Supporting prescribing in Irish primary care: protocol for a non-randomised pilot study of a general practice pharmacist (GPP) intervention to optimise prescribing in primary care

Background

Prescribing for patients taking multiple medicines (i.e. polypharmacy) is challenging for general practitioners (GPs). Limited evidence suggests that the integration of pharmacists into the general practice team could improve the management of these patients. The aim of this study is to develop and test an intervention involving pharmacists, working within GP practices, to optimise prescribing in Ireland, which has a mixed public and private primary healthcare system.

Methods

This non-randomised pilot study will use a mixed-methods approach. Four general practices will be purposively sampled and recruited. A pharmacist will join the practice team for 6 months. They will participate in the management of repeat prescribing and undertake medication reviews (which will address high-risk prescribing and potentially inappropriate prescribing, deprescribing and cost-effective and generic prescribing) with adult patients. Pharmacists will also provide prescribing advice regarding the use of preferred drugs, undertake clinical audits, join practice team meetings and facilitate practice-based education. Throughout the 6-month intervention period, anonymised practice-level medication (e.g. medication changes) and cost data will be collected. A nested Patient Reported Outcome Measure (PROM) study will be undertaken during months 4 and 5 of the 6-month intervention period to explore the impact of the intervention in older adults (aged ≥ 65 years). For this, a sub-set of 50 patients aged ≥ 65 years with significant polypharmacy (≥ 10 repeat medicines) will be recruited from each practice and invited to a medication review with the pharmacist. PROMs and healthcare utilisation data will be collected using patient questionnaires, and a 6-week follow-up review conducted. Acceptability of the intervention will be explored using pre- and post-intervention semi-structured interviews with key stakeholders. Quantitative and qualitative data analysis will be undertaken and an economic evaluation conducted.

Discussion

This non-randomised pilot study will provide evidence regarding the feasibility and potential effectiveness of general practice-based pharmacists in Ireland and provide data on whether a randomised controlled trial of this intervention is indicated. It will also provide a deeper understanding as to how a pharmacist working as part of the general practice team will affect organisational processes and professional relationships in a mixed public and private primary healthcare system.

[Aberrant birth of a radial artery in the upper third of the forearm: A case report]

We report the case of a 68-year-old patient, operated on in our department of a quadruple coronary bypass grafting. The grafting strategy consisted initially on harvesting the left internal thoracic artery and the left radial artery. The harvest of this latter failed because of a rare anatomical variation of the radial artery, which rose from the confluence of two branches: a superficial and a deep radial artery at the proximal third of the forearm approximately 10cm below the elbow.

Clinical and therapeutic features of brucellosis: An 11-year study at a tertiary care hospital in Riyadh, Saudi Arabia

To study the varying presentations, risk factors, and treatment outcomes among patients with physician-diagnosed brucellosis. This retrospective analysis evaluated all cases of brucellosis reported at King Khalid University Hospital during 2003-2013. Data were retrieved from patient records and a laboratory information system. Descriptive statistics were generated to summarize the study variables. Fisher's exact test or Pearson's chi-square test was used to compare categorical variables. Out of 163 patients identified with brucellosis, 76.7% of patients were culture positive. Fever was the most frequent symptom (85.9%), followed by arthralgia (46.6%). The most common clinical signs was splenomegaly (12.9%), followed by hepatomegaly (11.0%). Laboratory investigations revealed lymphocytosis and anemia in 66.3% and 55.2% of the patients, respectively. Approximately half of the patients (47.8%) had high erythrocyte sedimentation rates, and 56.4% had neutrophilia. Raw milk consumption and direct contact with animals were reported by 45.4% and 16.0% of patients, respectively. Treatment failure and relapse were observed in 8 (5.7%) cases. All treatment failures and relapses occurred among children <= 10 years of age or adults > 45 years old (11.0% vs. 0%; p = 0.006). Our findings demonstrate that raw milk consumption can be a substantial factor in brucellosis prevention in Saudi Arabia. Laboratory findings, along with the observed pattern in clinical signs and symptoms, can potentially mean underdiagnosis of mild cases. Age was the only factor associated with unfavorable treatment outcomes.

