Educating Substance Use Treatment Center Providers on Tobacco Use Treatments Is Associated with Increased Provision of Counseling and Medication to Patients Who Use Tobacco

Tobacco use is the leading preventable cause of death in America and is elevated among patients with non-tobacco substance use disorders. Substance use treatment centers (SUTCs) do not commonly address their patients' tobacco use. Lack of knowledge on treating tobacco use with counseling and medication may be a barrier that underlies this inaction. A multi-component tobacco-free workplace program implemented in Texas SUTCs educated providers on treating tobacco use with evidence-based medication (or referral) and counseling. This study examined how center-level changes in knowledge from pre- to post-implementation (i.e., over time) affected center-level behavioral changes in providers' provision of tobacco use treatment over time. Providers from 15 SUTCs completed pre- and post-implementation surveys (pre N = 259; post N = 194) assessing (1) perceived barriers to treating tobacco use, specifically, a lack of knowledge on treating tobacco use with counseling or medication; (2) receipt of past-year education on treating tobacco use with counseling or medication; and (3) their intervention practices, specifically, the self-reported regular use of (a) counseling or (b) medication intervention or referral with patients who use tobacco. Generalized linear mixed models explored associations between provider-reported knowledge barriers, education receipt, and intervention practices over time. Overall, recent counseling education receipt was endorsed by 32.00% versus 70.21% of providers from pre- to post-implementation; the regular use of counseling to treat tobacco use was endorsed by 19.31% versus 28.87% from pre- to post-implementation. Recent medication education receipt was endorsed by 20.46% versus 71.88% of providers from pre- to post-implementation; the regular use of medication to treat tobacco use was endorsed by 31.66% versus 55.15% from pre- to post-implementation. All changes were statistically significant (ps < 0.05). High versus low reductions in the provider-reported barrier of "lack of knowledge on pharmacotherapy treatment" over time were a significant moderator of effects, such that SUTCs with high reductions in this barrier were more likely to report greater increases in both medication education receipt and medication treatment/referral for patients who use tobacco over time. In conclusion, a tobacco-free workplace program implementation strategy that included SUTC provider education improved knowledge and resulted in increased delivery of evidence-based treatment of tobacco use at SUTCs; however, treatment provision rates-in particular, offering tobacco cessation counseling-remained less than desirable, suggesting that barriers beyond lack of knowledge may be important to address to improve tobacco use care in SUTCs. Moderation results suggest (1) differences in the mechanisms underlying uptake of counseling education versus medication education and (2) that the relative difficulty of providing counseling versus providing medication persists regardless of knowledge gains.

"There Is Method to This Madness" A Qualitative Investigation of Home Medication Management by Older Adults

OBJECTIVES

This paper explores (1) the systems and processes older adults use to manage medications at home, and (2) the well-being goals of personal interest that motivate them.

METHODS

Qualitative interviews were conducted in the homes of 12 older adults in a small city in the Midwest United States. Interviews were analyzed using inductive template analysis.

RESULTS

The average age of older adults in this study was 74.2 years (SD = 10.5), 66.7% were women. The most prominent home medication management tools used were pill boxes, containers and vials, and medication lists. Routines were often aligned with activities of daily living such as teeth brushing and eating. Their medication management work occurred in contexts of other household members and budget constraints. Routines and practices were sometimes idiosyncratic adaptations and supported goals of maintaining control and decreasing vulnerability.

CONCLUSION

In developing routines for home medication management, older adults developed systems and deliberate processes to make sense of their medication experiences in the context of their home environment and based on available resources.

Financial incentives to improve adherence: more clarity about their purpose may help the debate

Financial incentives for medication adherence have been controversial in mental healthcare. Much of the debate, however, may be based on a misconception of what financial incentives are and what their purpose is. Financial incentives are not meant to influence informed consent about treatment decisions, but to bridge the gap between intentions and behaviour and help patients achieve adherence to a treatment that they have agreed to. In this context, patients' positive views may reflect that the use of financial incentives can support a good therapeutic relationship rather than undermine it.

Effect of a Pharmacist Admission Medication Reconciliation Service at a Children's Hospital

OBJECTIVE

To evaluate the clinical effect and estimate cost avoidance attributed to a pharmacist-led admission medication reconciliation service at a children's hospital.

