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Nienke E Dijkstra,1,2 Marcia Vervloet,3 Carolien G M Sino,1 Eibert R Heerdink,2,4 Marjorie Nelissen-Vrancken,5 Nienke Bleijenberg,1,6 Marijn de Bruin,7 Lisette Schoonhoven6,8 1Research Group Care for the Chronically Ill, University of Applied Sciences Utrecht, Utrecht, the Netherlands; 2Research Group Innovation in Pharmaceutical Care, University of Applied Sciences Utrecht, Utrecht, the Netherlands; 3Nivel, Netherlands Institute for Health Services Research, Utrecht, the Netherlands; 4Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; 5Dutch Institute for Rational Use of Medicine, Utrecht, the Netherlands; 6Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; 7IQ Healthcare, Radboud University Medical Centre, Nijmegen, the Netherlands; 8School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southhampton, UKCorrespondence: Nienke E DijkstraResearch Group Proactive Care for Elderly People Living at Home, University of Applied Sciences Utrecht, Heidelberglaan 7, Utrecht, 3584 CS, the NetherlandsTel +31 641620681Email nienke.dijkstra@hu.nlPurpose: To describe nurses’ support interventions for medication adherence, and patients’ experiences and desired improvements with this care.Patients and Methods: A two-phase study was performed, including an analysis of questionnaire data and conducted interviews with members of the care panel of the Netherlands Patients Federation. The questionnaire assessed 14 types of interventions, satisfaction (score 0– 10) with received interventions, needs, experiences, and desired improvements in nurses’ support. Interviews further explored experiences and improvements. Data were analyzed using descriptive statistics and a thematic analysis approach.Results: Fifty-nine participants completed the questionnaire, and 14 of the 59 participants were interviewed. The satisfaction score for interventions was 7.9 (IQR 7– 9). The most common interventions were: “noticing when I don’t take medication as prescribed” (n = 35), “helping me to find solutions to overcome problems with using medications” (n = 32), “helping me with taking medication” (n = 32), and “explaining the importance of taking medication at the right moment” (n = 32). Fifteen participants missed ≥ 1 of the 14 interventions. Most mentioned the following: “regularly asking about potential problems with medication use” (33%), “regularly discussing whether using medication is going well” (29%), and “explaining the importance of taking medication at the right moment” (27%). Twenty-two participants experienced the following as positive: improved self-management of adequate medication taking, a professional patient–nurse relationship to discuss adherence problems, and nurses’ proactive attitude to arrange practical support for medication use. Thirteen patients experienced the following as negative: insufficient timing of home visits, rushed appearance of nurses, and insufficient expertise about side effects and taking medication. Suggested improvements included performing home visits on time, more time for providing support in medication use, and more expertise about side effects and administering medication.Conclusion: Overall, participants were satisfied, and few participants wanted more interventions. Nurses’ support improved participants’ self-management of medication taking and enabled patients to discuss their adherence problems. Adequately timed home visits, more time for support, and accurate medication-related knowledge are desired.Keywords: medication adherence, patient preference, home care, home care nurses, patient satisfaction, patient adherence

A practice guide to help nursing homes set up an antimicrobial stewardship (AMS) program was developed based on experiences gained during a project at one of the largest providers of elderly care in the South-east of the Netherlands. The guideline for the implementation of AMS in Dutch hospitals served as a starting point and were tailored to the unique characteristics of a nursing home setting. This practice guide offers recommendations and practical tools while emphasizing the importance of establishing a multidisciplinary approach to oversee AMS efforts. The recommendations and practical tools address various elements of AMS, including the basic conditions to initiate an AMS program and a comprehensive approach to embed an AMS program. This approach involves educating nurses and caregivers, informing volunteers and residents/their representatives, and the activities of an antibiotic team (A-team). The practice guide also highlights a feasible work process for the A-team. This process aims to achieve a culture of continuous learning and improvement that can enhance the overall quality of antibiotic prescribing rather than making individual adjustments to client prescriptions. Overall, this practice guide aims to help nursing homes establish an AMS program through collaborative efforts between involved physicians, pharmacists, clinical microbiologists, and infection control practitioners. The involved physician plays a crucial role in instilling a sense of urgency and developing a stepwise strategy., (© 2023. The Author(s).)

