Perspectives of community pharmacy staff on commonly encountered skin conditions and the key challenges towards enhancing their role in dermatology.

This research letter discusses the perspectives of community pharmacy staff on commonly encountered skin conditions and the key challenges towards enhancing their role in this area. A mixed methods online survey was created, and a total of 174 community pharmacy staff completed the survey. The results highlight the range of conditions currently encountered in community pharmacy and the breadth of challenges facing community pharmacy staff, in particular challenges surrounding providing a differential diagnosis. Community pharmacies are an integral part of the NHS and have a key role in managing skin conditions; however, in order to optimise this role, the perspectives of staff discussed in this letter need to be further explored and addressed.

Sleep disturbance in people living with dementia or mild cognitive impairment: a realist review of general practice.

BACKGROUND: Sleep disturbance is a prevalent condition among people living with dementia (PLwD) or mild cognitive impairment (MCI). Its assessment and management within primary care is complex because of the comorbidities, older age, and cognitive impairment typical of this patient group. AIM: To explore how primary care clinicians assess, understand, and manage sleep disturbance for PLwD or MCI; if and why such initiatives work; and how people and their carers experience sleep disturbance and its treatment. DESIGN AND SETTING: A realist review of existing literature conducted in 2022. METHOD: Six bibliographic databases were searched. Context-mechanism-outcome configurations (CMOCs) were developed and refined. RESULTS: In total, 60 records were included from 1869 retrieved hits and 19 CMOCs were developed. Low awareness of and confidence in the treatment of sleep disturbance among primary care clinicians and patients, combined with time and resource constraints, meant that identifying sleep disturbance was difficult and not prioritised. Medication was perceived by clinicians and patients as the primary management tool, resulting in inappropriate or long-term prescription. Rigid nursing routines in care homes were reportedly not conducive to good-quality sleep. CONCLUSION: In primary care, sleep disturbance among PLwD or MCI is not adequately addressed. Over-reliance on medication, underutilisation of non-pharmacological strategies, and inflexible care home routines were reported as a result of low confidence in sleep management and resource constraints. This does not constitute effective and person-centred care. Future work should consider ways to tailor the assessment and management of sleep disturbance to the needs of individuals and their informal carers without overstretching services.

What really is nontokenistic fully inclusive patient and public involvement/engagement in research?

Patient and public involvement and engagement (PPIE) is critically important in healthcare research. A useful starting point for researchers to understand the scope of PPIE is to review the definition from the National Institute for Health and Care Research (NIHR) as, 'research being carried out "with" or "by" members of the public rather than "to", "about" or "for" them'. PPIE does not refer to participation in research, but to actively shaping its direction. The 'Effectiveness of a decision support tool to optimise community-based tailored management of sleep for people living with dementia or mild cognitive impairment (TIMES)' study is funded through the NIHR programme grant for applied research. TIMES has thoroughly embraced PPIE by ensuring the person's voice is heard, understood, and valued. This editorial showcases how the TIMES project maximised inclusivity, and we share our experiences and top tips for other researchers. We base our reflections on the six key UK standards for public involvement; Inclusive Opportunities, Working Together, Support and Learning, Communications, Impact and Governance. We present our work, which had been co-led by our PPIE leads, academics and partners including, together in dementia everyday, Innovations in Dementia, The UK Network of Dementia Voices (Dementia Engagement & Empowerment Project) and Liverpool Chinese Wellbeing. We have a Lived Experience Advisory Forum on Sleep, which includes people with dementia, family carers, representatives of the South Asian Community and the Chinese community.

Community pharmacists' perceptions on managing people with oral health problems-A prioritisation survey.