METHODS

This was a prospective observational cohort study that measured pharmacist interventions for pediatric patients over a 90-day period. Pharmacists logged all interventions identified during medication reconciliation in real time. Patient demographic data were collected retrospectively. Cost avoidance from prevented adverse drug events (ADEs) was estimated based on previously published literature.

RESULTS

Pharmacists completed 283 admission medication reconciliations during the study period. Of those, 69% of medication reconciliations required intervention. Interventions affected care during the hospital admission in 21.9% of patients and 8 medication reconciliations resulted in prevention of a major ADE. This pharmacist-led service resulted in an estimated cost avoidance of $46,746.65 in the 3-month period.

CONCLUSIONS

Implementation of a pharmacist-led admission medication reconciliation service for pediatric patients improved medication safety and resulted in significant cost avoidance, which justifies investment in these pharmacist resources.

Treatment of refractory localized pulmonary nocardiosis caused by Nocardia mexicana with a combination of medication and surgery

Pulmonary nocardiosis is a rare disease that is often difficult to cure because of its tendency to recur. Here, we report a case of refractory localized pulmonary nocardiosis caused by Nocardia mexicana. A 60-year-old Japanese woman had recurring pulmonary nocardiosis four times previously and each time she was treated with antibiotics for a sufficient duration; nevertheless, the disease continued to recur, probably because of resistance to antibiotics. As a fifth treatment, we performed middle lobe resection and pre- and post-operative antimicrobial therapy for 6 months. The combination of medication and surgery was useful for treating refractory localized pulmonary nocardiosis.

Gastrointestinal barriers to levodopa transport and absorption in Parkinson's disease

Levodopa is the gold standard for the symptomatic treatment of Parkinson's disease (PD). There are well documented motor and non-motor fluctuations, however, that occur almost inevitably once levodopa is started after a variable period in people with PD. Whilst brain neurodegenerative processes play a part in the pathogenesis of these fluctuations, a range of barriers across the gastrointestinal (GI) tract can alter levodopa pharmacokinetics, ultimately contributing to non-optimal levodopa response and symptoms fluctuations. GI barriers to levodopa transport and absorption include dysphagia, delayed gastric emptying, constipation, Helicobacter pylori infection, small intestinal bacterial overgrowth and gut dysbiosis. In addition, a protein-rich diet and concomitant medication intake can further alter levodopa pharmacokinetics. This can result in unpredictable or sub-optimal levodopa response, 'delayed on' or 'no on' phenomena. In this narrative review, we provided an overview on the plethora of GI obstacles to levodopa transport and absorption in PD and their implications on levodopa pharmacokinetics and development of motor fluctuations. In addition, management strategies to address GI dysfunction in PD are highlighted, including use of non-oral therapies to bypass the GI tract.

Race Differences in the Association Between Sleep Medication Use and Risk of Dementia

BACKGROUND

The effect of sleep medications on cognition in older adults is controversial, possibly dependent upon sleep quality, and may differ by race.

OBJECTIVE

To determine the longitudinal association between sleep medication use and incident dementia over 15 years, and to explore whether the association is independent of nighttime sleep disturbances and if it differs by race.

METHODS

We examined 3,068 community-dwelling older adults (aged 74.1±2.9 years, 41.7% Black, 51.5% female) without dementia. Sleep medication use was recorded three times by asking "Do you take sleeping pills or other medications to help you sleep?" with the response options: "Never (0)", "Rarely (≤1/month)", "Sometimes (2-4/month)", "Often (5-15/month)", or "Almost Always (16-30/month)". Incident dementia was defined using hospitalization records, dementia medication prescription or clinically significant decline in global cognition.

RESULTS

138 (7.71%) of Whites and 34 (2.66%) of Blacks reported taking sleep medications "often or almost always". Whites were almost twice as likely to take all prescription hypnotics. 617 participants developed dementia over the follow-up. After adjustment for all covariates, participants who reported taking sleep medications ≥ 5/month versus ≤1/month were significantly more likely to develop dementia, and the association was only observed among Whites (HR = 1.79,1.21-2.66) but not Blacks (HR = 0.84,0.38-1.83); p for interaction = 0.048. Further adjustment for nighttime sleep did not appreciably alter the results. The association was similar for the cumulative frequency of sleep medication use and remained after introducing a time lag of 3 years.

