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Do community pharmacists have the attitudes and knowledge to support evidence based self-management of low back pain?
Silcock, Jonathan
Moffett, Jennifer Klaber
Edmondson, Hilary
Waddell, Gordon
Burton, A Kim
BMC Musculoskeletal Disorders
In many countries, community pharmacists can be consulted without appointment in a large number of convenient locations. They are in an ideal position to give advice to patients at the onset of low back pain and also reinforce advice given by other healthcare professionals. There is little specific information about the quality of care provided in the pharmacy for people with back pain. The main objectives of this survey were to determine the attitudes, knowledge and reported practice of English pharmacists advising people who present with acute or chronic low back pain.
A questionnaire was designed for anonymous self-completion by pharmacists attending continuing education sessions. Demographic questions were designed to allow comparison with a national pharmacy workforce survey. Attitudes were measured with the Back Beliefs Questionnaire (BBQ) and questions based on the Working Backs Scotland campaign. Questions about the treatment of back pain in the community pharmacy were written (or adapted) to reflect and characterise the nature of practice. In response to two clinical vignettes, respondents were asked to select proposals that they would recommend in practice.
335 responses from community pharmacists were analysed. Middle aged pharmacists, women, pharmacy managers and locums were over-represented compared to registration and workforce data. The mean (SD) BBQ score for the pharmacists was 31.37 (5.75), which was slightly more positive than in similar surveys of other groups. Those who had suffered from back pain seem to demonstrate more confidence (fewer negative feelings, more advice opportunities and better advice provision) in their perception of advice given in the pharmacy. Awareness of written information that could help to support practice was low. Reponses to the clinical vignettes were generally in line with the evidence base. Pharmacists expressed some caution about recommending activity. Most respondents said they would benefit from more education about back pain.
Those sampled generally expressed positive attitudes about back pain and were able to offer evidence based advice. Pharmacists may benefit from training to increase their ability and confidence to offer support for self-care in back pain. Further research would be useful to clarify the representativeness of the sample.
Related Articles
Patient attitudes regarding the role of the pharmacist and interest in expanded pharmacist services
Kelly, Deborah V.
Young, Stephanie
Phillips, Leslie
Clark, Deidre
Canadian Pharmacists Journal : CPJ
Pharmacists are consistently ranked among the most trusted professionals, and research shows high levels of satisfaction with pharmacist services. Studies have also shown that the public is generally unaware of the full range of roles and responsibilities of a pharmacist. The purpose of this study was to explore the public's knowledge and attitudes regarding the role of the community pharmacist and to determine their likelihood of using expanded pharmacist services.
Adults across Newfoundland and Labrador were surveyed by telephone. Survey questions addressed how frequently participants visited the pharmacy, understanding of duties undertaken by pharmacists, perceptions and attitudes regarding pharmacists as health care professionals, likelihood of using expanded pharmacist services and participant demographics. Comparisons were made between responses from urban and rural participants and frequent versus nonfrequent pharmacy users, to determine if there were any differences.
The majority of participants were generally aware of what pharmacists do when filling prescriptions; those who visited the pharmacy more frequently appeared to be more informed. Participants indicated they would take advantage of the expanded services suggested, with greatest interest in receiving advice for minor ailment management and prescription refills from pharmacists. Results support the prevailing view that pharmacists are trusted health professionals who should have access to patients' health information to provide best care.
The public is aware of aspects of the pharmacist's role, but opportunities exist to better educate the public on the knowledge, skills and unique professional abilities of pharmacists to support uptake of expanded pharmacist services.
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Safe storage of methadone in the home - an audit of the effectiveness of safety information giving
Bloor, Roger N
McAuley, Rosanna
Smalldridge, Norman
Harm Reduction Journal
Accidental poisoning by methadone occurs, particularly as a result of children ingesting a parent's methadone. Health care professionals have a responsibility to provide information and guidance to methadone users on safe storage of methadone. The objective of the study was to audit the effectiveness of information giving on the safety of methadone consumption, dose measurement and storage, and the effectiveness of sources of advice available for patients.
The study was undertaken prior to the introduction of a scheme for the supervised consumption of methadone, in the setting of an NHS Methadone clinic serving a district population of 490,000 in the UK. 185 consecutive patients attending a methadone clinic to collect a methadone prescription were the subject of an anonymous survey. Issues of safety of methadone consumption, storage and safety information provisions were assessed. A telephone survey of the community pharmacists dispensing the methadone covered the availability of measuring devices and provision of advice on safety was undertaken.
Methadone was stored in a variety of locations, a cupboard being most frequent. 95 patients (60.1%) had children either living in or visiting their home. All stored their methadone in a bottle with a child resistant lid; the majority measured doses using either the container supplied by the pharmacist or a plastic measure. 126 patients (78%) confirmed that a pharmacist provided a measuring container on their first visit, 24 (15%) were given a measure on every visit to the pharmacist. Advice on safe storage was recalled by 30% of the patients, and advice on measuring methadone by 28%. Methadone was seen as potentially dangerous by 82% of the patients.
The risks resulting from unsafe storage of methadone may be reduced by daily instalment prescribing and provision of measuring containers on request. Recall of provision of information on safety issues is poor and the adoption of a standard policy on provision information should be seen as a priority. A re-audit of safety of storage of methadone is recommended following the introduction of a standard policy on information provision.
Related Articles
Management of acute diarrhea in children by community pharmacists in Lagos, Nigeria
Ogbo, Patricia U.
Aina, Bolajoko A.
Aderemi-Williams, Roseline I.
Pharmacy Practice
Acute diarrhea in children leads to dehydration and death if not appropriately managed. World Health Organization (WHO) recommends treating diarrhea with oral rehydration therapy (ORT), fluids and foods. Proper management is hinged on accurate assessment of patients to identify the acute watery diarrhea.
To compare the knowledge and attitude of community pharmacists in the management of acute diarrhea in children with their observed practice.
This study was carried out using two instruments: structured self-administered questionnaire to assess knowledge and attitude of community pharmacists in the management of acute diarrhea in children and simulated patient visits to evaluate assessment of patients, recommendation of products and instructions on feeding and fluid intake. The simulated patient visits were done in 186 pharmacies in the city of Lagos, Nigeria.
The study reveals that the knowledge and attitude of community pharmacists in the management of acute diarrhea in children was different from their observed practice. The difference was statistically significant (p<0.05). During the simulations, 23% carried out appropriate assessment before recommending any products, and 15% recommended ORT alone. Although information to the pharmacists indicated non-dysentery, non-cholera, acute watery diarrhea, antibiotics and antidiarrheals were irrationally recommended and these were the mainstay of symptoms' management in practice. Questionnaire data revealed that 24% of pharmacists knew the correct instructions to give on food and fluid intake during diarrhea, whereas 8% followed WHO guideline on food and fluid intake during the visits.
Assessment of patients to determine acute diarrhea was inadequate. Observed practice in managing acute diarrhea in children was inappropriate and significantly different from their claims in the questionnaire. The recommendation of ORT was scanty and advice on food and fluid intake was inadequate and sometimes inappropriate. This study shows that only 15% of community pharmacists managed acute diarrhea in children according to the WHO guidelines.
Diarrhea; Community Pharmacy Services; Professional Practice; Guideline Adherence; Patient Simulation; Nigeria
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Experiences of community pharmacists involved in the delivery of a specialist asthma service in Australia
Emmerton, Lynne M
Smith, Lorraine
LeMay, Kate S
Krass, Ines
Saini, Bandana
Bosnic-Anticevich, Sinthia Z
Reddel, Helen K
Burton, Deborah L
Stewart, Kay
Armour, Carol L
BMC Health Services Research
The role of community pharmacists in disease state management has been mooted for some years. Despite a number of trials of disease state management services, there is scant literature into the engagement of, and with, pharmacists in such trials. This paper reports pharmacists' feedback as providers of a Pharmacy Asthma Management Service (PAMS), a trial coordinated across four academic research centres in Australia in 2009. We also propose recommendations for optimal involvement of pharmacists in academic research.
Feedback about the pharmacists' experiences was sought via their participation in either a focus group or telephone interview (for those unable to attend their scheduled focus group) at one of three time points. A semi-structured interview guide focused discussion on the pharmacists' training to provide the asthma service, their interactions with health professionals and patients as per the service protocol, and the future for this type of service. Focus groups were facilitated by two researchers, and the individual interviews were shared between three researchers, with data transcribed verbatim and analysed manually.
Of 93 pharmacists who provided the PAMS, 25 were involved in a focus group and seven via telephone interview. All pharmacists approached agreed to provide feedback. In general, the pharmacists engaged with both the service and research components, and embraced their roles as innovators in the trial of a new service. Some experienced challenges in the recruitment of patients into the service and the amount of research-related documentation, and collaborative patient-centred relationships with GPs require further attention. Specific service components, such as the spirometry, were well received by the pharmacists and their patients. Professional rewards included satisfaction from their enhanced practice, and pharmacists largely envisaged a future for the service.
The PAMS provided pharmacists an opportunity to become involved in an innovative service delivery model, supported by the researchers, yet trained and empowered to implement the clinical service throughout the trial period and beyond. The balance between support and independence appeared crucial in the pharmacists' engagement with the trial. Their feedback was overwhelmingly positive, while useful suggestions were identified for future academic trials.
