Non-dispensing pharmacists integrated into general practices as a new interprofessional model: a qualitative evaluation of general practitioners' experiences and views.

BACKGROUND: A new interprofessional model incorporating non-dispensing pharmacists in general practice teams can improve the quality of pharmaceutical care. However, results of the model are dependent on the context. Understanding when, why and how the model works may increase chances of successful broader implementation in other general practices. Earlier theories suggested that the results of the model are achieved by bringing pharmacotherapeutic knowledge into general practices. This mechanism may not be enough for successful implementation of the model. We wanted to understand better how establishing new interprofessional models in existing healthcare organisations takes place. METHODS: An interview study, with a realist informed evaluation was conducted. This qualitative study was part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in primary care Teams (POINT) project. We invited the general practitioners of the 9 general practices who (had) worked closely with a non-dispensing pharmacist for an interview. Interview data were analysed through discussions about the coding with the research team where themes were developed over time. RESULTS: We interviewed 2 general practitioners in each general practice (18 interviews in total). In a context where general practitioners acknowledge the need for improvement and are willing to work with a non-dispensing pharmacist as a new team member, the following mechanisms are triggered. Non-dispensing pharmacists add new knowledge to current general practice. Through everyday talk (discursive actions) both general practitioners and non-dispensing pharmacists evolve in what they consider appropriate, legitimate and imaginable in their work situations. They align their professional identities. CONCLUSIONS: Not only the addition of new knowledge of non-dispensing pharmacist to the general practice team is crucial for the success of this interprofessional healthcare model, but also alignment of the general practitioners' and non-dispensing pharmacists' professional identities. This is essentially different from traditional pharmaceutical care models, in which pharmacists and GPs work in separate organisations. To induce the process of identity alignment, general practitioners need to acknowledge the need to improve the quality of pharmaceutical care interprofessionally. By acknowledging the aspect of interprofessionality, both general practitioners and non-dispensing pharmacists will explore and reflect on what they consider appropriate, legitimate and imaginable in carrying out their professional roles. TRIAL REGISTRATION: The POINT project was pre-registered in The Netherlands National Trial Register, with Trial registration number NTR-4389.

Hydraulic Conductivity from Nuclear Magnetic Resonance Logs in Sediments with Elevated Magnetic Susceptibilities.

This study examined the application of slim-hole nuclear magnetic resonance (NMR) tools to estimate hydraulic conductivity (KNMR ) in an unconsolidated aquifer that contains a range of grain sizes (silt to gravel) and high and variable magnetic susceptibilities (MS) (10-4 to 10-2 SI). A K calibration dataset was acquired at 1-m intervals in three fully screened wells, and compared to KNMR estimates using the Schlumberger-Doll research (SDR) equation with published empirical constants developed from previous studies in unconsolidated sediments. While KNMR using published constants was within an order of magnitude of K, the agreement, overprediction, or underprediction of KNMR varied with the MS distribution in each well. An examination of the effects of MS on NMR data and site-specific empirical constants indicated that the exponent on T2ML (n-value in the SDR equation, representing the diffusion regime) was found to have the greatest influence on KNMR estimation accuracy, while NMR porosity did not improve the prediction of K. KNMR was further improved by integrating an MS log into the NMR analyses. A first approach detrended T2ML for the effects of MS prior to calculating KNMR , and a second approach introduced an MS term into the SDR equation. Both were found to produce similar refinements of KNMR in intervals of elevated MS. This study found that low frequency NMR logging with short echo times shows promise for sites with moderate to elevated MS levels, and recommends a workflow that examines parameter relationships and integrates MS logs into the estimation of KNMR .

Effects of non-dispensing pharmacists integrated in general practice on medication-related hospitalisations.