CONCLUSION

Frequent sleep medication use was associated with an increased risk of dementia in White older adults. Further research is needed to determine underlying mechanisms.

Effects of Oral Levodopa on Balance in People with Idiopathic Parkinson's Disease

BACKGROUND

Balance impairment is a frequent cause of morbidity and mortality in people with Parkinson's disease (PD). As opposed to the effects of appendicular motor symptoms, the effects of Levodopa on balance impairment in idiopathic PD are less clear.

OBJECTIVE

To review the literature on the effects of oral Levodopa on clinical balance test performance, posturography, step initiation, and responses to perturbation in people with idiopathic PD (PwPD).

METHODS

A systematic search of three scientific databases (Pubmed, Embase, and Web of Science) was conducted in accordance with PRISMA guidelines. For the pilot meta-analysis, standardized mean differences with 95% confidence intervals were calculated using an inverse variance random effects model. Data not suitable for implementation in the meta-analysis (missing means or standard deviations, and non-independent outcomes) were analyzed narratively.

RESULTS

A total of 2772 unique studies were retrieved, of which 18 met the eligibility criteria and were analyzed, including data of 710 idiopathic PwPD. Levodopa had a significant positive effect on the Berg Balance Scale, the Push and Release test, and jerk and frequency parameters during posturography. In contrast, some significant negative effects on velocity-based sway parameters were found during posturography and step initiation. However, Levodopa had no significant effect on most step initiation- and all perturbation parameters.

CONCLUSION

The effects of Levodopa on balance in PwPD vary depending on the outcome parameters and patient inclusion criteria. A systematic approach with well-defined outcome parameters, and prespecified, sensitive and reliable tests is needed in future studies to unravel the effects of oral Levodopa on balance.

A Pilot Study on Pharmacists' Knowledge, Attitudes and Practices towards Medication Dysphagia via Asynchronous Online Focus Group Discussion

Medication dysphagia (MD) refers to difficulty swallowing oral medications. To cope, patients may inappropriately modify or skip medications, leading to poorer outcomes. Little is known about healthcare professionals' (HCPs') perspectives in managing MD. This study investigated pharmacists' knowledge, attitudes, and practices (KAP) in caring for patients with MD. An asynchronous online focus group was pilot tested in seven pharmacists, with up to two questions posted daily on an online platform over 15 days. Thematic analysis of the transcripts revealed five interrelated themes: (1) knowledge about MD; (2) management of MD; (3) expectations of patient proactivity; (4) desire for objectivity; (5) professional roles. The findings provided insight into pharmacists' KAP and may be incorporated into a full-scale study involving various HCPs.

Internet Use for Obtaining Medicine Information: Cross-sectional Survey

BACKGROUND

The internet is increasingly being used as a source of medicine-related information. People want information to facilitate decision-making and self-management, and they tend to prefer the internet for ease of access. However, it is widely acknowledged that the quality of web-based information varies. Poor interpretation of medicine information can lead to anxiety and poor adherence to drug therapy. It is therefore important to understand how people search, select, and trust medicine information.

OBJECTIVE

The objectives of this study were to establish the extent of internet use for seeking medicine information among Norwegian pharmacy customers, analyze factors associated with internet use, and investigate the level of trust in different sources and websites.

METHODS

This is a cross-sectional study with a convenience sample of pharmacy customers recruited from all but one community pharmacy in Tromsø, a medium size municipality in Norway (77,000 inhabitants). Persons (aged ≥16 years) able to complete a questionnaire in Norwegian were asked to participate in the study. The recruitment took place in September and October 2020. Due to COVID-19 restrictions, social media was also used to recruit medicine users.

RESULTS

A total of 303 respondents reported which sources they used to obtain information about their medicines (both prescription and over the counter) and to what extent they trusted these sources. A total of 125 (41.3%) respondents used the internet for medicine information, and the only factor associated with internet use was age. The odds of using the internet declined by 5% per year of age (odds ratio 0.95, 95% CI 0.94-0.97; P=.048). We found no association between internet use and gender, level of education, or regular medicine use. The main purpose reported for using the internet was to obtain information about side effects. Other main sources of medicine information were physicians (n=191, 63%), pharmacy personnel (n=142, 47%), and medication package leaflets (n=124, 42%), while 36 (12%) respondents did not obtain medicine information from any sources. Note that 272 (91%) respondents trusted health professionals as a source of medicine information, whereas 58 (46%) respondents who used the internet trusted the information they found on the internet. The most reliable websites were the national health portals and other official health information sites.