Ivacaftor for cystic fibrosis: An evaluation of real world utilisation and expenditure in the Irish Healthcare Setting

In Ireland, Ivacaftor is reimbursed, on the High-Tech Drug Scheme, for the treatment of cystic fibrosis in patients age 6 years and older who have the G551D mutation. The aim of this study was to analyse the utilisation and expenditure of Ivacaftor on this scheme in the 12 month period post-reimbursement. All patients who had received Ivacaftor (regardless of General Medical Services Scheme eligibility/ineligibility) were included. A total of 140 individuals (male=74; 53%) received Ivacaftor over the defined 12 month study period (from January 2015 to December 2015 inclusive). The cohort ranged in age from 6 years to 61 years. The mean age was 22 years; a positive skew in age distribution indicated that a greater number of the cohort were in the younger age groups. No statistically significant difference was detected in the mean ages of the male and female subgroups. Drug acquisition expenditure by the Health Services Executive on Ivacaftor over the 12 month study period was €29.81 million.

Disease ecology, health and the environment: a framework to account for ecological and socio-economic drivers in the control of neglected tropical diseases

Reducing the burden of neglected tropical diseases (NTDs) is one of the key strategic targets advanced by the Sustainable Development Goals. Despite the unprecedented effort deployed for NTD elimination in the past decade, their control, mainly through drug administration, remains particularly challenging: persistent poverty and repeated exposure to pathogens embedded in the environment limit the efficacy of strategies focused exclusively on human treatment or medical care. Here, we present a simple modelling framework to illustrate the relative role of ecological and socio-economic drivers of environmentally transmitted parasites and pathogens. Through the analysis of system dynamics, we show that periodic drug treatments that lead to the elimination of directly transmitted diseases may fail to do so in the case of human pathogens with an environmental reservoir. Control of environmentally transmitted diseases can be more effective when human treatment is complemented with interventions targeting the environmental reservoir of the pathogen. We present mechanisms through which the environment can influence the dynamics of poverty via disease feedbacks. For illustration, we present the case studies of Buruli ulcer and schistosomiasis, two devastating waterborne NTDs for which control is particularly challenging.This article is part of the themed issue 'Conservation, biodiversity and infectious disease: scientific evidence and policy implications'.

Abstract P5-10-08: Estrogen receptor quantitative measures and differences in breast cancer survival

Introduction: In New Mexico, Hispanic women have a 1.7-fold increased risk of breast cancer-specific death compared to non-Hispanic white women. In previous studies, race/ethnic minority women have had larger survival disparities in estrogen receptor positive (ER+) than ER- disease, suggesting some aspect of ER may mediate survival outcomes. We thus conducted an extensive assessment of ER quantitative measures.

Objective: To determine whether ER percent positive and intensity differs by ethnicity, and to evaluate whether that potential difference might account for a proportion of survival disparities.

Methods: We conducted a population-based case-cohort study of first invasive breast cancer diagnosed in white females from 1997-2009 in six NM counties, identified through Surveillance Epidemiology End Results (SEER). We selected 15% of breast cancer cases and all breast cancer deaths through 2012. After IRB approval, pathology reports and tissue microarrays served as sources of ER, PR, and Her2 information. Tumors were classified according to modified intrinsic subtypes based on immunohistochemistry. Data were analyzed using Cox proportional hazards models adapted for case-cohort with weighted estimates (cohort weighted by 6.67x), and estimated hazard ratios (HR) and 95% confidence intervals (CI) using the robust variance and alpha=.05. The proportional hazards assumption was verified by Schoenfeld residuals. All analyses were adjusted for age. Interaction was assessed by inclusion of main effects and a product term (subtype* exposure).

Results: ER and intrinsic subtype information was available for 76% of the cohort (867/1143) and 70% of breast cancer deaths (689/991). Median follow up was 7.8 years. In analyses stratified by intrinsic subtype, Hispanic women experienced elevated mortality relative to non-Hispanic whites for luminal A (HR 1.9;95% CI 1.4-2.6), Luminal B (HR 2.9;95% CI 1.5-5.7), and TN tumors (HR 1.9;95% CI 1.0-3.6) but not Her2+ER- disease (HR 1.1;95% 0.3-3.4).