BACKGROUND: Alternative sources of oral health information are likely to be of benefit to the public, particularly where access to dental services is limited. There is evidence that community pharmacists are willing to advocate for oral health, but it is unclear what is needed to develop this role. OBJECTIVES: The aims of this study were to obtain the views of community pharmacy staff on the frequency and type of oral health conditions they encounter challenges in management and training/research priorities. METHODS: An anonymous online survey targeted pharmacy staff and elicited quantitative data related to the types and frequencies of oral health conditions experienced. Participants were stratified by age, gender, ethnicity, experience and setting. Free text responses allowed participants to detail challenging aspects of patient management, their priorities for service development and future research. Reflexive thematic analysis of free text responses identified key themes. RESULTS: Oral/facial pain and swelling were seen weekly by most respondents, and daily by 28.8%. Other commonly presenting conditions were ulcers, dry-mouth, thrush and denture issues. Challenges in managing oral health conditions included: access to NHS dentistry, awareness of referral pathways, examination/diagnosis and understanding 'Red Flags'. CONCLUSION: Acute and chronic oral health conditions commonly present to community pharmacists who lack necessary knowledge/training, which may result in missing 'red flag' symptoms for oral cancer or acute facial swellings which can be life threatening. There is a need to support pharmacists, who are willing to act as oral health advocates, in recognition, prevention and onward referral for oral diseases.

How can community pharmacists be supported to manage skin conditions? A multistage stakeholder research prioritisation exercise.

OBJECTIVE: To establish research priorities which will support the development and delivery of community pharmacy initiatives for the management of skin conditions. DESIGN: An iterative, multistage stakeholder consultation consisting of online survey, participant workshops and prioritisation meeting. SETTING: All data collection took place online with participants completing a survey (delivered via the JISC Online Survey platform, between July 2021 and January 2022) and participating in online workshops and meetings (hosted on Microsoft Teams between April and July 2022). PARTICIPANTS: 174 community pharmacists and pharmacy staff completed the online survey.53 participants participated in the exploratory workshops (19 community pharmacists, 4 non-pharmacist members of pharmacy staff and 30 members of the public). 4 healthcare professionals who were unable to attend a workshop participated in a one-to-one interview.29 participants from the workshops took part in the prioritisation meeting (5 pharmacists/pharmacy staff, 1 other healthcare professional and 23 members of the public). RESULTS: Five broad areas of potential research need were identified in the online survey: (1) identifying and diagnosing skin conditions; (2) skin conditions in skin of colour; (3) when to refer skin conditions; (4) disease-specific concerns and (5) product-specific concerns.These were explored and refined in the workshops to establish 10 potential areas for research, which will support pharmacists in managing skin conditions. These were ranked in the prioritisation meeting. Among those prioritised were topics which consider how pharmacists work with other healthcare professionals to identify and manage skin conditions. CONCLUSIONS: Survey responses and stakeholder workshops all recognised the potential for community pharmacists to play an active role in the management of common skin conditions. Future research may support this in the generation of resources for pharmacists, in encouraging public take-up of pharmacy services, and in evaluating the most effective provision for dealing with skin conditions.

A realist review of medication optimisation of community dwelling service users with serious mental illness.

BACKGROUND: Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI. OBJECTIVE: Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community? METHODS: A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations. RESULTS: Our programme theory represents a continuum from a service user's initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation. CONCLUSIONS: Supported decision-making and trust are foundational to overcoming stigma and establishing 'safety' and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers. PROSPERO REGISTRATION NUMBER: CRD42021280980.

The potential for medicinal cannabis to help manage challenging behaviour in people with intellectual disability: A perspective review.

