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Healthcare values are fairly ubiquitous across the globe, focusing on caring and respect, patient health, excellence in care delivery, and multi-stakeholder collaboration. Many individual pharmacists embrace these core values. However, their ability to honor these values is significantly determined by the nature of the system in which they work. The paper starts by presenting the prevailing pharmacist workforce model, the 'Atomistic' Model, in Scotland, in which core roles are typically separated into hierarchically disaggregated jobs focused on one professional 'pillar': Clinician/Practice Provider; Educator; Leader/Manager; and Researcher. This skills-segregation yields a workforce of individuals working in isolation rather than collaborating, lacking a shared purpose. Key strategic flaws include suboptimal responsiveness to population needs, inconsistency/inequity of care, erosion of professional agency, and lower job satisfaction. It is conjectured that this results from a lack of congruence between values, professional ethos, and organizational structure. 'Atomism' culminates in a syndrome of widespread professional-level cognitive dissonance. The paper contrasts this with an emerging workforce vision, the Collaborative Care Model. This new model defines a systems-first-approach, built on the principle that all jobs must include all four professional 'pillars'. Vertical skills integration, involving education and task sharing, supports sustainability and succession planning. Horizontal skills integration (across practice, leadership/management, education, and research) is included to improve responsiveness to population need and individual professional agency. The working conditions, supportive ethos, and career structure needed to make the model work are described. Moral and workforce theory are used to justify why the model may be more effective for population health, delivering greater job satisfaction for individuals and ultimately helping systematically realize healthcare values. Finally, the paper sketches the first steps needed to implement the model at the national level, starting with the operationalization of new multi-'pillar' professional curricula across the career spectrum. Potential challenges also are discussed.

BACKGROUND Longitudinal Integrated Clerkships exist in undergraduate medicine courses. A pilot Pharmacy Longitudinal Clerkship (pPLC) was funded to investigate delivery of this model of clinical education for student pharmacists. OBJECTIVE(S) To investigate the development, implementation and initial evaluation of a pPLC. METHODS The 11-week pPLC was delivered to two students in two GP practices in Scotland. Mixed theory-based methods were used to gather information on the pPLC structures and processes required and qualitative semi-structured Theoretical Domains Framework (TDF) based interviews explored outcomes with key stakeholders. Informed written consent was obtained. Interviews were audio-recorded, transcribed verbatim and analysed thematically. University Ethics approval was granted. RESULTS Data were generated on resources and processes required for a pPLC including funds budgeted for and actually spent on staffing, student travel/subsistence and student clinical 'Kit Bags', learning outcomes, curriculum and training timetable, GP Practice/University contracts. Interviews were completed with the two students, three linked GP clinical supervisors and two Regional Tutors involved. The seven themes were identified and mapped to seven TDF domains including: increased levels of student confidence, and increased student enthusiasm for a career in pharmacy, need for definition of the role of the Regional Tutor for the PLC and GP positivity towards the expected outcomes of clerkship model versus traditional placements. CONCLUSION Findings are limited by the small number of participants and settings, but evaluation was positive and the work garnered information on requirements for resources and processes. This will inform 'roll out' of the PLC.

Pharmacy has developed many novel patient-facing roles across the globe, typically delivered through the lens of pharmaceutical care. The macro-level implementation of such interventions is, however, fraught with difficulty. At an individual-level, psychological barriers of pharmacists and their ability to deliver autonomous complex clinical care are key considerations. As the United Kingdom imminently plans to launch a new advanced pharmacist practice curriculum and credentialing process to support advanced skills development, this commentary discusses where progress to date has taken us and what other developmental, environmental and cultural changes are needed to support this. The commentary also challenges some of pharmacy's historic dogma, discusses a requirement for teaching to transcend simplistic concepts of medicines-harm, considers the need for the standardisation of clinical skills and discusses the necessity of formal advanced practice programmes and preceptorship models. It finally proposes the concept of Advanced Pharmacist Practitioners as the ultimate future vision of autonomous practice and the need for Government Policy to support their creation.

BACKGROUND: The role of General Practice Clinical Pharmacists is becoming more clinically complex. Some are undertaking Advanced Clinical Examination & Assessment courses to further develop their skillsets.AIM To explore General Practice Clinical Pharmacists’ experience of Advanced Clinical Examination and Assessment courses, skills development and implementation. METHOD: This research used qualitative methods with theoretical underpinning at each stage. General Practice Clinical Pharmacists working in the Scottish National Health Service who had completed the relevant course were invited for qualitative online mini-focus groups. Informed written consent was obtained. A topic guide was developed using the Theoretical Domains Framework and piloted. Mini-focus groups were recorded, transcribed verbatim and analysed using a framework analysis informed by Theoretical Domains Framework and the “Capability, Opportunity, Motivation Behaviour System”. Ethics approval was granted. RESULTS: Fourteen pharmacists participated from eight Health Boards across Scotland. Themes were identified and mapped to frameworks underpinning this research. Participants reported that the course allowed them to gain skills needed to become clinically autonomous and supported them in taking a more holistic approach when reviewing patients. However, the pharmacist-product from the course in terms of skillset acquisition, and its potential application in general practice, was perceived by participants as poorly understood at the micro, meso and macro level. There was frustration among participants at the perceived lack of advanced practice opportunities within the current contractual healthcare system in general practice. CONCLUSION: Policy drivers should be urgently devised to reform general practice pharmacy services to best utilise pharmacists with these skills.

