Exploring the implementation of a novel community pharmacist-led support service for people living with severe and persistent mental illness

BACKGROUND

Community pharmacists are well-placed to promote and provide mental health medication management services. However, literature evaluating the impact of pharmacy services in supporting people living with severe and persistent mental illness (SPMI) is currently limited. An individualised, goal-oriented pharmacist-led support service that focused on improving the physical and mental health of consumers living with SPMI, namely the PharMIbridge intervention, was provided to consumer participants as part of the PharMIbridge Randomised Controlled Trial (RCT).

OBJECTIVE(S)

To explore the experiences of the participants who delivered and supported the implementation of the PharMIbridge intervention and propose ideas and supports needed for broader implementation and sustainability of pharmacist-led support services for people living with SPMI.

METHODS

Interviews and focus group discussions were undertaken with PharMIbridge pharmacists and mentors, respectively. Audio-recordings were de-identified and transcribed verbatim. Data analysis was conducted using an iterative, inductive approach. The key themes identified were furthered divided into subthemes. Subthemes were then mapped to the EPIS (Exploration, Preparation, Implementation and Sustainment) framework.

RESULTS

Data were collected from one focus group involving six RCT mentors and 16 semi-structured interviews with community pharmacists. Five overarching themes emerged: "Training needs", "Pharmacist integration within the healthcare system", "Environmental factors", "Attitudes and behaviour" and "Pharmacy operations". Twelve subthemes were mapped to EPIS phases "Preparation", "Implementation" and "Sustainment" and EPIS constructs "Outer" context, "Inner" context and "Bridging" factors.

CONCLUSION

Adequate remuneration and supports to encourage healthcare professional collaboration are necessary to establish and sustain functioning, integrated pharmacy mental health services. A shift in pharmacy business and workflow models is necessary to support community pharmacies to implement mental health services. In addition, there is a need to promote psychological support services to ensure that pharmacists are well supported while delivering pharmacy mental health services.

Are SMART goals fit-for-purpose? Goal planning with mental health service-users in Australian community pharmacies

Goal planning is an important element in brief health interventions provided in primary healthcare settings, with specific, measurable, achievable, realistic/relevant, and timed (SMART) goals recommended as best practice. This study examined the use of SMART goals by Australian community pharmacists providing a brief goal-oriented wellbeing intervention with service-users experiencing severe and persistent mental illnesses (SPMIs), in particular, which aspects of SMART goal planning were incorporated into the documented goals. Goal data from the PharMIbridge Randomized Controlled Trial (RCT) were used to investigate how community pharmacists operationalized SMART goals, goal quality, and which SMART goal planning format aspects were most utilized. Goals were evaluated using the SMART Goal Evaluation Method (SMART-GEM) tool to determine how closely each documented goal met the SMART criteria. Goals were also categorized into five domains describing their content or purpose. Descriptive analysis was used to describe the SMART-GEM evaluation results, and the Kruskal-Wallis H test was used to compare the evaluation results across the goal domains. All goals (n = 512) co-designed with service-users (n = 156) were classified as poor quality when assessed against the SMART guidelines for goal statements, although most goals contained information regarding a specific behaviour and/or action (71.3% and 86.3%, respectively). Less than 25% of goals identified how goal achievement would be measured, with those related to lifestyle and wellbeing behaviours most likely to include measurement information. Additionally, the majority (93.5%) of goals lacked details regarding monitoring goal progress. Study findings raise questions regarding the applicability of the SMART goal format in brief health interventions provided in primary healthcare settings, particularly for service-users experiencing SPMIs. Further research is recommended to identify which elements of SMART goals are most relevant for brief interventions. Additionally, further investigation is needed regarding the impact of SMART goal training or support tools on goal quality.

Patient-targeted interventions for opioid deprescribing: An overview of systematic reviews

BACKGROUND

Deprescribing (reduction or cessation) of prescribed opioids can be challenging for both patients and healthcare professionals.

OBJECTIVE

To synthesize and evaluate evidence from systematic reviews examining the effectiveness and outcomes of patient-targeted opioid deprescribing interventions for all types of pain.

METHODS

Systematic searches were conducted in five databases with results screened against predetermined inclusion/exclusion criteria. Primary outcomes were (i) reduction in opioid dose, reported as change in oral Morphine Equivalent Daily Dose (oMEDD) and (ii) success of opioid deprescribing, reported as the proportion of the sample for which opioid use declined. Secondary outcomes included pain severity, physical function, quality of life and adverse events. The certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

FINDINGS

Twelve reviews were eligible for inclusion. Interventions were heterogeneous in nature and included pharmacological (n = 4), physical (n = 3), procedural (n = 3), psychological or behavioural (n = 3) and mixed (n = 5) interventions. Multidisciplinary care programmes appeared to be the most effective intervention for opioid deprescribing; however, the certainty of evidence was low, with significant variability in opioid reduction across interventions.

CONCLUSIONS

Evidence is too uncertain to draw firm conclusions about specific populations who may derive the greatest benefit from opioid deprescribing, warranting further investigation.

Healthcare professionals' knowledge, confidence and attitudes in relation to psychosis care: A systematic review

BACKGROUND

Psychosis is a mental disorder that, despite its low prevalence, causes high disease and economic burden. Inadequate knowledge, lack of confidence and stigmatising attitudes of healthcare professionals (HCPs) may lead to suboptimal care.

AIM

To review the literature exploring HCPs' knowledge, confidence and attitudes in relation to psychosis care.

METHOD

A systematic search was undertaken across three databases (MEDLINE, Embase, PsycINFO) using a search strategy encompassing the concepts: 'healthcare professionals', 'knowledge, attitude, and confidence in care' and 'psychotic illnesses and symptoms' to identify relevant records published from 1st January 2002 to 18th March 2022. Results were screened against predetermined inclusion and exclusion criteria by title and abstract, followed by full text. Data were extracted into tables and synthesised narratively.

RESULTS

Initially, 7,397 studies were identified. Following two-stage screening, 24 studies were eligible for inclusion. Of these studies, 16 explored attitudes, four explored knowledge and attitudes, one explored knowledge, one explored confidence, one explored attitudes and confidence in care and one explored all three constructs. Most HCPs in the included studies demonstrated stigmatising attitudes towards people with psychosis. Furthermore, certain HCPs, including nurses and general practitioners, demonstrated low levels of knowledge, while psychiatrists, occupational therapists, psychologists and nurses had low levels of confidence in caring for people with psychosis. Conversely, positive attitudes were also observed in some HCPs resulting from having acquaintances with lived experience of psychosis. The need for additional education and training to improve HCPs' knowledge and confidence in relation to caring for people living with psychosis was identified.