BACKGROUND: Around 2% of the population have intellectual disabilities. Over one-third people with intellectual disabilities (PwID) present with 'challenging behaviour', which nosologically and diagnostically is an abstract concept. Challenging behaviour is influenced by a range of bio-psycho-social factors in a population, which is unable to suitably comprehend and/or communicate concerns. This predisposes to poor health and social outcomes. There is no evidence-based treatments for managing challenging behaviour. Cannabidiol (CBD) and tetrahydrocannabinol (THC) are being trialled for a range of disorders, which are over-represented in PwID and provoke challenging behaviours, such as severe epilepsy, spasticity, post-traumatic stress disorder, social phobia, pain, etc. METHODS: This perspective review explores the different conditions, which benefit from medicinal CBD/THC preparations, by analysing recent literature from neurobiological, pre-clinical and clinical studies related to the topic. The evidence is synthesised to build an argument of the therapeutic benefits and challenges of medicinal cannabis to manage severe challenging behaviour in PwID. RESULTS: There is developing evidence of medicinal CBD/THC improving psychiatric and behavioural presentations in general. In particular, there is emergent proof in certain key areas of influence of medicinal CBD/THC positively supporting challenging behaviour, for example in children with neurodevelopmental disorders. However, there are significant challenges in employing such treatments in vulnerable populations such as PwID. CONCLUSION: Further clinical research for the considered use of medicinal CBD/THC for challenging behaviour management in PwID is needed. Strong co-production with experts with lived experience is needed for further testing to be done in this exciting new area.

Physicians' and nurses' perceptions of the factors influencing the implementation of paediatric clinical pharmacy services in Hong Kong: a qualitative study.

OBJECTIVES: To identify barriers and facilitators that influence the implementation of paediatric clinical pharmacy services in Hong Kong public hospitals from physicians' and nurses' perspectives. METHODS: A qualitative study was conducted based on semistructured interviews of physicians and nurses who worked in the field of paediatrics in four public hospitals in Hong Kong. Interviews were held via telephone conversations using spoken Cantonese which were audio recorded, then translated and transcribed directly into English by the research team. Thematic analysis was used for data analysis and reflexivity was engaged through member checking, making field notes and reporting using the Consolidated Criteria for Reporting Qualitative Studies checklist. RESULTS: A total of six barriers and five facilitators were identified from interviewing 17 participants, which included 7 physicians and 10 nurses. The barriers identified were the public's lack of understanding and recognition of clinical pharmacists, a culture of medical dominance, lack of resources and heavy workload, the need for a more transparent and defined role of clinical pharmacist at the institutional level, lack of proactive approach and involvement in direct patient care activities. The facilitators identified were the belief in the improvement of patient outcomes and the overall pharmaceutical service efficiency, trust and confidence in clinical pharmacy services, filling the clinical gap as a medicine information provider, and direct and coherent communication as a multidisciplinary team member. CONCLUSIONS: Physicians and nurses reported that the implementation of paediatric clinical pharmacy services was adequate, but several key barriers were identified at both the external and internal levels.

What are patients' experiences of discontinuing clozapine and how does this impact their views on subsequent treatment?

BACKGROUND: Discontinuing what is considered the most effective treatment for treatment-resistant schizophrenia may precipitate feelings of failure or a relapse of illness. Clozapine treatment is discontinued for a variety of reasons, including non-adherence, intolerance, or lack of efficacy. Patients' experiences of discontinuing the "best" treatment and the impact on perceptions of subsequent antipsychotic treatment are important in developing an understanding of the factors affecting people's treatment choices. This study is the first of its type, seeking to explore people's perspectives on clozapine discontinuation. METHOD: Semi-structured interviews with sixteen patients who had received clozapine and discontinued treatment-thirteen males and three females, age range: thirty-two to seventy-eight years old-were audio-recorded and transcribed. A modified inductive approach to analysis, based on grounded theory, was taken to identify commonalities and differences in patients' perceptions. RESULTS: The three main themes identified from participants' experiences were: (1) positive and negative effects of treatment; (2) feelings of agency, being the capacity to make decisions about treatment and act independently; (3) choice of treatment in the future. Participants exhibited agency in making choices about medication, including risking relapse, while attempting self-management of medication effects. Different participants perceived the same side effect as beneficial or intolerable. Variation in subsequent treatment choices was reported, with some participants favouring depot (long-acting) injections. A participant was frightened when not told about clozapine's side effects, which led to the participant not being engaged in future treatment decisions. Others, despite suffering serious adverse effects, retained positive perceptions of clozapine; they experienced despair at finding an effective alternative. CONCLUSIONS: Experiences with clozapine discontinuation evoked powerful emotions and resulted in clozapine being the benchmark for other treatments. Knowledge, agency, and being in control were important to participants in relation to treatment. Personal perceptions of treatments or beliefs about illness could lead to non-adherence. People value the clinician listening to their experiences to better understand their perspective, enabling concerns about medication to be addressed through true shared decision making. TRIAL REGISTRATION: NHS Health Research Authority and Health and Care Research Wales, IRAS Project ID 225753, Research Ethics Committee (REC) reference: 18/NW/0413, 25/06/2018.