AIMS: To evaluate the effect of non-dispensing pharmacists (NDPs) integrated in general practice on medication-related hospitalisations, drug burden index and costs in patients at high risk of medication problems (being 65 years or older and using 5 or more chronic medications). METHODS: This was a multicentre, nonrandomised, controlled intervention study with pre-post comparison (2013 vs June 2014 to May 2015) in 25 general practices in the Netherlands, comparing NDP-led care (intervention) with 2 current pharmaceutical care models (usual care and usual care plus). In the intervention group, 10 specially trained NDPs were employed in general practices to take integral responsibility for the pharmaceutical care. They provided a broad range of medication therapy management services both on patient level (e.g. clinical medication review) and practice level (e.g. quality improvement projects). In the control groups, pharmaceutical care was provided as usual by general practitioners and community pharmacists, or as usual plus, when pharmacists were additionally trained in performing medication reviews. RESULTS: Overall, 822 medication-related hospitalisations were identified among 11 281 high-risk patients during the intervention period. After adjustment for clustering and potential confounders, the rate ratio of medication-related hospitalisations in the intervention group compared to usual care was 0.68 (95% confidence interval: 0.57-0.82) and 1.05 (95% confidence interval: 0.73-1.52) compared to usual care plus. No differences in drug burden index or costs were found. CONCLUSIONS: In general practices with an integrated NDP, the rate of medication-related hospitalisations is lower compared to usual care. No differences with usual care plus were found.

Acne: a side-effect of masculinizing hormonal therapy in transgender patients.

BACKGROUND: Masculinizing hormonal treatment in transgender men has the potential to increase the level of androgens at end organs, including the pilosebaceous unit. Androgen-induced sebocyte growth and differentiation, sebum production and infundibular keratinization may underlie the development of acne vulgaris among patients receiving this therapy. OBJECTIVES: The aim of this article is to familiarize dermatologists with the sensitivities and challenges of treating acne in transgender male individuals. METHODS: This review article discusses the pathogenesis and treatment of acne in transgender men on testosterone therapy and highlights the unique considerations in treating this underserved patient population. RESULTS: Despite the incidence of treatment-related acne and the unique considerations in treating transgender men, studies addressing this topic among this patient population are limited. CONCLUSIONS: Generally, the standard guidelines for the treatment of acne can be followed in treating these patients; however, several medical, social and psychological factors should be considered.

New approaches for isolation of previously uncultivated oral bacteria.

A significant number of microorganisms from the human oral cavity remain uncultivated. This is a major impediment to the study of human health since some of the uncultivated species may be involved in a variety of systemic diseases. We used a range of innovations previously developed to cultivate microorganisms from the human oral cavity, focusing on anaerobic species. These innovations include (i) in vivo cultivation to specifically enrich for species actively growing in the oral cavity (the "minitrap" method), (ii) single-cell long-term cultivation to minimize the effect of fast-growing microorganisms, and (iii) modifications of conventional enrichment techniques, using media that did not contain sugar, including glucose. To enable cultivation of obligate anaerobes, we maintained strict anaerobic conditions in most of our cultivation experiments. We report that, on a per cell basis, the most successful recovery was achieved using minitrap enrichment (11%), followed by single-cell cultivation (3%) and conventional plating (1%). Taxonomically, the richest collection was obtained using the single-cell cultivation method, followed by minitrap and conventional enrichment, comprising representatives of 13, 9, and 4 genera, respectively. Interestingly, no single species was isolated by all three methods, indicating method complementarity. An important result is the isolation and maintenance in pure culture of 10 strains previously only known by their molecular signatures, as well as representatives of what are likely to be three new microbial genera. We conclude that the ensemble of new methods we introduced will likely help close the gap between cultivated and uncultivated species from the human oral cavity.

Poland's syndrome and carcinoma of the breast: a case report.

Poland's syndrome is a rare congenital anomaly that may include mammary hypoplasia and has been described in association with various malignancies. We report the case of a 42-year-old woman with unilateral Poland's syndrome who developed carcinoma in the hypoplastic breast. A review of the literature reveals no previous report of carcinoma of the hypoplastic breast with Poland's syndrome.

Long-term in vivo survival of receptor-modified syngeneic T cells in patients with human immunodeficiency virus infection.