Introduction: Marketing materials from pharmaceutical companies attempt to create a positive image of marketed, often new, medicines. To gain more insight in strategies pharmaceutical companies use to influence primary care practitioners' attitudes towards marketed medicines, we investigated the use of persuasion strategies in direct marketing mailings and advertisements from pharmaceutical companies sent to general practitioners., Methods: General practitioners in the Netherlands were recruited to collect all direct marketing mailings, meaning all leaflets, letters and other information sent by pharmaceutical industries to the practice during one month (June 2022). Direct marketing mailings and advertisements in collected medical journals concerning medicines or diseases (together called marketing materials) were analysed according to presence of one of the seven common persuasion strategies, i.e. reciprocity, consistency/commitment, social proof, liking, authority, scarcity and unity; as well as marketed medicine and year of introduction., Results: Twenty general practices collected 68 unique marketing materials concerning 37 different medicines. Direct factor Xa inhibitors (n = 12), glucagon-like peptide-1 analogues (n = 5) and sodium-glucose co-transporter 2 inhibitors (n = 4) were the most frequently marketed medicines. The median year of introduction of all marketed medicines was 2012. All seven persuasion strategies were identified, with liking (64.7% of all materials) and authority (29.4%) as most prominent strategies, followed by social proof (17.6%), unity (14.7%), scarcity (13.2%), reciprocity (11.8%) and consistency/commitment (2.9%). In addition to those strategies, we identified emotional pressure (30.9%) as one commonly used new strategy., Conclusion: Marketing materials sent to general practices use a wide range of persuasion strategies in an attempt to influence prescription behaviour. Primary care practitioners should be aware of these mechanisms through which pharmaceutical companies try to influence their attitudes towards new medicines., Competing Interests: Dankers M, Weber K, Nelissen-Vrancken HJMG, and Mantel-Teeuwisse AK declare no conflict of interests. Van Dijk L received an unrestricted grant from TEVA Pharmaceuticals and Biogen for a research project not related to this study. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Dankers et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Little is known about prescription patterns of expensive non-recommended newer long-acting insulins (glargine 300 U/mL and degludec) for patients with type 2 diabetes mellitus (T2DM)., Aim: To identify practice variation in, and practice- and patient-related characteristics associated with, the prescription of newer long-acting insulins to patients with T2DM in primary care., Design and Setting: A retrospective cohort study in Dutch general practices (Nivel Primary Care Database)., Method: A first prescription for intermediate or long-acting insulins in 2018 was identified in patients aged ≥40 years using other T2DM drugs. Per practice, the median percentage and interquartile range (IQR) of patients with newer insulin prescriptions were calculated. Multilevel logistic regression models were constructed to calculate intraclass correlation coefficients (ICCs) and quantify the association of patient and practice characteristics with prescriptions for newer insulins (odds ratios [ORs] and 95% confidence intervals [CIs])., Results: In total, 7757 patients with prescriptions for intermediate or long-acting insulins from 282 general practices were identified. A median percentage of 21.2% (IQR 12.5-36.4%) of all patients prescribed intermediate or long-acting insulins per practice received a prescription for newer insulins. After multilevel modelling, the ICC decreased from 20% to 19%. Female sex (OR 0.77, 95% CI = 0.69 to 0.87), age ≥86 years compared with 40-55 years (OR 0.22, 95% CI = 0.15 to 0.34), prescriptions for metformin (OR 0.66, 95% CI = 0.53 to 0.82), sulfonylurea (OR 0.58, 95% CI = 0.51 to 0.66), or other newer T2DM drugs (OR 3.10, 95% CI = 2.63 to 3.66), and dispensing practices (OR 1.78, 95% CI = 1.03 to 3.10) were associated with the prescription of newer insulins., Conclusion: The inter-practice variation in the prescription of newer insulins is large and could only be partially explained by patient- and practice-related differences. This indicates substantial opportunities for improvement., (© The Authors.)

Objectives: To evaluate the effect of the PROPER intervention in nursing home residents with dementia on the prevalence of psychotropic drug use and neuropsychiatric symptoms., Design: A cluster-randomized controlled design with two parallel groups (intervention versus usual care) and assessments at 0, 6, 12, and 18 months., Setting: Thirty-one dementia special care units within 13 long-term care organizations in the Netherlands., Participants: Three hundred eighty nursing home residents with dementia., Intervention: The PROPER intervention consisted of a structured and repeated multidisciplinary medication review, supported by education and continuous evaluation., Measurements: Prescriptions of antipsychotics, antidepressants, anxiolytics, and hypnotics, and occurrence of neuropsychiatric symptoms., Results: The prescription of any type of psychotropic drugs increased in the intervention group, and decreased in the control group, with an estimated difference of 3.9 percentage points per 6 months (p = 0.01). Effects for the individual drug groups were minor (differences of 1.6 percentage points and below per 6 months) and not statistically significant. The occurrence of neuropsychiatric symptoms remained stable in both the intervention and control groups during the follow-up of 18 months., Conclusions: The PROPER intervention failed to demonstrate effectiveness in reducing the prevalence of psychotropic drugs. It may be interesting to enrich the intervention with components that address personal attitudes and communication between nursing home professionals, not only with respect to the prescription of psychotropic drugs, but also to neuropsychiatric symptoms.The study has been registered in The Netherlands Trial Register (NTR3569).

