Engaging Student Pharmacists in Social Determinants of Health and Health Equity Through Photovoice

OBJECTIVE

This study aimed to evaluate the impact of an interactive photovoice activity on the perceptions of social determinants of health (SDOH) and health equity among first professional year student pharmacists.

METHODS

This study used a mixed-methods exploratory approach at 4 institutions. All students completed a standardized intervention using a prerecorded lecture, active learning using photovoice, and an in-depth debriefing session. The photovoice responses and reflections were analyzed through a deductive approach using content analysis with the applied frameworks of Rolfe's reflection model and the social-ecological model. A presurvey/postsurvey assessed the students' perceptions of SDOH and health equity. Paired sample t tests were conducted to assess the prechange and postchange.

RESULTS

A total of 349 students participated; most students reflected at the "what" level (97.7%), whereas 65% reached the "now what" level. Students identified more SDOH factors at the institutional/community level (75.9%) than at the individual/interpersonal level (59.4%) or the society/policy level (28.0%); 191 (55%) students had matchable survey data. A statistically significant improvement was found in the comprehension of health equity concepts (4 items), perceptions of health disparities and system response (4 items), awareness of structural factors impacting equity (3 items), and readiness for inclusivity behavior (3 items).

CONCLUSION

A structured teaching and learning activity allowed deeper reflections among student pharmacists. Student perception of the basic terminologies and the impact of beliefs on health care improved after the photovoice assignment. Although students became aware of the SDOH, they had difficulty identifying the structural or upstream factors when addressing SDOH.

Patient-reported outcomes before treatment for localized prostate cancer: are there differences among countries? Data from the True North Global Registry

INTRODUCTION

Similar Patient-Reported Outcomes (PROs) at diagnosis for localized prostate cancer among countries may indicate that different treatments are recommended to the same profile of patients, regardless the context characteristics (health systems, medical schools, culture, preferences…). The aim of this study was to assess such comparison.

METHODS

We analyzed the EPIC-26 results before the primary treatment of men diagnosed of localized prostate cancer from January 2017 onwards (revised data available up to September 2019), from a multicenter prospective international cohort including seven regions: Australia/New Zealand, Canada, Central Europe (Austria / Czech Republic / Germany), United Kingdom, Italy, Spain, and the United States. The EPIC-26 domain scores and pattern of three selected items were compared across regions (with Central Europe as reference). All comparisons were made stratifying by treatment: radical prostatectomy, external radiotherapy, brachytherapy, and active surveillance.

RESULTS

The sample included a total of 13,483 men with clinically localized or locally advanced prostate cancer. PROs showed different domain patterns before treatment across countries. The sexual domain was the most impaired, and the one with the highest dispersion within countries and with the greatest medians' differences across countries. The urinary incontinence domain, together with the bowel and hormonal domains, presented the highest scores (better outcomes) for all treatment groups, and homogeneity across regions.

CONCLUSIONS

Patients with localized or locally advanced prostate cancer undergoing radical prostatectomy, EBRT, brachytherapy, or active surveillance presented mainly negligible or small differences in the EPIC-26 domains before treatment across countries. The results on urinary incontinence or bowel domains, in which almost all patients presented the best possible score, may downplay the baseline data role for evaluating treatments' effects. However, the heterogeneity within countries and the magnitude of the differences found across countries in other domains, especially sexual, support the need of implementing the PRO measurement from diagnosis.

Assessing perspectives of a global health area of concentration within the PharmD curriculum

INTRODUCTION

While global health education in pharmacy expands, limited research has described the outcome of completing a global health area of concentration on career decisions, perceptions on cultural sensitivity, health disparity awareness, and global health competencies among pharmacists and students.

METHODS

This mixed methods study enrolled 21 graduates and 17 student pharmacists who participated in a global health concentration at one school of pharmacy in the United States. Data sources included graduate interviews and surveys, student pharmacist focus groups, and global health competency self-assessments.

RESULTS

Five themes emerged among graduates: (1) skills were applicable to diverse settings, (2) early exposure to underserved care prepared graduates for current practice, (3) participation impacted the lens through which graduates viewed careers, (4) participation influenced patient care in current practice, and (5) graduates gained insight on complex global health issues. Three themes were identified among student pharmacists: (1) the program provided opportunities to personalize education, (2) participants gained insight through hands-on experience, and (3) participants developed new perspectives on approaching underserved care. Many graduates (77.4%) currently practiced in an underserved setting. Graduates and fourth professional year students reported improvement in all seven global health competency domains.

CONCLUSIONS

A global health concentration in pharmacy curricula can facilitate skills and global health competencies that are applicable across a wide variety of patient care contexts. This concentrated experience provided opportunities to further develop career interests and personalize education, creating a cadre of pharmacists dedicated towards addressing health disparities and serving the underserved.

Impact of service-learning placement on pharmacy student knowledge, attitudes, and confidence in helping patients navigate Medicare Part D

INTRODUCTION

Pharmacists are in a prime position to empower patients to navigate Medicare Part D. This study aimed to determine if service-learning has a place in pharmacy student Medicare education. The primary objective of the study was to assess knowledge, attitudes, and confidence of first-year pharmacy students at Medicare focused service-learning sites compared to students at alternative sites.

METHODS

First-year pharmacy students at the University of Pittsburgh School of Pharmacy were assessed on their knowledge, attitudes, and confidence of Medicare Part D after a semester of service-learning either at a State Health Insurance Assistance Program (SHIP) or at an alternative site not focused on Medicare (control). All students attended a four-part lecture series on Medicare before starting service-learning. Students were surveyed at baseline and after their service-learning experience.