CONCLUSIONS

Norwegian pharmacy customers use the internet as a source of medicine information, but most still obtain medicine information from health professionals and packet leaflets. People are aware of the potential for misinformation on websites, and they mainly trust high-quality sites run by health authorities.

Cancer occurrence after SLE: effects of medication-related factors, disease-related factors and survival from an observational study

OBJECTIVES

To explore the survival and risk factors for cancer occurrence after SLE (SLE-CA).

METHODS

Patients with cancer diagnosed after SLE in Peking Union Medical College Hospital between January 2006 and September 2017 were recruited and followed. Data regarding medication-related and disease-related factors and survival were collected and compared with matched controls. Logistic regressions were applied to identify risk factors. The Kaplan-Meier method with a log-rank test was performed to evaluate survival.

RESULTS

Forty-five SLE-CA patients and 128 controls were included, with the most common cancer site being the female genital system. SLE-CA patients were exposed to a higher cumulative dosage of CYC, with less mucocutaneous and haematologic involvement and higher anti-dsDNA positivity. At the time of cancer diagnosis, SLE-CA patients had lower SLEDAI 2000 (SLEDAI-2K), tended to achieve Definitions of Remission in SLE remission and minimal disease activity, but had higher SLICC/ACR Damage Index. Multivariable analysis identified high dosage of CYC [odds ratio (OR) 1.027, 95% CI 1.008, 1.046; P = 0.005] and low SLEDAI-2K at cancer diagnosis (OR 0.756, 95% CI 0.579, 0.986; P = 0.039) as risk factors. Mucocutaneous (OR 0.330, 95% CI 0.110, 0.991; P = 0.048) and haematologic involvement (OR 0.304, 95% CI 0.103, 0.902; P = 0.032) were negatively associated with cancer occurrence after SLE. The 5- and 10-year survival rates in SLE-CA patients were 95.2% and 92.1%, respectively. No significant difference of survival was observed between SLE-CA patients and controls (P = 0.177).

CONCLUSION

High dosage of CYC and disease-related factors (low SLEDAI-2K, less mucocutaneous and haematologic involvement) were related factors for cancer occurrence after SLE, while no survival difference was observed.

Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions

BACKGROUND

Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions.

OBJECTIVE

The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS.

METHODS

Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted.

RESULTS

Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I² = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms.

CONCLUSIONS

Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.

Quality improvement through audit: Zuclopenthixol acetate prescribing, monitoring and patient outcomes in a regional health service

OBJECTIVE

Prescribers' expectations of Zuclopethixol Acetate's (ZA) efficacy and tolerability are shaped by clinical experience and organisational culture; however, these expectations may not be consistent with current evidence and best practice.

METHODS

Quality improvement project (QIP) through a process audit of ZA prescribing, monitoring and patient outcomes (adverse events) in order to identify issues requiring intervention to align with service standards and practices.

RESULTS

QIP interventions resulted in a statistically significant shift in psychiatrist oversight, identifying high dose ZA with adverse outcomes and cessation of prescribing/administration within the Emergency Department. Clinically significant changes in patterns of prescribing were observed between pre-post intervention audits.

CONCLUSION

Entrenching an evidence-based QIP approach to clinical practice can effect clinically significant patterns of practice change to improve safe prescribing and drug monitoring.

Willingness to pay for medications among patients with Rome IV Irritable Bowel Syndrome

BACKGROUND

Little is known about willingness to pay for medications among individuals with irritable bowel syndrome (IBS).

METHODS

We collected demographic, gastrointestinal symptom, psychological health, quality of life, and healthcare usage data from 752 adults with Rome IV-defined IBS. We examined willingness to pay for a hypothetical medication in return for improvement in IBS symptoms using a contingent valuation method, according to these variables.

