opportunity-Motivation-Behaviour approach. All interviews were audio-recorded, transcribed ad verbatim, and thematically analysed. RESULTS: Data saturation was reached after interviewing 14 community pharmacists. All informants reported dispensing non-prescribed natural medicines. Nine had experienced dispensing prescribed natural medicines, mainly fulfilling paediatricians' requests. The most common information given was about product usage, while information about safety (i.e. side effects, interaction) was rarely provided. Although numerous registered natural medicines have been available, informants had low motivation to supply a variety of types, primarily because little opportunity to receive requests from doctors and the community. Limited capability due to a lack reliable source of information about natural medicines was another reason. CONCLUSIONS: Poor motivation to supply natural medicines was because community pharmacists had little opportunity for such requests and limited capability due to scarcity of information. This indicated support from natural medicine manufacturers, researchers, and the government is highly required.

Influence of age at disease onset on future relapses and disability progression in patients with multiple sclerosis on immunomodulatory treatment.

BACKGROUND AND PURPOSE: To investigate the relation of age at disease onset and clinical outcomes across the lifespan from adolescence in patients with multiple sclerosis (MS) on disease-modifying therapy (DMT). METHODS: We analysed data from the Swiss Association for Joint Tasks of Health Insurers database containing data from 14 718 patients with MS. Patients were included in this analysis when they were on DMT for at least 1 year. The influence of age at disease onset on future relapses and disability worsening was explored using multivariable Cox proportional hazard regression models. RESULTS: Data from 9705 patients with MS were analysed. Pediatric-onset MS patients (n = 236) had higher relapse rates and marginally slower disability worsening rates compared with adult-onset MS (n = 9469). The risk of relapses was highest in childhood and decreased continuously to about 35 years of age. It remained stable for about a decade and then again continuously decreased. In contrast, disability worsening hazards remained stable from childhood to about 32 years of age and then increased sharply around the age of 45 years. CONCLUSIONS: Age is an important factor independently affecting clinical outcomes in MS. This should be considered when designing clinical trials or choosing DMT.

An explanatory model of community pharmacists' support in the secondary prevention of cardiovascular disease.

BACKGROUND: Community pharmacists have faced ongoing challenges in the delivery of clinical pharmacy services. Various attitudinal and environmental factors have been found to be associated with the provision of general clinical pharmacy services or services which focus on a specific condition, including cardiovascular disease (CVD). However, the interrelationship and relative influence of explanatory factors has not been investigated. OBJECTIVE: To develop a model illustrating influences on CVD support provision by community pharmacists. METHODS: Mail surveys were sent to a random sample of 1350 Australian community pharmacies to investigate determinants of CVD support provision. A theoretical model modified from the Theory of Planned Behavior (TPB) was used as a framework for the survey instrument. Structural equation modeling was used to determine how pharmacists' attitudes and environmental factors influence CVD support. RESULTS: A response rate of 15.8% (209/1320) was obtained. The model for CVD support provision by community pharmacists demonstrated good fit: χ(2)/df = 1.403, RMSEA = 0.047 (90% CI = 0.031-0.062), CFI = 0.962, TLI = 0.955 and WRMR = 0.838. Factors found to predict CVD support included: two attitudinal latent factors ("subjective norms of pharmacists' role in CVD support" and "pharmacists' perceived responsibilities in CVD support") and environmental factors i.e. pharmacy infrastructure (documentation and a private area), workload, location; government funded pharmacy practice programs; and pharmacists' involvement with Continuing Professional Development and attendance at CVD courses. CONCLUSIONS: Pharmacists' attitudes appeared to be the strongest predictor of CVD support provision. The TPB framework was useful in identifying "subjective norms" and "pharmacists' beliefs" as key constructs of community pharmacists' attitudes. Community pharmacies would be able to provide such an advanced clinical service if they strongly believed that this was an acknowledged part of their scope of practice, had adequate infrastructure and employed sufficient numbers of pharmacists with appropriate and relevant knowledge.

Challenges in the management of chronic noncommunicable diseases by Indonesian community pharmacists.