RESULTS

A total of 110 (94.8%) students successfully completed both the pre- and post-survey. Knowledge improved significantly in the SHIP group (P = .01) and did not increase significantly in the control group (P = .06). Attitudes toward Medicare Part D, assessed on a Likert scale, became less favorable in the control group (-0.40, P < .001). Student confidence in the ability to counsel patients on Medicare part D improved in the SHIP group (0.42, P < .001) and decreased in the control group (-0.80, P < .001).

CONCLUSIONS

Combining a didactic lecture series on Medicare Part D with service-learning involving Medicare counseling may solidify student knowledge of Medicare as well as students' confidence in helping patients navigate Medicare Part D.

Impact of an International Service Trip on Pharmacy and Medical Learners' Attitudes Toward Interprofessional Collaboration

Objective. The purpose of this study was to evaluate the impact of an interprofessional medical service trip to rural Honduras on pharmacy and medical learners' attitudes toward interprofessional learning.Methods. In this mixed-methods research, 19 participating students and residents from medicine and pharmacy completed the Readiness for Interprofessional Learning Scale (RIPLS) before and after the service trip in fall 2017 and spring 2018. Individual semi-structured interviews were conducted with participants following each trip to better understand which aspects of the experience shaped their interprofessional learning.Results. Following the service trip, a significant improvement was found for the Teamwork & Collaboration subscale and the Negative Professional Identity subscale of the RIPLS. Several themes emerged from interviews, including that face-to-face interaction promotes collaboration; limited resources encourage team-based problem-solving; time together outside of work strengthens interprofessional connections; participating in another profession's patient care activities fosters appreciation of individual roles; interprofessional care takes time; and participants felt a greater desire to pursue interprofessional practice in the future.Conclusion. Interprofessional learning during a medical service trip improved participants' attitudes toward collaboration. This study highlights which aspects of this experience contributed most to interprofessional learning, and our results may guide future efforts to design effective interprofessional education experiences.

Evaluating Students' COVID-19 Knowledge, Attitudes and Practices (COVKAP) during the COVID-19 Pandemic

The COVID-19 pandemic led to significant disruption in students’ lives through lockdowns, restricted movement, remote instruction, and mixed information. Therefore, this study aimed to capture the knowledge, attitudes, and practices of student pharmacists during 2020–2021. A 43-item COVID-19 Knowledge, Attitudes, and Practices (COVKAP) survey previously developed was administered at four schools of pharmacy across the U.S. during Fall 2020 and Spring 2021. A total of 418 responses were analyzed from graduating classes of 2021–2024. There were no significant differences in correct COVID-19 knowledge responses across the four graduating years. Respondents’ attitudes around COVID-19 were homogenous with the exception for their belief in their preparedness to administer COVID-19 vaccines. Respondents reported wearing masks daily (76.8%), infrequently visiting restaurants (82.1%), practicing social distancing daily (45.7%), and referring to medical journals for information (72%). In conclusion, during the pandemic, student pharmacists experienced significant changes in their academic lives. Their knowledge and subsequent attitudes and practices were consistent with the state of evidence during Fall 2020 and Spring 2021. Subsequently, as newer information has emerged, the authors suggest that the COVKAP survey may be modified and administered frequently to address student needs and concerns as the pandemic evolves.

Quō vādis? Short-term medical missions in a globalized world and the role of pharmacy

Short-term medical missions (STMMs) have evolved in the past few decades to provide non-emergent care including routine and follow-up primary care for acute and chronic conditions, along with treatment of neglected tropical diseases. Many STMMs operate outside the local health care infrastructure and may have limited local partnerships. STMM outcomes in improving local population health are often inferred but not well documented. Concerns such as ethical conduct, provider bias, and lack of adequate training and preparation continue to be raised. When disruptions occur (e.g. the COVID-19 pandemic), STMMs need to develop and prepare for challenges such as the inability to travel and provide care. Pharmacists as health professionals play a unique role when volunteering in STMMs. However, pharmacists' roles in STMMs need further development along with a framework to guide STMM work. Often driven by a few dynamic individuals, STMMs need to be aware of local geo-socio-political issues and develop local partnerships toward a meaningful legacy of building sustaining, long-lasting systems that will continue to serve others beyond the life of the STMMs and their founders.

Free Clinic Patients' Perceptions and Barriers to Applying for Health Insurance After Implementation of the Affordable Care Act

Despite implementation of the Affordable Care Act (ACA), many Americans remain uninsured and receive care in free clinics. It is unknown what free clinic attendees in Pennsylvania know about health insurance expansion or what they perceive as barriers in enrolling in health insurance. The objective of this study was to assess the perceptions and experiences of free clinic patients from southwestern Pennsylvania when applying for health insurance after implementation of the ACA. We designed and implemented a survey of patients at three free clinics within Allegheny County, Pennsylvania from September 2016 to February 2017. Our survey included 22-items, 7 sociodemographic questions and 15 questions regarding the patient's health status and their perspectives related to obtaining health insurance. Data was obtained from 203 patient surveys; 110 (55.3%) of the respondents were men and 99 (48.8%) were African American. There were 48 respondents (24.1%) who did not report any income at the time of the study, and of those that did report an income, 92 (46.2%) respondents reported an income below 133% of the federal poverty level. The main barriers patients faced when applying for health insurance were: (1) lack of knowledge about health insurance (n = 127, 58.1%), (2) cost of health coverage (n = 85, 41.9%), (3) lack of resources (n = 83, 40.4%), and (4) lack of enrollment documentation (n = 43, 23.8%). Significant work is needed to better educate patients about their eligibility and options for health insurance. Free clinics can play a key role in eliminating barriers to health insurance enrollment.