CONCLUSIONS

Most attitudes identified were negative and stemmed from stigma, while some were positive due to HCPs' compassion and familiarity with psychosis. The level of knowledge and confidence identified were mostly suboptimal, and so further research is required to develop and evaluate tailored interventions to address this gap.

Experiences of goal planning in Australian community pharmacy settings for people experiencing mental illness: A qualitative study

BACKGROUND

Person-centred goal planning is increasingly being incorporated into healthcare interventions. People experiencing severe and persistent mental illnesses (SPMIs) have high levels of co-occurring health conditions, reducing their life expectancy when compared with the general population. As medications are commonly used in the treatment of SPMIs, community pharmacists are well-placed to support the health and wellbeing of this population.

OBJECTIVES

To examine pharmacists' and service users' experiences of goal planning as a component of a community pharmacy-based health intervention for people experiencing SPMIs (PharMIbridge intervention).

METHODS

This study utilised a qualitative exploratory approach with an interpretive description method. Semistructured interviews were undertaken with community pharmacists (n = 16) and service user participants (n = 26) who had participated in pharmacist support services for people experiencing SPMIs (PharMIbridge intervention).

RESULTS

Four themes relating to goal planning were identified. First, goal planning provided purpose and motivation for participation in the intervention. Planning realistic goals was important but often challenging. Both pharmacists and service users highlighted the relational aspects of goal planning and how strong relationships supported positive behaviour change and outcomes. Finally, individualised and flexible approaches were important aspects of the intervention, ensuring goals were meaningful to service users.

CONCLUSIONS

The findings from this study identified positive outcomes from the inclusion of goal-planning processes in a community pharmacy-based health intervention. Further research regarding tools, strategies or training that could support future goal-planning interventions in primary healthcare is needed.

PATIENT OR PUBLIC CONTRIBUTION

The PharMIbridge randomised controlled trial research team included lived experience members and was overseen by an expert panel that included members with a lived experience of mental illness and representatives from key organisations. The training provided to pharmacists was co-designed and co-delivered by the researchers and lived experience representatives, and pharmacists were supported by lived experience mentors. Service user participants were invited to participate in the interviews through a number of pathways (e.g., at the completion of the intervention, flyers). Those interested were provided with the full study participant information and provided with a $30 gift voucher at the conclusion of the interview.

Medication-related problems identified by community pharmacists: a descriptive case study of two Australian populations

BACKGROUND

Medication-related problems (MRPs) contribute significantly to preventable patient harm and global healthcare expenditure. Vulnerable populations, including Indigenous Australians (please note that the use of the term 'Indigenous' in this paper includes all Aboriginal and Torres Strait Islander people and acknowledges their rich traditions and heterogenous cultures.) and people living with severe and persistent mental illness (SPMI), may be at increased risk of MRPs. Pharmacist-led medication reviews can identify MRPs for targeted action.

OBJECTIVE

To characterize MRPs identified and recommendations made by community pharmacists during medication reviews conducted with Indigenous Australians and people living with SPMI.

METHODS

Participants were recruited through two Australian trials testing the feasibility and/or effectiveness of novel community pharmacist-led interventions, the Indigenous Medication Review Service (IMeRSe) feasibility study (June 2018-July 2019) and Bridging the Gap between Physical and Mental Illness in Community Pharmacy (PharMIbridge) randomized controlled trial (September 2020-December 2021). Trained community pharmacists conducted medication reviews responsive to the cultural and health needs of participants. MRPs, MRP severity and pharmacist recommendations were documented and classified using an established classification system (DOCUMENT). MRP severity was assessed by pharmacists and an independent assessor. Data were analysed descriptively, and paired t-tests were used to compare severity ratings.

RESULTS

Pharmacists identified 795 MRPs with 411 participants across both trials (n = 255 IMeRSe, n = 156 PharMIbridge). Non-adherence to medication was the most common (n = 157, 25.1%) and second-most common (n = 25, 14.7%) MRP in IMeRSe and PharMIbridge, respectively. Undertreatment was the second-most common MRP in the sample of Indigenous Australians (n = 139, 22.2%), and reports of toxicity/adverse reactions were most common in people living with SPMI (n = 41, 24.1%). A change in pharmacotherapy was the most frequent recommendation made by pharmacists (40.2% and 55.0% in IMeRSe and PharMIbridge, respectively). Severity ratings varied, with the majority being 'Mild' or 'Moderate' in both groups. Significant differences were found in the severity rating assigned by trial pharmacists and the independent assessor.

CONCLUSIONS

Community pharmacists identified a range of MRPs experienced by two at-risk populations, most commonly non-adherence and toxicity or adverse reactions, when conducting medication reviews and proposed diverse strategies to manage these, frequently recommending a change in pharmacotherapy. These findings highlight the opportunity for more targeted approaches to identifying and managing MRPs in primary care and tailored community pharmacist-led interventions may be of value in this space.

TRAIL REGISTRATION

Australian and New Zealand Clinical Trial Registry records (IMeRSe ACTRN12618000188235 registered 06/02/2018 & PharMIbridge ACTRN12620000577910 registered 18/05/2020).

Refining a taxonomy of goals planned between mental health consumers and community pharmacists

BACKGROUND

People living with severe and persistent mental illnesses are more likely to experience co-morbid health conditions. Health-related behavior change can be promoted by the use of goal planning within community pharmacy settings.

OBJECTIVES

To trial and refine a recently developed taxonomy to categorize goals co-designed between community pharmacists and people living with severe and persistent mental illnesses. This study also compared the data to the previously published taxonomy data to determine if the taxonomy could be applied across a range of mental health conditions.

METHODS

The published goal taxonomy was refined using data from a cluster randomized controlled trial (PharMIbridge). Community pharmacists provided an individualized support service using goal planning with people living with severe and persistent mental illnesses. Goals were categorized using the existing taxonomy and inconsistencies were used to modify and refine the taxonomy. Additionally, participant characteristics and categorization of goals were compared with results from the previous study.

RESULTS

512 goals were reported by 158 consumer participants and categorized into five domains that included a diverse range of health behaviors (e.g., relationships, diet). Minor refinements to the taxonomy were made by replacing, adding or removing categories/descriptors.

CONCLUSIONS

Significant overlap between the goals of participants and the existing taxonomy was found, supporting the application of the taxonomy across different mental health conditions.

Psychological distress in community-dwelling individuals living with severe and persistent mental illness

OBJECTIVES

To explore psychological distress levels, using the validated Kessler 6 (K6), as well as the relationship between demographics and K6 scores, and incidence of mental health crises in a cohort of community-dwelling people living with severe and persistent mental illness (SPMI).

