Search

Transcutaneous electrical nerve stimulation (TENS) is an electrophysical modality used for pain management. This study investigated the dose response of different TENS intensities on experimentally induced pressure pain. One hundred and thirty TENS naïve healthy individuals (18-64 years old; 65 males, 65 females) were randomly allocated to 5 groups (n = 26 per group): Strong Non Painful TENS; Sensory Threshold TENS; Below Sensory Threshold TENS; No Current Placebo TENS; and Transient Placebo TENS. Active TENS (80 Hz) was applied to the forearm for 30 minutes. Transient Placebo TENS was applied for 42 seconds after which the current amplitude automatically reset to 0 mA. Pressure pain thresholds (PPT) were recorded from 2 points on the hand and forearm before and after TENS to measure hypoalgesia. There were significant differences between groups at both the hand and forearm (ANOVA; P = .005 and .002). At 30 minutes, there was a significant hypoalgesic effect in the Strong Non Painful TENS group compared to: Below Sensory Threshold TENS, No Current Placebo TENS and Transient Placebo TENS groups (P < .0001) at the forearm; Transient Placebo TENS and No Current Placebo TENS groups at the hand (P = .001). There was no significant difference between Strong Non Painful TENS and Sensory Threshold TENS groups. The area under the curve for the changes in PPT significantly correlated with the current amplitude (r(2) = .33, P = .003). These data therefore show that there is a dose-response effect of TENS with the largest effect occurring with the highest current amplitudes. PERSPECTIVE: This study shows a dose response for the intensity of TENS for pain relief with the strongest intensities showing the greatest effect; thus, we suggest that TENS intensity should be titrated to achieve the strongest possible intensity to achieve maximum pain relief. [ABSTRACT FROM AUTHOR]

Background: Reflexology has been shown to reduce anxiety and stress in various populations. The mechanism by which this occurs may be in modulating autonomic nervous system (ANS) function; however; there is limited evidence available in the area. Primary Study Objective: The aim of the study was to investigate the feasibility of using an experimental model to determine the physiological effect of reflexology on stress. Methods/design: A feasibility study to assess an experimental study design to compare the effect of reflexology and control interventions on heart rate (HR) and blood pressure (BP) following mental stress tests. Setting: The Health and Rehabilitation Science Research Institute at the University ofUlster, Northern Ireland, United Kingdom. Participants: Twenty-six healthy volunteers. Intervention: Mental stress was induced before and after intervention. Participants in the reflexology group received 20 minutes of reflexology, and the control group received 20 minutes of relaxation with a therapist holding each participant's feet. Primary Outcome Measures: The outcome measures, HR and BP, were measured throughout mental stress testing intervention, and a second period of mental stress testing following intervention. Results: The study design was considered feasible. There were significant reductions in systolic blood pressure (SBP) (22%; P = .03) and in diastolic blood pressure (DBP) (26%; P = .01) during mental stress following reflexology compared to the stress period prior to intervention. In contrast, there was a 10% reduction in SBP (P = .03) but a 5% increase in DBP (P = .67) during the period of mental stress following the control intervention compared to results obtained during mental stress prior to this intervention. However, there were no significant differences between reflexology and control groups. Conclusion: This study has demonstrated the feasibility of conducting an experimental study on the effect ofreflexology in stress using BP as the primary outcome measure. Results from such a study would address the lack of high-quality evidence for the physiological effects of reflexology. [ABSTRACT FROM AUTHOR]