An ethics-based approach to global health research part 4: Scholarship and publications

Disseminating research findings from global health collaborations is essential to advancing science. However, there are a number of ethical considerations and potential challenges to address to ensure thoughtful and non-exploitative reporting. The factors include the benefits and risks to publication, authorship criteria or values, and the accessibility of forums or journals in which to pursue publication. This paper provides commentary related to planning for writing, communicating intentions to publish, obtaining permissions to publish, risks in internationally collaborative work, authorship principles, and journal selection. Authors' and editors' knowledge of experienced individuals from both pharmacy literature, medical fields, and general publications is incorporated to provide an assessment of risks and benefits of publication of international global health research.

A qualitative assessment of diabetes care access and disease management in Central America

BACKGROUND

Diabetes is a growing concern in low-and middle-income countries. Medical missions play a role in increasing access to care and medicines, but often ignore non-communicable disease prevention and advanced management. Increased knowledge of local community needs and resources can lead to the development and implementation of pharmacist-supported interventions to improve diabetes management in rural areas.

OBJECTIVES

The purpose of this study was to 1) understand the availability of monitoring for diabetes locally; and 2) describe knowledge and health beliefs regarding diabetes management for those with diabetes, and prevention among those at high risk of developing diabetes.

METHODS

This qualitative evaluation used semi-structured interviews with key informants in a community in rural Honduras. Participants included those with diabetes, those at-risk for developing diabetes, and community leaders. Data was analyzed using thematic content analysis through an iterative process of coding and theme development.

RESULTS

A total of 35 interviews were conducted with five resulting themes: 1) participants identified multiple barriers to diabetes management including access to monitoring, access to certain medications, and access to advanced levels of care; 2) participants acknowledge the relationship between lifestyle choices and diabetes control, but struggled with adherence to a healthy lifestyle; 3) participants identify that they have limited knowledge of diabetes pathophysiology, diabetes management, and strategies to prevent diabetes; 4) participants felt that opportunities existed within the community to support diabetes education and prevention, and 5) providers should integrate culture, societal norms, and religion in diabetes management.

CONCLUSION

This research identifies challenges and resulting opportunities for managing diabetes in rural Honduras. Health care providers including pharmacy personnel should consider strategies to engage communities around self-care and diabetes education. Further, strategies are needed to enhance access to resources and essential medicines for diabetes management. These themes can guide clinicians in supporting communities to enhance diabetes care.

User-centered design and usability testing of RxMAGIC: a prescription management and general inventory control system for free clinic dispensaries

BACKGROUND

To address challenges related to medication management in underserved settings, we developed a system for Prescription Management And General Inventory Control, or RxMAGIC, in collaboration with the Birmingham Free Clinic in Pittsburgh, Pennsylvania. RxMAGIC is an interoperable, web-based medication management system designed to standardize and streamline the dispensing practice and improve inventory control in a free clinic setting. This manuscript describes the processes used to design, develop, and deploy RxMAGIC.

METHODS

We transformed data from previously performed mixed-methods needs assessment studies into functional user requirements using agile development methods. Requirements took the form of user stories that were prioritized to drive implementation of RxMAGIC as a web-application. A functional prototype was developed and tested to understand its perceived usefulness before developing a production system. Prior to deployment, we evaluated the usability of RxMAGIC with six users to diagnose potential interaction challenges that may be avoided through redesign. The results from this study were similarly prioritized and informed the final features of the production system.

RESULTS

We developed 45 user stories that acted as functional requirements to incrementally build RxMAGIC. Integrating with the electronic health record at the clinic was a requirement for deployment. We utilized health data standards to communicate with the existing order entry system; an outgoing electronic prescribing framework was leveraged to send prescription data to RxMAGIC. The results of the usability study were positive, with all tested features receiving a mean score of four or five (i.e. somewhat easy or easy, respectively) on a five-point Likert scale assessing ease of completion, thus demonstrating the system's simplicity and high learnability. RxMAGIC was deployed at the clinic in October 2016 over a two-week period.

CONCLUSIONS

We built RxMAGIC, an open-source, pharmacist-facing dispensary management information system that augments the pharmacist's ability to efficiently deliver medication services in a free clinic setting. RxMAGIC provides electronic dispensing and automated inventory management and alerting capabilities. We deployed RxMAGIC at the Birmingham Free Clinic and measured its usability with potential users. In future work, we plan to continue to measure the impact of RxMAGIC on pharmacist efficiency and satisfaction.

A public-health approach to site-specific formulary management: addressing deficient drug supplies in Malawi

OBJECTIVES

Maintaining a well-stocked dispensary at a private non-profit clinic in a developing country can often be challenging due to limited financial and human resources. Organizations face frequent drug shortages, excesses of unnecessary medications and potentially inappropriate international donations. To promote adherence to international recommendations and enable targeted requests for international drug donations, this paper describes a process using a public-health approach to create a site-specific pharmacy formulary in a resource-poor setting using the World Health Organization's (WHO) Model List of Essential Medicines ('Model List').