Overall ER Quantitative measures: Among ER+ women, breast cancer mortality decreased with increasing ER+ staining, measured by percent (p-trend=.004) or quartile (p-trend=.002). After adjustment for ER percent(ER%+), women with increased ER intensity (score&gt;2) had reduced mortality, relative to score=1 (HR 0.6;95% CI 0.4-.1.0). Results did not differ by Luminal A or B subtype (p interaction&gt; .05).

Ethnicity-specific ER quantitative measures: ER%+ distribution did not differ by Hispanic ethnicity. However, among Hispanic women, interaction terms for ER%+ (p=.04) or quartile (p=.08) by subtype in relation to breast cancer survival suggest that Hispanic women with increasing ER staining have a reduced risk of mortality in Luminal A but not Luminal B tumors. Such differences were not evident among non-Hispanic white women. In multivariate models, inclusion of ER%+ and staining intensity did not alter Hispanic survival disparity overall, but mediated 8.6% in Luminal B.

Conclusion: After inclusion of ER%+, ER staining intensity is an independent risk factor for breast cancer survival. Differences in ER quantitative measures appear to account for only a small proportion of survival disparities. Survival gaps in ER+ breast cancer may be attributable to host or other tumor factors.Introduction: In New Mexico, Hispanic women have a 1.7-fold increased risk of breast cancer-specific death compared to non-Hispanic white women. In previous studies, race/ethnic minority women have had larger survival disparities in estrogen receptor positive (ER+) than ER- disease, suggesting some aspect of ER may mediate survival outcomes. We thus conducted an extensive assessment of ER quantitative measures.

Objective: To determine whether ER percent positive and intensity differs by ethnicity, and to evaluate whether that potential difference might account for a proportion of survival disparities.

Methods: We conducted a population-based case-cohort study of first invasive breast cancer diagnosed in white females from 1997-2009 in six NM counties, identified through Surveillance Epidemiology End Results (SEER). We selected 15% of breast cancer cases and all breast cancer deaths through 2012. After IRB approval, pathology reports and tissue microarrays served as sources of ER, PR, and Her2 information. Tumors were classified according to modified intrinsic subtypes based on immunohistochemistry. Data were analyzed using Cox proportional hazards models adapted for case-cohort with weighted estimates (cohort weighted by 6.67x), and estimated hazard ratios (HR) and 95% confidence intervals (CI) using the robust variance and alpha=.05. The proportional hazards assumption was verified by Schoenfeld residuals. All analyses were adjusted for age. Interaction was assessed by inclusion of main effects and a product term (subtype* exposure).

Results: ER and intrinsic subtype information was available for 76% of the cohort (867/1143) and 70% of breast cancer deaths (689/991). Median follow up was 7.8 years. In analyses stratified by intrinsic subtype, Hispanic women experienced elevated mortality relative to non-Hispanic whites for luminal A (HR 1.9;95% CI 1.4-2.6), Luminal B (HR 2.9;95% CI 1.5-5.7), and TN tumors (HR 1.9;95% CI 1.0-3.6) but not Her2+ER- disease (HR 1.1;95% 0.3-3.4).

Overall ER Quantitative measures: Among ER+ women, breast cancer mortality decreased with increasing ER+ staining, measured by percent (p-trend=.004) or quartile (p-trend=.002). After adjustment for ER percent(ER%+), women with increased ER intensity (score&gt;2) had reduced mortality, relative to score=1 (HR 0.6;95% CI 0.4-.1.0). Results did not differ by Luminal A or B subtype (p interaction&gt; .05).

Ethnicity-specific ER quantitative measures: ER%+ distribution did not differ by Hispanic ethnicity. However, among Hispanic women, interaction terms for ER%+ (p=.04) or quartile (p=.08) by subtype in relation to breast cancer survival suggest that Hispanic women with increasing ER staining have a reduced risk of mortality in Luminal A but not Luminal B tumors. Such differences were not evident among non-Hispanic white women. In multivariate models, inclusion of ER%+ and staining intensity did not alter Hispanic survival disparity overall, but mediated 8.6% in Luminal B.

Conclusion: After inclusion of ER%+, ER staining intensity is an independent risk factor for breast cancer survival. Differences in ER quantitative measures appear to account for only a small proportion of survival disparities. Survival gaps in ER+ breast cancer may be attributable to host or other tumor factors.