To study human immunodeficiency virus (HIV)-specific cellular immunity in vivo, we transferred syngeneic lymphocytes after ex vivo expansion and transduction with a chimeric receptor gene (CD4/CD3-zeta) between identical twins discordant for HIV infection. Single and multiple infusions of 10(10) genetically modified CD8(+) T cells resulted in peak fractions in the circulation of approximately 10(4) to 10(5) modified cells/10(6) mononuclear cells at 24 to 48 hours, followed by 2- to 3-log declines by 8 weeks. In an effort to provide longer high-level persistence of the transferred cells and possibly enhance anti-HIV activity, we administered a second series of infusions in which both CD4(+ )and CD8(+) T cells were engineered to express the chimeric receptor and were costimulated ex vivo with beads coated with anti-CD3 and anti-CD28. Sustained fractions of approximately 10(3) to 10(4) modified cells/10(6) total CD4(+) or CD8(+) cells persisted for at least 1 year. Assessment of in vivo trafficking of the transferred cells by lymphoid tissue biopsies revealed the presence of modified cells in proportions equivalent to or below those in the circulation. The cell infusions were well tolerated and were not associated with substantive immunologic or virologic changes. Thus, adoptive transfer of genetically modified HIV-antigen-specific T cells was safe. Sustained survival in the circulation was achieved when modified CD4(+ )and CD8(+) T cells were infused together after ex vivo costimulation, indicating the important role played by antigen-specific CD4(+) T cells in providing "help" to cytotoxic effectors. (Blood. 2000;96:467-474)

Adolescent alcohol and drug abuse and health.

PURPOSE: To examine the relationship of adolescent alcohol and drug use over a 5-year period to cumulative health problems in late adolescence and young adulthood. METHODS: We prospectively examined self-reported health problems in a sample of adolescents, some of whom received treatment for substance use disorders and had consistently poor substance use outcomes (n = 38), some of whom received treatment for substance use disorders and had positive substance use outcomes (n = 30), and a low alcohol and drug use community comparison group (n = 48). Data regarding health-related problems of these adolescents (mean, 15.9 years; 83% Caucasian; 56.5% female) were collected at 2, 4, and 6 years following initial assessments. RESULTS: Alcohol and/or drug involvement severe enough to warrant treatment during adolescence was associated with more cumulative health problems and severe health problems for girls and more cumulative health problems for boys. Protracted and continuous abuse of alcohol and drugs was associated with more cumulative and severe health problems for girls and more severe health problems for boys. CONCLUSIONS: These results suggest that significant health problems and concerns are related to both brief and protracted alcohol and drug abuse during adolescence. Health problems will likely become even more evident as early-onset, chronic substance abusers continue to age.

Lifetime patterns of social phobia: a retrospective study of the course of social phobia in a nonclinical population.

This study describes the natural course of social phobia as recalled by a sample of nonclinical subjects and explores, using qualitative research methods, perceived risk factors and factors that may cause changes in its course. Thirty-nine respondents with a lifetime diagnosis of social phobia were interviewed using a semistructured interview schedule based on DSM-IV criteria. Four main lifetime patterns emerged: a slight worsening of social phobic symptoms over time, no change, slight improvement and complete remission. Thirty-eight percent of the sample was in remission at the time of interview. The mean age of onset was 12.8 +/- 4.1 years. The average duration of illness was 29.0 +/- 12.7 years. Factors perceived by respondents to precipitate social phobia, using contract analysis, were family and school environment, onset of adolescence, low self-esteem, temperament and poverty. Factors perceived to improve symptoms were building self-esteem, exposure, determination, maturity and counseling. Factors perceived to worsen symptoms were avoidance, exposure to negative attention and comorbid disorders.

A direct-interview family study of generalized social phobia.

OBJECTIVE: The goal of this direct-interview family study was to replicate and extend an earlier finding of a familial liability for social phobia. The authors hypothesized that there would be higher rates of the generalized type of social phobia--but not the nongeneralized (or "discrete") type--among relatives of probands with generalized social phobia. They also hypothesized that rates of avoidant personality disorder, a frequent comorbid condition, would be higher in relatives of probands with generalized social phobia. METHOD: The authors examined rates of three social phobia subtypes defined a priori--discrete, nongeneralized, and generalized--as well as rates of avoidant personality disorder by direct interview of 106 first-degree relatives of 23 patients with generalized social phobia and 74 first-degree relatives of 24 comparison subjects without social phobia. RESULTS: Relative risks for generalized social phobia and avoidant personality disorder were markedly higher (approximately 10-fold) among first-degree relatives of probands with generalized social phobia than among first-degree relatives of comparison probands. In contrast, relative risks for discrete social phobia and nongeneralized social phobia were not significantly different between the two groups of first-degree relatives. CONCLUSIONS: These results confirm earlier findings of a higher rate of social phobia among relatives of probands with generalized social phobia and extend these findings by specifically indicating that it is only the generalized type (and its probable axis II counterpart, avoidant personality disorder) that occurs more often among the families of probands with generalized social phobia. Implications for subsequent genetic studies are discussed.