METHODS

People living with SPMI taking antipsychotic or mood stabiliser medications were recruited from Australian community pharmacies between September 2020 and Februrary 2021 and completed an electronic survey, including the K6 scale. Pharmacists were interviewed and supplied written reports with details of the consultation when participants obtained 'very high' (⩾19/30) K6 scores. Records were reviewed and coded by an independent coder. Multivariate linear regression was used to determine predictors of K6 scores.

RESULTS

The median K6 score was 16/30 (IQR = 11,21; range = 6-30). Younger age, unemployment and multimorbid mental health diagnoses were significant predictors of higher K6 scores (p < .01; R2 = .24). Fifty-nine (39.3%) consumers scored ⩾19, of which 25/59 (42.4%) were reported to be exhibiting signs of psychological distress and none were experiencing mental health crises.

CONCLUSION

People living with SPMI have high levels of psychological distress as measured by the K6. Further work is needed to understand the prevalence, extent, precipitating factors and impact of psychological distress in people living with SPMI.

Mental Health First Aid crisis role-plays between pharmacists and simulated patients with lived experience: a thematic analysis of debrief

PURPOSE

Healthcare professionals, including pharmacists, can recognise and assist people experiencing mental health crises. Despite this, little is known about how pharmacists assist and engage with people presenting with signs and symptoms of mental health crises. This study aimed to (i) examine pharmacists' mental health crisis assessment language during simulated patient role-plays (SPRPs) and (ii) explore participants' experiences of participating in SPRPs of Mental Health First Aid (MHFA) scenarios.

METHODS

Fifty-nine MHFA-trained pharmacy staff participated in audio-recorded SPRPs of three crisis scenarios enacted by a mental health consumer educator (MHCE). Post-SPRP, pharmacy staff members (including role-playing and observing participants), engaged in reflective debrief discussions with the facilitator and MHCEs. Debrief discussions were transcribed verbatim and analysed using inductive thematic analysis and suicide assessment language was explored.

RESULTS

The majority of role-playing pharmacists asked about suicidal ideation using appropriate, direct language (n = 8). Qualitative analyses of debrief discussions yielded four themes: (i) Relationship with the consumer, (ii) Verbal and non-verbal communication, (iii) Challenges with crisis assessment, which included difficulties associated with initiating conversations about suicide and mania, and (iv) Reflective learning.

CONCLUSION

While pharmacists demonstrated the appropriate suicide assessment language post-MHFA training, pharmacists felt uncomfortable initiating conversations around suicide and lacked confidence during crisis assessments. SPRPs provided pharmacists with opportunities to reflect on and practice MHFA skills in a safe learning environment. Future research exploring how MHFA training and SPRPs impact pharmacists' ability to provide MHFA in real-world settings is warranted.

Implementing a randomised controlled trial through community pharmacies to support people living with severe and persistent mental illness: Lessons learnt during the COVID-19 pandemic

Public health orders were introduced in many countries, including Australia, during the COVID-19 pandemic to reduce the spread of the virus. However, for many people this led to an exacerbation of mental health symptoms, particularly those living with severe or persistent mental illness (SPMI). Additionally, the conduct of clinical research was severely impacted during the pandemic, with many difficulties encountered in the conduct of clinical trials. This paper describes the COVID-related impacts experienced during the implementation of a randomised controlled trial (RCT) testing the effectiveness of a community pharmacist-led support service for people living with SPMI in Australia (the PharMIbridge RCT), and the strategies used to successfully implement the RCT. Australian public health orders led to interstate border closures, stay-at-home orders and work-from-home requirements, resulting in necessary changes to allow for the continuation of the RCT including; changes to trial regions, transferring some training materials online while delaying face-to-face (F2F) training components, delays in pharmacy and consumer recruitment, encouraging telehealth service delivery and extensions to timelines with existing funding. Having a solution-focussed and flexible approach, while still ensuring critical trial protocol elements were adhered to, such as providing opportunities for F2F skills-based training for pharmacists, as well as F2F site visits from researchers and mentors to support trial implementation, resulted in high pharmacy and consumer participant retention through to trial conclusion. Future planning for RCTs should consider possible pandemic-related risks and rapid responses from approval bodies to ensure researchers can be agile and adapt to ensure successful trial completion.

The impact of COVID-19 on clinical research at Australian and New Zealand universities: A qualitative study

Background

The COVID-19 pandemic resulted in the implementation of social distancing measures, travel restrictions, and infection control measures that introduced a myriad of disruptions in the conduct of clinical research worldwide. As a result, many aspects of clinical research were variably impacted.

Aim

To explore the impact of the first 18 months of the COVID-19 pandemic on clinical research across accredited nursing, pharmacy, and medicine program providers in Australian and New Zealand universities.

Methods

Representatives from all program providers across Australian and New Zealand universities, with publicly available contact information, were invited to participate in this qualitative study, whereby semi-structured interviews were completed with participants who held senior research or leadership positions within their institution. Interviews were transcribed verbatim and inductively analysed using thematic content analysis.

Findings

Interviews were conducted with 16 participants between August and October 2021. Two major themes were identified (Immediate Research Impact and Broader Research Impact) with six subthemes: Prioritisation, Continuation, and Dissemination of Research; Modifications to Research; Funding and Changes to Research Focus; Collaboration; Research Workforce; Context-specific Impacts.

Discussion

The impact on clinical research in Australian and New Zealand universities included changes to data collection methods, a perceived decreased quality of research, changes to collaboration, neglect of basic disease research, and loss of the research workforce.

Conclusion

This study highlights the impact of the COVID-19 pandemic on clinical research within the Australian and New Zealand university context. Implications of these impacts should be considered to ensure long-term sustainability of research and preparedness for future disruptions.

Guidance on the Conduct of Clinical Research within OECD Countries during the Early Stages of the COVID-19 Pandemic: A Systematic Review

BACKGROUND

In response to the COVID-19 pandemic, member countries of the Organisation for Economic Co-operation and Development (OECD) rapidly published guidance regarding the conduct of clinical research. A systematic review was conducted to explore the recommendations issued in relation to the commencement, continuation and termination of clinical research during the early phases of the pandemic.

METHODS

Searches consisting of the terms "COVID-19", "clinical research", and "guidance", were conducted in PubMed, Embase, MEDLINE, Trip, Guidelines International Network, and Google in April-May 2021 (up to 4 May 2021). Data were extracted from guidance published from OECD member countries and mapped to inductively-developed categories.

RESULTS

9419 references were systematically screened, resulting in the inclusion of 46 publications from 27 OECD countries. Thirty-three sources made recommendations regarding monitoring, risk-benefit assessments and information technology. There was limited specific recommendations made in relation to personal protective equipment (PPE) in the included guidance. Findings demonstrate that guidance differed by publication date demonstrating the rapidly evolving environment within which research was conducted. Importantly, many organisations opted to endorse existing guidance published by the United States' Food and Drug Administration and the European Medicines Agency rather than develop their own recommendations.