Citation Format: Hill D, Royce M, Lomo L, Barry M, Kang H, Wiggins C, Prossnitz E. Estrogen receptor quantitative measures and differences in breast cancer survival [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-10-08.

Preliminary performance data of the RHE/IL-18 assay performed on SkinEthic™ RHE for the identification of contact sensitizers

OBJECTIVE

The purpose of this study was to evaluate the performances of the RHE/IL-18 assay using the SkinEthic^™ RHE model for the identification of contact sensitizers.

METHODS

A set of 18 substances and mixtures was tested on this epidermal model, following the RHE/IL-18 protocol. The final results of the assay were obtained following 5 interpretation schemes, to determine the optimal prediction model for this assay with this specific test system. The data were analysed with a special focus on the basal level of IL-18 release and on the performance obtained with respect to three different gold standards: LLNA, HRIPT and an integrated reference, constructed from all available results.

RESULTS

No important differences were found in the performance levels depending on the three gold standards. The performances obtained with the SkinEthic^™ RHE model support that this model may be considered as an alternative to different reconstructed epidermis models (EpiDERM^™ , EpiCS^™ and VUMC-EE) for the performance of RHE/IL-18 assays.

CONCLUSION

The prediction model to be used was refined, and more substances have to be tested in order to gather enough data for this evaluation and to determine the right criteria applicable for this assay using the SkinEthic^™ RHE test system.

The treatment of open and contaminated fractures

The treatment of any open fracture should follow a logical sequence extending from injury to final rehabilitation. In the past, open fractures were usually sustained in armed conflicts and treated by military surgeons. Currently, the majority of open fractures are sustained as the result of motor vehicle accidents, but the management principles developed in the past are the same. The initial treatment should start in the resuscitation room using trauma resuscitation protocols. Once the patient is stable and any immediately life-threatening injuries treated, the wound should be debrided as early as possible and the skeleton stabilized. The wound is re-inspected 48 h later, and at that stage plans for definitive soft tissue cover can be made. Once soft tissue cover has been obtained, rehabilitation of the whole patient can start. Delayed union or bone loss should be aggressively treated to limit functional deficit and subsequent morbidity.

Abstract P1-09-05: Survival disparities: Quality of care apparently not the answer

Introduction: In New Mexico (NM), Hispanic women have a 1.6-fold increased risk of breast cancer-specific death compared to non-Hispanic white women. In previous studies, race/ethnic minority women have been less likely to receive recommended adjuvant treatments, including radiation in women undergoing breast conservation, and hormonal therapy.

Objective: To determine whether non-receipt of recommended therapies contributed to disparate survival.

Methods: We conducted a case-cohort study of breast-cancer-specific survival within a population-based cohort of first invasive breast cancer diagnosed in white females from 1997-2009 in six NM counties, identified through Surveillance Epidemiology End Results (SEER). We selected fifteen percent of all women diagnosed with breast cancer and all breast cancer deaths. After IRB approval, data were collected from comprehensive medical chart reviews, supplemented by SEER information. Receipt of standard of care, vs. not, was defined based on age, diagnosis year and tumor characteristics, according to changes in treatment guidelines. Women who had a reported contraindication or refused therapy were omitted from assessment of quality of care for that therapy. Cox proportional hazards models for case-cohort were conducted using weighted estimates, with calculation of robust variance and hazard ratios (HR) and 95% confidence intervals (CI), using an alpha level of .05. Analyses were restricted to women of age 70 or less who survived at least 12 months. The proportional hazards assumption was verified by Schoenfeld residuals. All analyses were adjusted for age.

Results: Comprehensive medical records reviews were completed for 91% of eligible women (674 cohort members, 519 breast cancer deaths; median follow up 7.8 years). All others were omitted from analysis. Of women eligible for guideline-based treatment, receipt of guideline-appropriate therapy did not differ by Hispanic ethnicity for any treatment, and Hispanic women were slightly more likely overall to receive appropriate therapy (difference not significant). Among guideline-eligible women, at least 91% received radiotherapy, 78% received chemotherapy, 82% received endocrine therapy, and 89% received anti-HER2 targeted agents. After adjustment for other treatment, lack of receipt of guideline-appropriate therapy was related to an increased risk of breast cancer death for endocrine (HR 1.76; 95% CI 1.09-2.84) and radiation therapy (HR 2.05; 95% CI 1.14-3.69). The few HER2-positive women not treated precluded further assessment. After accounting for endocrine and radiation therapy the survival disparity HR of 1.6 in Hispanic women was reduced to 1.57 suggesting only 2% of the disparity was due to differences in receipt of these treatments.

