Ko au tēnei: This is me - Exploring the lived experience of underrepresented groups with pharmacy services to inform the development of pharmacy case-based learning

INTRODUCTION

Demographic and social characteristics of underrepresented groups are often poorly described in pharmacy case-based learning, leading to poor representation of these groups in the pharmacy curriculum. This research project aimed to understand the lived experience of underrepresented groups with pharmacy services and to use this to inform the development of pharmacy case-based student learning materials.

METHODS

This was a single centre, grounded theory, qualitative study. Focus groups were undertaken with six underrepresented groups: Māori, Pacific, Asian, LGBTQIA+ (lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual), disability, and refugee. These focus groups were conducted in Dunedin, Aotearoa New Zealand from July to August 2022. Focus group sessions were recorded and analysed to identify beliefs, ideas, and themes shared between participants and groups.

FINDINGS

Participants in all focus groups had a strong desire to be seen and represented in pharmacy cases, however this was conditional on the learning being delivered in a way that upholds their beliefs, values, and voices. From these lived experiences, cultural, environmental, personal, and social factors were identified as being critical for inclusion in pharmacy case-based learning materials.

CONCLUSIONS

The lived experience of underrepresented populations provides critical insights that will enhance pharmacy case-based learning. The key factors that could be included in case-based learning are: ethnicity, personal beliefs, language, disability, gender identity, sexual identity, and family. To achieve health equity and improve cultural awareness and intelligence of our future pharmacy workforce, these experiences need to become more present in curricula.

Quantitative Assessment of Brain Networks in Children With Sturge-Weber Syndrome Using Resting State Functional Magnetic Resonance Imaging (MRI)

In this study, we examined whether topologic network analysis, using resting state functional magnetic resonance imaging (MRI), can detect abnormalities of functional brain connectivity in children with unilateral brain injury due to Sturge-Weber syndrome. Three children with Sturge-Weber syndrome (ages 1, 3, and 10 years) underwent structural and resting state functional MRI, glucose metabolism positron emission tomography (PET), and neurocognitive evaluation. Eight different resting state networks were compared between the affected and unaffected hemispheres by quantitatively accessing communication efficiency measures. Significantly reduced efficiency values were found in all 3 patients. Visual network deficiency was present in both children with a visual field defect; frontal network abnormalities were associated with fine motor impairment. Location of network abnormalities corresponded to and, in some cases, extended beyond structural MRI and glucose PET abnormalities. The presented approach can detect early functional abnormalities of specific brain networks in children with Sturge-Weber syndrome.

Brain damage and IQ in unilateral Sturge-Weber syndrome: support for a "fresh start" hypothesis

We tested the hypothesis that extent of severe hypometabolism measured by fluorodeoxyglucose PET has a U-shaped (nonlinear) relationship to IQ in children with unilateral Sturge-Weber syndrome. Thirty-five consecutive children (age range: 30-153 months) with Sturge-Weber syndrome and unilateral brain involvement were enrolled in the study. Participants underwent cognitive assessment and interictal fluorodeoxyglucose PET scans. Regression analyses tested whether a quadratic model best accounted for the relationship between extent of severe cortical hypometabolism and IQ, controlling for seizure variables. A significant quadratic relationship was found between IQ and extent of severe (but not total) hypometabolism. Seizure variables also contributed significant variance to cognitive functions. Results suggest that intermediate size of severe hemispheric hypometabolism is associated with the worst cognitive outcomes, and small or absent lesions, with the best cognitive outcomes. Children in whom a very large extent of the hemisphere is severely affected are likely to have relatively preserved cognitive function.

Problems of service assessment ab intra: research and evaluation relating to a new early intervention community psychiatric nursing service

This paper summarizes a 12-month evaluation of an emergency assessment and community care psychiatric nursing service to demonstrate the possibility and desirability of health service providers evaluating their own service provision. The radical question central to such an assessment is: 'What would have been the case if the service assessed had not existed?' This question is more difficult to answer than might at first appear. However, recent changes in UK legislation concerning health care in general, and community care of the mentally ill in particular, make the assessment of new services of great importance. What is most needed in making such assessments is not technical expertise in data collection and analysis but non-specialized critical acumen in making inferences from data routinely collected in the course of providing any service. This is illustrated using the example of a community psychiatric nursing service which afforded an opportunity to consider the impact of a new project on established services.

