Pharmacy counselling models: a means to improve drug use.

BACKGROUND AND OBJECTIVE: Failure to achieve the intended benefit of medical treatment is recognized as an immense problem. The study objective was to examine the usefulness of counselling models containing key questions to facilitate the identification of drug-related problems (DRPs), and to follow up on both pharmacy practitioner and patient experiences. METHODS: Fifty-one pharmacies in Sweden were recruited, along with matching controls. Patients of six therapeutic groups were selected for the counselling model intervention. DRPs were documented in the Swedish DRP database. A telephone follow-up with the patients and a questionnaire survey with the pharmacy practitioners were conducted. An additional follow-up was made in patients sending a representative to pick up their prescribed medications at the pharmacy. RESULTS AND DISCUSSION: In all, 880 DRPs were documented in patients with 8100 prescriptions (10·9%). The DRP documentation rates in study pharmacies were, in general, superior to the control pharmacy rates. DRPs were identified in 24·8% of the non-steroidal anti-inflammation drug (NSAID) patients using a representative to pick up their medications, compared with 9·2% in patients visiting the pharmacy themselves. Of the patients who took part in the follow-up, 94% said that they received suggestions on problem resolution, and twice as many DRPs were reported resolved vs. unresolved. Most patients and pharmacy practitioners were pleased with the new practice. CONCLUSION: The practice of counselling models appears to be a means to improve drug use. More DRPs were found in patients sending a representative to pick up their medications than in patients visiting the pharmacy themselves.

Effects of long-term whole-body cold exposures on plasma concentrations of ACTH, beta-endorphin, cortisol, catecholamines and cytokines in healthy females.

OBJECTIVE: Cold therapy is used to relieve pain and inflammatory symptoms. The present study was designed to determine the influence of long-term regular exposure to acute cold temperature. Two types of exposure were studied: winter swimming in ice-cold water and whole-body cryotherapy. The outcome was investigated on humoral factors that may account for pain alleviation related to the exposures. MATERIAL AND METHODS: During the course of 12 weeks, 3 times a week, a group of healthy females (n = 10) was exposed to winter swimming (water 0-2 degrees C) for 20 s and another group (n = 10) to whole-body cryotherapy (air -110 degrees C) for 2 min in a special chamber. Blood specimens were drawn in weeks 1, 2, 4, 8 and 12, on a day when no cold exposure occurred (control specimens) and on a day of cold exposures (cold specimens) before the exposures (0 min), and thereafter at 5 and 35 min. RESULTS: Plasma ACTH and cortisol in weeks 4-12 on time-points 35 min were significantly lower than in week 1, probably due to habituation, suggesting that neither winter swimming nor whole-body cryotherapy stimulated the pituitary-adrenal cortex axis. Plasma epinephrine was unchanged during both experiments, but norepinephrine showed significant 2-fold to 3-fold increases each time for 12 weeks after both cold exposures. Plasma IL-1-beta, IL-6 or TNF alpha did not show any changes after cold exposure. CONCLUSIONS: The main finding was the sustained cold-induced stimulation of norepinephrine, which was remarkably similar between exposures. The frequent increase in norepinephrine might have a role in pain alleviation in whole-body cryotherapy and winter swimming.

Lung function after acute and repeated exposures to extremely cold air (-110 degrees C) during whole-body cryotherapy.

Whole-body cryotherapy (WBC) is one mode of cold therapy, during which rheumatic patients are exposed to very cold air (-110 degrees C) in minimal clothing. It is also proposed to have a bronchodilatory effect. The aim was to examine the effects of WBC on lung function in healthy humans after acute and repeated exposures. Twenty-five healthy, non-smoking subjects participated in the study. They were exposed to WBC for 2 min three times per week for 12 weeks. The peak expiratory flow rate (PEF) and forced expiratory volume in 1 s (FEV1) were measured before and after (at 2 and 30 min) the first WBC, and then similarly at 4, 8 and 12 weeks. At all time points, after 30 min of the WBC the PEF values were slightly lower compared with values before the WBC, and the reductions reached statistical significance at 1 month (5.1 +/- 1.2%), and at 3 months (3.2 +/- 1.7%). After 30 min of the first WBC, the FEV1 was significantly reduced by 2.3 +/- 0.8%, but no other changes were observed during the study. In conclusion, the WBC induced minor bronchoconstriction in healthy humans instead of proposed bronchodilatation. The WBC seems not to be harmful for lung function, but should be used with caution in susceptible individuals.

Acute and long-term effects of winter swimming and whole-body cryotherapy on plasma antioxidative capacity in healthy women.

The effects of severe cold stress on total peroxyl radical trapping antioxidant capacity of plasma (TRAP) were studied in two groups of healthy women: a whole-body cryotherapy group (WBC, n = 10) and a winter swimming group (WS, n = 10). The biovariability of TRAP values was also analysed. The WBC group was exposed to -110 degrees C for 2 min, whereas the exposure for the WS group lasted 20 s in ice-cold water. Sessions were organized three times per week for 12 weeks. Blood specimens were collected at 2, 4, 8 and 12 weeks at rest, 2 and 35 min after the cold exposures and at the corresponding times without cold exposure on a separate day. Conventional methods were used to determine TRAP values. The between-subject variation was 13.6% and the within-subject variation 6.4%. The index of individuality was 0.46, and the index of heterogeneity was 0.079. These results indicate a marked heterogeneity among subjects. During the first 4 weeks, the mean TRAP value significantly increased at 2 min after cold exposure in the WBC group, returning to baseline 35 min after the exposure. Similar changes were observed in the WS group. However, all changes due to cold were relatively mild (<5%). After 4 weeks no changes in TRAP values after the cold exposures were noticed and no long-term changes in basal TRAP values were observed. In the main, regular WBC and WS do not seem to be harmful as far as plasma antioxidative capacity is concerned.

