Acknowledgement: "My sincere thanks to my supervisors Julie, Alison and Christina" - Identified Julie and Alison from the Department staff webpages - sm 26/02/2019 / There is little research investigating factors that facilitate or inhibit timely access to palliative care medicines from community pharmacies. Though palliative care is recognised within the UK government’s strategy and community pharmacists are considered to have a role it is uncertain to what extent this aim is incorporated into local practice. This thesis uses mixed methods to investigate the time taken to access palliative care medication from five community pharmacies in one area of England. The effect of prescription errors, stock availability and other factors is examined. Furthermore, semi-structured interviews with five community pharmacists and eleven other healthcare professionals explore medication access and the community pharmacist’s role in palliative care using the Framework method. Stock availability led to delays with one in five customers going to more than one pharmacy to get urgently required palliative care medications. Legal prescription errors were more common on computer generated prescriptions but did not lead to delays. Three subthemes were identified in accessing palliative care medicines: environment and resources; communication and collaboration; skills and knowledge. The community pharmacist’s role in palliative care was limited due to reluctance from other healthcare professionals to share information, poor access to patient records and lack of integration into the primary healthcare team. This study highlights implications for professionals, commissioners and providers to improve services for those trying to access palliative medication. Community pharmacies remain a largely untapped resource for supporting patients, relatives and carers towards the end of life in both cancer and other advanced life-limiting diseases.

There is little research investigating factors that facilitate or inhibit timely access to palliative care medicines from community pharmacies. Though palliative care is recognised within the UK government’s strategy and community pharmacists are considered to have a role it is uncertain to what extent this aim is incorporated into local practice. This thesis uses mixed methods to investigate the time taken to access palliative care medication from five community pharmacies in one area of England. The effect of prescription errors, stock availability and other factors is examined. Furthermore, semi-structured interviews with five community pharmacists and eleven other healthcare professionals explore medication access and the community pharmacist’s role in palliative care using the Framework method. Stock availability led to delays with one in five customers going to more than one pharmacy to get urgently required palliative care medications. Legal prescription errors were more common on computer generated prescriptions but did not lead to delays. Three subthemes were identified in accessing palliative care medicines: environment and resources; communication and collaboration; skills and knowledge. The community pharmacist’s role in palliative care was limited due to reluctance from other healthcare professionals to share information, poor access to patient records and lack of integration into the primary healthcare team. This study highlights implications for professionals, commissioners and providers to improve services for those trying to access palliative medication. Community pharmacies remain a largely untapped resource for supporting patients, relatives and carers towards the end of life in both cancer and other advanced life-limiting diseases.

This study aimed to evaluate the use of a shared electronic primary health care record (EHR) to assist with medicines reconciliation in the hospital from admission to discharge. Methods: This is a prospective cross-sectional, comparison evaluation for 2 phases, in a short-term elderly admissions ward in the United Kingdom. In phase 1, full reconciliation of the medication history was attempted, using conventional methods, before accessing the EHR, and then the EHR was used to verify the reconciliation. In phase 2, the EHR was the initial method of retrieving the medication history-validated by conventional methods. Results: Where reconciliation was led by conventional methods, and before any access to the EHR was attempted, 28 (28%) of hospital prescriptions were found to contain errors. Of 99 prescriptions subsequently checked using the EHR, only 50 (50%) matched the EHR. Of the remainder, 25% of prescriptions contained errors when verified by the EHR. However, 26% of patients had an incorrect list of current medications on the EHR. Using the EHR as the primary method of reconciliation, 33 (32%) of 102 prescriptions matched the EHR. Of those that did not match, 39 (38%) of prescriptions were found to contain errors. Furthermore, 37 (36%) of patients had an incorrect list of current medications on the EHR. The most common error type on the discharge prescription was drug omission; and on the EHR, wrong drug. Common potentially serious errors were related to unidentified allergies and adverse drug reactions. Conclusions: The EHR can reduce medication errors. However, the EHR should be seen as one of a range of information sources for reconciliation; the primary source being the patient or their carer. Both primary care and hospital clinicians should have read-and-write access to the EHR to reduce errors at care transitions. We recommend further evaluation studies.