Deprescribing psychotropic medicines for behaviours that challenge in people with intellectual disabilities: a systematic review.

BACKGROUND: Clear evidence of overprescribing of psychotropic medicines to manage behaviours that challenges in people with intellectual disabilities has led to national programmes within the U.K. such as NHS England's STOMP to address this. The focus of the intervention in our review was deprescribing of psychotropic medicines in children and adults with intellectual disabilities. Mental health symptomatology and quality of life were main outcomes. METHODS: We reviewed the evidence using databases Medline, Embase, PsycINFO, Web of Science, CINAHL and Open Grey with an initial cut-off date of 22nd August 2020 and an update on 14th March 2022. The first reviewer (DA) extracted data using a bespoke form and appraised study quality using CASP and Murad tools. The second reviewer (CS) independently assessed a random 20% of papers. RESULTS: Database searching identified 8675 records with 54 studies included in the final analysis. The narrative synthesis suggests that psychotropic medicines can sometimes be deprescribed. Positive and negative consequences were reported. Positive effects on behaviour, mental and physical health were associated with an interdisciplinary model. CONCLUSIONS: This is the first systematic review of the effects of deprescribing psychotropic medicines in people with intellectual disabilities which is not limited to antipsychotics. Main risks of bias were underpowered studies, poor recruitment processes, not accounting for other concurrent interventions and short follow up periods. Further research is needed to understand how to address the negative effects of deprescribing interventions. TRIAL REGISTRATION: The protocol was registered with PROSPERO (registration number CRD42019158079).

Providing a Supportive Environment for Disclosure of Sexual Violence and Abuse in a Sexual and Reproductive Healthcare Setting: A Realist Review.

Background: Sexual and reproductive healthcare services (SRHS) are an environment where medical care relevant to sexual violence and abuse (SV) is available. However, barriers to disclosure need to be overcome to allow timely access to this care. There is limited research identifying and explaining how interventions remove barriers and create a safe and supportive environment for disclosure. The purpose of this review was to develop and refine theories that explain how, for whom and in what context SRHS facilitate disclosure. Methods: Following published realist standards we undertook a realist review. After focussing the review question and identifying key contextual barriers, articles pertaining to these were identified using a traditional systematic database search. This strategy was supplemented with iterative searches. Results: Searches yielded 3172 citations, and 28 articles with sufficient information were included to develop the emerging theories. Four evidence-informed theories were developed proposing ways in which a safe and supportive environment for the disclosure of SV is enabled in SRHS. The theories consider how interventions may overcome barriers surrounding SV disclosure at individual, service-delivery and societal levels. Conclusions: Benefits of SRHS engagement with health promotion and health activism activities to address societal level barriers like lack of service awareness and stereotypic views on SV are presented. Although trauma informed practice and person-centred care were central in creating a safe and supportive environment for disclosure the review found them to be poorly defined in this setting.

Surveying Over the Counter and Prescription Only Medication Misuse in Treatment Services During COVID-19.