Same axonal regeneration rate after different endoneurial response to intraneural glycerol and phenol injection.

Glycerol (an atoxic alcohol) and phenol (a toxic monohydroxybenzene) are currently used as neurolytic blocking agents to relieve pain or spasticity. In the present study we compared the endoneurial response of anhydrous glycerol and 7% phenol-aqua after intraneural injection into rat sciatic nerve, using electron microscopy and immunohistochemical stainings. Despite the wide use of these drugs, a systematic morphological study of their action has not been done. Electron microscope studies showed different patterns of nerve damage for glycerol and phenol. Glycerol injection resulted in gross sciatic nerve injury, with myelin fragments widely dispersed in the endoneurium 1-2 weeks after the injury. Phenol-aqua injection resulted in gross sciatic nerve injury with focal haemorrhagic necrosis; nerve fibres were segmentally dissolved 1-2 weeks after the injury. In both groups the first axonal sprouts appeared in the area of the lesion 2 weeks after the injury and the sprouts became myelinated in both groups by 4 weeks. Immunohistochemical staining showed that in the glycerol-treated nerves macrophages were widely scattered in the endoneurium by day 3; the number of macrophages proximal to the lesion site and at the lesion site was significantly higher in the glycerol-treated nerves than in the phenol-treated nerves both at days 3 and 7. In the phenol-treated nerves, macrophages appeared after 1 week and they exceeded the number of macrophages in the glycerol-treated nerves at 2 weeks. The number of Schwann cells remained low until 4 weeks in both groups. The results show that glycerol-induced nerve fibre damage with breaching of myelin fragments is followed by invasion of macrophages into the endoneurium after 3 days. The delayed invasion of macrophages after phenol injection may be due to occluded vessels or may be related to the denaturing effect of phenol on the proteins needed for macrophage attraction. Despite the rapid invasion of macrophages after glycerol injection axonal regeneration was delayed when compared to that seen after traumatic axotomy, but the axonal regeneration occurred at the same time in both experimental groups. Thus, the results suggest that after chemical axonotmesis the axonal regeneration rate is not dependent on the macrophage invasion rate alone and that other endoneurial changes also play a role.

The endoneurial response to neurolytic agents is highly dependent on the mode of application.

BACKGROUND AND OBJECTIVES: The variability and predictability of neurolytic neural blocks were studied using an experimental rat sciatic nerve model. The goal of the study was to compare endoneurial and clinical responses to commonly used neurolytic agents. METHODS: The sciatic nerves of 80 rats were treated either with intra- or perineural injections of 7% phenol-aqua, anhydrous glycerol, or 5% phenol-glycerol. Lidocaine and saline injections were used as controls. Muscle function and trophic changes of the hind limbs were evaluated, and samples for morphologic analysis were taken 1, 2, 4, and 8 weeks after the injections. RESULTS: Intra- and perineural injections of 7% phenol-aqua resulted in gross endoneural damage of the sciatic nerve and hind limb paresis. Perineural 5% phenol-glycerol and anhydrous glycerol injections caused subperineural damage with slight paresis; gross endoneural damage and noticeable paresis were present only after intraneural injections. When 7% phenol-aqua was compared to other neurolytic agents, the differences in the lesion size (P < .0001) were statistically significant after perineural injections. Regeneration occurred in a stereotypic fashion in all neurolytic groups. Axonal sprouts were noted at the injured area 2 weeks after intraneural and 1 week after perineural injections. Motor function had partially recovered at 8 weeks. CONCLUSION: There were no differences in the effects of clinically used neurolytic agents after intraneural injections. Although the perineurally applied 7% phenol-aqua induced marked endoneural damage, the destructive effect of glycerol and phenol-glycerol injections seemed to be prevented by the perineurium; phenol-glycerol and glycerol treatments induced subperineural damage only after perineural injections. The ability to penetrate the perineurium favors the use of 7% phenol-aqua in peripheral perineural blocks when complete neurolysis is the goal.

Factors influencing the detection rate of drug-related problems in community pharmacy.

This study analyzes relationships between the number of drug-related problems detected in community pharmacy practice and the educational level and other characteristics of pharmacy personnel and their work sites. Random samples of pharmacists, prescriptionists and pharmacy technicians were drawn nationwide in Sweden. One hundred and forty-four (63%) of those meeting the inclusion criteria agreed to take part. The participants documented medication-related problems, interventions and patient variables on a data collection form. The drug-related problems were weighted by the number of patients served by each professional. The regression analysis showed the educational level of the professional to have a statistically significant effect on the detection rate, with pharmacists finding on average 2.5 more drug-related problems per 100 patients than prescriptionists and about 3.6 more than technicians. Previous participation in a study or activity on drug-related problems and the size of the pharmacy also had statistically significant effects on the problem detection rate. The use of open-ended questions to create a dialogue with the patient seemed to be a successful means to discover problems. The results of this study indicate the importance of education and training of pharmacy personnel in detection of drug-related problems. This findings speaks in favor of increasing the pharmacist to other personnel ratio, provided the higher costs will be offset by societal benefits.