Full and partial posttraumatic stress disorder: findings from a community survey.

OBJECTIVE: Full and partial posttraumatic stress disorder (PTSD) following trauma exposure were examined in a community sample in order to determine their prevalence and their relative importance and functional significance. METHOD: A standardized telephone interview with a series of trauma probes and a DSM-IV PTSD checklist was administered to a random sample of 1,002 persons in a midsized Midwestern Canadian city. The authors determined current (i.e., 1-months) prevalence rates of full PTSD, i.e., all DSM-IV criteria, and partial PTSD, i.e., fewer than the required number of DSM-IV criterion C symptoms (avoidance/numbing) or criterion D symptoms (increased arousal). Additional questions about interference with functioning were also posed. RESULTS: The estimated prevalence of full PTSD was 2.7% for women and 1.2% for men. The prevalence of partial PTSD was 3.4% for women and 0.3% for men. Interference with work or school was significantly more pronounced in persons with full PTSD than in those with only partial symptoms, although the latter were significantly more occupationally impaired than traumatized persons without PTSD. CONCLUSIONS: These findings in an epidemiologic sample underscore observations from patient and military groups that many traumatized persons suffer from a subsyndromal form of PTSD. These persons with partial PTSD, although somewhat less impaired than persons with the full syndrome, nonetheless exhibit clinically meaningful levels of functional impairment in association with their symptoms. This subthreshold form of PTSD may be especially prevalent in women. Additional study of partial PTSD is warranted.

Paroxetine in the treatment of generalized social phobia: open-label treatment and double-blind placebo-controlled discontinuation.

We conducted an 11-week forced-escalation open-label study of paroxetine in the treatment of 36 patients with generalized social phobia. At the mean dosage of 47.9 +/- 6.2 mg/day, 23 of 30 completers (77%) were deemed responders on the basis of a clinician rating of either "very much improved" or "much improved" on the Clinical Global Impressions scale. Duke Social Phobia Scale ratings declined from 35.5 +/- 13.1 at baseline to 19.7 +/- 17.4 at week 11 (p < 0.0005), and Liebowitz Social Anxiety Scale ratings declined from 75.1 +/- 25.4 at baseline to 37.2 +/- 32.5 at week 11 (p < 0.0005). Sixteen responders were randomized to an additional 12 weeks of either paroxetine (with no dosage change) or placebo (after a taper period) on a double-blind basis. To the best of our knowledge, this is the first controlled medication-discontinuation study in social phobia. One of eight patients randomized to continue paroxetine relapsed versus five of eight patients randomized to placebo. These findings call for a double-blind, placebo-controlled treatment study of paroxetine in generalized social phobia. They also suggest that relapse rates are high if medication is discontinued early and that further study is needed to determine (1) the optimal duration of maintenance pharmacotherapy for social phobia and (2) if specific psychotherapeutic interventions before medication discontinuation may prevent relapse.

Childhood physical and sexual abuse in patients with anxiety disorders and in a community sample.

OBJECTIVE: The authors investigated whether histories of childhood physical or sexual abuse were reported more frequently in a clinical sample of patients with anxiety disorders than in a matched community comparison sample. METHOD: A standardized interview with an extensive series of trauma probes was administered to 125 patients with DSM-IV anxiety disorders (panic disorder, social phobia, or obsessive-compulsive disorder) and to 125 age- and gender-matched subjects drawn from a random community sample. RESULTS: Childhood physical abuse was higher among both men (15.5%) and women (33.3%) with anxiety disorders than among comparison subjects (8.1%). Childhood sexual abuse was higher among women with anxiety disorders (45.1%) than among comparison women (15.4%) and was higher among women with panic disorder (60.0%) than among women with other anxiety disorders (30.8%). CONCLUSIONS: These findings confirm the association between anxiety disorders and reported childhood physical and sexual abuse and extend earlier findings by pointing to a particular association between sexual abuse and panic disorder in women.