The aim of this cluster randomised controlled trial was to test the impact of an infection control education and training programme on meticillin-resistant Staphylococcus aureus (MRSA) prevalence in nursing homes. Nursing homes were randomised to intervention (infection control education and training programme; N=16) or control (usual practice continued; N=16). Staff in intervention homes were educated and trained (0, 3 and 6 months) in the principles and implementation of good infection control practice with infection control audits conducted in all sites (0, 3, 6 and 12 months) to assess compliance with good practice. Audit scores were fed back to nursing home managers in intervention homes, together with a written report indicating where practice could be improved. Nasal swabs were taken from all consenting residents and staff at 0, 3, 6 and 12 months. The primary outcome was MRSA prevalence in residents and staff, and the secondary outcome was a change in infection control audit scores. In all, 793 residents and 338 staff were recruited at baseline. MRSA prevalence did not change during the study in residents or staff. The relative risk of a resident being colonised with MRSA in an intervention home compared with a control home at 12 months was 0.99 (95% confidence interval: 0.69, 1.42) after adjustment for clustering. Mean infection control audit scores were significantly higher in the intervention homes (82%) compared with the control homes (64%) at 12 months (P<0.0001). Consideration should be given to other approaches which may help to reduce MRSA in this setting. [ABSTRACT FROM AUTHOR]

Background: Little is known about how community pharmacists make decisions about which over-the-counter (OTC) medication to supply to a patient and the role of clinical evidence in making those decisions.Objective: To explore factors that influence product selection by the pharmacist and the role of evidence-based practice in this decision.Methods: In this qualitative study, community pharmacists registered in Northern Ireland and recruited via advertising and various qualitative sampling techniques, participated in face-to-face, semi-structured interviews (June 2007-September 2007) to discuss issues around OTC medication, including the use of evidence, how they judged a product to be effective, and their views on evidence-based medicine and its application to OTC medication. All interviews were digitally recorded, fully transcribed and analysed using the principles of constant comparison.Results: Twenty-six pharmacists participated in interviews. Safety was the over-arching consideration for pharmacists when making decisions. The subordinate themes were product, patient and professional factors. In terms of the product subordinate theme, use or consideration of evidence was secondary in the selection of OTC medicines. Pharmacists considered the potential for harm in the first instance and if the product was deemed safe, although lacking any evidence for effectiveness, the product was supplied. In relation to patient factors, it emerged that pharmacists were influenced by patient demand for a particular OTC product and wanted to meet patient expectations, provided that the requested product was judged to be safe. Similarly, professional factors such as ethical considerations (primarily in relation to safety) and respecting patient choice also influenced decision making. However, pharmacists recognized the conflict between professional requirements to practise according to evidence-based principles and patient demands.Conclusion: This study suggests that pharmacists considered safety above all other factors when recommending OTC products to patients, and evidence of effectiveness was seldom considered when selling OTC medicines. If evidence-based practice is to influence this type of decision, pharmacists need to use the evidence that is available and be prepared to discuss evidence with patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To test the effect of an adapted U.S. model of pharmaceutical care on prescribing of inappropriate psychoactive (anxiolytic, hypnotic, and antipsychotic) medications and falls in nursing homes for older people in Northern Ireland (NI). DESIGN: Cluster randomized controlled trial. SETTING: Nursing homes randomized to intervention (receipt of the adapted model of care; n=11) or control (usual care continued; n=11). PARTICIPANTS: Residents aged 65 and older who provided informed consent (N=334; 173 intervention, 161 control). INTERVENTION: Specially trained pharmacists visited intervention homes monthly for 12 months and reviewed residents' clinical and prescribing information, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to improve the prescribing of these drugs. The control homes received usual care. MEASUREMENTS: The primary end point was the proportion of residents prescribed one or more inappropriate psychoactive medicine according to standardized protocols; falls were evaluated using routinely collected falls data mandated by the regulatory body for nursing homes in NI. RESULTS: The proportion of residents taking inappropriate psychoactive medications at 12 months in the intervention homes (25/128, 19.5%) was much lower than in the control homes (62/124, 50.0%) (odds ratio=0.26, 95% confidence interval=0.14-0.49) after adjustment for clustering within homes. No differences were observed at 12 months in the falls rate between the intervention and control groups. CONCLUSION: Marked reductions in inappropriate psychoactive medication prescribing in residents resulted from pharmacist review of targeted medications, but there was no effect on falls. [ABSTRACT FROM AUTHOR]

There are few studies on acupuncture or reflexology for insomnia. We conducted a pilot study with music as a control. Recruitment, retention and outcome measures were satisfactory, indicating that a definitive trial is feasible. [ABSTRACT FROM AUTHOR]