CONCLUSIONS

Given the rapidly evolving nature of the pandemic, particularly in the early stages, findings demonstrate the global response in relation to clinical research conduct, thereby providing important insights for future public health emergencies.

Observed behaviours and suicide assessment language post-Mental Health First Aid training in Australia and the United States: a mixed methods study using discourse analysis

BACKGROUND

Mental Health First Aid (MHFA) training teaches participants how to respond to mental health crises, including suicide. Little is known about the impact of training on participants' observed MHFA behaviours. This exploratory study aimed to compare MHFA-trained Australian and US student pharmacists' performance and suicide assessment language during simulated patient role-play (SPRP) assessments.

METHODS

Student pharmacists (n = 265) completed MHFA training and participated (n = 81) in SPRPs with simulated patients (SP) who were people with lived experience of mental illness. Each SPRP was marked by three raters (student, tutor and SP). One-way ANOVA, chi-squared tests and independent samples t-tests were used to compare scores and pass/fail rates, where appropriate. Transcribed audio-recordings of suicide assessments underwent discourse analysis. A chi-squared test was conducted to investigate the differences in how suicide assessment language was coded across six discursive frames ('confident'/'timid', 'empathetic'/'apathetic', and 'direct'/'indirect').

RESULTS

Three raters assessed 81 SPRPs, resulting in quantitative analysis of 243 rubrics. There were no significant differences between student pharmacists' mean scores and pass/fail rates across countries. Overall, both cohorts across Australia and the US performed better during the mania scenario, with a low failure rate of 13.9 and 19.0%, respectively. Most students in both countries passed their SPRP assessment; however, 27.8% did not assess for suicide or used indirect language during suicide assessment, despite completing MHFA training. Australian student pharmacists demonstrated, more direct language (76.9% versus 67.9%) and empathy (42.3% versus 32.1%) but less confidence (57.7% versus 60.7%) compared to US student pharmacists, during their suicide assessment; however, these differences were not statistically significant.

CONCLUSIONS

Findings indicate most MHFA-trained student pharmacists from Australia and the US can provide MHFA during SPRPs, as well as assess for suicide directly, empathetically and confidently. This exploratory study demonstrates the importance of practicing skills post-training and the need for further research exploring participants' hesitance to assess for suicide, despite training completion.

Psychotropic medication use in people living with severe and persistent mental illness in the Australian community: a cross-sectional study

BACKGROUND

Psychotropic polypharmacy and high-dose prescribing may play a role in therapy, however, with associated risks. The aim of this study was to describe current prescribing practices and use of four psychotropic medication groups (antipsychotics, antidepressants, mood stabilisers and benzodiazepines), focusing on polypharmacy (across and within groups) and high-dose prescribing in adults experiencing severe and persistent mental illness (SPMI) in the Australian community.

METHODS

318 people taking psychotropic medication for SPMI had a medication review undertaken by a community pharmacist. Participants were recruited as part of an RCT from three Australian states/territories between September 2020-July 2021. All psychotropic medication and daily doses were recorded and reviewed for alignment with current clinical guidelines. Univariate and multiple logistic regression models investigated factors associated with antipsychotic, antidepressant, and mood stabiliser polypharmacy, and antipsychotic and antidepressant high-dose therapy. Variables included age, gender, geographic location, self- reported mental illness(es), hospital admission(s) in previous 6-months and prescriber type.

RESULTS

806 psychotropic medications were prescribed for the 318 participants. Mood stabiliser polypharmacy was recorded in 19.0% of participants prescribed mood stabilisers; antipsychotic polypharmacy in 18.4% of participants prescribed antipsychotics; antidepressant polypharmacy in 11.3% of those prescribed antidepressants; and three participants (5.1%) were prescribed two benzodiazepines concurrently. Almost 18.6% of the cohort was receiving high-dose treatment; 18 participants were prescribed high-dose antipsychotics and 39 high-dose antidepressants, with two participants prescribed both. Adjusted logistic regression for polypharmacy found male gender, psychiatrist as sole prescriber, or multiple prescribers, were associated with antipsychotic polypharmacy. The adjusted model for high-dose therapy found psychiatrist as sole prescriber was significantly associated with antipsychotic and antidepressant high-dose prescribing.

CONCLUSION

Psychotropic polypharmacy was common in this community cohort experiencing SPMI. Whilst polypharmacy is not always inappropriate, it is a complex construct with potential benefits alongside potential risks. Benefits and harms need to be balanced however this practice is not supported by clear guidance to assist health practitioners. This study highlights the important need for regular medication reviews and strengthened communication between consumers and all healthcare professionals involved in community mental health care, to support safe and effective use of psychotropic medications.

Pharmacist-led interventions for people living with severe and persistent mental illness: A systematic review

OBJECTIVE

People living with severe and persistent mental illness experience poorer physical health, often due to medication and preventable lifestyle factors, and exacerbated by barriers to accessing healthcare services. Pharmacists are well-positioned to improve the physical and mental health of this population. However, little is known about pharmacists' current practices when providing services to this population nor the impact of pharmacist-led interventions on consumer health outcomes. We undertook a systematic review to identify, describe and assess the effectiveness of pharmacist-led interventions for supporting people living with severe and persistent mental illness and the impact on consumer outcomes.

METHODS

MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, Scopus, Cochrane Library, International Pharmaceutical Abstracts and ProQuest Dissertations and Theses were searched between January 1990 and April 2020. Full-text studies exploring pharmacist-led interventions in any setting for people living with severe and persistent mental illness were included. A risk of bias assessment was conducted.

RESULTS

A total of 37 studies were included. More than half of the pharmacist interventions were multifaceted. The most common components of pharmacist-led interventions included education and/or patient counselling, providing recommendations to healthcare professionals and conducting medication reviews. Multifaceted interventions demonstrated improvements in clinical outcomes, whereas single interventions focused mostly on consumer-reported outcomes. The methodological quality of included studies was moderate-to-high risk of bias and there was considerable heterogeneity in the study design, interventions described, and outcomes reported.

CONCLUSION

There is evidence that pharmacist-led interventions improve consumer-reported and clinical outcomes for people living with severe and persistent mental illness. Pharmacists are capable and have a role in supporting people living with severe and persistent mental illness, either individually or as interprofessional collaborators with other healthcare professionals. Future research should attempt to better understand which particular intervention components have the greatest impact and also evaluate the implementation and long-term sustainability of such interventions.

