Conceptualising production, productivity and technology in pharmacy practice: a novel framework for policy, education and research

CONTEXT AND BACKGROUND

People and health systems worldwide face serious challenges due to shifting disease demographics, rising population demands and weaknesses in healthcare provision, including capacity shortages and lack of impact of healthcare services. These multiple challenges, linked with the global push to achieve universal health coverage, have made apparent the importance of investing in workforce development to improve population health and economic well-being. In relation to medicines, health systems face challenges in terms of access to needed medicines, optimising medicines use and reducing risk. In 2017, the International Pharmaceutical Federation (FIP) published global policy on workforce development ('the Nanjing Statements') that describe an envisioned future for professional education and training. The documents make clear that expanding the pharmacy workforce benefits patients, and continually improving education and training produces better clinical outcomes.

AIMS AND PURPOSE

The opportunities for harnessing new technologies in pharmacy practice have been relatively ignored. This paper presents a conceptual framework for analysing production methods, productivity and technology in pharmacy practice that differentiates between dispensing and pharmaceutical care services. We outline a framework that may be employed to study the relationship between pharmacy practice and productivity, shaped by educational and technological inputs.

METHOD AND RESULTS

The analysis is performed from the point of view of health systems economics. In relation to pharmaceutical care (patient-oriented practice), pharmacists are service providers; however, their primary purpose is not to deliver consultations, but to maximise the quantum of health gain they secure. Our analysis demonstrates that 'technology shock' is clearly beneficial compared with orthodox notions of productivity or incremental gain implementations. Additionally, the whole process of providing professional services using 'pharmaceutical care technologies' is governed by local institutional frames, suggesting that activities may be structured differently in different places and countries.

DISCUSSION AND CONCLUSION

Addressing problems with medication use with the development of a pharmaceutical workforce that is sufficient in quantity and competence is a long-term issue. As a result of this analysis, there emerges a challenge about the profession's relationship with existing and emerging technical innovations. Our novel framework is designed to facilitate policy, education and research by providing an analytical approach to service delivery. By using this approach, the profession could develop examples of good practice in both developed and developing countries worldwide.

Correlation of tumor-associated macrophages and clinicopathological factors in Wilms tumor

Background/purpose

Despite high long-term survival rates in patients with Wilms tumor, there is a need to develop better prognostic biomarkers in order to maximize cure while avoiding treatment-associated morbidities. Tumor-associated macrophages have been recently associated with poorer prognosis and increased disease progression in a number of adult cancers. We investigated the relationship between macrophages and clinicopathological fators in this pediatric solid tumor.

Methods

Tissue microarray sections of 124 Wilms tumor cases obtained from the Cooperative Human Tissue Network were stained with CD68, a macrophage marker using standard immunohistochemical techniques and quantified using digital image processing techniques. Macrophage densities were correlated by tumor stage, and survival analyses were conducted with available clinical data. Immunohistochemistry was performed on 25 additional Wilms tumor cases obtained from the tumor bank at Columbia University Medical Center and correlated with presence of tumor microvascular invasion.

Results

Mean macrophage count densities in stage IV tumors were significantly greater than densities in stage I and III tumors (p=.021, .036). Although the overall and disease-free survival did not differ between high and low macrophage presence groups across all stages, increased macrophage presence was associated with decreased disease-free survival in patients with stage II tumors (p=0.035). Increased macrophage presence may have also correlated with decreased disease-free survival in stage IV patients, but the sample size was too small to allow detection of this difference with significance (p=0.575). Increased macrophage presence was associated with tumor microvascular invasion (p=0.0004).

Conclusion

Our results suggest that macrophage recruitment may be associated with disease progression in Wilms tumor. Quantitation of macrophage presence may therefore be a useful adjunct in refining staging algorithms for patients with stage II Wilms tumor. Such data might be useful in the effort to reduce the risk of adverse effects associated with under- or overtreatment of this neoplasm.

[Five years of the Robert Koch Institute guidelines for reprocessing of flexible endoscopes. A look back and a look forward]

In a short review the national and international reception of the German guidelines for reprocessing flexible endoscopes is presented. The recommendations of the guidelines are discussed in view of recent knowledge on old problems such as prion inactivation and new infectious diseases and new microorganisms such as SARS, avian influenza and C. difficile. New disinfectants and new methods for endoscope disinfection are mentioned, the importance of careful cleaning is underlined. The German guidelines of the Robert Koch Institute and the US Multi-Society guidelines, published in 2003, are compared. The discrepancies concerning recommendations for water quality for final rinsing and need of microbiological controls of endoscope reprocessing are stressed. Aspects not mentioned in the German guidelines, e.g. duration of storage after reprocessing and risk of infection transmission by the endo-washer, are discussed.