Pharmacy; Asthma; Disease management service; Experiences; Feedback
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The feasibility and acceptability of the provision of alcohol screening and brief advice in pharmacies for women accessing emergency contraception: an evaluation study
Brown, Sally
Henderson, Emily
Sullivan, Claire
BMC Public Health
It is widely accepted that excessive drinking contributes to both health and social problems. There has been considerable interest in the potential of community pharmacies as a setting for health advice, and evidence suggests that interventions by pharmacists can be effective. Research on interventions relating to alcohol consumption in primary care has focused on general practice, and although some evidence exists about the efficacy of pharmacy interventions, little research to date has taken place in the UK. The aim of this study was to evaluate the acceptability of alcohol screening and brief interventions to women accessing emergency hormonal contraception (EHC) in community pharmacies.
An initiative whereby women who accessed community pharmacies for EHC would be asked to complete an AUDIT questionnaire following their EHC consultation was introduced by a Primary Care Trust (PCT) in the North-East of England. The evaluation incorporated three strands: interviewing pharmacists (n = 14) about the implementation and acceptability of the initiative; interviewing clients (n = 22) identified as "low risk" to understand their perceptions of the initiative; conducting online follow-up surveys with clients in the "risky" group (n = 53) to evaluate the impact of the initiative on their alcohol consumption and contraceptive behaviour, as well as their perceptions of the service.
Pharmacists' attitudes towards screening were generally positive, although there were organisational obstacles to providing the service. Some felt uncertain about engaging clients in conversation about a sensitive topic. However, clients themselves did not report feeling embarrassed or upset, and most were happy to talk to the pharmacist and be given advice. Most clients felt that the pharmacist was an appropriate person to carry out alcohol screening and advice.
It is feasible for pharmacists to carry out screening and brief advice, and most customers find it acceptable. However, pharmacist take-up of the service and participation in the study was low. Pharmacists were enthusiastic about providing screening and other health promotion services; targeting different population groups for alcohol screening may be more successful. Delivery of the AUDIT tool by pharmacists may not obtain reliable responses from some specific client groups.
Alcohol brief intervention; Community pharmacy; Women; AUDIT questionnaire; Emergency contraception; UK
Related Articles
Assessment of community pharmacists' counselling skills on headache management by using the simulated patient approach: a pilot study
Santos, Ana P.
Mesquita, Alessandra R.
Oliveira, Karolline S.
Lyra, Divaldo P.
Pharmacy Practice
Headache, or cephalalgia, is one of the 20 most disabling diseases in the world and affects a large portion of the world's population. People generally use over-the-counter medications to treat headaches and other minor symptoms. A pharmacist should help patients choose the most effective, safe, and convenient pharmacotherapeutic option.
To assess the counselling skills of community pharmacists for headache management by using the simulated patient approach.
A cross-sectional study was conducted from March 2010 to July 2010. Data were obtained from a convenience sample consisting of one pharmacist from each of the 24 participating community pharmacies. In order to evaluate the pharmacists' counselling skills, a simulated patient role played a standardized headache case requesting self-medication. The interactions of the simulated patient with the pharmacists were audiovisually recorded using a hidden micro camera, and these recordings were analysed using a validated questionnaire.
Of the 24 evaluated pharmacists, 19 (79.1%) were women. Information was spontaneously provided by 15 (62.5%) pharmacists. At least one question was asked by the pharmacist to assess the signs and symptoms. Most pharmacists (n=17, 70.8%) recommended sodium dipyrone, either alone or in combination with other drugs. The most discussed items in the simulation visits were contraindications (n=17, 70.8%), indications (n=10, 41.6%), and drug administration times (n=8, 33.3%). None of the pharmacists recommended any non-pharmacological therapeutic alternatives. The overall impressions of the pharmacists' professional counselling skills ranged from poor to fair.
This study showed that the pharmacists' counselling skills and the guidance provided by the pharmacists to the simulated patient were insufficient for the satisfactory management of headache.
Headache; Community Pharmacy Services; Professional Practice; Pharmacists; Patient Simulation; Brazil
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Piloting the role of a pharmacist in a community palliative care multidisciplinary team: an Australian experience
Hussainy, Safeera Y
Box, Margaret
Scholes, Sandy
BMC Palliative Care
While the home is the most common setting for the provision of palliative care in Australia, a common problem encountered here is the inability of patient/carers to manage medications, which can lead to misadventure and hospitalisation. This can be averted through detection and resolution of drug related problems (DRPs) by a pharmacist; however, they are rarely included as members of the palliative care team. The aim of this study was to pilot a model of care that supports the role of a pharmacist in a community palliative care team. A component of the study was to develop a cost-effective model for continuing the inclusion of a pharmacist within a community palliative care service.
The study was undertaken (February March 2009-June 2010) in three phases. Development (Phase 1) involved a literature review; scoping the pharmacist's role; creating tools for recording DRPs and interventions, a communication and education strategy, a care pathway and evidence based patient information. These were then implemented in Phase 2. Evaluation (Phase 3) of the impact of the pharmacist's role from the perspectives of team members was undertaken using an online survey and focus group. Impact on clinical outcomes was determined by the number of patients screened to assess their risk of medication misadventure, as well as the number of medication reviews and interventions performed to resolve DRPs.
The pharmacist screened most patients (88.4%, 373/422) referred to the palliative care service to assess their risk of medication misadventure, and undertook 52 home visits. Medication reviews were commonly conducted at the majority of home visits (88%, 46/52), and a variety of DRPs (113) were detected at this point, the most common being "patient requests drug information" (25%, 28/113) and "condition not adequately treated" (22%, 25/113). The pharmacist made 120 recommendations in relation to her interventions.
Fifty percent of online survey respondents (10/20) had interacted 10 or more times with the pharmacist for advice. All felt that the pharmacist's role was helpful, improving their knowledge of the different medications used in palliative care. The six team members who participated in the focus group indicated that there were several benefits of the pharmacist's contributions towards medication screening and review.
The inclusion of a pharmacist in a community palliative care team lead to an increase in the medication-related knowledge and skills of its members, improved patients' medication management, and minimised related errors. The model of care created can potentially be duplicated by other palliative care services, although its cost-effectiveness was unable to be accurately tested within the study.
Related Articles
Effect of Household-Based Drinking Water Chlorination on Diarrhoea among Children under Five in Orissa, India: A Double-Blind Randomised Placebo-Controlled Trial
Boisson, Sophie
Stevenson, Matthew
Shapiro, Lily
Kumar, Vinod
Singh, Lakhwinder P.
Ward, Dana
Clasen, Thomas
PLoS Medicine
Sophie Boisson and colleagues conducted a double-blind, randomized placebo-controlled trial in Orissa, a state in southeast India, to evaluate the effect of household water treatment in preventing diarrheal illnesses in children aged under five years of age.
Please see later in the article for the Editors' Summary
Boiling, disinfecting, and filtering water within the home can improve the microbiological quality of drinking water among the hundreds of millions of people who rely on unsafe water supplies. However, the impact of these interventions on diarrhoea is unclear. Most studies using open trial designs have reported a protective effect on diarrhoea while blinded studies of household water treatment in low-income settings have found no such effect. However, none of those studies were powered to detect an impact among children under five and participants were followed-up over short periods of time. The aim of this study was to measure the effect of in-home water disinfection on diarrhoea among children under five.
Methods and Findings
We conducted a double-blind randomised controlled trial between November 2010 and December 2011. The study included 2,163 households and 2,986 children under five in rural and urban communities of Orissa, India. The intervention consisted of an intensive promotion campaign and free distribution of sodium dichloroisocyanurate (NaDCC) tablets during bi-monthly households visits. An independent evaluation team visited households monthly for one year to collect health data and water samples. The primary outcome was the longitudinal prevalence of diarrhoea (3-day point prevalence) among children aged under five. Weight-for-age was also measured at each visit to assess its potential as a proxy marker for diarrhoea. Adherence was monitored each month through caregiver's reports and the presence of residual free chlorine in the child's drinking water at the time of visit. On 20% of the total household visits, children's drinking water was assayed for thermotolerant coliforms (TTC), an indicator of faecal contamination. The primary analysis was on an intention-to-treat basis. Binomial regression with a log link function and robust standard errors was used to compare prevalence of diarrhoea between arms. We used generalised estimating equations to account for clustering at the household level. The impact of the intervention on weight-for-age z scores (WAZ) was analysed using random effect linear regression.
Over the follow-up period, 84,391 child-days of observations were recorded, representing 88% of total possible child-days of observation. The longitudinal prevalence of diarrhoea among intervention children was 1.69% compared to 1.74% among controls. After adjusting for clustering within household, the prevalence ratio of the intervention to control was 0.95 (95% CI 0.79–1.13). The mean WAZ was similar among children of the intervention and control groups (−1.586 versus −1.589, respectively). Among intervention households, 51% reported their child's drinking water to be treated with the tablets at the time of visit, though only 32% of water samples tested positive for residual chlorine. Faecal contamination of drinking water was lower among intervention households than controls (geometric mean TTC count of 50 [95% CI 44–57] per 100 ml compared to 122 [95% CI 107–139] per 100 ml among controls [p<0.001] [n = 4,546]).