OBJECTIVES: We explored factors influencing Indonesian primary care pharmacists' practice in chronic noncommunicable disease management and proposed a model illustrating relationships among factors. METHODS: We conducted in-depth, semistructured interviews with pharmacists working in community health centers (Puskesmas, n=5) and community pharmacies (apotek, n=15) in East Java Province. We interviewed participating pharmacists using Bahasa Indonesia to explore facilitators and barriers to their practice in chronic disease management. We audiorecorded all interviews, transcribed ad verbatim, translated into English and analyzed the data using an approach informed by "grounded-theory". RESULTS: We extracted five emergent themes/factors: pharmacists' attitudes, Puskesmas/apotek environment, pharmacy education, pharmacy professional associations, and the government. Respondents believed that primary care pharmacists have limited roles in chronic disease management. An unfavourable working environment and perceptions of pharmacists' inadequate knowledge and skills were reported by many as barriers to pharmacy practice. Limited professional standards, guidelines, leadership and government regulations coupled with low expectations of pharmacists among patients and doctors also contributed to their lack of involvement in chronic disease management. We present the interplay of these factors in our model. CONCLUSION: Pharmacists' attitudes, knowledge, skills and their working environment appeared to influence pharmacists' contribution in chronic disease management. To develop pharmacists' involvement in chronic disease management, support from pharmacy educators, pharmacy owners, professional associations, the government and other stakeholders is required. Our findings highlight a need for systematic coordination between pharmacists and stakeholders to improve primary care pharmacists' practice in Indonesia to achieve continuity of care.

An Efficient Genome-Wide Multilocus Epistasis Search.

There has been a continuing interest in approaches that analyze pairwise locus-by-locus (epistasis) interactions using multilocus association models in genome-wide data sets. In this paper, we suggest an approach that uses sure independence screening to first lower the dimension of the problem by considering the marginal importance of each interaction term within the huge loop. Subsequent multilocus association steps are executed using an extended Bayesian least absolute shrinkage and selection operator (LASSO) model and fast generalized expectation-maximization estimation algorithms. The potential of this approach is illustrated and compared with PLINK software using data examples where phenotypes have been simulated conditionally on marker data from the Quantitative Trait Loci Mapping and Marker Assisted Selection (QTLMAS) Workshop 2008 and real pig data sets.

Challenges in the care of clients with established cardiovascular disease: lessons learned from Australian community pharmacists.

BACKGROUND: As primary healthcare professionals, community pharmacists have both opportunity and potential to contribute to the prevention and progression of chronic diseases. Using cardiovascular disease (CVD) as a case study, we explored factors that influence community pharmacists' everyday practice in this area. We also propose a model to best illustrate relationships between influencing factors and the scope of community pharmacy practice in the care of clients with established CVD. METHODS: In-depth, semi-structured interviews were conducted with 21 community pharmacists in New South Wales, Australia. All interviews were audio-recorded, transcribed ad verbatim, and analysed using a "grounded-theory" approach. RESULTS: Our model shows that community pharmacists work within a complex system and their practice is influenced by interactions between three main domains: the "people" factors, including their own attitudes and beliefs as well as those of clients and doctors; the "environment" within and beyond the control of community pharmacy; and outcomes of their professional care. Despite the complexity of factors and interactions, our findings shed some light on the interrelationships between these various influences. The overarching obstacle to maximizing the community pharmacists' contribution is the lack of integration within health systems. However, achieving better integration of community pharmacists in primary care is a challenge since the systems of remuneration for healthcare professional services do not currently support this integration. CONCLUSION: Tackling chronic diseases such as CVD requires mobilization of all sources of support in the community through innovative policies which facilitate inter-professional collaboration and team care to achieve the best possible healthcare outcomes for society.

Fast genomic predictions via Bayesian G-BLUP and multilocus models of threshold traits including censored Gaussian data.