Yes / Objective Medication arrangements for patients with severe mental illness (SMI), including schizophrenia and bipolar disorder, can be complex. Some have shared care between primary and secondary services while others have little specialist input. This study investigated the contribution a specialist mental health clinical pharmacy team could make to medicines optimisation for patients on the SMI register in primary care. Research shows that specialist mental health pharmacists improve care in inpatient settings. However, little is known about their potential impact in primary care. Method Five general practice surgeries were allocated half a day per week of a specialist pharmacist and technician for 12 months. The technician reviewed primary and secondary care records for discrepancies. Records were audited for high-dose or multiple antipsychotics, physical health monitoring and adherence. Issues were referred to the pharmacist for review. Surgery staff were encouraged to refer psychotropic medication queries to the team. Interventions were recorded and graded. Results 316/472 patients on the SMI register were prescribed antipsychotics or mood stabilisers. 23 (7%) records were updated with missing clozapine and depot information. Interventions by the pharmacist included clarifying discharge information (12/104), reviewing high-dose and multiple antipsychotic prescribing (18/104), correcting errors (10/104), investigating adherence issues (16/104), following up missing health checks (22/104) and answering queries from surgery staff (23/104). Five out of six interventions possibly preventing hospital admission were for referral of non-adherent patients. Conclusion The pharmacy team found a variety of issues including incomplete medicines reconciliation, adherence issues, poor communication, drug errors and the need for specialist advice. The expertise of the team enabled timely resolution of issues and bridges were built between primary and secondary care.

Yes / Purpose Medicine shortages have a detrimental impact on stakeholders in the pharmaceutical supply chain (PSC). Existing studies suggest that building resilience strategies can mitigate the effects of these shortages. As such, this research aims to examine whether resilience strategies can reduce the impact of medicine shortages in the United Kingdom's (UK) PSC. Design/methodology/approach A sequential mixed-methods approach that involved qualitative and quantitative research enquiry was employed in this study. The data were collected using semi-structured interviews with 23 key UK PSC actors at the qualitative stage. During the quantitative phase, 106 respondents completed the survey questionnaires. The data were analysed using partial least square-structural equation modelling (PLS-SEM). Findings The results revealed that reactive and proactive elements of resilience strategies helped tackle medicine shortages. Reactive strategies increased relational issues such as behavioural uncertainty, whilst proactive strategies mitigated them. Practical implications The findings suggest that PSC managers and decision-makers can benefit from adopting structural flexibility and proactive strategies, which are cost-effective measures to tackle medicine shortages. Also engaging in strategic alliances as a proactive strategy mitigates relational issues that may arise in a complex supply chain (SC). Originality/value This study is the first to provide empirical evidence of the impact of resilience strategies in mitigating medicine shortages in the UK's PSC.

Implementation and uptake of novel and cost-effective medicines can improve patient health outcomes and healthcare efficiency. However, the relative uptake of new medicines recommended by the National Institute for Health and Care Excellence often lags behind other comparative countries’ health systems. One example is the uptake of direct oral anticoagulants (DOACs) for stroke prevention in atrial fibrillation, which was slow and had a high level of unexplained variation across different health economies in England. This research aimed to explore barriers and enablers to the uptake of DOACs from the perspectives of patients, healthcare professionals, and key stakeholders by conducting systematic and narrative reviews and semi-structured interviews. Data collected from 21 patients, 23 healthcare professionals, and 23 key stakeholders recruited from three different health economies was analysed using the Framework method. The findings identified a range of intersecting factors acting as barriers and/or enablers to the uptake DOACs. While there were a wide range of experiences and views, an agreement between patients and healthcare professionals/key stakeholders on several identified factors was observed. Attributes of the innovation, characteristics of patients and prescribers, local health economy readiness for change, implementation process, and external health system context were suggested as influences. Mapping of the findings to the Diffusion of Innovations in Service Organisations model identified 11 components for a future toolkit development to facilitate uptake of nationally recommended new medicines. This thesis highlighted the role of patients, consideration of all costs associated with new medicines, and compatibility with the health economy’s care model impact on the uptake.