Objectives: The contribution of vascular changes to the development of heart failure is largely unknown. In the present study, we evaluated endothelial and vascular contractile function in the rat hindlimb vascular bed after myocardial infarction (MI), including the modulatory role of basal nitric oxide (NO) production and the effects of treatment with the angiotensin converting enzyme inhibitor captopril on vascular function., Methods: MI was induced in male Wistar rats by ligation of the left coronary artery. Acetylcholine-induced dilatations were assessed in the ex vivo perfused hindlimb at various time points. At 2 and 5 weeks post-MI, vascular contractile function in the perfused hindlimb was assessed from resistance changes induced by 35 mM and 125 mM potassium (K+) and the maximum increase in resistance (delta Rmax, 125 mM K+ and 3 mg phenylephrine). Basal NO synthesis was blocked for 2 weeks with L-nitro-arginine methylester (L-NAME) in sham and MI rats and similar contractility experiments were performed. The effect of captopril treatment from 2 to 5 weeks post-MI on vasoconstrictor responses was also tested., Results: Acetylcholine-induced dilatations in the presence of 10 microM indomethacin were not different between sham and MI rats. Vasoconstrictor responses to K+ and delta Rmax were reduced at 2 weeks after MI. This reduction in vasoconstrictor ability was similar to that seen in L-NAME-treated sham rats, while chronic L-NAME treatment did not affect vasoconstrictor reactivity in MI rats. Similarly, L-NAME induced an increase in mean arterial pressure in sham rats, but not in MI rats. At 5 weeks after MI, vasoconstriction to 125 mM K+ and delta Rmax were still reduced in MI rats; this response was however partially restored after captopril treatment., Conclusion: The development of vascular contractile hyporeactivity in the rat hindlimb after MI may be due to reduced basal NO production. Delayed treatment with captopril improves peripheral vascular contractile function in this setting.

Objective: To investigate the effects of long-term treatment with blockers of the renin-angiotensin system on capillarization and growth of fibers in ischemic hind-limb muscles and in muscles under normal growth conditions., Methods: Ischemia was induced by partial ligation of the left common iliac artery., Results: Ischemia resulted in a significant increase in capillary and fiber density in the soleus muscle, a significant decrease in mean fiber size and a decrease in muscle cross-sectional area after 4 weeks compared with the contralateral nonischemic muscle. Ischemia also significantly decreased the muscle: body weight ratio of the left soleus muscle. We observed no significant effect on total number of capillaries and capillary: fiber ratio, suggesting that ischemia did not result in an increase in capillarization in this muscle. Treatments with subhypotensive and with hypotensive doses of the angiotensin converting enzyme (ACE) inhibitor benazeprilat, the angiotensin (Ang) II AT1 antagonist valsartan, or the Ang II AT2 antagonist PD 123 319 for 4 weeks did not influence any of the above-described changes in the normal and ischemic muscles and treatment effects were also independent of the degree of reduction of blood pressure., Conclusion: Treatments with an ACE inhibitor and with Ang II receptor antagonists in dose ranges that moderately lower blood pressure do not influence vessel density and any of the other structural adaptations after hind-limb ischemia. Administrations of ACE inhibitors and Ang II AT1 antagonists may therefore be adequate and beneficial therapies under ischemic conditions, such as in the treatment of hypertension complicated by intermittent claudication, for which treatment must not increase ischemia.

To investigate the role of local renin angiotensin systems in the functional responses to angiotensin I and II, the effects of angiotensin I and angiotensin II on resistance were measured in perfused hindlimbs of rats under normal conditions and during infusion of enalaprilate, lisinopril, zabiciprilate and captopril at two infusion rates. The angiotensin-converting enzyme (ACE) inhibitors significantly increased ED50 and decreased maximal resistance changes of angiotensin I dose dependently, without effects on angiotensin II responses. Captopril increased the ED50 of angiotensin I significantly more than did the other ACE inhibitors at a low infusion rate. The ACE inhibitors, except for lisinopril, increased the ED50 of angiotensin I pressor responses in vivo to the same extent, and were similarly potent to inhibit plasma ACE activity at 15 min after injection. The ratio of the doses of the ACE inhibitors used in vivo was the same as in perfused hindlimbs. These results suggest that, in the hindlimbs, angiotensin I causes ACE-dependent vasoconstriction. Captopril may be more effective to inhibit local ACE than the other ACE inhibitors investigated.