Our study was designed to overcome the shortcomings of previous double-blinded trials of household water treatment in low-income settings. The sample size was larger, the follow-up period longer, both urban and rural populations were included, and adherence and water quality were monitored extensively over time. These results provide no evidence that the intervention was protective against diarrhoea. Low compliance and modest reduction in water contamination may have contributed to the lack of effect. However, our findings are consistent with other blinded studies of similar interventions and raise additional questions about the actual health impact of household water treatment under these conditions.
Trial Registration
ClinicalTrials.gov NCT01202383
Please see later in the article for the Editors' Summary
Editors' Summary
Millennium Development Goal 7 calls for halving the proportion of the global population without sustainable access to safe drinking water between 1990 and 2015. Although this target was met in 2010, according to latest figures, 768 million people world-wide still rely on unimproved drinking water sources. Access to clean drinking water is integral to good health and a key strategy in reducing diarrhoeal illness: Currently, 1.3 million children aged less than five years die of diarrhoeal illnesses every year with a sixth of such deaths occurring in one country—India. Although India has recently made substantial progress in improving water supplies throughout the country, currently almost 90% of the rural population does not have a water connection to their house and drinking water supplies throughout the country are extensively contaminated with human waste. A strategy internationally referred to as Household Water Treatment and Safe Storage (HWTS), which involves people boiling, chlorinating, and filtering water at home, has been recommended by the World Health Organization and UNICEF to improve water quality at the point of delivery.
Why Was This Study Done?
The WHO and UNICEF strategy to promote HWTS is based on previous studies from low-income settings that found that such interventions could reduce diarrhoeal illnesses by between 30%–40%. However, these studies had several limitations including reporting bias, short follow up periods, and small sample sizes; and importantly, in blinded studies (in which both the study participants and researchers are unaware of which participants are receiving the intervention or the control) have found no evidence that HWTS is protective against diarrhoeal illnesses. So the researchers conducted a blinded study (a double-blind, randomized placebo-controlled trial) in Orissa, a state in southeast India, to address those shortcomings and evaluate the effect of household water treatment in preventing diarrhoeal illnesses in children under five years of age.
What Did the Researchers Do and Find?
The researchers conducted their study in 11 informal settlements (where the inhabitants do not benefit from public water or sewers) in the state's capital city and also in 20 rural villages. 2,163 households were randomized to receive the intervention—the promotion and free distribution of sodium dichloroisocyanurate (chlorine) disinfection tablets with instruction on how to use them—or placebo tablets that were similar in appearance and had the same effervescent base as the chlorine tablets. Trained field workers visited households every month for 12 months (between December 2010 and December 2011) to record whether any child had experienced diarrhoea in the previous three days (as reported by the primary care giver). The researchers tested compliance with the intervention by asking participants if they had treated the water and also by testing for chlorine in the water.
Using these methods, the researchers found that over the 12-month follow-up period, the longitudinal prevalence of diarrhoea among children in the intervention group was 1.69% compared to 1.74% in the control group, a non-significant finding (a finding that could have happened by chance). There was also no difference in diarrhoea prevalence among other household members in the two groups and no difference in weight for age z scores (a measurement of growth) between children in the two groups. The researchers also found that although just over half (51%) of households in the intervention group reported treating their water, on testing, only 32% of water samples tested positive for chlorine. Finally, the researchers found that water quality (as measured by thermotolerant coliforms, TTCs) was better in the intervention group than the control group.
What Do These Findings Mean?
These findings suggest that treating water with chlorine tablets has no effect in reducing the prevalence of diarrhoea in both children aged under five years and in other household members in Orissa, India. However, poor compliance was a major issue with only a third of households in the intervention group confirmed as treating their water with chlorine tablets. Furthermore, these findings are limited in that the prevalence of diarrhoea was lower than expected, which may have also reduced the power of detecting a potential effect of the intervention. Nevertheless, this study raises questions about the health impact of household water treatment and highlights the key challenge of poor compliance with public health interventions.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001497.
The website of the World Health Organization has a section dedicated to household water treatment and safe storage, including a network to promote the use of HWTS and a toolkit to measure HWTS
The Water Institute hosts the communications portal for the International Network on Household Water Treatment and Safe Storage
Related Articles
Patients' perception, views and satisfaction with pharmacists' role as health care provider in community pharmacy setting at Riyadh, Saudi Arabia
Al-Arifi, Mohamed N.
Saudi Pharmaceutical Journal : SPJ
This study will provide guiding information about the population perception, views and satisfaction with pharmacist's performance as health care provider in the community pharmacy setting in Riyadh, Saudi Arabia.
The study was conducted in Riyadh, Saudi Arabia, from July through December 2010. A total of 125 community pharmacies in Riyadh city were randomly selected according to their geographical distribution (north, south, east, and west). They represent about 10–15% of all community pharmacies in the city. The questionnaire composed of 8 items about patients' views and satisfaction with the pharmacists' role in the current community pharmacy practice. The questionnaire was coded, checked for accuracy and analyzed using the Statistical Package for Social Sciences (SPSS) version 17.0 for Windows (SPSS Inc., Chicago, Illinois).
The response rate was almost 85% where 2000 patients were approached and 1699 of them responded to our questionnaire. The majority of respondents is young adults and adults (82.8%), male (67.5%) and married (66.9%). Seventy one percent of respondents assured that community pharmacist is available in the working while only 37.3% of respondents perceived the pharmacist as a mere vendor. About 38% assured sou moto counseling by the pharmacist, 35% reported pharmacist plays an active role in their compliances to treatments, 43% acknowledged the role of pharmacist in solving medication related problems, 34% considered the pharmacist as a health awareness provider and 44.6% felt that pharmacist is indispensable and an effective part of the health care system.
The image and professional performance of community pharmacist are improving in Saudi Arabia. The Saudi patients show better satisfaction, perception and appreciation of the pharmacists' role in the health care team. However, extra efforts should be paid to improve the clinical skills of the community pharmacists. Community pharmacists need to be able to reach out to patient, assess their hesitations and promptly offer solution which was appreciated by the patients as the survey indicates. They should play a pro-active role in becoming an effective and indispensable part of health care. Furthermore, they should be able to advice, guide, direct and persuade the patient to comply correct usage of drugs. Finally, community pharmacists should equip themselves with appropriate knowledge and competencies in order to tender efficient and outstanding pharmaceutical health care.
Community; Pharmacist; Satisfaction; Care; Drug; Perception
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Exploring successful community pharmacist-physician collaborative working relationships using mixed methods
Snyder, Margie E.
Zillich, Alan J.
Primack, Brian A.
Rice, Kristen R.
Somma McGivney, Melissa A.
Pringle, Janice L.
Smith, Randall B.
Research in social & administrative pharmacy : RSAP
Collaborative working relationships (CWRs) between community pharmacists and physicians may foster the provision of medication therapy management services, disease state management, and other patient care activities; however, pharmacists have expressed difficulty in developing such relationships. Additional work is needed to understand the specific pharmacist-physician exchanges that effectively contribute to the development of CWR. Data from successful pairs of community pharmacists and physicians may provide further insights into these exchange variables and expand research on models of professional collaboration.
To describe the professional exchanges that occurred between community pharmacists and physicians engaged in successful CWRs, using a published conceptual model and tool for quantifying the extent of collaboration.
A national pool of experts in community pharmacy practice identified community pharmacists engaged in CWRs with physicians. Five pairs of community pharmacists and physician colleagues participated in individual semistructured interviews, and 4 of these pairs completed the Pharmacist-Physician Collaborative Index (PPCI). Main outcome measures include quantitative (ie, scores on the PPCI) and qualitative information about professional exchanges within 3 domains found previously to influence relationship development: relationship initiation, trustworthiness, and role specification.
On the PPCI, participants scored similarly on trustworthiness; however, physicians scored higher on relationship initiation and role specification. The qualitative interviews revealed that when initiating relationships, it was important for many pharmacists to establish open communication through face-to-face visits with physicians. Furthermore, physicians were able to recognize in these pharmacists a commitment for improved patient care. Trustworthiness was established by pharmacists making consistent contributions to care that improved patient outcomes over time. Open discussions regarding professional roles and an acknowledgment of professional norms (ie, physicians as decision makers) were essential.
The findings support and extend the literature on pharmacist-physician CWRs by examining the exchange domains of relationship initiation, trustworthiness, and role specification qualitatively and quantitatively among pairs of practitioners. Relationships appeared to develop in a manner consistent with a published model for CWRs, including the pharmacist as relationship initiator, the importance of communication during early stages of the relationship, and an emphasis on high-quality pharmacist contributions.
Pharmacists; Physicians; Collaborative working relationships; Pharmacist-physician collaborative index; Community
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Societal perspectives on community pharmacy services in West Bank - Palestine
Khdour, Maher R.
Hallak, Hussein O.
Pharmacy Practice
Understanding the public's view of professional competency is extremely important; however little has been reported on the public's perception of community pharmacists in Palestine
To determine the perception of Palestinian consumers of the community pharmacist and the services they offer.
This project used the survey methodology administered by structured interviews to consumers who attended the 39 randomly selected pharmacies, in six main cities in Palestine. The questionnaire had range of structured questions covering: Consumers' patronage patterns, consumers' interaction with community pharmacists, consumers' views on how the pharmacist dealt with personal health issues, procedure with regard to handling private consultations.