METHODS

The study site was a Malawian-run non-profit private clinic serving over 3000 people annually. The organization focuses on providing community support for orphans from the HIV/AIDS crisis in sub-Saharan Africa. While using the Model List as a backbone, we incorporated the clinic's drug inventory, patient needs, clinician prescribing patterns, and the country's national drug list into the final formulary. After analyzing site-specific factors, we determined which WHO Model List therapeutic classes were necessary for the clinic to address in the final formulary.

KEY FINDINGS

Of the drug products currently available in the inventory, 65.6% were expired, 29.8% of which were international donations. After removing expired medications from the inventory, seven Model List priority categories remained unaddressed by the clinic's initial inventory. Based on the results of a structured needs assessment, 54 products were selected for the final simplified formulary.

CONCLUSIONS

Conscious selection of pharmaceuticals, resulting in a systematic formulary for drug distribution management, is critical so that a clinic can focus on procuring and prescribing the most needed medications. This selection process using the WHO Model List and a public-health approach to drug management could serve as a private clinic model for pharmaceutical optimization and targeted international drug donations in sub-Saharan Africa and other resource limited settings.

Provision of clinical pharmacy services in two safety net provider settings

OBJECTIVE

The purpose of this report is to characterize the patient population served by the Grace Lamsam Pharmacy Program and to describe program outcomes.

METHODS

A chart review was conducted for all patients (n=100) participating in the Grace Lamsam Pharmacy Program from January 1, 2007 to February 6, 2008. The primary outcome data collected were the medication related problems (unnecessary drug therapy, needs additional drug therapy, ineffective drug therapy, dosage too low, dosage too high, adverse drug reaction, noncompliance, and needs different drug product) identified by pharmacists, the number and type of pharmacist interventions made, estimated cost savings from perspective of the patient and clinical data (hemoglobin A1C, blood pressure measurements, and LDL-C) for patients with diabetes, hypertension, and hyperlipidemia, respectively. Basic demographic data was collected, including: patient gender, age, education level, race/ethnicity, marital status, and income. Patients' smoking status, type and number of medical conditions, medications being used at baseline, and number of pharmacist visits per patient during the study review period were also recorded.

RESULTS

The majority of patients cared for were male, middle-aged, and African-American. The majority (90%) of patients had an income below 150% of the 2007 Federal poverty level. Patients were most commonly treated for diabetes, hypertension, and hyperlipidemia. During the period of review, 188 medication related problems were identified and documented with noncompliance being the most common medication related problem identified. Pharmacists completed 477 Pharmaceutical Manufacturer Assistance Program applications for 68 patients. These interventions represented a cost savings from the patients' perspective of approximately 243 USD per month during the review period. Blood pressure, A1C, and LDL-C readings improved in patients enrolled in the clinical pharmacy program at the free clinic and the community health center.

CONCLUSION

A clinical pharmacy services model provides a role for the pharmacist in an interdisciplinary team (beyond the traditional dispensing role) to identify medication related problems in the drug therapy of patients who utilize safety-net provider health care services.

The Lilongwe Central Hospital Patient Management Information System: a success in computer-based order entry where one might least expect it

Computer-based order entry is a powerful tool for enhancing patient care. A pilot project in the pediatric department of the Lilongwe Central Hospital (LCH) in Malawi, Africa has demonstrated that computer-based order entry (COE): 1) can be successfully deployed and adopted in resource-poor settings, 2) can be built, deployed and sustained at relatively low cost and with local resources, and 3) has a greater potential to improve patient care in developing than in developed countries.

Smoking cessation in a homeless population: there is a will, but is there a way?

This cross-sectional study sought to determine the prevalence of smoking, readiness to quit, and preferences for smoking cessation treatments among a sample of 236 homeless adults attending 9 sites serving homeless persons (mean age 41.8 years; 73% male). Two thirds (69%) were current smokers, of whom 37% reported readiness to quit smoking within the next 6 months. In bivariate analyses, persons were significantly (P <.05) more likely to be ready to quit if they had tried to quit in the past and if they had social support to quit smoking. Nicotine replacement was the most commonly preferred assistance method (44%), and self-efficacy to quit (10-point scale) was significantly greater if assistance was available (7.3 vs 4.9; P <.001). The findings suggest an urgent need to develop and implement smoking cessation programs for homeless persons.

Smoking cessation in a homeless population: there is a will, but is there a way?

This cross-sectional study sought to determine the prevalence of smoking, readiness to quit, and preferences for smoking cessation treatments among a sample of 236 homeless adults attending 9 sites serving homeless persons (mean age 41.8 years; 73% male). Two thirds (69%) were current smokers, of whom 37% reported readiness to quit smoking within the next 6 months. In bivariate analyses, persons were significantly (P <.05) more likely to be ready to quit if they had tried to quit in the past and if they had social support to quit smoking. Nicotine replacement was the most commonly preferred assistance method (44%), and self-efficacy to quit (10-point scale) was significantly greater if assistance was available (7.3 vs 4.9; P <.001). The findings suggest an urgent need to develop and implement smoking cessation programs for homeless persons.

Congenital midline cleft of the posterior arch of atlas: a rare cause of symptomatic cervical canal stenosis

Developmental symptomatic C1 canal stenosis is very rare. We describe the computed tomography (CT) and magnetic resonance imaging (MRI) appearances in a 8-year-old child who presented with progressive upper and lower limb neurological symptoms and in whom imaging revealed the medial posterior hemiarches of a bifid C1 to be inturned and compressing the cervical cord. This particular configuration of the posterior arch of atlas is frequently associated with other craniocervical bony anomalies and presents with neurological symptoms early in life. Early CT or MRI examination of patients with symptomatic posterior arch of C1 defects is necessary, in order to detect such an appearance, since surgical treatment may prevent neurological deterioration.