Background Patients’ negative illness perceptions and beliefs about cardiac rehabilitation (CR) can influence uptake and adherence to CR. Little is known about the interpartner influence of these antecedent variables on quality of life of patients with coronary artery disease (CAD) and their family caregivers. The aims of the study were: 1) to assess differences in illness perceptions, beliefs about CR and quality of life between patients with CAD and their family caregivers upon entry to a CR programme and at 6 months follow-up; and 2) to examine whether patients’ and caregivers’ perceptions of the patient’s illness and beliefs about CR at baseline predict their own and their partner’s quality of life at 6 months. Methods In this longitudinal study of 40 patient-caregiver dyads from one CR service, patients completed the Brief Illness Perception Questionnaire and Beliefs about Cardiac Rehabilitation Questionnaire at baseline and 6 months; and caregivers completed these questionnaires based on their views about the patient’s illness and CR. The Short-Form 12 Health Survey was used to assess patients’ and caregivers’ perceived health status. Dyadic data were analysed using the Actor–Partner Interdependence Model. Results Most patients (70%) were men, mean age 62.45 years; and most caregivers (70%) were women, mean age 59.55 years. Caregivers were more concerned about the patient’s illness than the patients themselves; although they had similar scores for beliefs about CR. Patients had poorer physical health than caregivers, but their level of mental health was similar. Caregivers’ poorer mental health at 6 months was predicted by the patient’s perceptions of timeline and illness concern (i.e. partner effects). Patient’s and caregiver’s illness perceptions and beliefs about CR were associated with their own physical and mental health at 6 months (i.e. actor effects). Conclusions Overall, the patients and caregivers had similar scores for illness perceptions and beliefs about CR. The actor and partner effect results indicate a need to focus on specific illness perceptions and beliefs about CR, targeting both the individual and the dyad, early in the rehabilitation process to help improve patients and caregivers physical and mental health (outcomes).

Background Adherence to medication regimens is essential for preventing and reducing adverse outcomes among patients with coronary artery disease (CAD). Greater understanding of the relation between negative illness perceptions, beliefs about cardiac rehabilitation (CR) and medication adherence may help inform future approaches to improving medication adherence and quality of life (QoL) outcomes. The aims of the study are: 1) to compare changes in illness perceptions, beliefs about CR, medication adherence and QoL on entry to a CR programme and 6 months later; 2) to examine associations between patients’ illness perceptions and beliefs about CR at baseline and medication adherence and QoL at 6 months. Methods A longitudinal study of 40 patients with CAD recruited from one CR service in Scotland. Patients completed the Medication Adherence Report Scale, Brief Illness Perception Questionnaire, Beliefs about CR questionnaire and the Short-Form 12 Health Survey. Data were analysed using the Wilcoxon Signed Ranks test, Pearson Product Moment correlation and Bayesian multiple logistic regression. Results Most patients were men (70%), aged 62.3 mean (SD 7.84) years. Small improvements in ‘perceived suitability’ of CR at baseline increased the odds of being fully adherent to medication by approximately 60% at 6 months. Being fully adherent at baseline increased the odds of staying so at 6 months by 13.5 times. ‘Perceived necessity, concerns for exercise and practical barriers’ were negatively associated with reductions in the probability of full medication adherence of 50, 10, and 50%. Small increases in concerns about exercise decreased the odds of better physical health at 6 months by about 50%; and increases in practical barriers decreased the odds of better physical health by about 60%. Patients perceived fewer consequences of their cardiac disease at 6 months. Conclusions Patients’ beliefs on entry to a CR programme are especially important to medication adherence at 6 months. Negative beliefs about CR should be identified early in CR to counteract any negative effects on QoL. Interventions to improve medication adherence and QoL outcomes should focus on improving patients’ negative beliefs about CR and increasing understanding of the role of medication adherence in preventing a future cardiac event.

Developing collaborative practice through interprofessional education (IPE) activities in undergraduate healthcare curricula is advocated by the World Health Organisation and the regulatory bodies for Medicine and Pharmacy within the UK.Our local faculty, comprising educators from within the Highland Pharmacy Education and Research Centre (HPERC) and Highland Medical Education Centre (HMEC), developed a 5-day IPE placement for pharmacy and medical students on clinical placement within NHS Highland.We collected qualitative evaluation data using face-to-face focus group discussions with five pharmacy and four medical students (January 2020 cohort). Three key categories and multiple themes within each category were identified from participant narratives: Category 1, overall perception of experience-(themes: better than previous IPE experience; greater exposure to clinical pharmacy); Category 2, student interactions-(themes: learning with a buddy; understanding of interprofessional roles); Category 3, suggestions for improvement-(themes: choice of relevant clinical rotation and content; increase learning from clinical pharmacists; better orientation to placement). Overall, students valued their participation during this week and reported many benefits of learning with students from another profession. Students also highlighted suggestions to improve their learning experience.This evaluation has indicated students' support for embedding interprofessional placements into their curricula. Clinical educators should consider designing similar placements, while further work should focus on inclusion of higher student numbers and look to include a range of professions and practice settings.

Objectives To investigate relationships between factors influencing medication taking and behavioural determinants in patients who have undergone percutaneous coronary intervention (PCI). Methods A cross-sectional survey using a postal questionnaire distributed to PCI patients. The questionnaire was iteratively developed by the research team with reference to the theoretical domains framework (TDF) of behavioural determinants, reviewed for face and content validity and piloted. Data were analysed using descriptive and principal component analysis (PCA). Inferential analysis explored relationships between PCA component scores and factors influencing medicating taking behaviour. Key findings Adjusted response rate was 62.4% (325/521). PCA gave three components: (C1) Self-perceptions of knowledge and abilities in relation to medication taking; (C2) Aspects relating to activities and support in medication taking; (C3) Emotional aspects in taking medication. Generally, respondents held very positive views. Statistically significant relationships between all three components and self-reported chest pain/discomfort indicated patients with ongoing chest pain/discomfort post-PCI are more likely to have behavioural determinants and beliefs which make medication taking challenging. Respondents who were on 10 or more medications had lower levels of agreement with the C2 and C3 statements indicating challenges associated with their activities/support and anxieties in medication taking. Conclusions PCI patients show links between TDF behavioural determinants and factors influencing medication taking for those reporting chest pain or polypharmacy. Further research needs to explore the effective design and implementation of behavioural change interventions to reduce the challenge of medication taking.