RESULTS

The median amount of money individuals was willing to pay was £1-£50 (IQR £0-£100) per month for a medication with a 100% chance of improving IBS symptoms. Women, compared with men, (92.7% willing to pay "£0," 89.8% "£1-£50," 87.3% "£51-£100," 78.9% "£101-£200," and 78.5% "more than £200," p = 0.008) were less likely to be willing to pay for a pill with a 100% chance of improving IBS symptoms whilst those with an annual income of £30,000 or more (12.2% willing to pay "£0," 25.2% "£1-£50," 33.5% "£51-£100," 40.2% "£101-£200," and 35.1% "more than £200," p = 0.002) were more likely. We observed a higher willingness to pay among those with lower IBS-related quality of life (p = 0.002 for trend). Of all 752 individuals, 92.7%, 74.5%, and 58.0% would be willing to pay for a medication that would give them a 100%, 50%, or 30% chance of improving IBS symptoms, respectively.

CONCLUSION

Patients with IBS are willing to pay for medications which improve IBS symptoms. Future studies should investigate the relative importance of medication pricing, efficacy, and side effect profile among individuals with IBS.

Clinical insight in first episode psychosis: the role of metacognition

BACKGROUND

Poor clinical insight has been commonly reported in those with First Episode Psychosis (FEP) and thought to be influenced by a range of factors, including neurocognition and symptoms. Clinical insight may be compromised as a result of alterations in higher-level reflective processes, such as metacognitive ability and cognitive insight.

AIMS

To explore whether metacognitive ability and cognitive insight are associated with clinical insight while controlling for IQ, depression, and symptoms in FEP.

METHODS

60 individuals with FEP completed measures for clinical insight, metacognitive ability, cognitive insight, positive and negative symptoms, depression, and IQ.

RESULTS

Higher levels of metacognitive ability were associated with better clinical insight, even when controlling for IQ, depression, positive and negative symptoms, and medication. Integration subscale of metacognitive ability was most strongly associated with clinical insight. Cognitive insight was associated with clinical insight when controlling for covariates. However, when including metacognitive ability and cognitive insight in the predictive model, only metacognitive ability was significantly related to clinical insight.

DISCUSSION

Metacognitive ability, specifically the ability to describe one's evolving mental state to provide a coherent narrative, was significantly related to clinical insight, independent of covariates, and may be a potentially important target for intervention in FEP.

Discontinuation and reduction of asthma medications after metabolic and bariatric surgery: A systematic review and meta-analysis

Obesity is a risk factor for asthma. Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for obesity. Weight reduction via MBS, in turn, may improve asthma outcomes and decrease the need for asthma medications. The aim of the systematic review and meta-analysis is to explore the available evidence focused on the impact of MBS on the improvement of asthma outcomes via the discontinuation and reduction of asthma medications. After a comprehensive search in the PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases, 15 studies, including pre-post MBS data on asthma medication use among adults, were eligible for the systematic review. Thirteen studies reported the proportion of patient who discontinued asthma medication post-MBS and was meta-analyzed using random effects. Results showed 54% patients completely discontinued asthma medications (95% confidence interval 42%-67%, I²  = 86.2%, p < 0.001). The average number of asthma medications was also decreased by approximately 22%-46%. MBS provides strong therapeutic benefits for patients with asthma, as evidenced by the complete discontinuation of asthma medications in over 50% of MBS completers. The inference was limited by the small number, variations in follow-up time and rates, and heterogeneity of studies. Studies that include more ethnically diverse participant samples are needed to improve generalizability.

Continuity of antipsychotic medication use among migrant and Finnish-born populations with a psychotic disorder: a register-based study

BACKGROUND

Higher incidence of psychotic disorders and underuse of mental health services have been reported among many migrant populations. This study examines the initiation and continuity of antipsychotic treatment among migrants and non-migrants with a non-affective psychosis during a new treatment episode.

METHODS

This study is based on a nationwide sample of migrants and Finnish-born controls. Participants who were diagnosed with a psychotic disorder in 2011-2014 were identified from the Care Register for Health Care (n = 1693). Information on purchases of antipsychotic drugs in 2011-2015 was collected from the National Prescription Register. The duration of antipsychotic treatment since diagnosis was estimated using the PRE2DUP model. Cox regression analysis was used to study factors that are associated with discontinuing the use of medication.