Background: A greater understanding of Over the Counter (OTC) and Prescription Only Medication (POM) misuse amongst adults accessing substance misuse services (SMS) during COVID-19 is required to identify how SMS can better meet the needs of the people who require treatment. Aim: To use a questionnaire to explore OTC/POM misuse during COVID-19 in adults accessing community SMS in England. Methods: In 2020 to 2021 anonymous self-administered online/paper questionnaires which collated quantitative and qualitative data were completed. They were piloted for suitability and ethical approval was obtained. Thematic analysis was conducted for qualitative data and chi-square tests used to assess the relationship between quantitative variables. Results: Participants were Caucasian (94.6% British), majority male (58.9%), aged 18 to 61 years. Most were prescribed medication for problematic substance use, with a 92.5% self-reported adherence rate. The misuse of benzodiazepines (22.2%) codeine products (30.8%) and pregabalin (14.5%) predominated and 37.5% misused 2 or more medicines. Administration was usually oral and concomitant use of other substances was common: alcohol 44.6% (52% daily), tobacco/vaping 73.2% and illicit substances 58.9%. There were statistically significant associations identified, including between changes during COVID-19 to OTC/POM misuse and illicit use. Only 56 questionnaires were included in the analysis: we believe this low number was because of infection control measures, limited footfall in services, pressures on staff limiting their capacity to distribute the paper questionnaires and reliance upon telephone consultations limiting online distribution. Increasing OTC/POM misuse and obtaining illicit supplies were reported when access to usual supplies were restricted; however, changes to doses/dispensing arrangement liberalisation in response to COVID-19 were positively viewed. Conclusion: OTC/POM misuse, including polypharmacy and concomitant use of other substances occurred during COVID-19: SMS need to be vigilant for these issues and mitigate the associated risks for example with harm reduction interventions. Further qualitative research is required to explore the issues identified.

Understanding primary care diagnosis and management of sleep disturbance for people with dementia or mild cognitive impairment: a realist review protocol.

INTRODUCTION: The increasingly ageing population is associated with greater numbers of people living with dementia (PLwD) and mild cognitive impairment (MCI). There are an estimated 55 million PLwD and approximately 6% of people over 60 years of age are living with MCI, with the figure rising to 25% for those aged between 80 and 84 years. Sleep disturbances are common for this population, but there is currently no standardised approach within UK primary care to manage this. Coined as a 'wicked design problem', sleep disturbances in this population are complex, with interventions supporting best management in context. METHODS AND ANALYSIS: The aim of this realist review is to deepen our understanding of what is considered 'sleep disturbance' in PLwD or MCI within primary care. Specifically, we endeavour to better understand how sleep disturbance is assessed, diagnosed and managed. To co-produce this protocol and review, we have recruited a stakeholder group comprising individuals with lived experience of dementia or MCI, primary healthcare staff and sleep experts. This review will be conducted in line with Pawson's five stages including the development of our initial programme theory, literature searches and the refinement of theory. The Realist and Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and reporting standards will also be followed. The realist review will be an iterative process and our initial realist programme theory will be tested and refined in response to our data searches and stakeholder discussions. ETHICS AND DISSEMINATION: Ethical approval is not required for this review. We will follow the RAMESES standards to ensure we produce a complete and transparent report. Our final programme theory will help us to devise a tailored sleep management tool for primary healthcare professionals, PLwD and their carers. Our dissemination strategy will include lay summaries via email and our research website, peer-reviewed publications and social media posts. PROSPERO REGISTRATION NUMBER: CRD42022304679.

A novel Artificial Intelligence-based tool to assess anticholinergic burden: a survey.

BACKGROUND: many medications possess anticholinergic activity. Their use is associated with a number of serious adverse effects including cognitive effects. The cumulative anticholinergic effect of medications as assessed by tools such as the anticholinergic burden scale (AchB) can identify people particularly at risk of anticholinergic side-effects. Currently, >20 tools are available for clinicians to use, but there is no consensus on the most appropriate tool. METHODS: a newly created online tool-International Anticholinergic Cognitive Burden Tool (IACT)-based on natural language processing and chemical structure analysis, was developed and made available for clinicians to test its functions. We carried out a survey (between 8th of February and 31st of March 2021) to assess the overall need for an assessment tool as well as the usability of the IACT. RESULTS: a total of 110 responses were received from different countries and practitioners' groups. The majority of the participants (86.11%) stated they would use a tool for AchB assessment if available and when they were asked to rate the IACT against other tools, amongst 34 responders, 20.59% rated it better and 8.82% rated it significantly better, 44.12% rated it neither better, nor worse, 14.71% rated it worse and 11.76% somewhat worse. CONCLUSION: there is a need for an anticholinergic burden calculator to assess the anticholinergicity of medications. Tools such as the IACT potentially could meet this demand due to its ability to assign scores to current and new medications appearing on the market based both on their chemical structure and reported adverse pharmacological effects.