While studies have reported pharmacists' perspectives of research involvement, almost all are limited by sector, have little focus on research translation and have not incorporated behavior change theory. The objective of this research was to determine pharmacists' views and experiences of research conduct, dissemination and translation. This was an electronic cross-sectional survey of pharmacists across six Scottish health board areas. Survey items were: demographics; research activities (e.g. conduct, dissemination) in the last two years; research interests, experience and confidence in research tasks (e.g. proposal writing, data collection); and Likert statements on research conduct, dissemination and the translation of research findings into practice. Conduct/dissemination and translation items were based on the Theoretical Domains Framework (TDF). Data were analysed using descriptive and inferential statistics, and principal component analysis (PCA) of TDF items. Following determination of internal consistency, scores for each component were calculated. The response rate was 19.4% (136/701), with 17 (12.5%) currently involved in research. Responses were more positive for interest in research than experience or confidence. PCA of research conduct/dissemination items identified three internally-reliable components of support/opportunities, motivation/outcomes, and roles/characteristics. Component scores for support/opportunities to participate in research were most negative. PCA of translation items identified three internally-reliable components of current practices/abilities, consequences and support. Scores for all three components were positive, being most positive for consequences of research translation. Those in secondary care, with a postgraduate qualification and prescription responsibilities scored higher for interest, experience, confidence and for most components (p < 0.05). In conclusion, a minority of pharmacists are involved in research conduct/dissemination and these are more likely to be highly-qualified individuals, based in secondary care. Given the need to develop and evaluate new models of pharmaceutical care, involvement should be extended to all practice settings. Study findings could be used to develop behavior change interventions targeting individuals and organizations.

Introduction: External loop recorders (ELRs) are recommended for the investigation of syncope and palpitations. This study aimed to compare rates of arrhythmia detection between primary care (PC) and hospital-based cardiac unit (HBCU) fitted ELRs. Methods: Data were captured from January to December 2015. Twenty-eight general practitioner practices and 1 hospital took part. Patients were divided into those with ELR fitted in PC or HBCU. All ELR data were analyzed by a cardiac physiologist. Results: A total of 560 ELR recordings were analyzed; 219 (PC) versus 341 (HBCU). There was no difference between the baseline characteristics (all Ps > .05). The predominant indication for ELR in each group were palpitations; between-group variation was observed for syncope ( P = .0004). There were no significant between-group differences in the number of recordings per patient; however, PC group wore the ELR for less time (median 7 days vs median 14 days; P < .0001). There were no differences in arrhythmia detection between PC- and HBCU-fitted ELRs (16.2% [n = 39] vs 21.7% [n = 74], respectively; P = .28). PC placement of ELRs was highest in very remote rural communities ( P = .005) and correlated with distance from HBCU ( r = 0.39; P = .04). Conclusions: This study showed no difference in detection of arrhythmias between PC and HBCU fitted ELRs. This suggests adequate ELR recording can be completed by suitably trained staff in PC. Furthermore, ELRs were fitted for less time in PC without an adverse effect on diagnostic yield. ELR usage increased with increasing distance from the specialist center and rurality suggesting improved local access to arrhythmia detection services.

This project has been funded by the EU’s INTERREG VA programme, managed by the special EU Programmes Body (SEUPB) Background and Aims N-acetyl-L-cysteine (NAC) has been proposed as a prophylactic for the prevention of contrast induced nephropathy (CIN), a serious, adverse complication following administration of contrast media in patients with diabetes and chronic kidney disease (CKD). However, clinical trial results have failed to demonstrate consistently the beneficial qualities of NAC in this setting. The suggested mechanism by which NAC has been proposed to be effective is via antioxidant activity, but NAC itself appears not to be a powerful antioxidant; intracellular conversion of NAC to glutathione (GSH) is essential for antioxidant effects. We tested the hypothesis that oral or intravenous NAC fails to increase antioxidant activity in the plasma of healthy volunteers or CKD stage III patients undergoing elective coronary angiography. Method 16 healthy volunteers (8 receiving contrast media) and 8 patients with chronic renal failure were recruited to 3 separate groups as a part of a crossover design study. 66 patients with CKD stage III undergoing elective coronary angiography were recruited to a parallel group randomized controlled trial. Each volunteer or patient was randomised to receive NAC (i.v.; 50 mg/kg/hr infusion for 2 h, followed by 20 mg/kg/hr infusion for a further 5 h), or NAC (oral; 1200 mg twice daily, commencing the day before the study visit) or placebo. Participants attended the Clinical Research Facility on three occasions for the crossover groups, but only once in the parallel group trial. Patients were infused with para-aminohippurate (PAH) and inulin to enable measurement of renal function parameters. Plasma and paired buffy coat samples were collected at several time points for 2 hours before contrast infusion and for 6 hours after. Samples were used to measure various clinical parameters, along with intracellular and plasma thiol concentrations and the plasma antioxidant capacity (oxygen radical antioxidant capacity; ORAC). Results Plasma NAC concentrations peaked at 222 µM (healthy volunteers), 354 µM (CKD patients), 271 µM (healthy volunteers receiving contrast) and 348 µM (CKD patients undergoing elective coronary angiography) following infusion of NAC. The corresponding peak concentrations were ∼2 µM following oral NAC across all groups. No comparable increase in the plasma compartment ORAC antioxidant capacity was measured in any of the treatment groups. Equally, contrast infusion itself did not significantly reduce antioxidant capacity in plasma, even in the placebo group. Buffy coat measures showed that there was a significant increase of intracellular GSH in some patients. Also, no clear additional benefit was witnessed by increasing plasma NAC ∼100-fold through infusion of NAC over oral administration. Conclusion NAC fails to influence ORAC antioxidant capacity in the plasma compartment of CKD stage III patients receiving contrast media. Our results question the importance of oxidative stress in contrast-induced nephropathy. Furthermore, the findings fail to demonstrate a direct antioxidant impact of NAC in the plasma compartment and question the antioxidant hypothesis related to contrast-induced nephropathy and NAC.

