Medication adherence and activity patterns underlying uncontrolled hypertension: Assessment and recommendations by practicing pharmacists using digital health care.

OBJECTIVES: This report summarizes the first use of a digital health feedback system (DHFS) by practicing pharmacists to establish evidence-based blood pressure (BP) management recommendations. SETTING: Fifteen commercial pharmacies and 39 patients in the Isle of Wight participated. PRACTICE DESCRIPTION: The pharmacists were experienced in providing New Medicine Services to patients in their communities. PRACTICE INNOVATION: The pharmacists utilized a commercially available DHFS. The DHFS utilized FDA-cleared and CE-marked class 2 medical devices passively captured and shared information about medication-taking using an ingestible sensor, and daily patterns of rest, activity, and exercise using a wearable patch that incorporates an accelerometer. INTERVENTIONS: Pharmacists provided targeted counselling for BP management as guided by the digital information. EVALUATION: Blood pressure was measured serially, and patient and provider experiences with DHFS use were assessed using satisfaction surveys. RESULTS: The mean change in SBP over the 2-week evaluation period was -7.9 ± 22.1; mean change in DBP was -2.8 ± 12.9. A root cause for persistent hypertension was determined for all of these 34 patients: 68% had pharmaceutical resistance, and 32% had inadequate medication use. Specifically, 29% were found to be capable to achieving blood pressure control on their currently prescribed medications, 68% were found to have a need for additional pharmacological treatment, and 3% needed additional adherence support. Pharmacists found that the DHFD helped in targeting specific recommendations, and to create a collaborative experience with their patients. Patients found the experience to be positive and helpful. CONCLUSION: DHFS that provides confirmation of medication taking and objective measures of lifestyle patterns can help pharmacists to identify specific factors contributing to uncontrolled hypertension, to make evidence-based prescribing and lifestyle recommendations for achieving treatment goals, and to create a collaborative experience for patients in the management of their self-care.

Achieving all-age helmet use compliance for snow sports: strategic use of education, legislation and enforcement.

BACKGROUND: Nova Scotia is the first jurisdiction in the world to mandate ski and snowboard helmet use for all ages at ski hills in the province. This study represents a longitudinal examination of the effects of social marketing, educational campaigns and the introduction of helmet legislation on all-age snow sport helmet use in Nova Scotia. METHODS: A baseline observational study was conducted to establish the threshold of ski and snowboarding helmet use. Based on focus groups and interviews, a social marketing campaign was designed and implemented to address factors influencing helmet use. A prelegislation observational study assessed the effects of social marketing and educational promotion on helmet use. After all-age snow sport helmet legislation was enacted and enforced, a postlegislation observational study was conducted to determine helmet use prevalence. RESULTS: Baseline data revealed that 74% of skiers and snowboarders were using helmets, of which 80% were females and 70% were males. Helmet use was high in children (96%), but decreased with increasing age. Following educational and social marketing campaigns, overall helmet use increased to 90%. After helmet legislation was enacted, 100% compliance was observed at ski hills in Nova Scotia. CONCLUSIONS: Results from this study demonstrate that a multifaceted approach, including education, legislation and enforcement, was effective in achieving full helmet compliance among all ages of skiers and snowboarders.

Knowledge and practice of childhood motor vehicle restraint use in Nova Scotia: phase II.

OBJECTIVE: To examine changes to knowledge and practice of childhood motor vehicle restraint (CMVR) use in Nova Scotia after the implementation of stricter car seat and new booster seat (BS) legislation in 2007. METHODS: A random telephone survey of households (at least one child <12 years) was performed in 2004 and 2010. Logistic regression determined variables independently associated with correct knowledge and/or practice of CMVR use. RESULTS: Families were surveyed in the pre- (N=426 families, 728 children) and post- (N=453 families, 723 children) legislative periods. Reported appropriate use of forward-facing car seats (FFCSs) and BSs increased significantly (74-92% and 58-95%, respectively). After adjusting for covariates, the post-law period remained a significant predictor of increased knowledge of when to graduate to a BS or a seat belt alone (SB) (OR:1.4(95% CI:1.0-2.0) and 1.9(1.4-2.7), respectively), which was significantly associated with correct use. The strongest independent predictor of the correct use of FFCSs and BSs was the post-law period (OR:14(3.0-68) and 43(17-114), respectively). With regards to rear-facing car seats (RFCSs), new legislation and associated social marketing on graduating from a rear-facing car seat was not associated with increases in correct practice. CONCLUSIONS: Legislation, combined with social marketing at the time of introduction, is an effective means to educate parents on when to graduate from a FFCS and the importance of BSs while also influencing parents to use them, though not for RFCS graduation. The known protective effect of BSs dictates the need for all regions in Canada to adopt comprehensive BS legislation.

Helmets for skiing and snowboarding: who is using them and why.

BACKGROUND: In Canada, winter sports injuries are responsible for significant health care burden, with estimates of $400 million in direct and indirect annual health care costs. For ski-related injuries, helmets have been shown to provide significant protection. Current common practice in Canada, including the Province of Nova Scotia, is to leave the decision of whether to wear a helmet to the individual. The purposes of this study were to document skiers' and snowboarders' use of helmets and to isolate factors associated with helmet use and nonuse. METHODS: A mixed methods approach was used to collect data during a 2-month period at the province's three ski hills. Naturalistic observations documented helmet use and falls, whereas interviews identified factors influencing helmet use or nonuse. RESULTS: Helmets were used by most skiers (74%) and snowboarders (72%); the use varied significantly between ski hills, ranging from 69% to 79%. Females were more likely to wear helmets compare with males (80% vs. 70%). The highest rates of use were found among 4-year-old to 12-year-old children, with helmet use declining as age increases. Qualitative data revealed that helmet users were most influenced by the protective benefits of helmets (77%), personal choice (46%), family (44%), and rules (44%), while non-helmet users cited personal choice (29%), comfort (26%), rules (14%), and cost (11%) as reasons for nonuse. CONCLUSION: More than 25% of skiers and snowboarders remain at increased risk of a serious brain injury by not wearing a helmet. Changes in regulations may be required to ensure widespread use of helmets on ski hills. LEVEL OF EVIDENCE: Prognostic study, level II.

Friederich Nietzsche and the seduction of Occam's razor.

Friedrich Nietzsche developed dementia at the age of 44 years. It is generally assumed that the cause of his dementia was neurosyphilis or general pareisis of the insane (GPI). Others have proposed frontal-based meningioma as the underlying cause. We have reviewed Nietzsche's medical history and evaluated the evidence from the medical examinations he underwent by various physicians. We have viewed the possible diagnosis of GPI or meningioma in light of present neuro-ophthalmic understanding and found that Nietzsche did not have the neurological or neuro-ophthalmic symptoms consistent with a diagnosis of GPI. The anisocoria which was assumed to be Argyll Robertson pupil was present since he was six years of age. He did not have tongue tremor, lacked progressive motor features and lived at least 12 years following the onset of his neurological signs. Furthermore, the headaches that have been attributed to a frontal-based tumour were present since childhood and the pupil abnormality that has been interpreted as an "afferent pupillary defect" had the characteristics of an abnormality of the efferent pupillary innervation. None of the medical records or photographs suggest there was any ocular misalignment. We concluded that neither diagnosis of GPI nor frontal-based meningioma is convincing. It is likely that Nietzsche suffered from migraines, his blindness in his right eye was a consequence of high progressive myopia associated with retinal degeneration, his anisocoria explained by unilateral tonic pupil, and his dementia by an underlying psychiatric disease.