Effectiveness and cost effectiveness of pharmacist input at the ward level: a systematic review and meta-analysis

Background Pharmacists play important role in ensuring timely care delivery at the ward level. The optimal level of pharmacist input, however, is not clearly defined. Objective To systematically review the evidence that assessed the outcomes of ward pharmacist input for people admitted with acute or emergent illness. Methods The protocol and search strategies were developed with input from clinicians. Medline, EMBASE, Centre for Reviews and Dissemination, The Cochrane Library, NHS Economic Evaluations, Health Technology Assessment and Health Economic Evaluations databases were searched. Inclusion criteria specified the population as adults and young people (age >16 years) who are admitted to hospital with suspected or confirmed acute or emergent illness. Only randomised controlled trials (RCTs) published in English were eligible for inclusion in the effectiveness review. Economic studies were limited to full economic evaluations and comparative cost analysis. Included studies were quality-assessed. Data were extracted, summarised. and meta-analysed, where appropriate. Results Eighteen RCTs and 7 economic studies were included. The RCTs were from USA (n=3), Sweden (n=2), Belgium (n=2), China (n=2), Australia (n=2), Denmark (n=2), Northern Ireland, Norway, Canada, UK and Netherlands. The economic studies were from UK (n=2), Sweden (n=2), Belgium and Netherlands. The results showed that regular pharmacist input was most cost effective. It reduced length-of-stay (mean= -1.74 days [95% CI: -2.76, -0.72], and increased patient and/or carer satisfaction (Relative Risk (RR) =1.49 [1.09, 2.03] at discharge). At £20,000 per quality-adjusted life-year (QALY)-gained cost-effectiveness threshold, it was either cost-saving or cost-effective (Incremental Cost Effectiveness Ratio (ICER) =£632/ QALY-gained). No evidence was found for 7-day pharmacist presence. Conclusions Pharmacist inclusion in the ward multidisciplinary team improves patient safety and satisfaction and is cost-effective when regularly provided throughout the ward stay. Research is needed to determine whether the provision of 7-day service is cost-effective.Peer reviewe

An Experimental Comparison of Anomaly Detection Methods for Collaborative Robot Manipulators

A large number of methods for anomaly detection in robotic manipulation have been proposed, but their applicability and performance in real-world scenarios are often not established. In this paper, we therefore perform an experimental comparison of a broad range of practically applicable methods to detect exogenous anomalies in pick-and-place tasks. We first collect a dataset, which has been made freely available, on a state-of-the-art collaborative robot. The extensive experimental campaign comprises 600 runs under normal operation, and 80 runs where exogenous perturbations are present, and data is collected on the robot's joints, force-torque readings, and the time spent in each program node. Using the data collected during normal operation, we train a set of anomaly detection methods whose computational complexity is low enough to run on resource-constrained robot hardware. We then evaluate the trained methods on the data collected in the perturbed runs and find that several methods can achieve a high anomaly detection performance. We show that exploiting knowledge of the robot's program tree can increase the performance for some types of anomalies. We also observe that performance, in general, deteriorates when the application includes: (i) rarely-visited program branches, (ii) physical contact with the environment, and (iii) stochastic trajectories.</p

Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy:A Systematic Review

OBJECTIVES: To summarize available tools that can assist clinicians in identifying and reducing or stopping (deprescribing) potentially inappropriate medications and that specifically consider frailty or limited life expectancy. DESIGN: Systematic review and narrative synthesis. SETTING: We searched MEDLINE (via Ovid SP), EMBASE (via Ovid SP), and CINAHL from inception to December 2017, along with grey literature. We included articles that described a tool to guide deprescribing of medications. PARTICIPANTS: Frail older persons and older persons with limited life expectancy. MEASUREMENTS: Narrative description of tools. RESULTS: We identified 15 tools and organized them into three main categories: tools (n = 2) that described a model or framework for approaching deprescribing, tools (n = 9) that outlined a deprescribing approach for the entire medication list, and tools (n = 4) that provided medication-specific advice. The complexity of the tools ranged from simple lists to detailed, step-wise protocols. The development methodology varied widely, and the methods used to synthesize the tools were generally not well described. Most tools were based on expert opinion. Only four of the 15 tools have been tested in clinical practice (in very low-quality studies). CONCLUSION: Tools exist to help clinicians deprescribe in frail older persons and those with limited life expectancy. These tools may assist clinicians at various stages in the deprescribing process. However, it remains to be investigated whether use of such tools in practice is likely to improve clinical outcomes or reduce inappropriate medication use. J Am Geriatr Soc 67:172–180, 2019.</p

FOXO1, PXK, PYCARD and SAMD9L are differentially expressed by fibroblast-like cells in equine synovial membrane compared to joint capsule

Abstract Background The synovial membrane lines the luminal side of the joint capsule in synovial joints. It maintains joint homeostasis and plays a crucial role in equine joint pathology. When trauma or inflammation is induced in a joint, the synovial membrane influences progression of joint damage. Equine synovial membrane research is hampered by a lack of markers of fibroblast-like synoviocytes (FLS) to distinguish FLS from other fibroblast-like cells in musculoskeletal connective tissues. The aim of this study is to identify potential FLS markers of the equine synovial membrane using microarray to compare between gene expression in equine synovial membrane and the joint capsule in metacarpophalangeal joints. Results Microarray analysis of tissues from 6 horses resulted in 1167 up-regulated genes in synovial membrane compared with joint capsule. Pathway analysis resulted in 241 candidate genes. Of these, 15 genes were selected for further confirmation as genes potentially expressed by fibroblast-like synoviocytes. Four genes: FOXO1, PXK, PYCARD and SAMD9L were confirmed in 9 horses by qPCR as differentially expressed in synovial membrane compared to joint capsule. Conclusions In conclusion, FOXO1, PXK, PYCARD and SAMD9L were confirmed as differentially expressed in synovial membrane compared to joint capsule. These four genes are potential markers of fibroblast-like synoviocytes of the synovial membrane. As these genes are overexpressed in synovial membrane compared to joint capsule, these genes could shed light on synovial membrane physiology and its role in joint disease

A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why?

Background: Medication reviews for people transitioning from one healthcare setting to another potentially improve health outcomes, although evidence for outcome benefits varies. It is unclear when and why medication reviews performed by pharmacists in primary care for people who return from hospital to the community lead to beneficial outcomes. Objective: A realist synthesis was undertaken to develop a theory of what works, for whom, why and under which circumstances when pharmacists conduct medication reviews in primary care for people leaving hospital. Methods: The realist synthesis was performed in accordance with Realist And MEta-narrative Evidence Syntheses: Evolving Standards reporting standards. An initial programme theory informed a systematic literature search of databases (PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, International Pharmaceutical Abstracts, OpenGrey, Trove), augmented by agency and government sources of information. Documents were synthesised by exploring interactions between contexts, intervention, outcomes and causal mechanisms. Results: The synthesis identified 9 contexts in which 10 mechanisms can be activated to influence outcomes of pharmacist medication reviews conducted in primary care postdischarge. For a medication review to take place these include trust patients have in healthcare professionals, their healthcare priorities postdischarge, capacity to participate, perceptions of benefit and effort, and awareness required by all involved. For the medication review process, mechanisms which issue an invitation to collaborate between healthcare professionals, enable pharmacists employing clinical skills and taking responsibility for medication review outcomes were linked to more positive outcomes for patients. Conclusions: Medication reviews after hospital discharge seem to work successfully when conducted according to patient preferences, programmes promote coordination and collaboration between healthcare professionals and establish trust, and pharmacists take responsibility for outcomes. Findings of this realist synthesis can inform postdischarge medication review service models