Introduction: While a plethora of systematic reviews have provided evidence of efficacy, effectiveness and safety of direct-acting oral anticoagulants (DOACs) in the management of non-valvular atrial fibrillation (AF), there has been little emphasis on clinicians' perspectives. This systematic review aimed to critically appraise, synthesise and present the available evidence of clinicians' views and experiences. Methods: Studies published in English from January 2006 to July 2017 reporting the views and/or experiences of doctors, nurses or pharmacists on any individual DOAC or as a pharmacological group were included. Studies were assessed for quality by two researchers, data extracted and findings synthesised using a narrative approach. Results: Following exclusion of duplicates, 777 titles, 394 abstracts and 196 studies were screened. Ten studies were included in the review, nine of which were quantitative (cross-sectional surveys) and one qualitative (semi-structured interviews), with marked heterogeneity in outcomes reported. Studies were conducted exclusively in Europe and the United States. In those studies reporting clinician preference, DOACs were first choice over warfarin in na{uml}ive patients, based on perceptions of evidence of effectiveness equivalent or superior to warfarin and superior safety. Other advantageous factors were in those with an unstable INR and likely to miss appointments. There were, however, concerns relating to management of over-anticoagulation and experiences of observed bleeding rates. Conclusion: There is a limited evidence base of clinicians' perspectives of DOACs, necessitating further research, particularly given the trajectory of increased use worldwide.

Access to medicines and healthcare is more problematic in remote and rural areas.To quantify issues of access to general practitioners (GPs), community pharmacies and prescribed medicines in older people resident in the Scottish Highlands.Anonymized questionnaires were mailed to a random sample of 2000 older people (≥60 years) resident in the Scottish Highlands. Questionnaire items were: access and convenience to GP and pharmacy services (10 items); prescribed medicines (13 items); attitudinal statements based on the Theoretical Domains Framework (12 items); quality of life (SF8, 8 items); and demographics (12 items). Results were analysed using descriptive, inferential and spatial statistics, and principal component analysis (PCA) of attitudinal items.With a response rate of 54.2%, the majority reported convenient access to GPs (89.1%) and community pharmacies (84.3%). Older age respondents (p 0.0001) were more likely to state that their access to GP services was not convenient and those in rural areas to community pharmacies (p 0.01). For access to prescribed medicines, those in poorer health (p 0.001) and taking five or more regular prescribed medicines (p = 0.002) were more likely to state access not convenient. PCA identified three components of beliefs of capabilities, emotions and memory. Those with poorer health had more negative scores for all (p 0.001). Those reporting issues of access to prescribed medicines had more negative scores for beliefs of capabilities (p 0.001) while those of older age, living alone, and taking five or more regular prescribed medicines (all p 0.001) had more negative scores for emotions.While the majority of respondents have convenient access to their GP practice, pharmacy and prescribed medicines, there is a need for further review of the pharmaceutical care of those of older age with poorer health, living alone in the more remote and rural areas and taking five or more prescribed medicines.

Background A 12-month pilot was implemented in two general practices in remote and rural Scotland, with patients referred by general practitioners to specialist mental health pharmacist independent prescribers. Objective The objective was to evaluate the pilot service from the perspectives of the patients and the care team. Methods The pharmacists routinely recorded patient-specific data of all clinical issues and their actions at the time of each consultation. Further datasets comprised baseline and follow-up Patient Health Questionnaire (PHQ-9) and/or Generalised Anxiety Disorder (GAD-7) rating scales, a patient survey and interviews with members of the care team. Results Of the 75 patients, two-thirds (n = 47, 62.7%) were referred with a diagnosis of mixed depression and anxiety. There were 324 consultations (median 3, IQR 2-5, range 1-14) and 181 prescribing actions. At pilot completion, 34 patients (45.3%) had PHQ-9 and/or GAD-7 scores reduced by 50%. Patient questionnaires and staff interviews generated positive responses. Conclusion This pilot has provided evidence that specialist mental health pharmacist independent prescribers delivered quality care to patients with diagnoses of moderate to severe depression and/or anxiety. Whilst accepting study limitations, there is potential to translate the pilot model of care to sustained services throughout general practice.

Background Although there is evidence of suboptimal outcomes in older people with chronic pain, little emphasis has been placed on those in remote and rural settings. Objective To describe the perspectives of older people in the Scottish Highlands on their chronic pain management. Design Cross-sectional survey. Setting NHS Highland, the most remote and rural geographical health board in Scotland. Subjects Home-dwelling members of the public aged ≥70 years. Methods Anonymised questionnaires were mailed to a random sample of 1800 older people. Questionnaire items were demographics, nature of any chronic pain, management regimens and perceived effectiveness. Validated scales were the Pain Disability Questionnaire and the Tampa Scale for Kinesiophobia. Results Adjusted response rate was 39.3% (709/1755). One-quarter (25.0%, n = 177) were experiencing chronic pain, being more likely to live in deprived areas (P Conclusions Evidence of provision of appropriate integrated and person-centred chronic pain care is lacking.

Aims A recent systematic review highlighted the lack of robust studies on prescribers' perspectives of direct-acting oral anticoagulants (DOACs) for nonvalvular atrial fibrillation. The aim was to determine prescribers' views and experiences of prescribing DOACs. Methods A cross-sectional survey of prescribers in a remote and rural area of Scotland. Survey items were: demographics; prescribing of DOACs; views of potential influences on DOAC prescribing; knowledge of prescribing guidelines; and experiences. Items on potential influences were based on the Theoretical Domains Framework. Data were analysed using descriptive and inferential statistics, and content analysis of responses to open questions. Principal component analysis was performed on the items of potential influences. Results In total, 154 responses were received, 120 (77.9%) from doctors, 18 (11.7%) from nurse prescribers and 10 (6.4%) from pharmacist prescribers (6 missing). Principal component analysis of the Theoretical Domains Framework items of potential influences gave 4 components. Component scores for (i) role of professionals, their knowledge and skills and (ii) influences on prescribing were positive. Those for (iii) consequences of prescribing and (iv) monitoring for safety and effectiveness were more neutral. There were low levels of agreement for statements relating to DOACs being more effective, safer and cost-effective than warfarin. There were similar responses around the complexity of bleeding management and detection of over and under-anticoagulation. Conclusion This study has identified several key issues of DOAC prescribing (e.g. bleeding management) hence further emphasis is required in continuing professional development and during guideline implementation and evaluation.