Of 1,017 consumers approached, 790 consumers completed the questionnaire (77.7 %). Proximity to home and presence of knowledgeable pharmacist were the main reasons for patients to visit the same pharmacy. Physicians were identified as the preferred source of advice by 57.2% and pharmacists by 23.8%. Only 17% of respondents considered pharmacists as health professionals who know a lot about drugs and are concerned about and committed to caring for the public. In addition, 49% indicated that pharmacists spoke more quietly cross the counter during counseling and almost one third reported that the pharmacist used a private area within the pharmacy. The majority of respondents would be happy to receive different extended services in the community pharmacy like blood pressure monitoring.
Palestinian consumers have a positive overall perception of community pharmacists and the services they offer. Awareness should be created amongst the public about the role of pharmacist and the added value they can provide as health care professional. There is a need to consider privacy when giving patient counseling to increase user satisfaction.
Patient Satisfaction; Pharmacists; Professional Role; Middle East
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Public's attitudes towards community pharmacy in Qatar: a pilot study
El Hajj, Maguy Saffouh
Salem, Samah
Mansoor, Hend
Patient preference and adherence
To assess the public's attitudes towards the community pharmacist's role in Qatar, to investigate the public's use of community pharmacy, and to determine the public's views of and satisfaction with community pharmacy services currently provided in Qatar.
Materials and methods
Three community pharmacies in Qatar were randomly selected as study sites. Patients 16 years of age and over who were able to communicate in English or Arabic were randomly approached and anonymously interviewed using a multipart pretested survey.
Over 5 weeks, 58 patients were interviewed (60% response rate). A total of 45% of respondents perceived community pharmacists as having a good balance between health and business matters. The physician was considered the first person to contact to answer drug- related questions by 50% of respondents. Most patients agreed that the community pharmacist should provide them with the medication directions of use (93%) and advise them about the treatment of minor ailments (79%); however, more than 70% didn't expect the community pharmacist to monitor their health progress or to perform any health screening. Half of the participants (52%) reported visiting the pharmacy at least monthly. The top factor that affected a patient's choice of any pharmacy was pharmacy location (90%). When asked about their views about community pharmacy services in Qatar, only 37% agreed that the pharmacist gave them sufficient time to discuss their problem and was knowledgeable enough to answer their questions.
This pilot study suggested that the public has a poor understanding of the community pharmacist's role in monitoring drug therapy, performing health screening, and providing drug information. Several issues of concern were raised including insufficient pharmacist– patient contact time and unsatisfactory pharmacist knowledge. To advance pharmacy practice in Qatar, efforts may be warranted to address identified issues and to promote the community pharmacist's role in drug therapy monitoring, drug information provision, and health screening.
pharmacist; public; attitudes; Qatar
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Using scenarios to test the appropriateness of pharmacist prescribing in asthma management
Hanna, Tamer
Bajorek, Beata
LeMay, Kate
Armour, Carol L.
Pharmacy Practice
To explore the potential for community pharmacist prescribing in terms of usefulness, pharmacists' confidence, and appropriateness, in the context of asthma management.
Twenty community pharmacists were recruited using convenience sampling from a group of trained practitioners who had already delivered asthma services. These pharmacists were asked to complete a scenario-based questionnaire (9 scenarios) modelled on information from real patients. Pharmacist interventions were independently reviewed and rated on their appropriateness according to the Respiratory Therapeutic Guidelines (TG) by three expert researchers.
In seven of nine scenarios (78%), the most common prescribing intervention made by pharmacists agreed with TG recommendations. Although the prescribing intervention was appropriate in the majority of cases, the execution of such interventions was not in line with guidelines (i.e. dosage or frequency) in the majority of scenarios. Due to this, only 47% (76/162) of the interventions overall were considered appropriate. However, pharmacists were deemed to be often following common clinical practice for asthma prescribing. Therefore 81% (132/162) of prescribing interventions were consistent with clinical practice, which is often not guideline driven, indicating a need for specific training in prescribing according to guidelines. Pharmacists reported that they were confident in making prescribing interventions and that this would be very useful in their management of the patients in the scenarios.
Community pharmacists may be able to prescribe asthma medications appropriately to help achieve good outcomes for their patients. However, further training in the guidelines for prescribing are required if pharmacists are to support asthma management in this way.
Asthma; Drug Prescriptions; Community Pharmacy Services; Professional Practice; Professional Role; Patient Simulation; Australia
Related Articles
Willingness to pay for a pharmacist's dispensing service: a cross-sectional pilot study in the state of Penang, Malaysia
Shafie, Asrul A.
Hassali, Mohamed A.
Pharmacy Practice
The aim of this pilot study was to assess the value of the dispensing service of pharmacists from the general public's perspective using the contingent valuation technique in the State of Penang, Malaysia.
Participants were conveniently sampled from malls and were given a self-completed questionnaire that collected the patient's demographic information and their knowledge about the pharmacist's dispensing service. They were then presented with a description of the pharmacist's dispensing service, the risk of medication errors in prescriptions and their consequences, and the risk reduction of medication errors associated with pharmacist intervention. The willingness to pay (WTP) of the participants was later assessed using a contingent valuation interview that asked the likelihood and maximum amount they were willing to pay.
In the study, 100 people participated, and 57% were aged between 18 and 35 years. Of these participants, 51% were women, and 46% of them earned more than 1000 MYR (285.71USD) per month. In addition, 8% of the participants had never visited a community pharmacy. Finally, 67% of the participants were willing to pay for the pharmacists' dispensing service, and the median amount that the participants were willing to pay was 10 MYR (2.86USD). The WTP amount was moderately correlated with their knowledge of the community pharmacist's dispensing services (r=0.377, p=0.02).
Generally, the public valued the pharmacist's dispensing service. Their acceptance can be further improved by educating the public on the role of the pharmacist.
Fees; Pharmaceutical; Community Pharmacy Services; Malaysia
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Stakeholder experiences with general practice pharmacist services: a qualitative study
Tan, Edwin C K
Stewart, Kay
Elliott, Rohan A
George, Johnson
BMJ Open
To explore general practice staff, pharmacist and patient experiences with pharmacist services in Australian general practice clinics within the Pharmacists in Practice Study.
Qualitative study.
Two general practice clinics in Melbourne, Australia, in which pharmacists provided medication reviews, patient and staff education, medicines information and quality assurance services over a 6-month period.
Patients, practice staff and pharmacists.
Semi-structured telephone interviews with patients, focus groups with practice staff and semi-structured interviews and periodic narrative reports with practice pharmacists. Data were analysed thematically and theoretical frameworks used to explain the findings.
34 participants were recruited: 18 patients, 14 practice staff (9 general practitioners, 4 practice nurses, 1 practice manager) and 2 practice pharmacists. Five main themes emerged: environment; professional relationships and integration; pharmacist attributes; staff and patient benefits and logistical challenges. Participants reported that colocation and the interdisciplinary environment of general practice enabled better communication and collaboration compared to traditional community and consultant pharmacy services. Participants felt that pharmacists needed to possess certain attributes to ensure successful integration, including being personable and proactive. Attitudinal, professional and logistical barriers were identified but were able to be overcome. The findings were explained using D'Amour's structuration model of collaboration and Roger's diffusion of innovation theory.
This is the first qualitative study to explore the experiences of general practice staff, pharmacists and patients on their interactions within the Australian general practice environment. Participants were receptive of colocated pharmacist services, and various barriers and facilitators to integration were identified. Future research should investigate the feasibility and sustainability of general practice pharmacist roles.
Primary Care; Qualitative Research; Health Services Administration & Management
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Demonstration of epinephrine autoinjectors (EpiPen and Anapen) by pharmacists in a randomised, simulated patient assessment: acceptable, but room for improvement
Salter, Sandra M
Loh, Richard
Sanfilippo, Frank M
Clifford, Rhonda M
Allergy, Asthma, and Clinical Immunology : Official Journal of the Canadian Society of Allergy and Clinical Immunology
Successful treatment of anaphylaxis in the community relies on early and correct use of epinephrine autoinjectors. Community pharmacists supply these devices and have a crucial role teaching patients how to use them. Supply of epinephrine autoinjectors in Australia increased 70-fold in the past decade. New EpiPen and Anapen autoinjectors were launched in Australia in 2011 and 2012, with the potential to cause confusion. However there is no information about how pharmacists demonstrate epinephrine autoinjectors to patients. Therefore the aim of this study was to assess real-world community pharmacist demonstrations of EpiPen and Anapen. We also sought to identify consultation-based predictors of accurate demonstration.
Demonstration accuracy was assessed in simulated patient visits to 300 randomly selected pharmacies. Pharmacists were asked by the simulated patient how to use original EpiPen, new-look EpiPen or Anapen, and assessed against the relevant Australasian Society of Clinical Immunology and Allergy (ASCIA) Action Plan for Anaphylaxis. Other anaphylaxis advice provided by the pharmacist was also recorded. Accuracy was analysed descriptively. Binary logistic regression was used to identify predictors of accurate demonstration.
All 300 pharmacies were visited. Of 250 pharmacist demonstrations, 46 (18.4%) accurately demonstrated all four steps on ASCIA Action Plan. Failure to state 'do not touch the needle' (74.8%) or 'massage injection site' (68.8%) reduced accuracy. However 163 (65.2%) accurately demonstrated the three steps required to inject epinephrine (no difference by device, p = 0.15). Associations with accurate demonstration were: checking if the patient had an anaphylaxis action plan (odds ratio, OR = 16.1; 95% CI: 3.86-67.3); stating to call an ambulance after use (OR = 4.0; 95% CI: 1.44-11.1); or explaining side effects of epinephrine (OR = 4.5; 95% CI: 1.48-13.4).