Pharmacists' roles in mental healthcare: Past, present and future

Mental illnesses cause significant disease burden globally, with medicines being a major modality of treatment for most mental illnesses. Pharmacists are accessible and trusted healthcare professionals who have an important role in supporting people living with mental illness. This commentary discusses the role of pharmacists in mental healthcare, as part of multidisciplinary teams, the current evidence to support these roles, and the training, remuneration and policy changes needed to recognize these roles and embed pharmacists as core members of the mental healthcare team.

The simulated patient method: Design and application in health services research

The simulated patient method is becoming increasingly popular in health services research to observe the behaviour of healthcare practitioners in a naturalistic setting. This method involves sending a trained individual (simulated patient among other names), who is indistinguishable from a regular consumer, into a healthcare setting with a standardised scripted request. This paper provides an overview of the method, a brief history of its use in health services research, comparisons with other methods, ethical considerations, and considerations for the development of studies using the simulated patient method in health services research, with examples from pharmacy and other fields. Methods of analysis, mixed-methods, and the use of simulated patients with feedback are also discussed.

A scoping review of pharmacy participation in dental and oral health care

OBJECTIVES

To explore the scope of dental and oral health care (DOHC) provided by the pharmacy profession and associated outcomes, and attitudes of pharmacy staff and other key stakeholders about pharmacy involvement in this context.

METHODS

A scoping review of full-text articles describing outcomes related to pharmacy staff/student involvement in, knowledge of or attitudes towards DOHC in any setting, and stakeholder perspectives was conducted. Articles written in English were searched for using PubMed, EMBASE, EBSCO, International Pharmaceutical Abstracts, Education Resources Information Centre, Web of Science, Google Scholar, and ProQuest for Dissertations and Theses. No date restrictions were used. Key outcomes were mapped: role and practice, knowledge and attitudes, and training and education.

RESULTS

Seventy studies met the inclusion criteria: 49 were conducted in developed countries; 60 were quantitative in design; and 38 involved community pharmacy settings only. Pharmacists and pharmacy support staff commonly managed DOHC inquiries (n = 13), including the provision of advice and products with or without a further referral. Integrated pharmacist-led services in dental settings (n = 4) showed improved prescribing and quality use of medicines but low community pharmacy referrals were identified in studies involving mystery shoppers with potential oral cancer (n = 7). DOHC promotion programmes delivered by pharmacy staff and collaborations with dentists were limited. There was interest from the pharmacy profession for a role in DOHC; however, knowledge gaps were reported and needs for further training identified. Consumer participant DOHC outcomes were not reported.

CONCLUSIONS

Community pharmacists and pharmacy staff were interested in an expanded role in DOHC; however, this scoping review identified lack of knowledge and sub-optimal practice as potential barriers. Research on development, implementation and evaluation of DOHC-related services and practice by pharmacy staff was scarce. Further evidence of consumer-related oral health outcomes and their perceptions of the role of pharmacy is needed.

Ability of Pharmacy Students, Pharmacists and Pharmacy Support Staff to Manage Childhood Fever via Simulation

Objective. To ascertain how pharmacy students (novices) and pharmacy staff (experts) respond to a childhood fever scenario. Methods. Data were collected from 65 second year students and 51 fourth (final) year students in an over-the-counter fever scenario during assessment tasks. Data from pharmacy staff were collected via mystery shopping conducted over nine weeks between March and October 2015. All encounters were immediately scored by the trained simulated client, and immediate feedback was provided for pharmacy staff and fourth year students. Questioning scores and proportions of competent participants were collected in all groups. Statistical comparative analyses were made between fourth year students and pharmacy staff. Pharmacy staff scores were also tracked over time. Results. Second year students performed well, achieving a median questioning score of 100%. Conversely, pharmacy staff scored 22%. A large proportion of the fourth year students and pharmacy staff achieved appropriate outcomes (92% and 65%, respectively); however, a smaller proportion of second year students performed well (52%). The pharmacy staff achieved statistical improvements over time for median questioning scores. Conclusion. Protocol compliant questioning appears to decline with experience. However, experienced counselors are more likely to provide appropriate patient advice. Further improvements in outcomes can also occur when staff are provided feedback and coaching. Mystery shopping simulations can be used as a valuable educational tool.

The effectiveness of an online training programme to prepare teachers to provide asthma first aid

AIM

Asthma is prevalent in our primary (elementary) school population. Training in asthma management for school staff should be relevant and focused on the recognition and management of an acute severe exacerbation of asthma. Evidence suggests that online training can be as effective as face-to-face training for medical education; however, there is little information regarding the effectiveness of online asthma education.

METHODS

University students in the final year of their primary education degree completed the asthma first aid (AFA) knowledge questionnaire before undertaking a 1-h online training course in asthma management. After 3 weeks, participants underwent a second AFA knowledge questionnaire followed by an AFA scenario-based skills assessment. This skills assessment required the student to describe and demonstrate how they would manage a child having a severe exacerbation of asthma using the AFA equipment provided. Skills scores were further analysed to establish AFA competency.

RESULTS

AFA knowledge scores improved significantly after the asthma online training (64-79%), z = -6.11 (P < 0.001). The mean AFA skills score after the training was 20.5 (79%); however, the proportion of students who achieved a level of competency sufficient to save the life of a child having a severe exacerbation of asthma was only 29%.

CONCLUSION

This research has revealed that online asthma management training was effective in increasing the knowledge needed for AFA. This knowledge did not translate into effective AFA skills, with only 29% of participants deemed competent to save the life of a child in an asthma emergency.

Community pharmacy modifications to non-prescription medication requests: A simulated patient study

BACKGROUND

Self-care, and hence self-medication, is becoming an increasingly popular practice worldwide. Community pharmacies are an important destination for those seeking non-prescription medicines, and pharmacists and their staff are in a prime position to facilitate appropriate and safe self-medication.

PURPOSE

To determine what modifications (for example, a change in brand, change in drug, or non-supply) pharmacy staff make when presented with a request for a non-prescription medicine, and to determine what factors influence whether a modification is made.

METHODS

Sixty-one third year Bachelor of Pharmacy students from The University of Sydney were trained as mystery shoppers to make 9 visits once a week to 36 community pharmacies in the metropolitan region of Sydney, Australia from March-October 2015. Students presented to a different, pre-allocated pharmacy once a week with a direct product request for a non-prescription medicine relating to a common ailment (e.g. asthma, insomnia, allergic rhinitis) for 9 weeks. Student mystery shoppers audio-recorded each visit and collected the details of the interaction and product sold. Descriptive statistics, chi-squared analyses, and binary logistic regression were performed to find factors influencing modifications made by pharmacy staff to the simulated patient initial request.

RESULTS

Of 540 completed visits, 497 were eligible for analysis. Modification (change in brand, intra/interclass change, companion sale, or no product supplied) occurred in 49% (n = 245) of visits. Whether the product requested was deemed "not appropriate" given the scenario outline was the only significant predictor of whether a modification to the request occurred (42% modification, "appropriate" scenarios vs. 57% modification, "not appropriate" scenarios; χ² = 8.90; p < 0.01).