Adherence to medication is generally considered to be poor in many patient groups, but little is known about adherence to medication in the nursing home setting. It is also unclear if residents in nursing homes are involved in decision making about medication. This study sought to explore adherence to medication and resident involvement in prescribing and decision making in regard to medicines in the nursing home setting. This was a qualitative study. Participants took part in either semi-structured interviews (general practitioners [GPs] and residents) or focus groups (nurses) to discuss issues around prescribing and adherence to medication in nursing homes for older people in Northern Ireland. All interviews and focus groups were digitally recorded, fully transcribed and analysed using the principles of constant comparison. Eight GPs and 17 residents participated in semi-structured interviews and nine nurses participated in two focus groups (n = 4; n = 5). The main theme that emerged was control, which was manifested in many ways. Both groups of healthcare professionals needed to maintain control of prescribing or administration of medication in order to ensure safety, quality and continuity of care. All residents accepted control without question, reported that they were adherent to medication and had little involvement in prescribing decisions or administration of their own medicines. Although the healthcare professionals thought that more involvement in decisions around medication would contribute to resident autonomy and empowerment, it was also recognized that this could adversely affect control within the nursing home. Although adherence with medication was generally perceived not to be a problem in the nursing homes setting in this study, other findings raise major challenges for resident involvement in an important aspect of their own care. Although there may be some residents, because of cognitive decline, who are unable to become involved in aspects of decisions about prescribing and self-administration, healthcare professionals providing care to these patients should strive to involve them as far as possible in their own care. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to assess the levels of adherence in a sample of hypertensive patients being cared for in primary care in Northern Ireland and to explore the impact of depressive symptoms and medication beliefs on medication adherence.Methods: The study was conducted in 97 community pharmacies across Northern Ireland. A questionnaire containing measures of medication adherence, depressive symptoms and beliefs about medicines was completed by 327 patients receiving antihypertensive medications.Results: Analysis found that 9.3% of participants were non-adherent with their antihypertensive medication (self-report adherence scale) and 37.9% had scores indicative of depressive symptoms as determined by the Center for Epidemiological Studies Depression Scale (CES-D). In the univariate analysis, concerns about medications had negative effects on both adherence and depressive symptomatology. However, logistic regression analysis revealed that patients over the age of 50 were more likely to be adherent with their medication than those younger than 50. Depressive symptomatology and medication beliefs (concerns) were not significantly related to adherence in the regression analysis.Conclusion: Depressive symptomatology was high in the sample as measured by the CES-D. Age was the only significant predictor of medication adherence in this population.Practice implications: Health care professionals should consider the beliefs of the patient about their hypertensive medications and counsel younger patients on adherence. [ABSTRACT FROM AUTHOR]

The human papillomavirus immunisation programme for girls aged 12 to 13 years gets under way this September. As nurses prepare to deliver it, Cathryn Hughes gives an overview of cervical cancer diagnosis and treatment and shows why cervical screening will still be essential. [ABSTRACT FROM AUTHOR]

Compliance with medication has been frequently cited as a problem for patients living in community settings. However, there has been little commentary on compliance issues for residents in nursing homes. This is probably due to the assumption that residents will receive their medication on a regular basis and administration will be supervised and, therefore, compliance is not perceived to be a problem. However, regular compliance may not always be appropriate if the medication has not been reviewed for appropriateness and this 'enforced' compliance may give rise to side effects or adverse effects. Residents may also be exposed to 'erratic' compliance because of inconvenient administration times for staff or difficult and time-consuming administration instructions. This may have clinical implications for residents who require medication at regular intervals, e.g. those who have Parkinson's disease. Enforced or erratic compliance is at odds with shared decision making, which is being promoted as a way of empowering patients. It could be argued that because of a high degree of cognitive impairment, it is not appropriate for nursing home residents to become involved in decision making about medications. However, the nursing home population is heterogeneous in nature and the assumption should not be made that all residents are incapable of becoming more involved in some aspects of their own care. A greater focus on resident-centred care may promote more empowerment and autonomy, both generally and with respect to compliance with medication in particular, in nursing home residents. [ABSTRACT FROM AUTHOR]