The prevalence of abnormal involuntary movements among chronic schizophrenics

In an international survey of chronic schizophrenia, data were collected on the Abnormal Involuntary Movements Scale (AIMS) to ascertain the prevalence of tardive dyskinesia. Abnormal movements were found to present in 28% of the sample of 739 patients. Using the more stringent Research Criteria for Tardive Dyskinesia (RD-TD) the prevalence rate was found to be 13.6%. Statistically significant differences were obtained between patients meeting RD-TD criteria and patients with abnormal movement who did not meet RD-TD criteria on total score, global severity, degree of incapacity and patient awareness--all reflecting greater severity in the RD-TD group. A much lower rate of moderate/severe tardive dyskinesia than that reported in the literature was obtained in this sample. Using the Leonhard classification of chronic schizophrenia, it was found that patients with prominent negative symptomatology had a high prevalence of tardive dyskinesia--confirming the previous reported relationship between these variables. Prevalence differences, possibly related to specific psychopathological syndromes, were also obtained.

Conditioning and learning in relation to disease

Of the two generally recognized processes through which learning occurs--imprinting and conditioning--only the latter with its two paradigms, classical and operant, has both practical and heuristic implications for disease. From the classical conditioning experiments of Pavlov's laboratory over 100 years ago to the later work in operant conditioning by Skinner and others in the past four decades has evolved much of the basis of modern learning theory and its applications to disease in the form of behavior therapy. Variants of behavior therapy have been employed in the treatment of wide variety of medical and psychiatric illnesses. Recent developments in the study of brain function and biochemistry have led to renewed interest in the conditioning paradigm and its value as tool in these areas of research.

Neuroleptic-induced skin pigmentation in chronic hospitalized schizophrenic patients

In the framework of a multi-national collaborative study carried out in eight countries, 768 chronic hospitalized schizophrenic patients were surveyed. Skin pigmentation was found to be present in 13 patients (1.7%), that is, within the same range (1-2.9%) of the initial reports. While the mean age and mean duration of hospitalization in the skin-pigmented population was slightly higher and larger than in the total population of our survey, no definitive relationships between sex, diagnosis, drugs and dosage of medication were revealed.

Pharmacotherapy of chronic hospitalized schizophrenics: prescription practices

Prescription practices were examined as part of a multinational study of chronic hospitalized schizophrenic patients. The study included a total of 768 patients from 8 countries. All patients had a diagnosis (ICD-9) of schizophrenia and met defined criteria for chronic hospitalization. The patients were treated with psychotropic drugs from 6 categories, i.e., neuroleptics, antidepressants, lithium salts, anxiolytics, anticonvulsants, and antiparkinsonian medications, as well as with a variety of nonpsychotropic drugs. The majority of the patients received concurrently more than 1 neuroleptic, medications from 2 or more categories, and neuroleptics combined with other agents. Polypharmacy appeared to be universal in this population.

An international survey of tardive dyskinesia

As part of an international study of chronic schizophrenia, data on tardive dyskinesia were collected by clinical judgment and a standard rating scale, on over 700 patients. The frequently-reported positive correlation between age and prevalence rate was confirmed in this sample. While not statistically significant, high prevalence rates were associated with higher dosage levels and length of hospitalization. Positive relationships were also found to exist among prevalence rates and schizophrenic subtypes--particularly among those with high degrees of negative symptomatology.

The psychopharmacological treatment of depression in the medically ill patient

With the introduction of effective antidepressants, pharmacotherapy has not been limited exclusively to the psychiatrically ill, but has been expanded to include medically ill patients exhibiting depressive symptomatology as well. This has led to problems in diagnostic differentiation and, just as important, problems with interactions resulting from multiple medications. By describing the coexistence of depressive symptomatology in a large variety of physical illness, the physician is alerted to the complexities of psychiatric illness in the medically ill patient as well as the caution necessitated by the poly-pharmacotherapy required in this population.

Leonhard's classification of the chronic schizophrenias

The conceptual development of Leonhard's classification of the chronic schizophrenias is outlined. The recognition within that classification of the importance of the polarity dimension has led to the identification of two distinct populations--atypical nonsystematic and typical systematic schizophrenia--each with a variety of different subtypes. It is hoped that recognition and validation of this group of illnesses which, for three-quarters of a century, have been called "schizophrenia" will provide a basis for meaningful biological research. Increasing interest in the system has already produced an awareness that future progress in the understanding of mental illness will greatly depend upon re-establishing the central place of psychopathology in psychiatric research.