RESULTS

There were fewer initiators of antipsychotic treatment after being diagnosed with psychosis among migrants (68.1%) than among Finnish-born patients (73.6%). After controlling for sociodemographic background and factors related to the type of disorder and treatment, migrants were more likely to discontinue medication (adjusted hazard ratio 1.28, 95% confidence interval 1.08-1.52). The risk of discontinuation was highest among migrants from North Africa and the Middle East and Sub-Saharan Africa and among recent migrants. Non-use of antipsychotic treatment before being diagnosed with psychosis, involuntary hospitalization and diagnosis other than schizophrenia were associated with earlier discontinuation both among migrants and non-migrants.

CONCLUSIONS

Migrants with a psychotic disorder are less likely to continue antipsychotic treatment than non-migrants. The needs of migrant patients have to be addressed to improve adherence.

Comparison of mental health outcomes of augmenting medications for patients with posttraumatic stress disorder: A national veterans affairs study

RATIONALE

Posttraumatic stress disorder (PTSD) is highly prevalent among veterans. Many veterans with PTSD respond well to serotonin reuptake inhibitors (SRIs). Nonresponders may be prescribed augmenting medications, which are not as well-studied in PTSD.

AIMS AND OBJECTIVES

We used Veterans Health Administration electronic records to compare mental health outcomes (PTSD symptoms and rates of mental health hospitalizations and psychiatric emergency room visits) in patients with PTSD who were prescribed four different groups of augmenting medications (atypical antipsychotics, mirtazapine, prazosin or tricyclic antidepressants) in addition to SRIs-from the year before to the year after the start of the augmenting medication.

METHOD

We included data from 169,982 patients with a diagnosis of PTSD (excluding patients with comorbid bipolar or psychotic disorders) seen in Veterans Affairs care from 2007 to 2015 who were taking an SRI and filled a new prescription for one of the four augmenting medications for at least 60 days.

RESULTS

Patients evidenced minimal (<2%) reduction in PTSD symptoms and a larger reduction in psychiatric hospitalizations and psychiatric emergency room visits after receiving augmenting medications; this effect was largely similar across the four medication groups. Initiating augmenting medications was preceded by increases in PTSD symptoms, psychiatric hospitalizations and psychiatric emergency room visits. After initiating an augmenting medication, PTSD symptoms/hospitalizations/emergency room visits returned to baseline levels (before the start of the augmenting medication), but generally did not improve beyond baseline.

CONCLUSION

Importantly, these effects could be explained by regression to the mean, additional interventions or confounding. These findings should be further explored with placebo controlled randomized clinical trials.

Nurse Child Care Health Consultants, Professional Development, and Accreditation Improve Medication Safety in Child Care Programs

Medication administration is a critical safety issue in hospitals and the community. Children are especially at risk because of their dependence on adults to safely administer medications. The purpose of this study was to examine non-compliance with state child care medication administration regulations and factors associated with improved compliance. The data included routine, unannounced inspections of child care programs by state licensing specialists collected in two time periods over 10 years. Factors potentially associated with regulatory compliance were included in this secondary analysis. Most child care center medication administration regulations showed decreased non-compliance between the two time periods. However, regulations pertaining to prescriber orders and parent permission revealed a significant increase in non-compliance (58.4%). Factors positively associated with medication administration regulatory compliance included: compliance with annual professional development (p < 0.0001 in both periods), achievement of accreditation (p  =  0.0115 in Time 1), and among centers with children under 3 years of age, compliance with a weekly mandatory visit by a nurse consultant (p  =  0.0004 in Time 2). Though family child care homes had a lower frequency of medication administration non-compliance, only 19% were administering medications in Time 1. High quality, safe, and affordable child-care is essential for all children including those with special health care needs. This study highlights the importance of medication safety practices in child care programs, national child care health and safety standards, federal and state policies regarding medication administration regulations, and the critical role of nurse child care health consultants in promoting safe medication administration in child care programs.

Launching Relationship-Oriented Behavioral Services for Youth Opioid Use Disorder: Innovations in Medication Decision-Making and Adherence Planning

This article presents behavioral interventions designed to enhance uptake and retention on medication for opioid use disorder (MOUD) among transition-age youth (16-25 years) enrolled in treatment services. The article describes three relationship-oriented interventions designed to address barriers to MOUD uptake, enhance MOUD adherence planning, and strengthen OUD recovery among youth: Relational Orientation; Medication Education and Decision-making Support, and Family Leadership and Ownership of Adherence to Treatment. These interventions are inter-connected can be delivered flexibly. The article concludes with three case examples that illustrate how these modular interventions can be tailored to meet the needs of diverse client profiles.