Misuse of Over the Counter and Prescription Only Medication by Adults Accessing Specialist Treatment Services in the UK: A Narrative Synthesis.

Background: Concerns about the misuse of over the counter (OTC) and prescription only medication (POM) are due to their impact upon physical/mental wellbeing, drug interactions and drug-related deaths. Improving an understanding of the pattern of use by people accessing specialist substance misuse services (SMSs) should enable improvements to treatment provision. Aim: To review the literature on the misuse of OTC/POM among adults accessing SMS, including the pattern of use, types of medication and associated characteristics. Methods: This review is reported in line with PRISMA. The protocol has been registered on PROSPERO (CRD42020135216) and separately published. A search of Cochrane, OVID Medline, Pubmed, Scopus and Web of Science databases and grey literature was undertaken. Only English language publications outlining OTC/POM misuse by adults in receipt of psychological/pharmacological interventions for substance misuse were included. Two reviewers conducted the title, abstract and full-text reviews using predetermined selection criteria and a piloted data extraction form to ensure a consistent approach. A third reviewer resolved disagreements and the Mixed Methods Appraisal Tool assessed for bias. Ethical approval was not required. Results: Thirteen studies with notable heterogeneity were included in the narrative synthesis after non-UK-based and ineligible publications were excluded, from the 143 potentially relevant papers. To reduce bias all studies were included in the analysis and GRADE-CERQual was applied. 'High confidence' was identified for all review findings, despite moderate methodological limitations. Antihistamine, benzodiazepine and opioid misuse was mentioned most frequently. Usage patterns and supply sources varied. Adverse consequences and polypharmacy are concerning. Withdrawal symptoms perpetuated misuse, often alongside illicit substance use, comorbid psychiatric/pain disorders and street drug shortages. Conclusion: OTC/POM misuse is common amongst adults accessing SMS. A renewed approach to withdrawal management is required. The limited number of studies may impact on generalisability but allowed for a more detailed review. Restricting to UK studies improved relevance due to drug market variations and availability of medicines in different countries. Further UK-based research on OTC/POM misuse in SMS is needed to build upon the current paucity in the published literature.

Clinical pharmacists' perceptions of the barriers and facilitators to the implementation of paediatric clinical pharmacy services in Hong Kong.

OBJECTIVES: To identify barriers and facilitators that influenced the implementation of paediatric clinical pharmacy service (CPS) in Hong Kong's public hospitals from clinical pharmacists' perspective. METHODS: A qualitative study based on semi-structured interviews of clinical pharmacists who practiced in paediatrics in public hospitals in Hong Kong. Interview schedule was designed based on determined themes identified in previous research and pilot testing was performed. The coding process was performed by two researchers with the resulting topics organised by thematic analysis. Consensus was reached amongst the researchers for the identification of themes that emerged during the interviews. The Consolidated Criteria for Reporting Qualitative Research guideline was followed to ensure the complete and transparent reporting of this research. Ethical approval for this study was obtained from the research ethics committee of the relevant institutions. KEY FINDINGS: Of the 32 clinical pharmacists from across the study sites, 12 were interviewed. Five barriers and three facilitators were identified as main themes. The barriers that were identified which hindered service implementation include the service penetration into the healthcare system, practice environment constraints, lack of affirmation from the administrative stakeholders, governance of the profession and partnership with universities. The facilitators that were identified which enabled service implementation include other healthcare professionals' trust and confidence in the service, the support from the pharmacy management team and clinical pharmacists' self-efficacy. CONCLUSIONS: Clinical pharmacists interviewed reported that the successful implementation of CPS in paediatrics in public hospitals in Hong Kong is an area of continued development with several key barriers identified.