CONCLUSIONS

Modification from the original non-prescription medicine request occurred in approximately half the reported requests. A request for a product that was considered "not appropriate" was more likely to elicit a modification than a request for an "appropriate" non-prescription medicine.

Revision of the International Pharmaceutical Federation's Basel Statements on the future of hospital pharmacy: From Basel to Bangkok

PURPOSE

The processes used to revise the 2008 Basel Statements on the future of hospital pharmacy are summarized, and the revised statements are presented.

METHODS

The process for revising the Basel Statements followed an approach similar to that used during their initial development. The Hospital Pharmacy Section (HPS) of the International Pharmaceutical Federation (FIP) revised the 2008 FIP Basel Statements in four phases, including a survey of hospital pharmacists worldwide, an internal review, online forums, and a face-to-face "World Café" workshop in Bangkok, Thailand.

RESULTS

The global survey on the initial Basel Statements included input from 334 respondents from 62 countries. The majority of respondents agreed that most of the initial Basel Statements were acceptable as written and did not require revision. In total, 11 statements were judged by more than 10% of respondents as needing revision or deletion. The FIP HPS executive committee used the survey results to develop 69 initial revised draft statements. After an online discussion with the international hospital pharmacy community, including individuals from 28 countries representing all six World Health Organization regions, a final set of draft statements was prepared for the live discussion involving participants from 20 countries. The final 65 revised Basel Statements were voted on and accepted.

CONCLUSION

Systematic revision of the FIP Basel Statements resulted in an updated reflection of aspirational goals for the future of hospital pharmacy practice. While this revision reflects the development of new goals for hospital pharmacy practice, the core principles of the Basel Statements remain an essential foundation for the discipline.

Magnetic resonance imaging of muscle electroporation injury

Low frequency electrical currents traversing the body during electrical shock can produce tissue damage by effects of electrical forces on cellular organelles and proteins as well as by Joule heating beyond thermotolerance. Treatment for these different injuries are quite distinct. Therefore, it is important to accurately diagnose the form of injury. Here we discuss the use of MRI for this purpose.

Effect of timing of prostaglandin administration, controlled internal drug release removal and gonadotropin releasing hormone administration on pregnancy rate in fixed-time AI protocols in crossbred Angus cows

Two experiments were conducted to investigate the effects of timing of prostaglandin F2(alpha) (PGF2(alpha)) administration, controlled internal drug release device (CIDR) removal and second gonodotropin releasing hormone (GnRH) administration on the pregnancy outcome in CIDR-based synchronization protocols. In Experiment 1, suckled Angus crossbred beef cows (n = 580) were given 100 microg of GnRH+a CIDR on Day 0. Cows in Group 1 (modified Ovsynch-P) received 25 mg of dinoprost (PGF2(alpha)) and CIDR device removal on Day 8 (AM), 100 microg of GnRH 36 h later on Day 9 (p.m.), and fixed-time AI (FTAI) 16 h later on Day 10 (47.5+/-1.1 h after PGF2(alpha)). Cows in Group 2 (Ovsynch-P) received 25mg of PGF2(alpha) and CIDR device removal on Day 7 (p.m.), 100 microg of GnRH 48 h later on Day 9 and FTAI 16 h later on Day 10 (66.6+/-1.2 h after PGF2(alpha)). Pregnancy rates were 56.5% (170/301) for Group 1 and 55.6% (155/279) for Group 2, respectively (P = 0.47). In Experiment 2, beef cows (n=734) were synchronized with 100 microg of GnRH+CIDR on Day 0, 25 mg of PGF2(alpha) and CIDR device removal on Day 7 and either 100 microg of GnRH 48 h later on Day 9 (Ovsynch-P) and FTAI 16 h later on Day 10 (64.9+/-3.3 h from PGF2(alpha)) or 100 microg of GnRH on Day 10 (CO-Synch-P) at the time of AI (63.2+/-4.2 h from PGF2(alpha)). Pregnancy rates were 48.8% (180/369) for Ovsynch-P and 44.7% (163/365) for CO-synch-P groups, respectively (P = 0.11). In both experiments, there was a locationxtreatment interaction (P<0.05); pregnancy rates between locations were different (P < 0.05) in the Ovsynch-P group. In conclusion, in a CIDR-based Ovsynch synchronization protocol, delaying administration of prostaglandin and CIDR removal by 12 h, or timing of the second GnRH by 16 h, did not affect pregnancy rates to FTAI. Therefore, there may be an opportunity to make changes in synchronization protocols with out adversely affecting FTAI pregnancy rates.

Selective lymphoscintigraphy: a necessary adjunct to dye-directed sentinel node biopsy for breast cancer?

BACKGROUND

Dye-directed sentinel node biopsy (SNB) for breast cancer provides accurate staging with low morbidity, but for tumors distant from the axilla, its use has been questioned.

HYPOTHESIS

Can preoperative breast lymphoscintigraphy (BL) applied selectively to medial hemisphere tumors predict a subset of patients who may not require surgical staging of the axilla?

DESIGN

Prospective cohort study.

SETTING

Tertiary, multidisciplinary breast center.

PATIENTS

Thirty-two women with breast tumors located in the medial hemisphere (30) or inframammary crease (2).

INTERVENTION

Peritumoral injection of 500 microCi of technetium Tc 99m sulfur colloid and biplanar imaging. Nonpalpable lesions were localized with ultrasound or mammography. At the time of definitive breast surgery, isosulfan blue dye-directed SNB was performed. Axillary dissection was performed when the SN contained a tumor or could not be identified.

MAIN OUTCOME MEASURES

Regional nodal basins identified by BL; success rate of SNB.

RESULTS

Preoperative BL demonstrated axillary drainage in 28 patients (88%); 2 patients (6%) had isolated internal mammary radionuclide uptake, and 2 patients had no nodal uptake. Dye-directed axillary SNB succeeded in 27 (87%) of 31 patients, including both patients with failed BL. Breast lymphoscintigraphy had predicted isolated internal mammary drainage in 2 of 4 patients whose SNs could not be identified. Metastases were found in 5 patients (16%).

CONCLUSIONS

Axillary radionuclide uptake predicts but does not augment dye-directed SN identification. In those few patients with isolated internal mammary drainage, BL may obviate the need for surgical staging of the axilla.