People who experience an ST-elevation myocardial infarction (STEMI) due to an occluded coronary artery require prompt treatment. Treatments to open a blocked artery are called reperfusion therapies (RTs), and can include intravenous pharmacological thrombolysis (TL) or primary percutaneous coronary intervention (pPCI) in a cardiac catheterisation laboratory (cath lab). Optimal RT (ORT) with pPCI or TL reduces morbidity and mortality. In remote areas, a number of geographical and organisational barriers may influence access to ORT. These are not well understood, and the exact proportion of patients who receive ORT - and the relationship to time of day and remoteness from the cardiac cath lab - is unknown. The aim of this retrospective study was to compare the characteristics of ORT delivery in central and remote locations in the north of Scotland, and to identify potential barriers to optimal care with a view to service redesign. The study was set in the north of Scotland. All patients who attended hospital with a STEMI between March 2014 and April 2015 were identified from national coding data. A data collection form was developed by the research team in several iterative stages. Clinical details were collected retrospectively from patients' discharge letters. Data included treatment location, date of admission, distance of patient from the cath lab, route of access to health care, left ventricular function and RT received. Distance of patients from the cath lab was described as remote if they were more than ninety minutes of driving time from the cardiac cath lab, and described as central if they were ninety minutes or less of driving time from the regional centre. For patients who made contact in a pre-hospital setting, ORT was defined as pre-hospital TL (PHT) or pPCI. For patients who self-presented to the hospital first, ORT was defined as in-hospital TL or pPCI. Data were described as mean (standard deviation) as appropriate. Chi-squared and student's t-test were used as appropriate. Each case was reviewed to determine if ORT was received; if ORT was not received, the reasons for this were recorded to identify potentially modifiable barriers. Of the 627 acute myocardial infarction patients initially identified, 131 had a STEMI, and the others were non-STEMI. From this STEMI cohort, 82 (62%) patients were classed as central and 49 (38%) were remote. In terms of initial therapy, 26 (20%) received pPCI, 19 (15%) received PHTs, 52 (40%) received in-hospital TL, while 33 (25%) received no initial RT. ORT was received by 53 (65%) central and 20 (41%) remote patients; chi-squared = 7.05, degrees of freedom = 130, p < 0.01).Several recurring barriers were identified. This study has therefore demonstrated a significant health inequality between the treatment of STEMI in remote locations compared to central locations. Potential barriers identified include staffing availability and training, public awareness and inter-hospital communication. This suggests that there remain significant opportunities to improve STEMI care for people living in the north of Scotland.

AIMS: While a plethora of systematic reviews have provided evidence of efficacy, effectiveness and safety of direct‐acting oral anticoagulants (DOACs) in the management of nonvalvular atrial fibrillation, there has been little emphasis on clinicians' perspectives. This systematic review aimed to critically appraise, synthesize and present the available evidence of clinicians' views and experiences. METHODS: Studies published in English from January 2006 to July 2017 reporting the views and/or experiences of doctors, nurses or pharmacists on any individual DOAC or as a pharmacological group were included. Studies were assessed for quality by two researchers, data extracted and findings synthesized using a narrative approach. RESULTS: Following exclusion of duplicates, 777 titles, 394 abstracts and 196 studies were screened. Ten studies were included in the review, nine of which were quantitative (cross‐sectional surveys) and one qualitative (semistructured interviews), with marked heterogeneity in outcomes reported. Studies were conducted exclusively in Europe and the USA. In those studies reporting clinician preference, DOACs were first choice over warfarin in naïve patients, based on perceptions of evidence of effectiveness equivalent or superior to warfarin and superior safety. Other advantageous factors were in those with an unstable International Normalized Ratio and likely to miss appointments. There were, however, concerns relating to management of over‐anticoagulation and experiences of observed bleeding rates. CONCLUSION: There is a limited evidence base of clinicians' perspectives of DOACs, necessitating further research, particularly given the trajectory of increased use worldwide.

Background Recent evidence highlights the disproportionate rates of health inequality often experienced within remote and rural communities. Access to medicines within remote and rural communities may also prove problematic. Objective The aim was to understand the perspectives of older people in the most remote areas of the Scottish Highlands on issues of accessibility to healthcare, medicines and medicines-taking. Method Qualitative, semi-structured one-to-one interviews with 13 residents aged 65 years and over in the most remote and rural areas of the Scottish Highlands. Interviews were audio-recorded, transcribed and analysed using a framework approach. Setting Remote and rural areas in the Scottish Highlands. Participants had previously completed a cross-sectional survey. Main outcome measure Themes surrounding the perspectives of older people in the most remote areas of the Scottish Highlands on issues of accessibility to healthcare, medicines and medicines-taking. Results Healthcare was considered convenient, and positive relationships with providers being important. Review of medicines was perceived to be the remit of the doctor, with pharmacists seen as valuable suppliers of medicines. Conclusion Based on this qualitative study, experiences of access to healthcare, including community pharmacy, medicines and medicines-taking within this sample of older adults resident in the most remote areas of the Scottish Highlands are widely variable. There may be an unmet educational need, amongst residents, with regard to awareness of the role of pharmacists, the services they can provide and the benefits which may be experienced as a consequence of engagement. Electronic supplementary material The online version of this article (10.1007/s11096-018-0684-y) contains supplementary material, which is available to authorized users.