[Bacterial infections following injections and infusion caused by errors of hygiene--how to avoid them]

Even minor medical interventions, such as injections, are associated with the risk of life-threatening infections--both in the doctor's office and hospital settings. Medical personnel in particular must always assume that they may be contaminated by facultative pathogenic, but potentially highly virulent, germs, although they themselves remain asymptomatic. Against this background, hygienic hand disinfection and proper skin disinfection are important hygiene measures for the prevention of infections, in particular in the case of invasive interventions. Strict attention must be paid to asepsis when preparing for injections and infusions. Sterile items must be protected against contamination. With regard to compliance with and application of hygiene standards, every physician must be an exemplary role model. Furthermore, all medical professional groups must receive appropriate training in hygiene management.

[Reprocessing of flexible endoscopes and endoscopic accessories - an international comparison of guidelines]

Endoscopic examinations and procedures are essential for diagnosis and treatment of gastrointestinal diseases. As a result of poor reprocessing practice microorganisms can be transmitted via endoscope. The majority of infection transmissions is due to insufficient performance of cleaning and disinfection disregarding guidelines of societies of gastrointestinal endoscopy. A review of the literature and a comparison of European and American guidelines for reprocessing flexible endoscopes are given. Differences in the classification of endoscopic devices, on the possibility of prion transmission, recommendations on staff training and protection, quality assurance of reprocessing and evidence-based graduation of guidelines are stressed and discussed. With respect to the procedure of endoscope reprocessing, differences concerning the cleaning solution to choose, necessity of thoroughly manual cleaning and brushing of the accessible endoscope channels (even in the case of subsequent automatic reprocessing endoscopes in washers-disinfectors), disinfection solution, microbiological quality of water for final rinsing and rationale for alcohol flush of endoscope channels for better drying are mentioned. The need for experimental investigations of the cleaning and disinfection process is stressed. In contrast to recent guidelines of European and American societies of gastrointestinal endoscopy, the now updated recommendations of the Robert Koch-Institute for reprocessing flexible endoscopes and endoscopic accessories are evidence-based and graduated.

[HYGEA (Hygiene in gastroenterology--endoscope reprocessing): Study on quality of reprocessing flexible endoscopes in hospitals and in the practice setting]

The quality of reprocessing gastroscopes, colonoscopes and duodenoscopes in daily routine of 25 endoscopy departments in hospitals and 30 doctors with their own practices was evaluated by microbiological testing in the HYGEA interventional study. In 2 test periods, endoscopes ready for use in patients were found contaminated at high rates (period 1: 49 % of 152 endoscopes; period 2: 39 % of 154 endoscopes). Culture of bacterial fecal flora (E. coli, coliform enterobacteriaceae, enterococci) was interpreted indicating failure of cleaning procedure and disinfection of endoscopes. Detection of Pseudomonas spp. (especially P. aeruginosa) and other non-fermenting rods - indicating microbially insufficient final rinsing and incomplete drying of the endoscope or a contaminated flushing equipment for the air/water-channel - pointed out endoscope recontamination during reprocessing or afterwards. Cause for complaint was found in more than 50 % of endoscopy facilities tested (period 2: 5 in hospitals, 25 practices). Reprocessing endoscopes in fully automatic chemo-thermally decontaminating washer-disinfectors with disinfection of final rinsing water led to much better results than manual or semi-automatic procedures (failure rate of endoscopy facilities in period 2 : 3 of 28 with fully automatic, 8 of 12 with manual, 9 of 15 with semi-automatic reprocessing). The study results give evidence for the following recommendations: 1. Manual brushing of all accessible endoscope channels has to be performed even before further automatic reprocessing; 2. For final endoscope rinsing, water or aqua dest. should only be used disinfected or sterile-filtered; 3. Endoscopes have to be dried thoroughly using compressed air prior to storage; 4. Bottle and tube for air/water-channel flushing have to be reprocessed daily by disinfection or sterilization, and in use, the bottle have to be filled exclusively with sterile water. The HYGEA study shows that microbiological testing of endoscopes is useful for detection of insufficient reprocessing and should be performed for quality assurance in doctors' practices, too. The study put recommendations for reprocessing procedures in more concrete terms.