Impact of the cost of prescription drugs on clinical outcomes in indigent patients with heart disease

STUDY OBJECTIVE

To measure the impact that economic relief for prescription drugs to indigent patients with cardiovascular disease has on indicators of disease control.

DESIGN

Prospective cohort study.

SETTING

University inner-city outpatient clinic.

PATIENTS

One hundred sixty-three indigent patients with heart disease who were uninsured or whose insurance plan did not provide prescription drug coverage and who had baseline data.

INTERVENTION

Patients were assisted in obtaining prescription drugs, free of charge, in an attempt to improve adherence to their drug regimens.

MEASUREMENTS AND MAIN RESULTS

The primary end point was to determine if cardiovascular outcome measures (i.e., international normalized ratio [INR], blood pressure, low-density lipoprotein [LDL] cholesterol, and hospitalizations) and drug adherence improved in all patients after 6 months of prescription assistance compared with a 6-month baseline period. In patients receiving warfarin, mean INR increased from 2.44 +/- 0.64 at baseline to 2.61 +/- 0.53 at 6 months (p<0.05). In patients with hypertension, mean blood pressure decreased from 138 +/- 20/80 +/- 11 mm Hg at baseline to 138 +/- 19/78 +/- 12 mm Hg at 6 months (p<0.05 for diastolic blood pressure only). The mean LDL level for patients on lipid-lowering drugs significantly decreased from 126 +/- 39 mg/dl at baseline to 108 +/- 38 mg/dl at 6 months (p<0.001). For each disease measure, the improved disease control seen at 6 months persisted throughout 24 months of follow-up. Hospitalizations for the entire cohort decreased from 85 at baseline to 49 at 6 months. Patient drug adherence improved from 48.5% at baseline to 72.7% at 6 months (p<0.001).

CONCLUSIONS

Drug adherence and clinical outcomes improved, and the number of hospitalizations declined when cardiovascular drugs were obtained for patients who could not afford to pay for them. Health care insurance plans that do not provide coverage for cardiovascular prescription drugs may be more costly secondary to poor disease control and increased hospitalizations.

Magnetic resonance imaging of patients with epilepsy

Magnetic resonance imaging (MRI) is the radiological investigation of choice for the evaluation of patients with epilepsy. It is able to detect and characterize the structural origin of seizures, and significantly influences treatment planning and prognosis. The indications for MRI, protocols used for MRI in epilepsy and the relevant imaging anatomy are discussed. The major categories of epileptogenic lesions which result in chronic seizures are reviewed and illustrated. Mesial temporal sclerosis is emphasized, reflecting its major importance as a cause of medically intractable epilepsy. The role of MRI in the planning and assessment of epilepsy surgery is considered.

SPAMM, cine phase contrast imaging and fast spin-echo T2-weighted imaging in the study of intracranial cerebrospinal fluid (CSF) flow

AIM

To compare the qualitative assessment of cerebrospinal fluid (CSF) flow using a SPAMM (spatial modulation of magnetization) technique with cine phase contrast images (cine PC) and fast spin echo (FSE) T2-weighted images.

MATERIALS AND METHODS

SPAMM, PC and T2-weighted sequences were performed on 22 occasions in 19 patients. Eleven of the studies were performed following a neuroendoscopic third ventriculostomy (NTV), and in these cases, the success of the NTV was determined by clinical follow-up. Two observers used consensus to grade the presence of CSF flow at nine different sites for each study.

RESULTS

At 14 of the 178 matched sites, which could be assessed by both SPAMM and cine PC, SPAMM CSF flow grade was higher than that of cine PC. At a further 14/178 matched sites, the cine PC grade was higher than that of SPAMM. There was definite CSF flow at 113/182 (62%) of all the cine PC sites assessed, and 110/181 (61%) of all SPAMM sites assessed whilst 108/198 (54%) of FSE T2-weighted image sites demonstrated flow voids. Cine PC grades were higher than SPAMM at the cerebral aqueduct (P < 0.05, Wilcoxon sign rank test). Definite CSF flow within the anterior third ventricle was present in 4/5 (SPAMM) and 3/5 (cine PC) successful NTVs, 0/2 (SPAMM and cine PC) unsuccessful NTVs and 1/10 (SPAMM and cine PC) patients without NTV.

CONCLUSION

SPAMM provides a comparable assessment of intracranial CSF flow to that of cine phase contrast imaging at all CSF sites except the cerebral aqueduct.

The ability of plain radiography to predict intracranial aneurysm occlusion instability during follow-up of endosaccular treatment with Gugliemi detachable coils

Incomplete occlusion of an intracranial aneurysm at follow-up after treatment with Gugliemi detachable coils (GDC) increases the risk of rebleeding and serial angiographic monitoring is therefore currently indicated. We aimed to determine if a change in the plain radiographic appearances of the GDC ball could accurately predict the presence of unstable angiographic occlusion. Paired GDC radiographs (in two planes) and cerebral angiograms, performed immediately after treatment and at follow-up or at two consecutive follow-up examinations, were retrospectively compared. Radiographs were assessed for the radiographic change (loosening, compaction or reorientation) in the coil-ball and angiograms for unstable aneurysm occlusion (neck recurrence or deteriorating occlusion). We compared 49 paired films from 38 patients. Radiographic change in the coil ball had a negative predictive value of 96%, positive predictive value of 57% and accuracy of 76% for the presence of angiographic aneurysm instability. It may be possible to increase the interval between follow-up angiographic examinations after GDC treatment safely if there is no change in the radiographic appearances in two planes.