Chronic schizophrenia-a psychopharmacological aproach

Our work suggests that the Leonhard classification system holds much pron.ise as a framework for future neurological development. One might speculate along biochemical lines that the nonsystematic subpopulation of schizophrenics may suffer from altered dopamine β-hydroxylase activity which results in an excess of dopamine, This would eeplain why this class responds so well to dopamine receptor blocking agent when other patient do not.One might also speculate tint we are dealing with a number of diseases-each with different courses and progressing to different end states, but all with common pattern during the acute stage, e.g., increased dopamine levels or receptor sensitivity levels. This is probably why the acute stage can usually be controlled by the administration of a dopamine receptor blocking agent.A further speculation concerns the catatonic patient- who had begun to respond to psychosocial and milieu treatment prior to the introduction of neuroleptics. This particular group of patients do not seem to benefit from prophylactic treatment with neuroleptics. If, by activating a patient, catecholamines are released, it is hypothesized that the Catatonics are a completely separate subpopulation-not just clinically-but also biochemically.Completely different types of drugs may be helpful for the different schizophrenic subpopulations. Among the various substances, propranolol should be considered. Obviously, this drug will not be effective in all schizophrenics; but there arc certain types of patients who respond to β-blockers. There is also increasing evidence that clordine (which stimulates alpha-adrenergic receptors) may also have an effect on certain schizophrenics The most recent findings is that cholecystokinin-thought for Some time to be an exclusively peripheral substance-appears to be present in the brain and available in the form of ceulotide, a neuropeptide which is a dopamine agonist. This susbtance, also, seems to be effective in the treatment of certain schizophrenics.Chronic schizophrenia requires re-evaluation and it should be recognized that different drugs are effective in different types of patients. There is renewed interest in the various schizophrenic conditions and their end states. We must hope that the pharmacologists, provided with sufficient information, will search for new drugs with differentiated activities that will meaningfully influence the end states of schizophrenic disorders and/or prevent their development.

Organizing and conducting clinical trials

Of the three stages of clinical trial, i.e. design, data collection, analysis, the second stage is the most neglected. The literature abounds with discussions on design and analysis, but there is a dearth of information on the organization and execution of the trial itself. Easily the most time-consuming aspect of a trial, data collection is frequently carried out by individuals who have not designed the study and who will not perform the analysis of results. With different individuals involved in each of the stages, intercommunication on substantive and procedural issues is essential for the successful culmination of the clinical project.

A double-blind clinical trial of mianserin versus amitriptyline: differentiation by adverse symptomatology

A 6-week double-blind comparison of mianserin, a new antidepressant, and amitriptyline allowed us to explore the problem of demonstrating main effect differences in drug/drug trials when the focus is primarily only upon efficacy or upon common adverse symptomatology. Statistical analyses of standard psychiatric rating scales revealed no significant treatment differences, while both treatment groups exhibited significant parallel improvement across time. Examination of treatment emergent symptoms indicated that, while it evoked fewer anticholinergic symptoms than amitriptyline, mianserin exhibited a different profile of adverse symptomatology. The usefulness of a measure of the benefit/risk ratio was described as a means of clarifying drug/drug comparisons.

Viloxazine HCl in the treatment of endogenous depression: a standard (imipramine) controlled clinical study

In a four week, double-blind clinical trial, 20 patients with endogenous depression were randomly assigned to treatment with either viloxazine or imipramine. Statistically significant improvement was observed on the Hamilton Psychiatric Rating Scales for Depression and Anxiety for both treatment groups. There were no differences between the two treatment groups in the type, incidence, or severity of treatment emergent symptoms. No medication-related abnormalities in clinical laboratory values occurred in either treatment group.

A collaborative study of a new antidepressant, viloxazine, in neurotic and endogenous depressives

In a multicenter series of trials, viloxazine was compared with imipramine, amitriptyline, doxepin and placebo in 123 neurotic and endogenous depressive inpatients and outpatients. While significant period effects reflecting improvement were obtained on the majority of efficacy variables, no significant differences were obtained among the treatment groups or depressive types. Imipramine and amitriptyline exhibited more anticholinergic adverse reactions; while, viloxazine exhibited greater CNS effects. Dizziness and nausea were much more frequent in neurotic depressives which may be related to their psychopathology.