Sparsely populated areas are potentially predisposed to health inequalities due to limited access to services. This study aimed to explore and describe issues of access to medicines and related advice experienced by residents of the Scottish Highlands and Western Isles.Cross-sectional cohort study.Anonymized questionnaires were mailed to a random sample of 6000 residents aged ≥18 years identified from the electoral register. The questionnaire contained items on: access to medicines; interactions with health care services; and perceptions of the services. Results were analysed using descriptive, inferential and spatial statistics.Adjusted response rate was 49.5% (2913/5889). Almost two thirds (63.4%, 1847) were prescribed medicines regularly, 88.5% (1634) of whom considered the source convenient. Pharmacy (73.8%, 1364) or dispensing GP (24.0%, 443) were the most accessed sources. Prescription medicine advice was mainly obtained from the GP (55.7%, 1029). Respondents ≥80 years old were significantly (P 0.0001) more likely to live alone (45.3%, 92) compared with those80 (15.8%, 424). Almost a fifth (16.5%, 31) of those80 years living alone disagreed that they obtained prescribed medicines from a convenient source. The majority of respondents who felt they did not have a convenient medicines source, regardless of urban/rural classification, lived within five miles of a pharmacy or GP practice.Respondents accessed medicines and advice from a variety of sources. While most considered their access to medicines convenient, there were issues for those over 80 years and living alone. Perceived convenience would not appear to be solely based on geographical proximity to supply source. This requires further exploration given that these individuals are likely to have long-term conditions and be prescribed medicines on a chronic basis.

Atrial fibrillation is the most common heart-rhythm disorder, affecting about 1.5% to 2% of the population with an increased risk of mortality and morbidity due to stroke, thromboembolism, and heart failure. If the conversion back to sinus rhythm does not happen spontaneously, pharmacological or electrical cardioversion (ECV) is the next available treatment options for some patients. However, the long-term success following ECV is variable. This review describes the factors that are associated with maintenance of sinus rhythm following ECV and proposes a clinical strategy based on the available evidence.

Within the last decade, multiple new medications have been licensed for treating type 2 diabetes. These agents are vastly more expensive than their predecessors and usage requires review in practice. This retrospective case series reviewed 55 patients to assess the effect of glucagon-like peptide-1 (GLP-1) mimetics as add-on to existing antidiabetic therapy, including insulin, in clinical practice. The primary outcome measures were change in HbA1c and weight. Analyses were also conducted to test the effect of: initial HbA1c; concomitant insulin use; GLP-1 prescribed; and duration of diabetes on the change in HbA1c and weight. Mean BMI at initiation was 39.7 kg/m2; duration of diabetes at initiation 8.2 years; duration of GLP-1 therapy at review 18.3 months. The mean changes in HbA1c (-15.9 mmol/mol) and weight (-5.5 kg) were both highly significant (p < 0.0001). NICE targets for HbA1c and weight reductions were met in 34.5%. Significant negative correlations were found between initial HbA1c and subsequent change in HbA1c (p = 0.0001) and between initial BMI and subsequent change in weight (p = 0.04), whereas a significant positive correlation was observed between initial HbA1c and subsequent change in weight (p = 0.01). No statistically significant changes in HbA1c or weight were observed in relation to: concomitant insulin use; GLP-1 prescribed; or duration of diabetes. This study confirms GLP-1 agents provide clinically useful reductions in HbA1c and weight. Further work is required to assess their effect if used earlier. A practical and pragmatic approach to assessment of the effectiveness of GLP-1 has been proposed. Copyright © 2014 John Wiley & Sons, Ltd.

Patients with ST elevation myocardial infarction (STEMI) require prompt treatment, best done by primary percutaneous coronary intervention (PPCI). However, for patients unable to receive PPCI, immediate pre-hospital thrombolysis (PHT) is the best alternative. Evidence indicates that diagnostic and management support for staff increases the use of PHT. This study aimed to describe the patient demographics and management of patients, to determine any potential inter-area differences in referral rates to the ECG e-transmission service and to explore the views and experiences of key staff involved in ECG e-transmission within NHS Highland. Data from 2,025 patient episodes of ECG e-transmission identified a statistically significant geographical variation in ECG e-transmission and PHT delivery. Scottish Ambulance Service (SAS) staff were more likely than GPs to deliver PHT overall, however, GPs were more likely to deliver in remote areas. Interviews with six Cardiac Care Unit (CCU) nurses and six SAS staff highlighted their positive views of ECG e-transmission, citing perceived benefits to patients and interprofessional relationships. Poor access to network signal was noted to be a barrier to engaging in the system. This study has demonstrated that a specialist triage service based on e-transmission of ECGs in patients with suspected STEMI can be implemented in a diverse geographical setting. Work is needed to ensure equity of the service for all patients.

N-acetyl-l-cysteine (NAC) has long been used therapeutically for the treatment of acetaminophen (paracetamol) overdose, acting as a precursor for the substrate (l-cysteine) in synthesis of hepatic glutathione (GSH) depleted through drug conjugation. Other therapeutic uses of NAC have also emerged, including the alleviation of clinical symptoms of cystic fibrosis through cysteine-mediated disruption of disulfide cross-bridges in the glycoprotein matrix in mucus. More recently, however, a wide range of clinical studies have reported on the use of NAC as an antioxidant, most notably in the protection against contrast-induced nephropathy and thrombosis. The results from these studies are conflicting and a consensus is yet to be reached regarding the merits or otherwise of NAC in the antioxidant setting. This review seeks to re-evaluate the mechanism of action of NAC as a precursor for GSH synthesis in the context of its activity as an "antioxidant". Results from recent studies are examined to establish whether the pre-requisites for effective NAC-induced antioxidant activity (i.e. GSH depletion and the presence of functional metabolic pathways for conversion of NAC to GSH) have received adequate consideration in the interpretation of the data. A key conclusion is a reinforcement of the concept that NAC should not be considered to be a powerful antioxidant in its own right: its strength is the targeted replenishment of GSH in deficient cells and it is likely to be ineffective in cells replete in GSH.