Prescribing in care homes for older people has been the focus of much research and debate because of inappropriate drug choice and poor monitoring practices. In the US, this has led to the implementation of punitive and adversarial regulation that has sought to improve the quality of prescribing in this healthcare setting. This approach is unique to the US and has not been replicated elsewhere. The literature has revealed that there are limitations as to how much can be achieved with regulation that is externally imposed (an 'external factor'). Other influences, which may be categorised as 'internal factors' operating within the care home (e.g. patient, physician and care-home characteristics), also affect prescribing. However, these internal and external factors do not appear to affect prescribing uniformly, and poor prescribing practices in care homes continue to be observed. One intangible factor that has received little attention in this area of healthcare is that of organisational culture. This factor has been linked to quality and performance within other health organisations. Consideration of organisational culture within care-home settings may help to understand what drives prescribing decisions in this particularly vulnerable patient group and thus provide new directions for future strategies to promote quality care. [ABSTRACT FROM AUTHOR]

The purpose of this project was to evaluate how nursing staff on the telemetry unit at Merle West Medical Center, a rural Pacific northwest community medical center in the USA, spend their time on selected nursing tasks, and how they believed staffing and patient acuity levels could best be determined. A self-report survey tool was developed, piloted and administered. Of the tasks that were listed in the survey, registered nurses (RNs) reported spending 39% of their time performing tasks that RNs only can perform. RNs reported spending 12% of their time performing activities that certified nursing assistants (CNAs) could perform alone and 49% of their time was spent on tasks that both RNs and CNAs must perform. Results from the quantitative portion of the survey indicated that RNs may not be used efficiently due to task overlap. Administering a modified survey which includes a balance of direct and indirect patient care tasks, as well as only those tasks that are truly performed frequently, will increase the relevance of the results. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: One major concern associated with misuse/abuse of over-the-counter (OTC) products is the potential for over-dosage. The aim of this research study was to evaluate, over a 3-month period, OTC medicine-related overdoses (those involving OTC drugs only and OTC drugs in combination with other drugs) that led to patients presenting at the Accident and Emergency (A & E) departments in four Belfast hospitals. METHODS: A data collection sheet was designed to capture the information required from the A & E records in each hospital. A retrospective week-by-week data collection, reviewing A & E records, took place over a 3-month period (starting on 1 December 2002). All data related to cases presenting at the A & E departments because of drug overdoses (either accidental or deliberate according to Read Clinical Classification) were included in the study. Data were coded and entered into a custom designed SPSS database for analysis, using Chi square and Fisher exact tests. RESULTS: OTC drug-related overdoses comprised 40.1% of all overdoses, of which 24.0% were OTC-only overdoses. Those who overdosed on OTC drugs (solely or combined with other drugs) were mainly female (62.3%) and in the age category 31-50 years (44.9%; P <0.05). The majority (n=215) of OTC-related overdoses were intentional, whereas only 28 were accidental. Of those who attended the A & E departments and had an overdose history, one-third overdosed on OTC-related products and two-thirds overdosed on OTC drugs only. CONCLUSIONS: OTC drugs accounted for a significant proportion of overdose presentations at the A & E departments in Northern Ireland. Higher awareness of the potential of OTC product use in overdose cases (intentional or accidental) is recommended for both the public and health care professionals. [ABSTRACT FROM AUTHOR]