It is critical that anaphylaxis patients know how to use their prescribed epinephrine autoinjector correctly. Pharmacists have acceptable rates of EpiPen and Anapen demonstration accuracy, although more is needed to improve this. Those who pay attention to the need for action plans, emergency care after epinephrine use, and informing patients about the side effects of epinephrine may have better knowledge about anaphylaxis, and in turn significantly improve demonstration accuracy.
Primary care; Pharmacy practice; Simulated patient; Anaphylaxis; EpiPen; Anapen; Technique; Self-injectable epinephrine; Adrenaline
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An embedded longitudinal multi-faceted qualitative evaluation of a complex cluster randomized controlled trial aiming to reduce clinically important errors in medicines management in general practice
Cresswell, Kathrin M
Sadler, Stacey
Rodgers, Sarah
Avery, Anthony
Cantrill, Judith
Murray, Scott A
Sheikh, Aziz
There is a need to shed light on the pathways through which complex interventions mediate their effects in order to enable critical reflection on their transferability. We sought to explore and understand key stakeholder accounts of the acceptability, likely impact and strategies for optimizing and rolling-out a successful pharmacist-led information technology-enabled (PINCER) intervention, which substantially reduced the risk of clinically important errors in medicines management in primary care.
Data were collected at two geographical locations in central England through a combination of one-to-one longitudinal semi-structured telephone interviews (one at the beginning of the trial and another when the trial was well underway), relevant documents, and focus group discussions following delivery of the PINCER intervention. Participants included PINCER pharmacists, general practice staff, researchers involved in the running of the trial, and primary care trust staff. PINCER pharmacists were interviewed at three different time-points during the delivery of the PINCER intervention. Analysis was thematic with diffusion of innovation theory providing a theoretical framework.
We conducted 52 semi-structured telephone interviews and six focus group discussions with 30 additional participants. In addition, documentary data were collected from six pharmacist diaries, along with notes from four meetings of the PINCER pharmacists and feedback meetings from 34 practices. Key findings that helped to explain the success of the PINCER intervention included the perceived importance of focusing on prescribing errors to all stakeholders, and the credibility and appropriateness of a pharmacist-led intervention to address these shortcomings. Central to this was the face-to-face contact and relationship building between pharmacists and a range of practice staff, and pharmacists' explicitly designated role as a change agent. However, important concerns were identified about the likely sustainability of this new model of delivering care, in the absence of an appropriate support network for pharmacists and career development pathways.
This embedded qualitative inquiry has helped to understand the complex organizational and social environment in which the trial was undertaken and the PINCER intervention was delivered. The longitudinal element has given insight into the dynamic changes and developments over time. Medication errors and ways to address these are high on stakeholders' agendas. Our results further indicate that pharmacists were, because of their professional standing and skill-set, able to engage with the complex general practice environment and able to identify and manage many clinically important errors in medicines management. The transferability of the PINCER intervention approach, both in relation to other prescribing errors and to other practices, is likely to be high.
Qualitative evaluation; Randomized controlled trial; Pharmacist intervention; Primary care
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Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study
Gidman, Wendy
Ward, Paul
McGregor, Lesley
BMJ Open
To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs).
Qualitative study involving focus groups with members of the public.
The West of Scotland.
26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men.
Trust was seen as being crucial in healthcare settings. Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs. Importantly, participants' trust in GPs was greater than that in pharmacists. Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist's extended role was low. Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be 'high risk'. Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments. Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop. By contrast, participants' exposure to community pharmacists was limited. Additionally, a good understanding of the GPs' level of training and role promoted confidence.
Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust. It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be 'high risk', unless health systems change in a way that promotes trust in pharmacists. This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
Article summary
Article focus
Why do the public access GPs for services, which are also available in community pharmacies?
What sort of services do the public trust community pharmacists to deliver?
What factors underpin greater public trust in GP services relative to community pharmacy services?
Key messages
Public trust in GPs was greater than that in pharmacists; many were reluctant to trust pharmacists to deliver unfamiliar 'high-risk' services.
Numerous system-based factors reinforce public trust and confidence in GPs, including GP registration and appointment systems, GPs' expert/gatekeeper role and practice environments.
This study suggests that increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services could build public trust.
Strengths and limitations of this study
This is the first study to apply sociological perspectives of trust to understand public perspectives of community pharmacy.
The qualitative approach has allowed us to gather in-depth information in an under-researched area.
The study methodology limits generalisation, although theme saturation was achieved and the context of the study is explicitly defined.
Related Articles
The use of opioids at the end of life: knowledge level of pharmacists and cooperation with physicians
Borgsteede, Sander D.
Rhodius, Christiaan A.
De Smet, Peter A. G. M.
Pasman, H. Roeline W.
Onwuteaka-Philipsen, Bregje D.
Rurup, Mette L.
European Journal of Clinical Pharmacology
What is the level of knowledge of pharmacists concerning pain management and the use of opioids at the end of life, and how do they cooperate with physicians?
A written questionnaire was sent to a sample of community and hospital pharmacists in the Netherlands. The questionnaire was completed by 182 pharmacists (response rate 45%).
Pharmacists were aware of the most basic knowledge about opioids. Among the respondents, 29% erroneously thought that life-threatening respiratory depression was a danger with pain control, and 38% erroneously believed that opioids were the preferred drug for palliative sedation. One in three responding pharmacists did not think his/her theoretical knowledge was sufficient to provide advice on pain control. Most pharmacists had working agreements with physicians on euthanasia (81%), but fewer had working agreements on palliative sedation (46%) or opioid therapy (25%). Based on the experience of most of responding pharmacists (93%), physicians were open to unsolicited advice on opioid prescriptions. The majority of community pharmacists (94%) checked opioid prescriptions most often only after dispensing, while it was not a common practice among the majority of hospital pharmacists (68%) to check prescriptions at all.
Although the basic knowledge of most pharmacists was adequate, based on the responses to the questionnaire, there seems to be a lack of knowledge in several areas, which may hamper pharmacists in improving the quality of care when giving advice to physicians and preventing or correcting mistakes if necessary. If education is improved, a more active role of the pharmacist may improve the quality of end-of-life pharmacotherapy.
Opioids; Pain management; Pharmacists; Knowledge; Education; Multidisciplinary cooperation
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Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomised controlled trial
Holland, Richard
Brooksby, Iain
Lenaghan, Elizabeth
Ashton, Kate
Hay, Laura
Smith, Richard
Shepstone, Lee
Lipp, Alistair
Daly, Clare
Howe, Amanda
Hall, Roger
Harvey, Ian
BMJ : British Medical Journal
Objective To test whether a drug review and symptom self management and lifestyle advice intervention by community pharmacists could reduce hospital admissions or mortality in heart failure patients.
Design Randomised controlled trial.
Setting Home based intervention in heart failure patients.
Participants 293 patients diagnosed with heart failure were included (149 intervention, 144 control) after an emergency admission.
Intervention Two home visits by one of 17 community pharmacists within two and eight weeks of discharge. Pharmacists reviewed drugs and gave symptom self management and lifestyle advice. Controls received usual care.
Main outcome measures The primary outcome was total hospital readmissions at six months. Secondary outcomes included mortality and quality of life (Minnesota living with heart failure questionnaire and EQ-5D).
Results Primary outcome data were available for 291 participants (99%). 136 (91%) intervention patients received one or two visits. 134 admissions occurred in the intervention group compared with 112 in the control group (rate ratio=1.15, 95% confidence interval 0.89 to 1.48; P=0.28, Poisson model). 30 intervention patients died compared with 24 controls (hazard ratio=1.18, 0.69 to 2.03; P=0.54). Although EQ-5D scores favoured the intervention group, Minnesota living with heart failure questionnaire scores favoured controls; neither difference was statistically significant.
Conclusion This community pharmacist intervention did not lead to reductions in hospital admissions in contrast to those found in trials of specialist nurse led interventions in heart failure. Given that heart failure accounts for 5% of hospital admissions, these results present a problem for policy makers who are faced with a shortage of specialist provision and have hoped that skilled community pharmacists could produce the same benefits.
Trial registration number ISRCTN59427925.
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Impact of NGO Training and Support Intervention on Diarrhoea Management Practices in a Rural Community of Bangladesh: An Uncontrolled, Single-Arm Trial
Rahman, Ahmed S.
Islam, Mohammad Rafiqul
Koehlmoos, Tracey P.
Raihan, Mohammad Jyoti
Hasan, Mohammad Mehedi
Ahmed, Tahmeed
Larson, Charles P.
PLoS ONE
The evolving Non-Governmental Organization (NGO) sector in Bangladesh provides health services directly, however some NGOs indirectly provide services by working with unlicensed providers. The primary objective of this study was to examine the impact of NGO training of unlicensed providers on diarrhoea management and the scale up of zinc treatment in rural populations.
An uncontrolled, single-arm trial for a training and support intervention on diarrhoea outcomes was employed in a rural sub-district of Bangladesh during 2008. Two local NGOs and their catchment populations were chosen for the study. The intervention included training of unlicensed health care providers in the management of acute childhood diarrhoea, particularly emphasizing zinc treatment. In addition, community-based promotion of zinc treatment was carried out. Baseline and endline ecologic surveys were carried out in intervention and control villages to document changes in treatments received for diarrhoea in under-five children.