Antineoplastic agents 430. Isolation and structure of cribrostatins 3, 4, and 5 from the republic of maldives cribrochalina species

Continued investigation of cancer-cell growth-inhibitory constituents of the blue marine sponge Cribrochalina sp. has led to discovery of cribrostatins 3 (4a), 4 (5), and 5 (4b) in 10(-5) to 10(-7) % of the wet weight. The structure of cribrostatin 3 (4a) was determined by results of high field (500 MHz) (1)H and (13)C NMR and HRMS interpretations. The same general approach to the structures of cribrostatins 4 (5) and 5 (4b) was completed by X-ray crystal structure determinations. Cribrostatins 3, 4, and 5 provided significant cancer cell line inhibitory activities. Cribrostatins 1 and 2(2) and the newly isolated cribrostatins 3-5 displayed antibacterial and/or antifungal activities.

Common bile duct stone characteristics: correlation with treatment choice during laparoscopic cholecystectomy

Determining the most appropriate management approach for patients with unsuspected choledocholithiasis may be difficult because of the subjective nature of this decision in the absence of clinical data. Treatment of incidental choledocholithiasis during laparoscopic cholecystectomy was reviewed during a 25-month period. Operative cholangiograms were analyzed retrospectively to determine if associations exist between common bile duct stone characteristics and the intraoperative treatment selected by the operating surgeon. Cholangiographic data included quantification of common bile duct stones, stone dimension, position, and presence of radiopaque contrast flow into the duodenum. Two hundred thirty-six laparoscopic cholecystectomy patients underwent operative cholangiography; 25 (11%) demonstrated choledocholithiasis. Seven patients were converted to open common bile duct exploration (group I), 16 patients were referred for postoperative endoscopic retrograde cholangiopancreatography (group II), and two patients were observed (group III). Evaluation of the operative cholangiograms revealed multiple common bile duct stones (>1) in 86% (6 of 7) in group I, 25% (4 of 16) in group II, and none in group III. All patients in group I had at least one stone larger than 5 ml in greatest diameter, whereas only 33% (6 of 18) in groups II and III combined had stones larger than 5 ml. Group I had significantly (P = 0.027) more representation of delayed or no contrast flow during operative cholangiography compared to groups II and III. The intraoperative decision to proceed with laparoscopic cholecystectomy and rely on postoperative endoscopic retrograde cholangiopancreatography for stone retrieval rather than open common bile duct exploration was associated with (1) a single common bile duct stone, less than or equal to 5 ml in size on operative cholangiogram and (2) normal contrast flow into the duodenum. Open common bile duct exploration was more frequently associated with the demonstration of multiple or large (>5 ml) stones. A periampullary stone did not discriminate among treatment choices.

Distributing working versions of published mathematical models for biological systems via the Internet

Mathematical models are useful tools for investigating complex systems. By representing physiological systems as models, theories can be tested quantitatively against data from the system. Models can be used to explore new theories prior to experimentation and to design studies to optimize experimental resources. They can also be used as teaching tools to illustrate physiochemical principles. In spite of their usefulness and the time invested in developing models, published models are often underused due to the difficulty in obtaining working versions of the model. To address this problem we have designed a library for mathematical models of biological systems on the Internet. The library contains published models of biological systems in formats compatible with several modeling packages, from the fields of physiology, metabolism, endocrinology, biochemistry, and chemistry. The models can be viewed graphically, model solutions can be viewed as plots against data, and models can be downloaded to be run with software on the user's own system. The address of the library is: http://biomodel.georgetown.edu/model/ Investigators are invited to submit working versions of published models to the library. Models can be submitted electronically at the time a manuscript is accepted for publication. As journals go online, articles containing models can be linked to working versions of the models in the library. By increasing access to working versions of models, more of the investment in kinetic studies and model development can be realized.

Partial portacaval shunt for variceal hemorrhage: longitudinal analysis of effectiveness

OBJECTIVE

To determine rates of survival, long-term patency, and recurrent variceal hemorrhage among patients with alcoholic cirrhosis treated by partial portacaval shunt.

DESIGN

Single-institution cohort follow-up study of 72 consecutive patients who underwent small-diameter portacaval H-graft shunt with collateral ablation during a 10-year period (1981 through 1990). Subjects were enrolled and followed up for up to 15 years. Shunt patency was assessed by portography and/or ultrasonography. We performed 7-year Kaplan-Meier analyses of survival (in 65 patients in Child classes A and B), shunt patency, and absence of variceal bleeding.

SETTING

Tertiary academic referral center of the US Department of Veterans Affairs.

PATIENTS

Patients with alcoholic cirrhosis were considered for operation after at least 1 proven episode of variceal hemorrhage. Patients with portal vein thrombosis were excluded; patients in Child class C underwent operation only for compelling indications. Of the 72 who underwent partial shunting, 38 were in Child class A, 27 were in class B, and 7 were in class C.

INTERVENTIONS

Partial portacaval shunt (6-, 8- or 10-mm polytetrafluoroethylene H-graft with collateral ablation) and serial follow-up.

MAIN OUTCOME MEASURES

Study end points were death, recurrent variceal hemorrhage, and unavailability for follow-up. Other measures included graft patency and nonvariceal rebleeding.

RESULTS

Cumulative probability of 7-year patency for grafts at risk was 95%. The 7-year probability for absence of variceal bleeding in patients at risk was 92%. In 65 patients in Child classes A and B, operative mortality was 7.7% and the cumulative probability of 7-year survival was 54%.

CONCLUSION

For variceal bleeding associated with alcoholic cirrhosis, the small-diameter polytetrafluoroethylene portacaval H-graft with collateral ablation affords durable patency and protection against variceal rebleeding.

Modeling of arterial and cardiopulmonary baroreflex control of heart rate

We evaluated R-R interval changes (delta R-R interval) in 13 subjects (27 +/- 6 yr; 7 men and 6 women) as a function of blood pressure changes at the carotid sinus and aortic arch and central venous pressure changes at the cardiopulmonary receptors. Neck chamber pressure and suction were used to change pressure at the carotid sinus while lower body negative pressure, phenylephrine infusion, and nitroprusside infusion were used to change pressure at the carotid sinus (delta CSP), aortic arch (delta AAP), and cardiopulmonary receptors (delta CPP). Random effects regression analysis showed a significant linear relationship for delta R-R interval (-1.75 + 1.64 delta CSP + 15.40 delta AAP + 29.02 delta CPP + error), and the correlation (r) between the observed and predicted delta R-R interval was 0.82 (P < 0.00001). Sixty-seven percent of the delta R-R interval variability observed in the study is explained by the model. delta AAP accounts for approximately 63%, delta CSP for 14%, and delta CPP for 23% of the explained delta R-R interval.