Imaging of giant tumours involving the anterior skull base

Tumours involving the anterior skull base are a challenge in diagnosis and treatment. They may arise from the bony skull base itself, intracranially or from the sinonasal tract and orbit. It is often difficult to determine the site of origin of giant tumours as anatomical boundaries are frequently breached. Accurate imaging evaluation is useful in planning treatment and may help in the differential diagnosis. We review those CT and MRI features of giant anterior cranial fossa tumours which may be helpful in identifying a pre-operative diagnosis.

Traumatic basilar pseudoaneurysm with a basilar-cavernous arteriovenous fistula

A traumatic pseudoaneurysm of the basilar artery with a basilar-cavernous sinus arteriovenous fistula was diagnosed in a 12-year-old girl using CT, MRI and angiography. It was successfully treated by coil embolisation. We speculate on the mode of formation of this rare traumatic lesion.

Recurrence of non-Hodgkin's lymphoma isolated to the right masticator and left psoas muscles

We present the clinical and magnetic resonance imaging findings of a patient who, following treatment for pancreatic non-Hodgkin's lymphoma (NHL), relapsed with apparently isolated involvement of the right masticator space and left psoas muscles. Non-Hodgkin's lymphoma arising from the masticator space muscles is very rare. In addition, simultaneous lymphomatous involvement of multiple discrete skeletal muscle sites, in the absence of disease elsewhere, has previously only been reported in the limb or limb girdle muscles. Lymphoma should be considered as a cause of isolated enlarged skeletal muscles, even when involving such distant sites.

Problems in recruiting community-based physicians for health services research

OBJECTIVE

To qualitatively determine factors that are associated with higher participation rates in community-based health services research requiring significant physician participation burden.

MEASUREMENTS

A review of the literature was undertaken using MEDLINE and the Social Science Research Index to identify health services research studies that recruited large community-based samples of individual physicians and in which the participation burden exceeded that of merely completing a survey. Two reviewers abstracted data on the recruitment methods, and first authors were contacted to supplement published information.

MAIN RESULTS

Sixteen studies were identified with participation rates from 2.5% to 91%. Almost all studies used physician recruiters to personally contact potential participants. Recruiters often knew some of the physicians to be recruited, and personal contact with these "known" physicians resulted in greater participation rates. Incentives were generally absent or modest, and at modest levels, did not appear to affect participation rates. Investigators were almost always affiliated with academic institutions, but were divided as to whether this helped or hindered recruitment. HMO-based and minority physicians were more difficult to recruit. Potential participants most often cited time pressures on staff and themselves as the study burden that caused them to decline.

CONCLUSIONS

Physician personal contact and friendship networks are powerful tools for recruitment. Participation rates might improve by including HMO and minority physicians in the recruitment process. Investigators should transfer as much of the study burden from participating physicians to project staff as possible.

Computed tomography evidence of dental restoration as aetiological factor for maxillary sinusitis

Maxillary sinusitis due to dental causes is usually secondary to periodontal disease or periapical infection and is commonly associated with mucosal thickening of the floor of the maxillary antrum. Computed tomography (CT) is currently the modality of choice for evaluating the extent of disease and any predisposing factors in patients with symptoms of chronic maxillary sinusitis, but it is unable to diagnose dental disease reliably. The presence of restorative dentistry is, however, easily seen at CT and is associated with both periapical and periodontal disease. We aimed to determine whether its presence at CT may predispose to maxillary sinusitis, and in particular to focal mucosal thickening of the sinus floor characteristic of dental origin. Three hundred and thirty maxillary sinus CT images in 165 patients were reviewed for the presence of restorative dentistry in the adjacent teeth, focal maxillary sinus floor mucosal thickening, any maxillary sinus disease (including complete opacification, air fluid levels, diffuse mucosal thickening, focal mucosal thickening) and evidence of a rhinogenic aetiology (osteomeatal complex pathology, mucosal thickening in other sinuses). One hundred and ninety two sinuses adjacent to restorative dentistry and 178 sinuses not adjacent to restorative dentistry were analysed. Focal floor thickening both with, and without, evidence of a rhinogenic aetiology, was significantly more common adjacent to restorative dentistry. Maxillary sinus disease overall was no more common adjacent to restorative dentistry. This work demonstrated that the presence of restorative dentistry predisposes to focal mucosal thickening in the floor of the maxillary sinus and its presence should prompt clinical and radiographical assessment to exclude dental disease as a source of chronic maxillary sinusitis.

Imaging of malignant cervical lymphadenopathy

Diagnostic imaging is superior to clinical staging in the detection of malignant cervical lymphadenopathy, and thus helps influence therapy and prognosis. The imaging modalities of CT, MRI, US and PET each have their own diagnostic criteria, accuracy and limitations. Newer innovations such as functional imaging, novel MRI contrast agents and FNAC are being appraised with the aim of identifying the micrometastases which are currently radiologically occult.