Medication management in Minority, Asian and Black ethnic older people in the United Kingdom: A mixed-studies systematic review.

WHAT IS NEW AND OBJECTIVES: Older people from ethnic minorities experience the intersectionality of age and ethnicity in relation to complex medication management and polypharmacy. Minority ethnic groups in the United Kingdom are at risk of poor medication management because factors such as cultural beliefs, language barriers, lack of knowledge of how the healthcare system works may affect their ability to safely manage their medications. The aim of this systematic review was to review the literature focussing on medication management in the older population amongst ethnic minority communities in United Kingdom. METHODS: The review was conducted and reported according to methods in the Cochrane Handbook and in the PRISMA 2020 statement using databases such as EMBASE, ASSIA, MEDLINE, PsychINFO and others. Studies conducted in the United Kingdom on individuals over 60 years of age and from a minority ethnic background were included. A thematic analysis was used to synthesize the results. RESULTS AND DISCUSSION: Nine studies (eight from initial searches, one from a search update in 2021) met the inclusion criteria. Three main themes were identified: misbeliefs around medications, poor health literacy, communication and education as possible intervention to improve medication management. Misbeliefs around long-term illnesses exert a negative impact on medication management. Poor health literacy around medications influences patients' adherence to treatments. Poor communication is perceived as barrier to successful medication management. Despite extensive searching, the team identified a limited number of studies and a lack of intersectional studies focussing on minority ethnic groups and the older population. WHAT IS NEW AND CONCLUSION: Our findings suggest tailored education as a possible intervention to improve medication management amongst these minority groups. Future research should look at recruiting participants from specific ethnic groups and from rural as well as urban areas to explore how medication management operates in different areas of the United Kingdom.

Systematic literature review of pharmacists in general practice in supporting the implementation of shared care agreements in primary care.

BACKGROUND: Rising demand for healthcare continues to impact all sectors of the health service. As a result of the growing ageing population and the burden of chronic disease, healthcare has become more complex, and the need for more efficient management of specialist medication across the healthcare interface is of paramount importance. With the rising number of pharmacists working in primary care in clinical roles, is this a role that pharmacists could support to ensure the successful execution of shared care agreement (SCA) in primary care for these patients? AIM OF THE REVIEW: Systematic review to identify activities and assess the interventions provided by pharmacists in primary care on SCA provision and how it affects health-related quality of life (HRQoL) for patients. METHOD: Primary studies in English which tested the intervention or obtained views of stakeholders related to pharmacist input to shared care agreement within primary care were included. The following electronic databases were systematically searched from the date of inception to November 2021: AMED®, CINAHL®, Cochrane Database of Systematic Reviews (CDSR), EMBASE®, EMCARE®, Google Scholar, HMIC®, MEDLINE®, PsycINFO®, Scopus and Web of Science®. Grey literature sources were also searched. The search was adapted according to the respective database-specific search tools. It was searched using a combination of Medical Subject Heading terms (MeSH), free-text search terms and Boolean operators. RESULTS: A total of 5244 titles/abstracts were screened after duplicates were removed, and 64 full articles were assessed for eligibility. On examination of full text, no studies met the inclusion criteria for this review. CONCLUSION: This review highlights the need for further research to evaluate how pharmacists in general practice can support the safe and effective integration of specialist medication in primary care with the use of SCA. SYSTEMATIC REVIEW REGISTRATION: NIHR PROSPERO No: 2020 CRD42020165363 .

REalist Synthesis Of non-pharmacologicaL interVEntions for antipsychotic-induced weight gain (RESOLVE) in people living with severe mental illness (SMI).