Prevalence of Rho-inactivating epidermal cell differentiation inhibitor toxins in clinical Staphylococcus aureus isolates

Staphylococcus aureus produces exotoxins of the epidermal cell differentiation inhibitor (EDIN) family that ADP-ribosylate and inactivate Rho GTPases. The prevalence of genes encoding EDIN in clinical and nasal isolates of S. aureus was investigated. Of the 196 clinical S. aureus isolates tested, 15 (7.8%) were positive for 1 edin gene, whereas of 81 nasal isolates tested, only 3 (3.7%) were edin positive. Of the total 18 edin-positive isolates, 16 (90%) carried edin-B and 2 (10%) carried edin-C, but none was positive for edin-A. All edin-positive strains could produce the respective EDIN protein. Pulsed-field gel electrophoresis analysis suggested that the edin-B-positive S. aureus isolates are derived from one clone, and the edin-C-positive isolates are derived from another clone. Given that toxins acting on Rho GTPases are considered to be important for bacterial virulence, the EDIN toxins of S. aureus should receive more attention in future studies.

Drug resistance in intensive care units

Intensive care units (ICUs) are generally considered epicenters of antibiotic resistance and the principal sources of outbreaks of multi-resistant bacteria. The most important risk factors are obvious, such as excessive consumption of antibiotics exerting selective pressure on bacteria, the frequent use of invasive devices and relative density of a susceptible patient population with severe underlying diseases. Infections due to antibiotic-resistant bacteria have a major impact on morbidity and health-care costs. Increased mortality is not uniformly shown for all of these organisms: Methicillin-resistant Staphylococcus aureus (MRSA) seems to cause significantly higher mortality, in contrast to vancomycin-resistant enterococci (VRE). Therefore it is essential to diminish these potential risk factors, especially by providing locally adapted guidelines for the prudent use of antibiotic therapy. A quality control of antimicrobial therapy within a hospital, and especially within the ICU, might help to minimize the selection of multidrug-resistant bacteria. The restricted use of antimicrobial agents in prophylaxis and therapy has also been shown to have at least temporal effects on local resistance patterns. New approaches to the problem of drug resistance in ICUs are badly needed.

[Transfusion-associated HIV infection]

OBJECTIVE

Estimating the risk of HIV transmission by blood or inactivated plasma transfusion. A discussion of the methods and techniques for the diagnosis of HIV infection in blood donors.

DATA SOURCES

Reports in German and English on this topic as well as own experiences of the authors.

SELECTION CRITERIA

No specific selection criteria.

RESULTS

Transfusion associated HIV infection may be prevented by donor selection, the very efficient anti-HIV testing, by p24-antigen testing that may detect some anti-HIV negative donations especially during the early time of seroconversion and by more recent introduced techniques like polymerase chain reaction (PCR) and signal amplification assay (SAA). PCR and SAA are under development and until now not sensitive and specific enough to contribute significantly to an earlier detection of HIV infected blood. Procedures for the inactivation of HIV in plasma or whole blood have been described. Until now use of psoralens, methylene blue or direct UV irradiation may reduce viral load but have not definitely been proven by clinical trials to be 100% efficient.

CONCLUSIONS

To minimize transfusion associated HIV infection in future years reduction of total amount of transfused units, restriction to regional donor recruiting and further refinement of tests will be necessary. A 100% safety of blood transfusion for infectious agent cannot be achieved, especially considering new agents and further spread of until now geographically restricted viruses.

Detection by PCR of human polyomaviruses BK and JC in immunocompromised individuals and partial sequencing of control regions