Medication safety and improving communication at care transitions are an international priority. There is vast evidence on the scale of error associated with medicines reconciliation and some evidence of successful interventions to improve reconciliation. However, there is insufficient evidence on the factors that contribute towards medication error at transitions, or the roles of those involved. This thesis examined current UK medicines reconciliation practice within primary and secondary care, and the role of HCPs and patients. Using a mixed-method, multi-centre design, the type and severity of discrepancies at admission to hospital were established and staff undertaking medicines reconciliation across secondary and primary care were observed, using evidence-informed framework, based on a narrative literature review. The overall processes used to reconcile medicines were similar; however, there was considerable inter and intra-organisational variation within primary and secondary care practice. Patients were not routinely involved in discussions about their medication, despite their capacity to do so. Various human factors in reconciliation-related errors were apparent; predominantly inadequate communication, individual factors e.g. variation in approach by HCP, and patient factors e.g. lack of capacity. Areas of good practice which could reduce medicines reconciliation-related errors/discrepancies were identified. There is a need for increased consistency and standardisation of medicines reconciliationrelated policy, procedures and documentation, alongside communication optimisation. This could be achieved through a standardised definition and taxonomy of error, the development of a medicines reconciliation quality assessment framework, increased undergraduate and post-graduate education, improved patient engagement, better utilisation of information technology and improved safety culture.

Darbo tikslas. Įvertinti vyresnio amžiaus pacientų vaistų vartojimo valdymą. Uždaviniai: išanalizuoti vaistų vartojimo ypatumus vyresniame amžiuje; nustatyti gaunamos informacijos, susijusios su saugiu vaistų vartojimu, įtaką pagyvenusiems pacientams; įvertinti pagalbinių technologijų reikšmę vyresnių pacientų vaistų vartojimo valdymui. Tyrimo metodika. Tiriamųjų apklausa, dokumentacijos analizė, statistinė analizė. Anketavimo bei struktūrizuoto interviu metu buvo naudojamas klausimynai, skirti pacientams bei slaugytojoms, sudaryti pačios tyrėjos, remiantis literatūra. Tiriamųjų grupę sudarė 178 respondentai, besigydantys VšĮ II Kauno klinikinės ligoninės vidaus ligų skyriuje nuo 2009 metų rugsėjo mėn. iki 2010 vasario mėn. bei 14 bendrosios praktikos slaugytojų, dirbančių tame pačiame skyriuje. Statistinė duomenų analizė atlikta naudojant statistinės analizės programą "SPSS for Windows 15.0". Rezultatai statistiškai reikšmingi, jei paklaidos tikimybės reikšmė p<0,05. Kokybinių požymių pasiskirstymas buvo skaičiuojamas absoliučiu skaičiumi bei procentais, kiekybiniams požymiams skaičiuotas vidurkis ir standartinis nuokrypis, standartinė vidurkio paklaida. Ryšiai tarp požymių buvo vertinami chi kvadrato (χ²) kriterijumi bei laisvės laipsnių skaičiumi (lls). Rezultatai. Lietuvoje kaip ir visame pasaulyje vis didėja vyresnio amžiaus žmonių skaičius. Tai sąlygoja didesnį sergamumą ir su juo susijusį saugų vaistų vartojimą. Dažniausios problemos yra: širdies ir kraujagyslių ligos... [toliau žr. visą tekstą] / Aim of the study. To evaluate the managament of older patients medicines consumption. Objectives. To assess the pecularities of drug use by older patients; to identify the influence of available information of safe medicines consumption on senior patients behaviour; to evaluate the importance of supporting technologies to the management of senior patients medicines consumption. Research methods. Questionnaires for patients and nurses were created by researcher using literature. The study groups consisted of 178 respondents, which were hospitalized in 2nd Kaunas Clinical Hospital Internal Medicine Department since September, 2009, till February , 2010, and 14 general practice nurses, which are working in this department. Statistical data analyse was performed by using statistical analyse programme “SPSS for Windows 15.0“. The distribution of qualitative indicators was calculated in absolute number and percentage. For quantitative indicators an average and standard deviation were calculated. Relations between features were valued by chi square criterion ((χ²). Results. The most frequent conditions of older patients were cardiovascular diseases and respiratory diseases. Patients for a variety of problems could not use medicines on their own. Side effects of medications were frequent. From side effects more common were: dizziness (33,7 %), palpitations (30,3 %), general weakness (29,2 %), constipation (26,4 %). Aged patients used frequently over-the-counter medications, they... [to full text]