Adherence to medication is one of the most intriguing and complex behaviours demonstrated by patients. Non-adherence to a therapeutic regimen may result in negative outcomes for patients and may be compounded in populations with multiple morbidities which require multiple drug therapy. Such a population is exemplified by the elderly. However, non-adherence may not be more prevalent in older patients and there is no consensus in the literature that age is a predictor of poor adherence. Indeed, older patients may deliberately choose not to adhere to medication (intentional non-adherence) to avoid adverse effects. Furthermore, many of the studies on adherence lack commonality in terms of how adherence is measured, the definition of an 'older' patient and the range of disease states which have been examined. Adherence may also be affected by access to medications which may be restricted by the use of formularies or insurance programmes. However, non-adherence may represent a greater risk in older people resulting in poor disease control which may be compounded with multiple morbidity and polypharmacy. A range of strategies have been implemented to try and improve adherence in this patient population. The use of forgiving drugs (those which have a prescribed dosage interval that is 50% or less the duration of drug action) may facilitate occasional lapses in drug-taking. Drug holidays (deliberate, supervised non-adherence for a fixed period of time) have been used in Parkinson's disease to reduce adverse effects. Once-daily scheduling of drug administration may offer a pragmatic approach to optimising drug therapy in some patients; this may be supplemented through the use of compliance aids. What is increasingly apparent, however, is that the role of the patient (irrespective of age) is critical in decision-making about medication, together with communication between patients and healthcare professionals. This has been articulated through the concept of concordance which has been described as a therapeutic alliance between the patient and healthcare professional. In addition, interventions employed to improve adherence must be multifaceted, and together with practical approaches (reducing unnecessary drugs and simplifying dosage regimens), the patient perspective must be considered. Good adherence should be seen as a means of achieving a satisfactory therapeutic result and not as an end in itself. [ABSTRACT FROM AUTHOR]

Background: There is universal agreement that organizational characteristics of nursing facilities can and do influence the quality of care and resident outcomes.Objective: This study evaluated the relation between organizational characteristics and management of depression using antidepressants.Research Design: This was a cross-sectional study of Medicare/Medicaid certified nursing homes in 6 states in 2000.Subjects: We studied 87,907 residents with depression in 2,128 facilities.Measures: Minimum Data Set (MDS) provided information regarding use of antidepressants and resident factors. On-line Survey and Certification of Automated Records (OSCAR) provided facility characteristics information including structural, resource, and staffing levels. Adjusted estimates of organizational effects on antidepressant drug use were derived from generalized estimating equations.Results: Increased treatment of depression with antidepressants was associated with facilities with a higher percentage of residents from payer sources other than Medicare/Medicaid (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.02-1.06) and more professional nursing staff (OR, 1.15; 95% CI, 1.05-1.26). Decreased treatment tended to be related to larger homes (OR, 0.76; 95% CI, 0.68-0.84) or if the home employed full-time physicians (OR, 0.87; 95% CI, 0.78-0.96). Once the decision to treat was made, treatment with tricyclics tended to be inversely related to larger homes, for-profit facilities, and homes with more Medicare residents.Conclusions: Facilities that are required to be more fiscally conservative, be it larger facilities with fewer private pay patients or for profit facilities, have lower rates of pharmacologic treatment. Resource and structural characteristics influence the type of antidepressant being prescribed; resident characteristics may not be the over-riding factor in prescribing. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the impact of the prospective payment system (PPS) for skilled nursing facilities on the pharmacologic treatment of depression. METHODS: We used a quasi-experimental study comparing the pharmacological treatment rates for depression in the pre-PPS period (1997) to the post-PPS period (2000) in 8149 residents with documented depression living in over 500 nursing facilities in Ohio. Logistic regression models adjusting for clustering effects of residents residing in homes using generalized estimating equations provided estimates of the PPS effect on use of any antidepressant and the use of selective serotonin reuptake inhibitors (SSRIs). We evaluated the extent to which the PPS effect was modified by organizational characteristics, including structural characteristics, resource characteristics, and staff resources available in the homes. RESULTS: Overall, there was no difference in the likelihood of any antidepressant [odds ratio (OR), 1.05; 95% confidence interval (CI), 0.93 to 1.18, resident-adjusted model] or an SSRI being used (OR, 0.98; 95% CI, 0.86 to 1.12, resident-adjusted model) after the introduction of PPS compared with 1997 when this reimbursement system was not in place (referent group). These trends did not appear to be modified substantially by organizational characteristics. CONCLUSION: Although PPS did not appear to have influenced the treatment of depression in nursing homes, systems that provide checks and balances in relation to PPS are warranted. [ABSTRACT FROM AUTHOR]