Among surveyed household with an active or recent acute childhood diarrhoea episode, 69% sought help from a health provider. Among these, 62.8% visited an unlicensed private provider. At baseline, 23.9% vs. 22% of control and intervention group children with diarrhoea had received zinc of any type. At endline (6 months later) this had changed to 15.3% vs. 30.2%, respectively. The change in zinc coverage was significantly higher in the intervention villages (p<0.01). Adherence with giving zinc for 10 days or more was significantly higher in the intervention households (9.2% vs. 2.5%; p<0.01). Child's age, duration of diarrhoea, type of diarrhoea, parental year of schooling as well as oral rehydration solution (ORS) and antibiotic usage were significant predictors of zinc usage.
Training of unlicensed healthcare providers through NGOs increased zinc coverage in the diarrhoea management of under-five children in rural Bangladesh households.
Trial Registration
ClinicalTrials.gov NCT02143921
Related Articles
HIV-1 Drug Resistance Emergence among Breastfeeding Infants Born to HIV-Infected Mothers during a Single-Arm Trial of Triple-Antiretroviral Prophylaxis for Prevention of Mother-To-Child Transmission: A Secondary Analysis
Zeh, Clement
Weidle, Paul J.
Nafisa, Lillian
Lwamba, Humphrey M.
Okonji, Jully
Anyango, Emily
Bondo, Philip
Masaba, Rose
Fowler, Mary Glenn
Nkengasong, John N.
Thigpen, Michael C.
Thomas, Timothy
PLoS Medicine
Analysis of a substudy of the Kisumu breastfeeding trial by Clement Zeh and colleagues reveals the emergence of HIV drug resistance in HIV-positive infants born to HIV-infected mothers treated with antiretroviral drugs.
Nevirapine and lamivudine given to mothers are transmitted to infants via breastfeeding in quantities sufficient to have biologic effects on the virus; this may lead to an increased risk of a breastfed infant's development of resistance to maternal antiretrovirals. The Kisumu Breastfeeding Study (KiBS), a single-arm open-label prevention of mother-to-child HIV transmission (PMTCT) trial, assessed the safety and efficacy of zidovudine, lamivudine, and either nevirapine or nelfinavir given to HIV-infected women from 34 wk gestation through 6 mo of breastfeeding. Here, we present findings from a KiBS trial secondary analysis that evaluated the emergence of maternal ARV-associated resistance among 32 HIV-infected breastfed infants.
Methods and Findings
All infants in the cohort were tested for HIV infection using DNA PCR at multiple study visits during the 24 mo of the study, and plasma RNA viral load for all HIV-PCR–positive infants was evaluated retrospectively. Specimens from mothers and infants with viral load >1,000 copies/ml were tested for HIV drug resistance mutations. Overall, 32 infants were HIV infected by 24 mo of age, and of this group, 24 (75%) infants were HIV infected by 6 mo of age. Of the 24 infants infected by 6 mo, nine were born to mothers on a nelfinavir-based regimen, whereas the remaining 15 were born to mothers on a nevirapine-based regimen. All infants were also given single-dose nevirapine within 48 hours of birth. We detected genotypic resistance mutations in none of eight infants who were HIV-PCR positive by 2 wk of age (specimens from six infants were not amplifiable), for 30% (6/20) at 6 wk, 63% (14/22) positive at 14 wk, and 67% (16/24) at 6 mo post partum. Among the 16 infants with resistance mutations by 6 mo post partum, the common mutations were M184V and K103N, conferring resistance to lamivudine and nevirapine, respectively. Genotypic resistance was detected among 9/9 (100%) and 7/15 (47%) infected infants whose mothers were on nelfinavir and nevirapine, respectively. No mutations were detected among the eight infants infected after the breastfeeding period (age 6 mo).
Emergence of HIV drug resistance mutations in HIV-infected infants occurred between 2 wk and 6 mo post partum, most likely because of exposure to maternal ARV drugs through breast milk. Our findings may impact the choice of regimen for ARV treatment of HIV-infected breastfeeding mothers and their infected infants.
Trial Registration
ClinicalTrials.gov NCT00146380
Please see later in the article for the Editors' Summary
Editors' Summary
Globally, more than 2 million children are infected with the human immunodeficiency virus (HIV) that causes acquired immunodeficiency syndrome (AIDS), and half a million children are newly infected every year. These infections are mainly the result of mother-to-child transmission (MTCT) of HIV during pregnancy, labor and delivery, or through breastfeeding. MTCT can be greatly reduced by treating HIV-positive mothers and their babies with antiretroviral drugs (ARVs). Without ARVs, up to half of babies born to HIV-positive mothers become infected with HIV. This rate of transmission falls to below 5% if a combination of three ARVs is given to the mother throughout pregnancy. Unfortunately, this triple-ARV therapy is too expensive for use in the resource-limited countries where most MTCT occurs. Instead, many such countries have introduced simpler, shorter ARV regimens such as a daily dose of zidovudine (a nucleoside reverse transcriptase inhibitor or NRTI) given to HIV-positive women during late pregnancy coupled with single-dose nevirapine (a non-nucleoside reverse transcriptase inhibitor or NNRTI) at the onset of labor, zidovudine and lamivudine (another NRTI) during labor and delivery, and single-dose nevirapine given to the baby at birth.
Why Was This Study Done?
More than 95% of HIV-exposed children are born in resource-limited settings where breastfeeding is the norm and is crucial for child survival even though it poses a risk of HIV transmission. Consequently, several recent studies have investigated whether MTCT can be further reduced by giving the mother ARVs while she is breastfeeding. In the Kisumu Breastfeeding Study (KiBS), for example, researchers assessed the effects of giving zidovudine, lamivudine, and either nevirapine or nelfinavir (a protease inhibitor) to HIV-infected women from 34 weeks of pregnancy through 6 months of breastfeeding. The results of KiBS indicate that this approach might be a safe, feasible way to reduce MTCT (see the accompanying paper by Thomas and colleagues). However, low amounts of nevirapine and lamivudine are transferred from mother to infant in breast milk and this exposure to ARVs could induce the development of resistance to ARVs among HIV-infected infants. In this KiBS substudy, the researchers investigate whether HIV drug resistance emerged in any of the HIV-positive infants in the parent study.
What Did the Researchers Do and Find?
In KiBS, 32 infants were HIV-positive at 24 months old; 24 were HIV-positive at 6 months old when their mothers stopped taking ARVs and when breastfeeding was supposed to stop. The researchers analyzed blood samples taken from these infants at various ages and from their mothers for the presence of HIV drug resistance mutations (DNA changes that make HIV resistant to killing by ARVs). They detected no resistance mutations in samples taken from 2-week old HIV-positive infants or from the infants who became infected after the age of 6 months. However, they found resistance mutations in a third and two-thirds of samples taken from 6-week and 6-month old HIV-positive infants, respectively. The commonest mutations conferred resistance to lamivudine and nevirapine. Moreover, resistance mutations were present in samples taken from all the HIV-positive infants whose mothers who had received nelfinavir but in only half those taken from infants whose mothers who had received nevirapine. Finally, most of the mothers of HIV-positive infants had no HIV drug resistance mutations, and only one mother-infant pair had an overlapping pattern of HIV drug resistance mutations.
What Do These Findings Mean?
These findings indicate that, in this KiBS substudy, the emergence of HIV drug resistance mutations in HIV-infected infants whose mothers were receiving ARVs occurred between 2 weeks and 6 months after birth. The pattern of mutations suggests that drug resistance most likely arose through exposure of the infants to low levels of ARVs in breast milk rather than through MTCT of drug-resistant virus. These findings need confirming but suggest that infants exposed to ARVs through breast milk—a situation that may become increasingly common given the reduction in MTCT seen in KiBS and other similar trials—should be carefully monitored for HIV infection. Providers should consider the mothers' regimen when choosing treatment for infants who are found to be HIV-infected despite maternal triple drug prophylaxis. Infants exposed to a maternal regimen with NNRTI drugs should receive first-line therapy with lopinavir/ritonavir, a protease inhibitor. The significance of the NRTI mutations such as M184V with regard to response to therapy needs further evaluation. The M184V mutation may result in hypersensitization to other NRTI drugs and delay or reverse zidovudine resistance. Given the limited availability of alternative drugs for infants in resource-limited settings, provision of the standard WHO-recommended first-line NRTI backbone, which includes 3TC, with enhanced monitoring of the infant to ensure virologic suppression, could be considered. Such an approach should reduce both illness and morbidity among infants who become HIV positive through breastfeeding.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/ 10.1371/journal.pmed.1000430.
The accompanying PLoS Medicine Research article by Thomas and colleagues describes the primary findings of the Kisumu Breastfeeding Study
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
HIV InSite has comprehensive information on HIV/AIDS
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on children, HIV, and AIDS and on preventing mother-to-child transmission of HIV (in English and Spanish)
UNICEF also has information about children and HIV and AIDS (in several languages)
The World Health organization has information on mother-to-child transmission of HIV (in several languages), and guidance on the use of ARVs for preventing MTCT
Related Articles
Pharmacists' response to anaphylaxis in the community (PRAC): a randomised, simulated patient study of pharmacist practice
Salter, Sandra M
Delfante, Brock
de Klerk, Sarah
Sanfilippo, Frank M
Clifford, Rhonda M
BMJ Open
To evaluate how community pharmacists manage patients with anaphylaxis.