Objective To explore the association between medication adherence and qualitatively characterised patient-specific themes relating to medication adherence in patients following percutaneous coronary intervention (PCI). Methods Data-collection questionnaires and qualitative topic guides were piloted in two patients. A validated questionnaire generated an adherence score for a convenience sample of 20 patients within 7 days of PCI. Semi-structured qualitative interviews were subsequently carried out with all patients to explore patient-specific themes relating to measured medication adherence. Key findings Fourteen out of 20 patients (70%) had scores indicative of good adherence. Key factors associated with good adherence included having a good relationship with the doctor, having an understanding of the condition, knowledge of the indications and consequences of non-adherence, perceived health benefits and medications eliciting tangible symptom control. There were misconceptions of concern regarding adverse drug reactions and the importance of aspirin, both of which had a negative effect on adherence. The role of the community pharmacist was sometimes, although not always, misunderstood. Conclusion This study suggests there is an association between patients' beliefs, knowledge, understanding and misconceptions about medication and their adherence in a post-PCI cohort. To optimise medication adherence it is vital for prescribers to remain patient-focused and cognisant of patient-specific themes relating to medication adherence.

Aspirin or acetylsalicylic acid is an important therapy for many cardiology patients but hypersensitivity to this drug affects around 1% of the population and intolerance may affect up to 20%. While alternative medications to aspirin are available, in many cases there is a compelling need for aspirin therapy. In these patients, aspirin desensitization may be considered. However, this is a complex issue with a lack of international standardization. This article reviews the available evidence for aspirin desensitization and provides practical advice for the management of these patients.

Direct Renin Inhibitors (DRIs) are a new class of medication, and are the first which block the rate-limiting step of the renin-angiotensin-aldosterone-system (RAAS). Aliskiren, the first licensed orally active DRI, has been shown to be an effective antihypertensive agent. This review article outlines the pharmacological basis for DRI therapy, from discovery of the class to ongoing clinical trials and novel therapeutic applications of aliskiren.

Nicorandil is a popular anti-anginal drug in Europe and Japan. Apart from some common adverse drug reactions (ADR), its safety is satisfactory. Several reports have suggested a link between nicorandil, gastrointestinal (GI) ulceration and fistulas. The review aims to critically appraise, synthesize and present the available evidence of all known GI ADR per anatomical location. The study complied with the PRISMA statement. Literature and pharmacovigilance databases were used to provide rate and/or calculate parameters (median age, median dose, history of symptoms, length of therapy and healing time after withdrawal of the drug). Differences in distribution of quantitative variables were analyzed via Mann–Whitney test. Correlation between quantitative variables was assessed with a Spearman’s correlation coefficient. A p value

With over 150,000 strokes in the United Kingdom every year, and more than 1 million living survivors, stroke is the third most common cause of death and the leading cause of severe physical disability among adults. A major challenge in administering timely treatment is determining whether the stroke is due to vascular blockage (ischaemic) or haemorrhage. For patients with ischaemic stroke, thrombolysis (i.e. pharmacological ‘clot-busting’) can improve outcomes when delivered swiftly after onset, and current National Health Service Quality Improvement Scotland guidelines are for thrombolytic therapy to be provided to at least 80 per cent of eligible patients within 60 min of arrival at hospital. Thrombolysis in haemorrhagic stroke could severely compound the brain damage, so administration of thrombolytic therapy currently requires near-immediate care in a hospital, rapid consultation with a physician and access to imaging services (X-ray computed tomography or magnetic resonance imaging) and intensive care services. This is near impossible in remote and rural areas, and stroke mortality rates in Scotland are 50 per cent higher than in London. We here describe our current project developing a technology demonstrator with ultrasound imaging linked to an intelligent, multi-channel communication device − connecting to multiple 2G/3G/4G networks and/or satellites − in order to stream live ultrasound images, video and two-way audio streams to hospital-based specialists who can guide and advise ambulance clinicians regarding diagnosis. With portable ultrasound machines located in ambulances or general practices, use of such technology is not confined to stroke, although this is our current focus. Ultrasound assessment is useful in many other immediate care situations, suggesting potential wider applicability for this remote support system. Although our research programme is driven by rural need, the ideas are potentially applicable to urban areas where access to imaging and definitive treatment can be restricted by a range of operational factors.

Background Aspirin is one of the most widely used non-steroidal anti-inflammatory drugs (NSAIDs). It is also a commonly used anti-platelet drug, which inhibits the formation of the platelet activator, thromboxane A2 (TxA2) via inhibition of cyclooxygenase-1 (COX-1). However, the presence of a patient subset that fails to respond to aspirin despite reduced TxA2 concentrations suggests that the effect of aspirin might be more complex than exclusive COX-1 inhibition. Methods In this study we evaluated the impact of in vivo oral administration of a standard anti-platelet dose (75 mg) of aspirin in healthy volunteers on the acute impact of in vitro collagen-mediated platelet aggregation and generation of platelet-derived TxA2 and the 12-lipoxygenase (LOX) metabolite 12-hydroxyeicosatetraenoic acid (12-HETE). The eicosanoids were quantified using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Results Low-dose aspirin administration not only inhibited TxA2 generation but also decreased the production of 12-HETE. Furthermore, a significant correlation was observed between the levels of 12-HETE and collagen-induced platelet aggregation. Pre-treatment of platelets with the 12-LOX inhibitor, baicalein, prior to activation attenuated platelet aggregation. Conclusions These findings support a role for 12-HETE as a pro-aggregatory eicosanoid in platelet function and suggest a role for 12-HETE in variable sensitivity to aspirin. The study also highlights a potentially important mechanism by which aspirin impacts upon eicosanoid generation.