BACKGROUND: People with severe mental illnesses (SMI) such as schizophrenia die on average 15 to 20 years earlier than everyone else. Two thirds of these deaths are from preventable physical illnesses such as hypertension, cardiovascular disease, and diabetes, which are worsened by weight gain. Antipsychotics are associated with significant weight gain. In REalist Synthesis Of non-pharmacologicaL interVEntions (RESOLVE), a realist synthesis, combining primary and secondary data, will be used to understand and explain how, why, for whom, and in what contexts non-pharmacological interventions can help service users to manage antipsychotic-induced weight gain. METHODS: A five-step approach will be used to develop guidance: 1. Developing the initial programme theory An initial (candidate) programme theory, which sets out how and why outcomes occur within an intervention, will be developed. 2. Developing the search The initial programme theory will be refined using academic and grey literature. The proposed initial sampling frame are as follows: Context: people living with SMI, taking antipsychotics, different types of SMI. INTERVENTION: non-pharmacological interventions. MECHANISMS: triggered by the intervention. Outcomes e.g. weight, metabolic adverse events, quality of life, adherence, burden, economic. Searching for relevant documents will continue until sufficient data is found to conclude that the refined programme theory is coherent and plausible. Lived experience (service users) and stakeholder (practitioners) groups will provide feedback. 3. Selection, appraisal and data extraction Documents will be screened against inclusion and exclusion criteria. The text extracted from these documents will be coded as contexts, mechanisms and their relationships to outcomes. 4. Primary data collection Realist interviews with up to 30 service users and informal carers, and 20 practitioners will gather data to support, refute or refine the programme theory. 5. Data analysis A realist logic of analysis will be used to develop and refine the programme theory from secondary and primary data. The analysis will aim to identify practical intervention strategies to change contexts so that key mechanisms are triggered to produce desired outcomes. Guidance will be produced based on these strategies. DISCUSSION: This realist synthesis aims to develop guidance for service users and practitioners on the most appropriate interventional strategies to manage and limit antipsychotic weight gain. SYSTEMATIC REVIEW REGISTRATION: PROSPERO: CRD42021268697.

Higher anticholinergic burden from medications is associated with significant increase in markers of inflammation in the EPIC-Norfolk prospective population-based cohort study.

BACKGROUND: Higher medication anticholinergic burden is associated with increased risk of cardiovascular disease and cognitive decline. A mechanistic pathway has not been established. We aimed to determine whether inflammation may mediate these associations. METHODS: Participants were drawn from the European Prospective Investigation into Cancer, Norfolk cohort (40-79 years at baseline). Anticholinergic burden score (ACB) was calculated at first (1HC) (1993/97) and second (2HC) (1998/2000) health checks. Fibrinogen and C-reactive protein (CRP) were measured during 1HC and tumour necrosis factor alpha (TNF-α) and interleukin 6 (IL-6) during 2HC. Cross-sectional associations between ACB and inflammatory markers were examined for both health checks. Prospective associations were also examined between 1HC ACB and 2HC inflammatory markers. Models were adjusted for age, sex, lifestyle factors, comorbidities and medications. RESULTS: In total, 17 678 and 22 051 participants were included in cross-sectional analyses for CRP, and fibrinogen, respectively. Furthermore, 5101 participants with data on TNF-α and IL-6 were included in the prospective analyses. Cross-sectionally, compared to ACB = 0, ACB ≥ 4 was associated with higher fibrinogen, beta (95% confidence interval) = 0.134 g/L (0.070, 0.199), CRP 1.175 mg/L (0.715, 1.634), IL-6 0.593 pg/mL (0.254, 0.932) and TNF-α 0.137 pg/mL (0.033, 0.241). In addition, a point increase in ACB was associated with higher levels of all markers. Prospectively, compared to ACB = 0, ACB ≥ 4 was associated with higher IL-6(pg/mL) of 0.019 (-0.323, 0.361) and TNF-α (pg/mL) of 0.202% (0.81, 0.323). A unit increase in ACB was associated with a significantly higher TNF-α and IL-6. CONCLUSION: Higher ACB was associated with higher inflammatory markers. Inflammation may mediate the relationship between anticholinergic medications and adverse outcomes.