Asymmetrical hemithorax volume loss due to Wegener's granulomatosis

Three patients with Wegener's granulomatosis (WG) established by clinical, serological and histological criteria were noted to have marked asymmetrical hemithorax volume loss on thoracic CT. Lung dimensions were analysed from the CT in each case. Evidence of airways disease, parenchymal abnormalities and pleural changes was evaluated on CT, in order to establish the aetiology of the volume loss. Previous pulmonary infection and thoracic intervention were excluded by the clinical data. The three patients had chronic treated thoracic WG for 1-9 years. There was severe asymmetrical pleural disease in one case and parenchymal disease with evidence of fibrotic healing but no evidence of bronchial disease in two cases. Marked asymmetrical volume loss of a hemithorax is a previously unreported finding and should be added to the features of primary chronic thoracic WG. This finding does not require investigation for additional pathology.

Management of patients treated with aspirin or warfarin and evaluation of haemostasis prior to prostatic biopsy: a survey of current practice amongst radiologists and urologists

AIM

To document current practice concerning the management of patients taking aspirin or warfarin and the evaluation of haemostatic function prior to prostatic biopsy.

METHOD

A postal survey was performed with typed questionnaires being sent to 275 urology and 275 radiology centres.

RESULTS

A high proportion of radiology departments in particular (83%) had protocols in place concerning the management of aspirin or warfarin prior to prostatic biopsy. A significant proportion of both radiologists and urologists have postponed biopsies due to patients unexpectedly taking these medications. Few of the respondents reported the use of pre-biopsy screening blood tests. Fifty-two percent of radiologists and 27% of urologists terminated aspirin prior to prostatic biopsy, although the urologists stopped aspirin for a long time period. Ninety-five percent of radiologists and 84% of urologists terminated warfarin prior to prostatic biopsy, although again the urologists stopped warfarin at an earlier stage. Most of those respondents who stopped warfarin prior to biopsy, also checked the INR. The urologists generally stated a higher threshold (INR) which would be considered too high to proceed.

CONCLUSION

There are wide variations in practice both within and between the radiology and urology groups. This is unsurprising, since there is conflicting advice in the relevant literature.

General practitioner requests for upper abdominal ultrasound: their effect on clinical outcome

Many radiology departments offer direct access upper abdominal ultrasound (US) scanning to general practitioners (GPs). We aimed to examine the influence of the scan results on the subsequent management and clinical outcome of these patients. A retrospective review was performed on all the patients referred for primary upper abdominal US (n = 82) from a single Birmingham GP practice, of 10,000 patients, between 1991 and 1996. The follow-up period from US was mean 27.9 months, SD 18.2 months. 79 referrals complied with published guidelines. 77 referrals were for suspected gallstone disease. 23 (28%) patients had clinically relevant positive findings. 18 of the positive scans. 16 of whom had gallstones, were subsequently referred to hospital. Of those with gallstones, 15 underwent cholecystectomy, of whom 12 had no further upper abdominal symptoms. Of the 59 negative scans, eight cases (14%) were subsequently referred to hospital. Treatment was changed as a result of review and investigation in only two of these eight cases. The remaining 51 were diagnosed solely on history and clinical examination. 28 of the 51 had self-limiting symptoms which required minor or no treatment. In conclusion, direct access upper abdominal US is considerably reducing the requirement for hospital outpatient referrals from GPs. Positive scans are generally followed by referral to secondary care services with good clinical outcome.

Safety standards for stab-resistant body armour: a computer tomographic assessment of organ to skin distances

The protective properties of knife-resistant armour are quantified by the distance a test blade penetrates beyond a test sample into clay at a given energy. At present there are two proposed standards: penetration to 5 mm and penetration to 20 mm. Armour made to the higher standard specification (5mm) is necessarily heavier as it offers more protection. To determine the safety of these standards a retrospective review of 71 consecutive computerised tomographic (CT) scans was made. The minimum distance from the skin to the vital organs was measured. No organ would have been breached at 5 mm of knife penetration deep to body armour. 41% of pleurae, 61% of livers, 64% of femoral arteries, 25% of spleens and 6% of hearts would have been breached at a depth of 20 m of knife penetration. There was no significant difference in the minimum skin to organ distances between male and female subjects. The 20 mm standard does not offer adequate protection against knife attacks.

Intravenous contrast media: are they being administered safely in radiology departments?

A recent Royal College of Radiologists (RCR) publication is entitled Advice on The Management of Reactions to Intravenous Contrast Media. This study aims to determine whether radiology departments are adhering to the essential points, covered in the guidelines, regarding prevention, early recognition and prompt treatment of adverse reactions, and whether they are adequately equipped for the proposed contrast media reaction management protocols. A questionnaire was formulated and sent to the superintendent radiographers of 295 radiology departments in the United Kingdom of whom 233 (79%) replied. This was specifically directed at the use of intravenous contrast media in intravenous urography. In almost all departments there was provision for basic life support training, regular checking of equipment and drugs, and prompt access to emergency medical help. Certain "first line" drugs and monitoring equipment were not instantly accessible in the majority of institutions. Most departments did not adequately supervise post-injection patients and did not conform to the guidelines referring to the administration of intravenous contrast to children. Certain areas of the guidelines are being neglected by many radiology departments and there is still much to be done to improve the safety of intravenous contrast medium injection.