Conclusion: Limitations include likely undercounts of appropriate therapy, thus proportions cited are minimal estimates. Appropriate therapy includes only documented receipt as therapy completion could not always be assessed. Hispanic women have a disproportionately higher breast cancer mortality despite apparently receiving adjuvant therapies to a similar degree as non-Hispanic white women. Equalizing standard of care and attempting to reduce treatment disparities may not be sufficient to address the disproportionate mortality in Hispanic women.

Citation Format: Friend SC, Royce ME, Kang H, Lomo L, Barry M, Wiggins C, Prossnitz E, Hill DA. Survival disparities: Quality of care apparently not the answer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-09-05.

Generic medicines and generic substitution: contrasting perspectives of stakeholders in Ireland

BACKGROUND

The Health (Pricing and Supply of Medical Goods) Act 2013 passed into law in July 2013 and legislated for generic substitution in Ireland. The aim of the study was to ascertain the knowledge and perceptions of stakeholders i.e. patients, pharmacists and prescribers, of generic medicines and to generic substitution with the passing of legislation.

METHODS

Three stakeholder specific questionnaires were developed to assess knowledge of and perceptions to generic medicines and generic substitution. Purposive samples of patients, prescribers and pharmacists were analysed. Descriptive quantitative and qualitative analyses were undertaken.

RESULTS AND DISCUSSION

A total of 762 healthcare professionals and 353 patients were recruited. The study highlighted that over 84% of patients were familiar with generic medicines and are supportive of the concept of generic substitution. Approximately 74% of prescribers and 84% of pharmacists were supportive of generic substitution in most cases. The main areas of concern highlighted by the healthcare professionals that might impact on the successful implementation of the policy, were the issue of bioequivalence with generic medicines, the computer software systems used at present in general practitioner (GP) surgeries and the availability of branded generics. The findings from this study identify a high baseline rate of acceptance to generic medicines and generic substitution among patients, prescribers and pharmacists in the Irish setting. The concerns of the main stakeholders provide a valuable insight into the potential difficulties that may arise in its implementation, and the need for on-going reassurance and proactive dissemination of the impact of the generic substitution policy.

CONCLUSION

The existing positive attitude to generic medicines and generic substitution among key stakeholders in Ireland to generic substitution, combined with appropriate support and collaboration should result in the desired increase in rates of prescribing, dispensing and use of generic medicines.

Ovariectomy as treatment for ovarian bacterial granulomas in a Duvaucel's gecko (Hoplodactylus duvaucelii)

CASE HISTORY

An adult female Duvaucel's gecko (Hoplodactylus duvaucelii) from a threatened species breeding programme presented due to a prolonged gestation period and distended abdomen.

CLINICAL AND PATHOLOGICAL FINDINGS

The gecko was in lean body condition with an irregularly shaped, firm mass in the coelomic cavity. Radiographically there was a diffuse radio-opacity within the coelomic cavity with cranial displacement of the right lung field. Ultrasonography revealed a round homogenous abdominal mass of medium echogenicity with an echogenic capsule. Haematology showed a leucocytosis with a moderate left shift in heterophils and toxic changes. Bilateral ovariectomy was performed to remove two ovarian granulomas and Salmonella enterica subspecies houtenae (IV) was cultured from the ovarian tissue. The gecko recovered well from the surgery, regained weight and remained in good health 3 years following the surgery.

DIAGNOSIS

Pre-ovulatory stasis and ovarian granulomas associated with infection with Salmonella enterica subsp. houtenae.

CLINICAL RELEVANCE

The surgery described in this case resulted in recovery of the gecko, which despite its loss of reproductive capability is of value as an education animal. This is the first report of pre-ovulatory stasis and ovarian granulomas associated with infection with Salmonella enterica in a Duvaucel's gecko and is also the first reported case of pre-ovulatory stasis in a viviparous lizard species. The case adds to knowledge regarding potential reproductive pathology in lizards, which is particularly important information for managers of captive lizard breeding programmes.