Lenalidomide in combination with dexamethasone is a treatment for patients with relapsed or refractory myeloma. Although this combination demonstrates a high level of efficacy, it further exacerbates the hypercoaguable state that exists within myeloma. Thromboprophylactic regimen require careful selection and if warfarin is chosen, assiduous monitoring is required to ensure it will be clinically effective. We report the case of one patient who experienced multiple thrombotic events despite anticoagulant or antiplatelet thromboprophylaxis and review the contributing factors.

Background The potential of warfarin related harm is increased if clinicians lack the full patient specific information to make informed decisions—an e-proforma has been developed to communicate this information on hospital discharge. Objective To determine the views of general practitioners (GPs) on a warfarin discharge e-proforma. Method A cross-sectional survey of all GPs (n = 272) within the Raigmore Hospital catchment area of NHS Highland, Scotland. Results The response rate was 39.3 % (107/272). 84 (78.5 %) noticed recent changes to information supplied on discharge for warfarin patients. 64 (59.8 %) respondents thought this would result in more informed prescribing with regards to dosing, while 65 (60.7 %) felt this would improve safety. Accurate completion, timely receipt of the e-proforma and a realistic date for subsequent INR tests were considered important by GPs. Conclusion This study suggests the use of an e-proforma to communicate information about a high-risk medication, warfarin, to GPs on discharge optimises safe, informed prescribing and monitoring in primary care. The development of a discharge e-proforma for other high-risk medication as a patient safety improvement measure should be explored.

Background: Aspirin remains the mainstay of anti-platelet therapy in cardiac patients. However, if a patient is allergic to aspirin and dual anti-platelet therapy is indicated — such as with percutaneous coronary intervention (PCI), then there is no clear guidance. One possibility is aspirin desensitization. A variety of protocols exist for the rapid desensitization of patients with aspirin allergy. The aim of this survey was to assess current knowledge and practice regarding aspirin desensitization in the UK. Methods and results: We conducted a UK wide survey of all UK 116 PCI centers and obtained complete responses from 40 (35.4%) centers. Of these, just 7 (17.5%) centers had previously desensitised patients; 29 (87.9%) centers suggested a lack of a local protocol prevented them from desensitizing, with 10 (30.3%) unsure of how to conduct desensitization. Only 5 (12.5%) centers had a local policy for aspirin desensitization although 25 (64.1%) units had a clinical strategy for dealing with aspirin allergy; the majority (72%) giving higher doses of thienopyridine class drugs. Conclusions: In the UK, there appears to be no consistent approach to patients with aspirin allergy. Patients undergoing PCI benefit from dual anti-platelet therapy (including aspirin), and aspirin desensitization in those with known allergy may facilitate this. Sustained effort should be placed on encouraging UK centers to use desensitization as a treatment modality prior to PCI rather than avoiding aspirin altogether.

Objectives A proportion of cardiac patients managed at a cardiology outpatient clinic will die between clinic visits. This study aimed to identify the cause of death, to determine if case review occurred and if a formal review of such cases might be useful. Design Single-centre retrospective cohort study. Setting A remote regional centre in the North of Scotland. Participants All patients who had been removed from the cardiology outpatient clinic due to death in the community. Main outcome measures Cause of death, comorbidities and treatments were collected from hospital records and the national register of deaths. Chi-squared test and Student’s t-test were used with significance taken at the 5% level. Results Of 10,606 patients who attended the cardiology outpatient clinic, 75 (0.7%) patients died in the community. The majority (57.0%) died from a non-cardiac cause. Eleven patients (14.9%) died due to an unexpected cardiac death. A detailed case note review was undertaken. In only two (18.2%) cases was any note made as to the cause of death in the hospital records and in only one was there details of post mortem discussion between primary and secondary care. Conclusions A small proportion of patients attending a cardiology outpatient clinic died in the community. Documentation of the death in the hospital notes was very poor and evidence of post mortem communication between primary and secondary care was absent in all but one case. Better documentation and communication between primary and secondary care would seem desirable.

To gather preferences for novel pre-hospital physiologic monitoring technologies from emergency rescue services. Qualitative semi-structured interviews and focus groups were conducted with three groups from UK Search and Rescue (SAR); (1) Extractors (e.g. SAR teams), (2) Transporters (personnel primarily responsible for casualty transport), and (3) Treaters (e.g. Emergency Department doctors). Three themes were defined; SAR casualty management, novel physiologic monitor potential, and physiologic monitor physical properties. Some SAR groups already employed physiologic monitoring but there was no consensus on which monitor(s) to carry or what to monitor and how frequently. Existing monitors also tended to be bulky and heavy and could be unreliable in an unstable environment or if the casualty was cold. Those performing monitoring tended to have only basic first-aid training, and their workload was often high particularly if there was more than one casualty. The potential benefits of employing a novel monitor were strategic and clinical; an opportunity for transmitting data off-scene in order to facilitate monitoring or generate advice (i.e. telemedicine) was also voiced. A range of more intuitive, physical properties was also raised (e.g. small/compact, lightweight). SAR-specific technology should be simple to operate by those with less medical training, which means that clinical data interpretation and presentation should be carefully considered. It would be beneficial if novel monitors carried out a majority of the interpretation, allowing rescuers to proceed with their priority task of removing the casualty to safety.

Ivabradine is a new bradycardic agent acting on the If channels of sinoatrial nodal cells to decrease the rate of diastolic depolarization and thus heart rate. The benefit of ivabradine over other negatively chronotropic agents is its absence of negative inotropy. Effective management of coronary artery disease, in terms of reducing morbidity and mortality, is reliant on controlling heart rate. Ivabradine has been shown to safely and effectively reduce heart rate without compromising cardiac function in patients with coronary artery disease and more recently in patients with heart failure and raised heart rate. Furthermore, ivabradine has been shown to have a favourable side-effect profile compared with alternative bradycardic agents. This article reviews the evidence for ivabradine in coronary artery disease and heart failure and compares its safety with alternative bradycardic agents for these conditions.