Immunocompromised individuals were tested for the presence of the human polyomaviruses JC (JCV) and BK (BKV) by the polymerase chain reaction (PCR). The use of appropriate primers in a nested PCR allowed the detection of both viruses simultaneously. Viruses were differentiated by restriction fragment length analysis of amplified DNA fragments. Both BKV and JCV DNA were detected in the urine of an AIDS patient with progressive multifocal leukencephalopathy. In autopsy materials from this patient, JCV- but not BKV-DNA was found in brain and kidney tissue, whereas lung tissue was negative for both virus DNAs. To evaluate the methodology further, hybridization-positive urines from three recipients of bone marrow transplants and a positive urine of an acute myeloid leukemia patient were analyzed by this PCR method. One case was positive both for BKV and JCV, two cases were positive only for BKV, and one was negative for both. Parts of the control regions of JCV and BKV were sequenced directly from PCR-derived fragments. The JCV sequence from urine of the AIDS patient compared to sequences from a bone marrow transplant recipient and to archetypical reference strains showed two nucleotide (nt) exchanges out of 250 nt. The BKV sequences from the AML and the AIDS patients showed five nt exchanges out of 265 nt in the control region and were identified as BKV WW or WWT3 strains. In the agnogene region five exchanges were detected, two of them resulting in non-conservative amino acid exchanges. The possibility of testing clinical specimens of different origins by this PCR method is important for elucidating often unclear clinical courses in immunocompromised patients.(ABSTRACT TRUNCATED AT 250 WORDS)

HIV transmission by needle stick and eczematous lesion--three cases from Germany

Two cases of documented HIV-1 transmission by needle stick and one case of probable transmission by eczematous lesion in three nurses in Germany are reported in the period 1988 to 1991. In two of the cases the nurse knew of the AIDS status of the index patient. A review of the three cases reiterates the importance of repeated training on the prevention of accident and on measures to be taken after an accident, as well as the need to keep the workplace free of additional burden when AIDS or HIV-infected patients are treated.

[Differences in detectability of human immunodeficiency virus type 1 in tears and blood lymphocytes]

Reported data on the isolation of the human immunodeficiency virus type 1 (HIV-1) from tears are controversial. The purpose of the study was to try to isolate HIV-1 from tears in a large sample of HIV-1-positive patients at different stages of infection. 53 tear samples were obtained from 50 patients. Additionally isolation of HIV-1 from peripheral blood lymphocytes (PBL) was attempted. HIV-1 was isolated from none (= 0%) of the 53 tear samples. Isolation from PBL was successful depending on absolute CD4+ lymphocyte count and Walter Reed staging (Walter Reed stage 6: 83%; stage 2 to 5: 11%; p less than 0.0001). Treatment with zidovudine was not related to the frequency of HIV-1 isolation. These results suggest that tears of patients infected with HIV-1 contain low or no quantities of tissue-culture-infectious units of HIV-1. Nosocomial infection with HIV-1 from tears appears to be unlikely. The known precautions for the prevention of spread of viral disease in ophthalmological practice are sufficient and should be strictly followed.

[Azidothymidine and the nervous system]

By December 1988 reports on 525 ARC- (AIDS-Related Complex) and AIDS-patients with neurological or neuropsychological signs treated with Zidovudine (AZT = 3'-Azido-2,3'Dideoxythymidine) had been published in literature. In 204 (38.8%) cases of HIV infection a temporary improvement in the neurological deficits was reported. Peripheral and central neurological side-effects were observed in 124 (23.6%) patients.

[HIV and nervous system manifestations: a review]

Since 1986 the notation Human Immunodeficiency Virus (HIV) is used for the retroviral agent of the Acquired Immunodeficiency Syndrome (AIDS). At the beginning of the therapeutical interest in the immunodeficiency syndrome have been primarily focussed in the internal complications. 1982 one reported for the first time about nervous system manifestations (NS-M) in HIV-patients; according to the latest reports NS-M are diagnosed in 39-63% of these patients. In this review all important aspects of the pathogenesis, clinic and therapy for the HIV-associated peripheric- and central-neurological (like e.g. acute and chronic meningitis/meningoencephalitis, dementia, opportunistic infections, polyneuropathies and myopathies) and psychiatric diseases are described.

Pseudomonas pneumonia with bacteraemia

A previously healthy man developed fulminating pneumonia and bacteraemia due to Pseudomonas aeruginosa. This organism was isolated from sputum and blood before death, and from the lung, liver and spleen at autopsy. Bacteraemic psuedomonas pneumonia is rare, carries a high mortality, and is usually associated with serious underlying disease.

Some relations of grammar and lexicon in aphasia

A new form of a Sentence Order Test was applied to a group of Broca's, Wernicke's and total aphasics. Sentences cut into three movable cards should be put together. Some of the sentences could be arranged in two different ways. Broca's aphasics prefered to order the parts according to a logical string of lexical items neglecting the grammatical errors. Wernicke's aphasics arranged the material according to the grammatical structure being unaware of the odd lexical meaning. Most of the results of total aphasics were similar to those of Wernicke's aphasics others however performed like Broca's aphasics.