Numerous natural products are widely used as first-line/alternative therapeutics and dietary supplements in both western and eastern society. However, the safety and efficacy profiles for herbal products are still limited. Organic anion transporters (OATs; SLC22 family) are expressed in many barrier organs and mediate in vivo body disposition of a broad array of endogenous substances and clinically important drugs. As some dietary flavonoids and phenolic acids were previously demonstrated to interact with OATs, it is necessary to explore the potential interaction of such components found in natural products in order to avoid potential OAT-mediated drug-drug interactions (DDIs). The inhibitory effects of 23 natural products were assessed on the function of human (h) OATs, hOAT1 (SLC22A6), hOAT3 (SLC22A7), and hOAT4 (SLC22A11) and/or the murine (m) orthologs mOat1 and mOat3. For compounds exhibiting marked inhibition at initial screening, dose-response curves (IC50 values) and DDI indices were determined. At the initial screening concentrations, 14, 19, and 2 test compounds exhibited significant inhibition on hOAT1, hOAT3, and hOAT4, respectively. Additionally, all test Danshen (a Chinese herbal medicine) hydrophilic components significantly reduced mOat1- and mOat3-mediated substrate uptake at 1 mM. For selected compounds, the IC50 and Ki values were estimated to be in the micromolar or even nanomolar range. Considering the clinical plasma concentration and unbound fraction in plasma, DDI indices for gallic acid, gentisic acid, lithospermic acid, protocatechuic acid, rosmarinic acid, salvianolic acid B, and tanshinol indicated DDIs may occur in vivo in situations of co-administration of these compounds and clinical therapeutics known to be OAT substrates. Finally, a new, rapid, and sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) method was developed and validated to quantify gallic acid and gentisic acid in cell lysates in order to measure cellular uptake of these compounds in mOat1- or mOat3-expressing cells. Significant cellular uptake of gallic acid was observed in mOat1-expressing cells, compared with background control cells. The absorptive uptake was completely blocked by probenecid (known OAT inhibitor) at 1 mM. These results indicate that gallic acid is a substrate for mOat1 and suggest that human OAT1 might be involved in the active renal secretion of gallic acid.

Com o aparecimento crescente de diferentes formulações cosméticas a base de dimetilaminoetanol (DMAE) e seus diferentes sais, faz-se necessário desenvolvimento e validação de métodos analíticos para serem empregados controle de qualidade, tanto dos produtos acabados quanto das matérias-primas. O objetivo principal deste trabalho de pesquisa é propor duas metodologias analíticas (ressonância magnética nuclear 1H e eletroforese capilar) como ferramentas no controle de qualidade destes produtos Discutem-se também as técnicas de caracterização de matérias-primas contendo DMAE, bem como resultados obtidos em estudo de estabilidade acelerado. O método por ressonância magnética nuclear 1H foi validado usando água deuterada (amostras contendo DMAE bitartarato e DMAE base) dimetilsulfoxido (amostras contendo DMAE acetoamidobenzoato) como solventes. Os resultados obtidos foram confiáveis para todas as características de desempenho avaliadas na validação. Entre a desvantagem do metodo pode ser destacada a limitação do uso desta técnica nas amostras em creme e gel-creme. O método eletroforético foi completamente validado. Não foram observadas interferências e todos os parâmetros avaliados foram satisfatórios. Este método é simples e não requer tratamentos trabalhosos no preparo das amostras. Entre as vantagens do método destacam-se o pouco impacto ambiental e economia. O estudo de estabilidade acelerado não mostrou mudanças significativas em relação ao teor, porém, nas condições mais drásticas foram observadas mudanças em coloração e viscosidade aparente. / With the increasing amount of different cosmetic formulations containing dimetilaminoetanol (DMAE) and its salts, it is necessary to develop and validate analytical methods to be employed in the quality control of the active substances and commercial products. The primary purpose of this research to propose two analytical methodologies (nuclear magnetic resonance 1H and capillary electrophoresis) as tools to be used in the quality control of these products. It were also performed analysis for characterization of raw materials and stability studies of too cosmetic preparations. The nuclear magnetic resonance 1H method has been validated using deuterium oxide (for samples containing DMAE bitartrate and DMAE base) and DMSQ-d6 (for samples containing DMAE acetamidobenzoate) as solvents. The results were reliable for all the characteristics of performance evaluated in the validation. Nevertheless, the disadvantage of this method is the limited use this technique in the analysis of creams and gel-creams. The electrophoretic method has been fully validated. No interference was observed and all validation parameters evaluated were satisfactory. This method is simple and does not require laborious treatment for sample preparation. Among the advantages of this method is the little environmental impact and economics. The accelerated stability study showed no significant changes with regard to the content; the more drastic changes were observed in color and apparent viscosity.