Portacaval shunt for portal hypertensive gastropathy

Portal hypertensive gastropathy is a vascular disorder of the gastric mucosa distinguished by ectasia of the mucosal capillaries and submucosal veins without inflammation. During 1988 to 1993, 12 patients with biopsyproven cirrhosis (10 alcoholic, 2 posthepatitic) were evaluated and treated prospectively by portacaval shunt for active bleeding from severe portal hypertensive gastropathy. Eleven patients had been hospitalized for bleeding three to nine times previously, and one was bleeding uncontrollably for the first time. Requirement for blood transfusions ranged from 11 to 39 units cumulatively, of which 8 to 30 units were required specifically to replace blood lost from portal hypertensive gastropathy. Admission findings were ascites in 9 patients, jaundice in 8, severe muscle wasting in 10, hyperdynamic state in 9. Child's risk class was C in 7, B in 4, A in 1. Ten of the 12 patients had previously received repetitive endoscopic sclerotherapy for esophageal varices, which has been reported to precipitate portal hypertensive gastropathy. Eight patients had failed propranolol therapy for bleeding. Portacaval shunt was performed emergently in 11 patients and electively in 1, and permanently stopped bleeding in all by reducing the mean portal vein-inferior vena cava pressure gradient from 251 to 16 mm saline. There were no operative deaths, and two unrelated late deaths after 13 and 24 months. During 1 to 6.75 years of followup, all shunts remained patent by ultrasonography, the gastric mucosa reverted to normal On serial endoscopy, and there was no gastrointestinal bleeding. Recurrent portal-systemic encephalopathy developed in only 8% of patients. Quality of life was generally good. It is concluded that portacaval shunt provides definitive treatment of bleeding portal hypertensive gastropathy by eliminating the underlying cause, and makes possible prolonged survival with an acceptable quality of life.

Managing choledocholithiasis in the laparoscopic era

BACKGROUND

Management options for common bile duct stones have explained in the era of laparoscopic cholecystectomy (LC), and selecting the most appropriate method for each patient can be problematic due to the difficulty of predicting accurately which patients have choledocholithiasis (CDL). In order to improve selection of appropriate treatment for CDL, treatment options were analyzed for outcome retrospectively during a 25-month period beginning June 1, 1992.

PATIENTS AND METHODS

Four hundred four patients underwent LC; 48 (12%) had CDL identified at preoperative endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiogram (IOCG). Forty-seven patients were referred for preoperative ERCP for suspected CDL, 23 (49%) of whom had proven duct stones and underwent endoscopic sphincterotomy and stone retrieval with an 87% success rate.

RESULTS

Of 357 patients scheduled for LC without preoperative ERCP, 236 had IOCG, of which 25 (11%) demonstrated CDL. Seven patients had open common bile duct exploration (CBDE). Sixteen patients had postoperative ERCP after positive IOCG, 7 (44%) of which were positive for CDL and whose stones were removed with 100% success. Two patients were observed, anticipating spontaneous passage of a small stone.

CONCLUSIONS

Preoperative ERCP should be applied selectively. For the large majority of patients without preoperative evidence of CDL, we recommend routine IOCG; if CDL is demonstrated, an intraoperative decision can be made to proceed to postoperative ERCP in the usual case or to open CBDE for very large or multiple stones. Observation in anticipation of spontaneous passage may be appropriate for small, solitary common duct stones. Continuing advances in laparoscopic CBDE are likely to reduce further the need to rely on ERCP in managing CDL.

Surgical management of breast masses in pregnant women

OBJECTIVE

The goal of this study was to review the outcomes of breast biopsies in pregnant women in order to plan optimum management strategies for pregnant women with breast masses.

STUDY DESIGN

From January 1990 to October 1992, 17 pregnant women underwent breast biopsy at a university hospital. Parameters evaluated were (1) trimester at presentation, (2) timing of biopsy, (3) mode of anesthesia, (4) requirements for tocolytics, and (5) histology of the lesion.

RESULTS

Antepartum biopsy was performed on all 11 patients who presented in the first or second trimester. Biopsy was accomplished postpartum in four of five patients presenting in the third trimester. Only one patient required tocolysis (associated with biopsy followed by immediate mastectomy). Histologic diagnosis was predominantly lactating adenoma (13 of 17 patients).

CONCLUSION

These results demonstrate that breast biopsy can be safely performed on pregnant women. We recommend that women presenting with breast masses in the first or second trimester undergo antepartum biopsy. We recommend postpartum excision for masses presenting in the latter half of the third trimester. For those presenting in the first half of the third trimester, fine needle aspiration biopsy may be a suitable alternative, particularly for the mass suspicious for cancer.

Collateral ablation improves portal perfusion after partial portacaval shunt

Small-diameter portacaval H-grafts (partial shunts) effectively abolish bleeding from esophageal varices. Goals are 1) to prevent variceal hemorrhage by subtotal portal decompression, and 2) to minimize postshunt encephalopathy by maintaining substantial residual pressure and prograde flow in the portal vein. To reduce spontaneous shunting of portal blood away from the liver, we advocate ablation of collateral vessels after partial shunts. Others have performed partial shunts without collateral ablation. We postulated that ablation of collateral vessels would augment portal perfusion pressure and preserve prograde portal flow after partial shunts. In 15 patients undergoing 8 or 10 mm portacaval H-grafts, portal pressure was measured intraoperatively before and after ligation of principal venous collaterals. In another 13 patients, collateral embolization was performed during postoperative portography. The degree of portal perfusion was scored. Pressure measurements demonstrated a mean rise in portal pressure of 2.8 cm saline after ligation (P = 0.025). Angiographic perfusion scores after embolization improved by a mean of 0.57 points on a 4 point scale (P = 0.032). We conclude that intraoperative collateral ligation augments residual portal pressures and that postoperative collateral embolization improves portal flow patterns. Since both observed effects have been associated with decreased postshunt encephalopathy rates, ablation of collateral vessels must be an integral component of the partial portacaval shunt.

Surgical management of portal hypertension

Portal hypertension is frequently complicated by upper gastrointestinal tract bleeding and ascites. Hemorrhage from esophageal varices is the most common cause of death from portal hypertension. Medical treatment, including resuscitation, vasoactive drugs, and endoscopic sclerosis, is the preferred initial therapy. Patients with refractory hemorrhage frequently are referred for immediate surgical intervention (usually emergency portacaval shunt). An additional cohort of patients with a history of at least 1 episode of variceal hemorrhage is likely to benefit from elective shunt operations. Shunt operations are classified as total, partial, or selective shunts based on their hemodynamic characteristics. Angiographically created shunts have been introduced recently as an alternative to operative shunts in certain circumstances. Devascularization of the esophagus or splenectomy is done for specific indications. Medically intractable ascites is a separate indication for surgical intervention. Liver transplantation has been advocated for patients whose portal hypertension is a consequence of end-stage liver disease. In the context of an increasingly complex set of treatment options, we present an overview of surgical therapy for complications of portal hypertension.