Because of the increased availability of genome-wide sets of molecular markers along with reduced cost of genotyping large samples of individuals, genomic estimated breeding values have become an essential resource in plant and animal breeding. Bayesian methods for breeding value estimation have proven to be accurate and efficient; however, the ever-increasing data sets are placing heavy demands on the parameter estimation algorithms. Although a commendable number of fast estimation algorithms are available for Bayesian models of continuous Gaussian traits, there is a shortage for corresponding models of discrete or censored phenotypes. In this work, we consider a threshold approach of binary, ordinal, and censored Gaussian observations for Bayesian multilocus association models and Bayesian genomic best linear unbiased prediction and present a high-speed generalized expectation maximization algorithm for parameter estimation under these models. We demonstrate our method with simulated and real data. Our example analyses suggest that the use of the extra information present in an ordered categorical or censored Gaussian data set, instead of dichotomizing the data into case-control observations, increases the accuracy of genomic breeding values predicted by Bayesian multilocus association models or by Bayesian genomic best linear unbiased prediction. Furthermore, the example analyses indicate that the correct threshold model is more accurate than the directly used Gaussian model with a censored Gaussian data, while with a binary or an ordinal data the superiority of the threshold model could not be confirmed.

Robustness of Bayesian multilocus association models to cryptic relatedness.

Population-based association analyses are more powerful than within-family analyses in identifying genetic loci associated with a phenotype of interest. However, if the population or sample structure is omitted from the model, population stratification and cryptic relatedness may lead to false positive and negative signals caused by relatedness between individuals, rather than association due to close linkage of the marker and the trait loci. Therefore it is important to correct or account for these confounders in population-based association analyses. However, there is cumulative evidence that when fitting a multilocus association model, the genetic relationships between the individuals can be captured by the markers themselves, bringing about a possibility to use the models without an additional correction for the population or sample structure. In this work we have further investigated this possibility in the Bayesian multilocus association model context using the extended Bayesian LASSO and the indicator-based variable selection. In particular, we have studied whether these multilocus models benefit from an insertion of an additional polygenic term representing the genetic variation not captured by the markers and taking account of the residual dependencies between the individuals. We have found that although the models may benefit from the insertion of the polygenic component, omitting the component does not damage the model performance severely.

Back to basics for Bayesian model building in genomic selection.

Numerous Bayesian methods of phenotype prediction and genomic breeding value estimation based on multilocus association models have been proposed. Computationally the methods have been based either on Markov chain Monte Carlo or on faster maximum a posteriori estimation. The demand for more accurate and more efficient estimation has led to the rapid emergence of workable methods, unfortunately at the expense of well-defined principles for Bayesian model building. In this article we go back to the basics and build a Bayesian multilocus association model for quantitative and binary traits with carefully defined hierarchical parameterization of Student's t and Laplace priors. In this treatment we consider alternative model structures, using indicator variables and polygenic terms. We make the most of the conjugate analysis, enabled by the hierarchical formulation of the prior densities, by deriving the fully conditional posterior densities of the parameters and using the acquired known distributions in building fast generalized expectation-maximization estimation algorithms.

Pharmacists' and consumers' viewpoints on counselling on prescription medicines in Australian community pharmacies.

OBJECTIVE: The aim was to investigate and compare counselling on prescription medicine provided by Australian community pharmacists based on pharmacist and consumer self-reports, and to explore consumers' interest in receiving prescription medicine information. METHODS: Mail and face-to-face surveys containing comparable questions for both study groups. The setting was Sydney metropolitan community pharmacies, Australia (22 pharmacists and 157 consumers). KEY FINDINGS: No statistically significant differences were found between pharmacists and consumers in reporting provision of verbal information for new (Z = -0.57, P = 0.57) and repeat prescriptions (Z = -1.71, P = 0.09). However, there were statistically significant differences between the two cohorts in reporting dissemination of written information (Z = -2.6, P = 0.009 and Z = -2.68, P = 0.007 for new and repeat prescriptions, respectively). Both groups reported that the most common type of verbal information provided by pharmacists was in relation to medicine administration rather than safety aspects of medicines. Approximately 59% of consumers expressed an interest in receiving counselling for new prescriptions only. CONCLUSIONS: Pharmacists regularly provided verbal counselling on new prescription medicines, but infrequently provided written medicine information or any type of information for regular medicines. Lack of consumers' interest in receiving prescription medicine information may have contributed to the low counselling rates. Thus, there is a need to develop strategies to improve pharmacist counselling practice and to enhance consumer involvement in the counselling process.