Anxiety sensitivity and treatment outcome in panic disorder.

The purpose of this study was to examine the relationship between change in anxiety sensitivity, as measured by the Anxiety Sensitivity Index (ASI), and treatment outcome in a sample of 106 subjects with a DSM-III-R diagnosis of panic disorder (with or without agoraphobia) who were participants in an evaluation study of cognitive-behavioral treatment. Results revealed that subjects who received active treatment had significantly lower anxiety sensitivity scores at post-treatment than the wait-list control group. We also examined change in anxiety sensitivity from pre- to post-treatment in reference to Clinical Global Improvement (CGI) ratings and with the effect size statistic. Subjects who showed improvement based on CGI ratings also demonstrated a reduction in anxiety sensitivity. Furthermore, the effect sizes obtained with the ASI were greater in magnitude than those obtained with other widely used anxiety self-report measures. Taken together, the finds supported the use of the Anxiety Sensitivity Index as a treatment outcome measure in panic disorder research.

[3H]paroxetine binding to platelets of patients with social phobia: comparison to patients with panic disorder and healthy volunteers.

Recent studies suggest that serotonergic functioning may be aberrant in patients with social phobia. Capacity of the serotonin (5-HT) transporter, as determined by 3H-paroxetine binding, was measured in 18 drug-free patients with generalized social phobia and compared to 15 drug-free patients with panic disorder and 23 healthy control subjects. The density (Bmax) and affinity (1/Kd) of 3H-paroxetine binding sites was similar in all three groups. To the extent that the serotonin transporter in platelets and neurons is comparable, these findings suggest that this aspect of serotonergic function is normal in patients with social phobia.

A recruitment-of-praise package to increase productivity levels of developmentally handicapped workers.

This research examined the effectiveness of a recruitment package to increase production rates of three developmentally handicapped adults in a sheltered workshop. A baseline phase measured production rates of a paper-folding task under "typical" supervisory conditions. The recruitment package, introduced in a multiple-baseline design across subjects, involved goal setting by the experimenter, and self-monitoring, recruitment of praise, and self-delivery of a "happy face" by the worker. The recruitment package increased the production rates for two subjects, but decreased production rates for the third subject. Social validity data indicated that all subjects preferred the recruitment package, and staff continued to employ the recruitment package for two subjects when the formal research was terminated.

Release and metabolism of dopamine in a clonal line of pheochromocytoma (PC12) cells exposed to fenthion.

The effects of an organophosphate (OP) pesticide, fenthion (FEN), on the release and metabolism of dopamine were evaluated in a clonal line of rat pheochromocytoma (PC12) cells. HPLC was used to determine media concentrations of DA and the DA metabolites norepinephrine (NE), 3,4-dihydroxyphenylacetic acid (DOPAC), and homovanillic acid (HVA). The FEN formulation solvent did not significantly affect DA metabolism. In the first study, cultures were treated with 10(-5) or 10(-6) M FEN or 10(-5) M neostigmine, a non-OP acetylcholinesterase inhibitor. Concentrations of both catecholamines were elevated in cultures treated with 10(-5) M FEN by 2.8-fold for DA and 3.5-fold for NE. Neostigmine effects were of smaller magnitude and DA was decreased after 24 hr. Cultures were also treated with depolarizing levels of K+, but the effect of FEN was not altered, suggesting that FEN does not act by increasing DA release. In the second study, the effect of 10(-6) M FEN was evaluated in cultures treated with the DA uptake inhibitor benztropine, the monoamine oxidase (MAO) inhibitor pargyline, or the catechol-O-methyltransferase (COMT) inhibitor tropolone. Inhibitor effects were consistent with their known mechanisms of action. In all cultures treated with FEN, the ratio HVA/DOPAC was decreased after 3 and 6 hr of exposure. A decrease in HVA/DOPAC was also observed in cultures treated with neostigmine and tropolone. In combination with pargyline, FEN decreased DA in contrast to its usual effect of increasing DA. Neither the stimulation of DA release nor the inhibition of DA uptake affected the observed action of FEN in PC12 cultures.(ABSTRACT TRUNCATED AT 250 WORDS)