Viloxazine in the treatment of endogenous depression. A standard (amitriptyline) controlled clinical study

In a double-blind clinical trial with 20 patients suffering from endogenous depression statistically significant changes (improvement) were present in the scores of all assessment instruments. Although no statistically significant differences occurred between the groups, significant improvement on the HAM-D occurred earlier for amitriptyline and significant improvement occurred earlier on HAM-A for viloxazine. 2 patients were discontinued due to adverse reactions; one for nausea and vomiting while receiving viloxazine and one for paroxysmal atrial tachycardia while receiving amitriptyline. The same number of TES occurred for each group with seven unique to viloxazine (numbness, tingling, palpitation, ejaculation difficulty, nausea/vomiting, diarrhea, epigastric pain and gustatory disturbances) and seven unique to amitriptyline (insomnia, irritability, syncope, tremor, nasal congestion, orthostatic hypertension and paroxysmal atrial tachycardia). Other than for 1 patient who developed syncope and orthostatic hypotension and the patient who developed paroxysmal atrial tachycardia, there were no clinically significant changes in pulse rate, blood pressure and weight. There were no clinical laboratory findings with either drug that were judged to be pathological.

Psychopharmacology and Leonhard's classification of chronic schizophrenias

There is evidence to indicate that 15% of patients diagnosed as schizophrenic will become chronically hospitalized, and that worldwide one-third to one-half of all psychiatric beds are occupied by schizophrenic patients. In spite of these figures and the public health problem they represent, little attention is paid to chronic hospitalized schizophrenic patients. Even the most recent classification schemas fail to recognize the heterogeneity, exemplified by differential responsiveness to psychotropic drugs, within the chronic schizophrenic population. One systematic approach to classification which does address this problem has been proposed by Leonhard. In this paper, findings and procedures that demonstrate the clinical relevance of Leonhard's system along with some preliminary results and observations from psychopharmacological studies that indicate Leonhard's different subtypes of chronic schizophrenia may represent biologically distinct populations are presented.

Measuring chronic schizophrenic patients attitudes toward their illness and treatment

The right to refuse medication is a legal right now being extended by federal courts to many voluntary and involuntary mental patients. However, little is known of the insight that chronically ill mental patients bring to the decision of whether or not to accept prescribed medication. In this study, the authors interviewed 45 chronic schizophrenic inpatients to determine their understanding of their illness, need for admission, and need for medication and other treatment. Only 13 per cent understood they were mentally ill, and only 27 per cent of the patients understood that they needed medication. The findings suggest that many chronically mentally ill patients lack sufficient insight into their condition to make sound judgments about medication and treatment. Moreover, even those patients who improved with medication did not improve in their insight into their need for treatment.

Viloxazine in the treatment of depressive neurosis: a controlled clinical study with doxepin and placebo

In a four-week, double-blind, clinical trial thirty-one patients with depressive neurosis were treated with viloxazine, doxepin, or placebo. There were no differences among the three groups in therapeutic effects. Many depressed out-patients improve on placebo. Viloxazine hydrochloride is one of a series of compounds developed to explore the central nervous system activity of the aryloxypropanolamine type of beta-adreno-receptor antagonists. Initial clinical study support the hypothesis that viloxazine has antidepressant properties in man (Bayliss et al, 1974; Bereen, 1973; Pichot et al., 1975; Tsegos and Ekdawi, 1974).

Viloxazine in the treatment of depressive neurosis: a placebo and standard (imipramine) controlled clinical study

In a 4-week double-blind trial, 33 patients with depressive neurosis were randomly assigned to either viloxazine, imipramine or placebo. Statistically significant improvement was observed in all treatment groups. Imipramine exhibited significant improvement earlier in depressive symptoms, while viloxazine showed significant improvement earlier in anxious symptoms. The same frequency of treatment emergent symptoms occurred in the treatment groups. Premature termination as a consequence of adverse reactions was required in only 1 viloxazine and 1 placebo patient.

A double-blind comparison of three dosages of flutroline (CP-36,584) in the treatment of schizophrenia

Therapeutic and adverse effects of three dosages (1, 20 and 100 mg daily) of flutroline, a new gamma-carboline with a preclinical pharmacological profile similar to active neuroleptic agents, were compared in a double-blind clinical trial in 25 newly-admitted schizophrenic patients. Therapeutic effects and extrapyramidal signs were seen at the 20 and 100-mg daily dosages, but not at the 1-mg dosage. Serum prolactin levels were significantly elevated only at the 100-mg daily dosage.

Mianserin: determination of therapeutic dose range

Mianserin hydrochloride is a tetracyclic antidepressant with an EEG and clinical activity profile similar to amitriptyline. To investigate the drug's optimal dosage range, a 6-week open comparative trial sequentially assigned 12 depressed patients to one of three dose ranges (60, 90 and 120 mg). Improvement occurred in depressive symptomatology in all three treatment groups. There was no differential improvement noted in any group; however, the incidence of adverse effects was greater in the middle (90 mg) and high (120 mg) dose ranges.