A randomised, cross-sectional, simulated patient study of community pharmacist practice.
300 metropolitan pharmacies located in Perth Australia, randomised to three groups of 100 pharmacies. Each group corresponded to a different epinephrine autoinjector: original EpiPen, new-look EpiPen or Anapen.
300 pharmacies were visited with 271 simulated patient visits included in the final analysis (88=original EpiPen, 92=new-look EpiPen, 91=Anapen).
Outcome measures
Primary anaphylaxis preparedness (readiness to treat acute anaphylaxis). Secondary anaphylaxis engagement (willingness to engage the patient in a discussion about their anaphylaxis).
Simulated patients approached pharmacists, using a standardised scenario, for assistance with epinephrine autoinjector use and advice about the use of antihistamines in anaphylaxis. Scores for each outcome were obtained based on the number of predefined statements addressed by the pharmacist during the consultation (maximum score=5 for preparedness and 8 for engagement).
The mean anaphylaxis preparedness score was 2.39 points (SD 1.17). Scores for new-look EpiPen were significantly higher than for original EpiPen and Anapen (2.75 vs 2.38 points, p=0.027; 2.75 vs 2.03 points, p<0.001, respectively). Overall, 17.3% of pharmacists correctly demonstrated the epinephrine autoinjector. The mean anaphylaxis engagement score was 3.11 points (SD 1.73). Scores for new-look EpiPen were similar to original EpiPen and Anapen (3.11 vs 3.32 points; 3.11 vs 2.90 points, both p=0.42). Engagement was associated with preparedness. For each additional engagement point, preparedness increased by 7% (0.357 points; 95% CI 0.291 to 0.424; p<0.001).
Pharmacists demonstrated reasonable knowledge of anaphylaxis symptoms and emergency care, but had poor epinephrine autoinjector technique and rarely discussed anaphylaxis action plans. Pharmacists who had a more comprehensive discussion about anaphylaxis with patients, were more prepared for anaphylaxis emergencies. Future research should evaluate the nature and significance of errors in pharmacists' autoinjector technique.
Primary CAre; Pharmacy Practice; Simulated Patient; Anaphylaxis
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Awareness of the need for safe storage of Methadone at home is not improved by the use of protocols on recording information giving
Mullin, Annemarie
McAuley, Rosanna J
Watts, Derrett J
Crome, Ilana B
Bloor, Roger N
Harm Reduction Journal
Methadone is a synthetic, narcotic analgesic used in the treatment of drug misuse. Tragedies involving children being poisoned by the accidental ingestion of methadone are no longer a rare occurrence. Following an audit of the effectiveness of the provision and recall of information to patients attending an NHS Methadone Clinic a protocol was introduced to ensure that staff documented the provision of such information and patients gave a written confirmation that they had received the information.
The study was undertaken in the setting of an NHS methadone clinic with the aim of re- auditing the storage of methadone at home following the introduction of the new protocols. 174 patients completed an anonymous questionnaire regarding where they store methadone at home and whether they recall being given advice about safe storage. Community pharmacists were contacted by telephone to assess the level of advice given to methadone patients regarding safety.
Only 49 (28.2%) patients recalled being given advice about safe storage, 24 (13.8%) recalled that information was provided by clinic staff. 170 (97.7%) patients regard methadone as being dangerous. (28.2%). Methadone is most commonly stored in a cupboard (37.9%). All methadone is dispensed in a bottle with a child resistant cap on it. All patients reported they stored their methadone in the original bottle provided by the pharmacist.
Recall of information on safety issues is very poor. Provision of written as well as verbal information is needed. The use of printed safety information cards which patients can take away for future reference may be of use. It is the responsibility of health professionals to ensure they provide information and advice to methadone users on the safe storage of their methadone at home.
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"Packing for Bodrum!" Top 5 Page for this destination Bodrum Packing List Tip by Lyndra
Bodrum What to Pack: 5 reviews and 3 photos
Luggage and bags: Try to leave a wee bit of space in your case for any bargains you might find (leather goods are everywhere in Bodrum).
Clothing/Shoes/Weather Gear: Weather starts to rise from mid 20's in June to low 40's in August. Beach wear obviously required but take cool clothes for the evenings as even a short walk makes you "glow"! No rain at all in the summer months along the Aegean so leave the brolly and raincoat at home.
Toiletries and Medical Supplies: Bodrum has a couple of excellent pharmacies and some very large well stocked supermarkets so I would say to bring the bare minimum of toiletries (unless you have a particular taste in sun screen). You can get many famous brands but beware the fake stuff from smaller shops.
Camping/Beach/Outdoor Gear: You can buy very cheap toys (lilo's etc) from the beach front shops.
Miscellaneous: Food shopping in Bodrum is fine. Many UK branded foods are available so if you are self catering there is plenty of choice.
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Utopia Resturant at Down Town Long Beach
445 E. 1st st.
Long Beach, CA 90802
View Map | 562-432-6888
Cost: $ 50
Tuesday October 21, 2008 at 7 pm
Special guest Mr. Tom Halby
SEAFOOD CEVICHE, Grilled shrimp, calamari s& scallops in a spicy tomato cilantro sauce
Tay's Creek Chardonnay2005, Maipo Valley, Chile
PAN SAUTÉED SALMON, with Chilean Tomatillo Sauce
Tay's Creek Merlot 2005, Maipo Valley, Chile
BEEF PEBRE, filet Mignon topped with coriander, basil, mint garlic and limejuice sauce
Tay's Creek Cabernet Sauvignon 2005, Maipo Valley, Chile
UTOPIA HOMEMADE BREAD PUDDING with vanilla ice cream
St. Alicia Muscat 2005, Maipo Valley, Chile
Price: $ 50/ person (Tax & Gratuity not included)
Posted By: Utopia
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Event ID #207588
You can find current events for Long Beach by clicking here.
LocalWineEvents.com is the #1 ranked website for consumers who ARE ACTIVELY seeking local wine & food events to attend.
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ever since i bought this 2006 bmw 650i, at first the passenger side airbag malfunction light comes on and off, but now it's at a steady on light which is very annoying. BMW claims my year and vin isn't part of their recall which i think is bs. I fondled with the sensor on the bottom but it still comes on and off. please help.
by bklynzdknyjai in Brooklyn, NY on October 26, 2010


text:
Midwest City police lay canine officer to rest
MIDWEST CITY — Bonzo, a Midwest City police dog, was known around the squad room as "the old man" with a lot of heart for his job. Bonzo was buried Monday afternoon in Precious Pets Cemetery in Spencer, alongside several of his canine comrades in law enforcement. The funeral service was well attended by Midwest City police members, along with canine officers and their handlers from Guthrie, Del City, Ponca City and Logan and Oklahoma counties. Bonzo died Friday surrounded by fellow officers, said Jerry Kennedy, supervisor of the police department's K-9 unit. The 12-year-old Belgium Malinois had hip and spinal problems, and at the advice of a veterinarian, a decision was made to end his suffering, Kennedy said. "He was a good officer, but he got where he couldn't work anymore," Kennedy said. "That for him was probably worse than the pain." Bonzo was born and trained in Holland and brought to the United States by a trainer in Muskogee, Kennedy said. His expertise was drug detection, but he had extensive tracking and patrol experience too, he said. Bonzo recently assisted Choctaw police in tracking a home invasion suspect through a mobile home park. He helped find the suspect in an abandoned car, Kennedy said. "He's helped us find a lot of drugs through the years, but he was more than a tool for law enforcement," Kennedy said. "He was a partner to our officers." In 1999, Midwest City purchased Bonzo from the Muskogee trainer. Cpl. Randy Neal was his handler for about eight years and Bonzo worked a short stint with officer Lacky Harkins, Kennedy said. Six months before his death, Bonzo was partnered with officer Jake Doles. "Everyone always knew when I was on the radio, because they'd hear him barking in the background," Dole said. "He was an old man, but he loved the job." The night before his death, Bonzo went out on one last patrol with Doles. Bonzo was one of two police dogs with the Midwest City Police Department. There are plans to recruit another dog, Kennedy said.