Patient counseling--a focus on maintenance therapy

Pharmacist counseling of patients receiving long-term medications for chronic diseases is discussed. Patient counseling should be viewed as one component of the overall drug-use process. Pharmacists counseling patients prescribed long-term medications need to understand the lifestyle effects of chronic illness, particularly the different types of "work" the chronically ill patient must undertake. Pharmacists need to go beyond traditional sender-message-receiver communication models in counseling patients and to adopt a problem-solving approach through which each patient's needs and level of understanding are taken into account. Patients should be actively involved in their therapy decisions. Patients will be at varying stages in terms of making any behavioral changes needed to maximize therapeutic outcomes, and counseling must be adapted to fit the stage of change. The Indian Health Service (IHS) model of counseling uses open-ended questions to determine patients' knowledge of their disease and medications; this enables the pharmacist to fill in any gaps and review specific points. The health communication model provides strategies for enhancing patient compliance and recall and complements the IHS model. In practice, the techniques used will depend on whether the patient is a new-prescription patient or an established patient. The models can be adapted to counseling care-givers and can be complemented by compliance aids. The demand for pharmacist counseling of patients with chronic illnesses is likely to increase, and, to effectively counsel patients about long-term medication use, pharmacists need to appreciate the personal impact of chronic illness beyond the direct effects of the biomedical disease itself, and must understand modern communication models.

The relation of exercise habits to health beliefs and knowledge about osteoporosis

The relation of exercise habits of 113 female college students to their knowledge about osteoporosis and their health beliefs was investigated, using the health belief model to determine why some people participate in self-care preventive actions but others do not. Age was positively correlated with the level of osteoporosis knowledge, awareness of personal susceptibility, and motivation for general health behaviors. Older participants, however, perceived more barriers to exercise as an osteoporosis-prevention measure than did the younger respondents. The authors' conclusions support the importance of early osteoporosis education and lifetime physical activities to prevent osteoporosis.

Synthesis of carbon-11-, fluorine-18-, and iodine-125-labeled GABAA-gated chloride ion channel blockers: substituted 5-tert-butyl-2-phenyl-1,3-dithianes and -dithiane oxides

A series of substituted 5-tert-butyl-2-phenyl-1,3-dithianes and 5-tert-butyl-2-phenyl-1,1,3,3-tetraoxo-1,3-dithianes was synthesized as ligands for the GABAA receptor complex-associated neuronal chloride ion channels. The in vitro binding affinities of these compounds for the GABA-gated chloride ion channel were determined by their ability to compete with [3H]TBOB for binding to rat brain slices. Of the eight compounds tested, trans-5-tert-butyl-2-(4-cyanophenyl)-2-methyl-1,1,3,3-tetraoxo+ ++-1,3-dithiane, 9b, trans-5-tert-butyl-2-(4-fluorophenyl)-1,1,3,3-tetraoxo-1,3-dithian e, 10, and trans-5-tert-butyl-2-(4-iodophenyl)-2-methyl-1,1,3,3-tetraoxo-1,3- dithiane, 11, showed moderately high binding affinities (Ki = 41, 180, and 105 nM, respectively). Four radioligand candidates from this series, 5-tert-butyl-2-(4-cyanophenyl)-2-[11C]methyl-1,3-dithiane, [11C]6, 5-tert-butyl-2-(4-[18F]fluorophenyl)-1,3-dithiane, [18F]7, 5-tert-butyl-2-(4-[18F]-fluorophenyl)-1,1,3,3-tetraoxo-1,3- dithiane, [18F]10, and 5-tert-butyl-2-(4-[125I]iodophenyl)-2-methyl-1,1,3,3- tetraoxo-1,3-dithiane, [125I]11, have been successfully prepared for evaluation as in vivo imaging agents useful for positron emission tomography and single photon emission computed tomography. Preliminary in vivo studies indicate significant uptake into mouse brain for [18F]7, [18F]10, and [125I]11.

Low immunogenicity of therapeutic rat CD45 antibodies when used for pre-treatment of donor organs for transplantation

Immunoassays for the measurement of human anti-immunoglobulin responses against the CD45 specific rat monoclonals, YTH 24.5 and YTH 54.12, have been developed. The assays are based on a 'double antigen' ELISA system and are reproducible with coefficients of variation of less than 15%. The assays were used to measure anti-immunoglobulin responses in sera from 40 patients who had received kidneys pre-treated with the pair of anti-CD45 monoclonals YTH 24.5 and YTH 54.12. Only two patients elicited a weak human antimurine antibody (HAMA) response.

Using algorithms to teach dosage calculation

The study of mathematics and specifically dosage calculation can be difficult for both student and instructor. The authors describe how algorithms can be effectively used to reduce instructional and learning time, serve as a performance aid for students, help students understand the logic of mathematical operations, and allow students independent practice. The application of an algorithm is illustrated through the inclusion of a sample lesson on the calculation of intravenous drip rates.

A Comparison of Algorithmic and Teacher-Directed Instruction in Dosage Calculation Presented Via Whole and Part Methods for Associate Degree Nursing Students

The accurate calculation of drug dosages is a critical skill for nurses. This study compared two different treatments, algorithmic-based instruction (ABI) and teacher-directed instruction (TDI), as ways of providing instruction in dosage calculation. The ABI treatment relied exclusively on the use of a written study guide with algorithms, whereas the TDI treatment utilized lecture. Both treatments included an equal number of practice sessions structured via a whole or part method. The sample included 55 nursing students who were randomly assigned to either the whole or part method, and to TDI or ABI treatment. Initial learning and retention were measured by the use of two post-tests. Analysis of covariance indicated that neither of the treatments nor methods were statistically different for initial learning or retention. Both treatments, however, were found to be effective. The ABI treatment, moreover, was very efficient since it eliminated 75 minutes of instruction presented by a lecturer. Implications of this finding are considered.