Midwest City police Cpl. Randy Neal demonstrates how Bonzo uses his sense of smell to search a vehicle in this 2004 photo. Bonzo died Friday. OKLAHOMAN ARCHIVE PHOTO by Paul Hellstern


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|Sparks, Nev.
|High School:
|Spanish Springs HS
|3 Letters
Freshman Follow-Up: Q&A With Ashley Decker (july 12, 2011)
Freshman Feature: Q&A With Ashley Decker (Oct. 25, 2010)
2012 Quick Hits:
- Played in 36 games as DP or in the outfield
- Slugging .517, hitting .283
Berkeley Regional (2012):
- Pinch hit then started game seven in right
- Hit, slugged and had an OBP of .400 with two RBI in five at-bats
2011 Quick Hits:
- Named a Pac-10 All-Freshman Honorable Mention
- Played in 53 of Cal's 58 games, making 46 starts
- Sixth on the team in hitting at .242
- Split time between second base, outfield and designated player
- Was up for NFCA All-America status
- Hit .174 with four RBI in postseason
Women's College World Series (2011):
- Hit the very first triple of her career to score three runs against Alabama
- Was second on the team, hitting .333
- Tallied a team-high .667 slugging percentage and .500 on-base percentage
Lexington Super Regional (2011):
- Drew a walk in the top of the first in game three to score Cal's first run
High School:
- Named to the first-team all-state and all-league each of her four years
- Heralded as player of the year her senior and junior seasons
- Won three Nevada state championships with Spanish Springs High School
Club Ball:
- Took fifth place at the 2010 18 Gold Premier Nationals 5th Place with Sorcerer Gold
- With Arizona Hotshots Gold, she won the York, PA NQ Championships and finished 13th at 2009 ASA Gold Nationals
- Has been playing ASA since 2003, when she was 10
- Finished 13th at `08 ASA Gold Nationals with Sorcerer Gold and were the Boulder 18 Gold champion
- Nevada State Champions in 2006 with her 14U team, as well as in 2005 with the 12U
- Parents are Troy and Kim Decker
- Hopes to play for Team USA
- Considering majoring in American studies
- Lists playing in the Under Armour All-American game during her sophomore and senior years as her best sports moment to date
Have Bike and Phone, Will Travel: If you ask Ashley what's one thing she cannot live without, she will answer her phone. In her spare time, in addition to talking on the phone, Decker enjoys riding motorcycles and camping.
Native Nevadan: Of the five freshmen and 18 student-athletes on the squad, Ashley Decker is the only American not from the state of California. Decker came to Berkeley by way of Sparks, Nev. In each of her four years as a prepster at Spanish Springs High School, Decker was named first-team all-state and all-league, winning three Nevada state championships.
Why I Have My Number: My favorite numbers are 1, 22 and 23. I was number 1 in high school, was born on the 22nd and I just like the number 23. At Cal, I asked for 23, which was also my travel ball number.


text:
- Home
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This apartment is currently off the market. Go to the building page to see availabilities.
2 Bedroom, 1 Bath
Call for Availabilities
Starting from:$1,325
Call for Availabilities
Available immediately
One Year, Market Rate Lease
248 Reynolds Terrace
Orange, NJ 07050
Cross streets:
Carteret Place, South Center Street
Orange, NJ 07050
Cross streets:
Carteret Place, South Center Street
Tali Gonzalez
(973) 256-6344
Available No Fee Apartments at 248 Reynolds Terrace
Apartment Features
- Heat and Hot Water Included
- Electricity Included
- Cooking Gas Included
Building Features & Amenities
- Elevator
- Rental Property
Owner / Manager / Leasing Information for 248 Reynolds Terrace
For more information on this listing, contact:
Property Management:
MRM Management LLC
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2 Bedroom
2 Bedroom


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Death Toll Rises in Somalia Truck Bombing
Death Toll Rises in Somalia Truck Bombing
33817 results for 'News'. Showing results 24229 - 24246
Death Toll Rises in Somalia Truck Bombing
Scalia: Judges 'Ain't What They Used to Be'
GOP Demands Health Repeal with 1.6M Signatures
Justices Tackle 'Ministerial' Issue Involving Churches
Lawyers Fear Iran Concocting Case Against Pastor
Expert: US Gov't 'Terrorizing' Business Owners
Professor: Vanderbilt Univ. 'Suppressing' Christians
School Launches Probe into 'God Bless You' Case
Camp Helps Wounded Vets Climb Past Disabilities
Study: Exercise Can Lower Cancer Recurrence
TSA Tests New Airport Pre-Screening Program
Moody's Downgrades Italy's Bond Rating
What Christie's Absence Means for the GOP Field
Tomblin Wins W. Va. Special Election for Gov
Senate Dems Scramble to Rewrite Jobs Bill
Senate Ramping up for Trade War with China?
Death Toll Rises in Listeria Cantaloupe Outbreak
House: Investigate Atty. Gen. in 'Fast and Furious'


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Lavender is a fun, unique color produced by freshwater pearl mollusks. The color is completely natural and will not fade over time. Our lavender pearl earrings are available in a button shape which lays flat against the ear, or a round, traditional shape.
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text:
|I-6/2 I-6/2, Narmadanagar Bholav Industrial Estate, G I D, Bharuch, Gujarat, 392001 Wood and paper
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April 8th, 2012 (10:26 PM).
Showstealer Pro: Trial Version
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neon.png - Think I've given you a CnC on this.
eye-1.png - I quite like this, the intense colors work great with how gritty the tag looks. If you're going for a dead-center focal though, it's best that you not make it look symmetrical. Give it more rounded effects. Watch the quality too, it's really sharpened at places.
glitch.png - Nice use of displace. Nothing much to say though, haha.
shellshock.png - Love it, really scenic and the colors are spot-on. Again, watch out with the quality. You should add dust particles, to give it a more chaotic look. Otherwise, very hot.
laundryposter.jpg - Nice text, clean and simple.
Nyan cat is super randommm
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Jon Shenk's profile of Mohamed Nasheed, the first democratically elected leader of the Republic of Maldives, "The Island President," opens today at New York's Film Forum, following a surge of press after Nasheed was forced to leave office following a coup d'etat by loyalists to his predecessor, dictator Maumoon Abdul Gayoom.
Made before the tumultuous events of the past several weeks (he resigned February 7), "The Island President" follows Nasheed's quest as President to make his country (the lowest nation in the world, and therefore vulnerable to rising sea levels) the first to go carbon-neutral. Shenk, who also served as the film's cinematographer, tracks Nasheed's first year in office, leading up to the U.N. Climate Change Conference in Copenhagen in December 2009.
Indiewire caught up with Shenk in New York to discuss the making of "The Island President," whether he saw this dispiriting turn of events coming and why he didn't go back to shoot more following Nasheed's resignation.
How and when did you first become aware of Nasheed's efforts?
I read about Mohamed in October of 2008 when he won the first ever Democratic election for President in the Maldives. He just kind of jumped off the page at me because he was the first Democratic leader of a nation that was 100% Muslim, which at the time in '08 was very unusual. He stepped into office and immediately started saying these provocative and profoundly honest things about the environment.
I started following the story on the internet. Then in early '09, he made this commitment to make the Maldives carbon neutral. I thought, man this is just awesome. He was doing something for me, which I thought could come across in a film -- he was making climate change about people, about the human struggle. I thought, wait a minute, climate's been dealt with in films, but it always feel like a kind of medicine we need to take. There was a deadness about it.
In fact when we went for funding, several broadcasters said, "Oh, we can't do another film about climate change."
So I wanted to make a film about a person overcoming this task. In pitching to Nasheed, we realized we were asking for something insane: for the State to give a documentary crew access to his life and his world. To his credit, he's such a champion of transparency and good governance. He basically said let's do it.
I think at the time he didn't quite know what we needed (laughs).
You spent a full year and a half with him, correct?
We filmed for a year and ahalf, but we weren't there for the whole time, as much as I would haved loved to move to the Maldives. We did five trips. It was just a thrill. It's beautiful to get to know a country by getting to know its fledging democracy movement. It felt like you were watching history unfold before your eyes.
And also, to travel with Nasheed to these international climate meetings almost felt like being inside a James Bond movie. It's very intriguing to hear, "The meeting with China's set up. How are we going to play that?" It's almost like "The West Wing." You don't get to see that in truth because it's so delicate. But here was an opportunity to actually see the reality of it.
Your film doesn't give the sense that Nasheed was under this intense scrutiny and pressure following his victory. Were you surprised by the news of his forced resignation, or had you seen it coming having been with him for that long?
That's a great question. I kind of feel two ways about it. On one hand, we felt the shadow of the dictator.
You did?
Oh, yeah. When we first went there and we would meet out Maldivian contacts to talk about things that we wanted to film, often times we would ask questions and our answers would come in the form of whispers. The reason for that is that Gayoom, the dictator, had ruled with an iron fist. He used fear. People were scared that they could be arrested. They felt that Nasheed was an inspiring new hero for their country, but they also weren't confident that it would last. They had grown up in a country where there was one president for their entire lives. How could this young guy hold onto power after all that?
I always thought, gosh, why are you being so careful? Let's talk more openly. But in hindsight they were right to be scared. The police force still had a lot of people working fo Gayoom. They were loyalists to the dictator, probably because they were on the payroll of his supporters. Same with the military. The judiciary had never properly been reformed. Most of the judges in the Maldives were still appointees of the dictator. So you can imagine what Nasheed was up against.


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IBM Vt layoffs estimated at more than 300July 04,2013
IBMs layoffs put
at more than 300
MONTPELIER The states labor commissioner estimated that IBM laid off more than 300 Vermont workers in its recent round of job cuts, but a firmer total should be known by the end of next week.
Annie Noonan said IBM is required to notify the Labor Department within 24 hours of job separations becoming final, which is set to happen July 12.
She said by then the state should have a reliable figure of the total job cuts made public last month.
IBM has a policy of not releasing layoff totals.
Noonan said her estimate of about 310 layoffs is based on the number of IBM employees who have been showing up at state-run seminars on seeking new work.MORE IN This Just InMONTPELIER Former gubernatorial candidate Dan Feliciano plans to run for state auditor as a... Full StoryHONOLULU Hawaii could become the first state in the United States to enter gun owners into an... Full StoryNORRISTOWN, Pa. Full Story
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