Incidence and prevalence of drugs used for chronic diseases in survivors of adult-onset gynaecological cancer - A nationwide cohort study

OBJECTIVES

To evaluate both incidence and prevalence of drugs used for chronic diseases in survivors of adult-onset gynaecological cancer.

DESIGN

A prospective study.

SETTING

Population-based registries.

POPULATION

1.76 million women, including 17 500 women with gynaecological cancers.

METHODS

Data from the Cancer Registry of Norway was linked to the Norwegian Prescription Database and other national databases.

MAIN OUTCOME MEASURES

Prevalence ratios (PRs) and hazard ratios (HRs), with 95% confidence intervals (CIs), of dispensed drugs in gynaecological cancer patients (up to 15 years after diagnosis) were estimated by log-binomial and Cox regression, respectively, with cancer-free women as reference.

RESULTS

For gynaecological cancer patients, the incidence of drugs used for pain control was higher than in cancer-free women, especially the first 5 years after diagnosis, and the prevalence was high at least 10 years after. The prevalence of sex hormones was high in women with gynaecological cancer at least 10 years after diagnosis (cervical and ovarian cancer PR = 23, 95% CI 18-30 and PR = 29, 95% CI 15-38, respectively), but low in cancer-free women (0.3%). Patients with uterine corpus cancer had a higher prevalence of antidiabetics before and at least 10 years after diagnosis, most pronounced in women diagnosed before age 50 (PR = 10, 95% CI 5.0-21). The prevalence of antidepressants was moderately elevated in women with gynaecological cancers.

CONCLUSIONS

Gynaecological cancer survivors, particularly cervical and ovarian cancer survivors, had an increased long-term use of drugs for pain control and sex hormones. Survivors of uterine corpus cancer used antidiabetics more often, both before and after diagnosis.

Association Between Purchase of Over-the-Counter Medications and Ovarian Cancer Diagnosis in the Cancer Loyalty Card Study (CLOCS): Observational Case-Control Study

BACKGROUND

Over-the-counter (OTC) medications are frequently used to self-care for nonspecific ovarian cancer symptoms prior to diagnosis. Monitoring such purchases may provide an opportunity for earlier diagnosis.

OBJECTIVE

The aim of the Cancer Loyalty Card Study (CLOCS) was to investigate purchases of OTC pain and indigestion medications prior to ovarian cancer diagnosis in women with and without ovarian cancer in the United Kingdom using loyalty card data.

METHODS

An observational case-control study was performed comparing purchases of OTC pain and indigestion medications prior to diagnosis in women with (n=153) and without (n=120) ovarian cancer using loyalty card data from two UK-based high street retailers. Monthly purchases of pain and indigestion medications for cases and controls were compared using the Fisher exact test, conditional logistic regression, and receiver operating characteristic (ROC) curve analysis.

RESULTS

Pain and indigestion medication purchases were increased among cases 8 months before diagnosis, with maximum discrimination between cases and controls 8 months before diagnosis (Fisher exact odds ratio [OR] 2.9, 95% CI 2.1-4.1). An increase in indigestion medication purchases was detected up to 9 months before diagnosis (adjusted conditional logistic regression OR 1.38, 95% CI 1.04-1.83). The ROC analysis for indigestion medication purchases showed a maximum area under the curve (AUC) at 13 months before diagnosis (AUC=0.65, 95% CI 0.57-0.73), which further improved when stratified to late-stage ovarian cancer (AUC=0.68, 95% CI 0.59-0.78).

CONCLUSIONS

There is a difference in purchases of pain and indigestion medications among women with and without ovarian cancer up to 8 months before diagnosis. Facilitating earlier presentation among those who self-care for symptoms using this novel data source could improve ovarian cancer patients' options for treatment and improve survival.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03994653; https://clinicaltrials.gov/ct2/show/NCT03994653.

[The pharmacy tourism. Part I. The analysis of state of medicinal support of patients with rare diseases]

In Russia, the orphan diseases for many years are the object of intent attention both of the national legislation and health care system. The lower prevalence of these diseases in population causes predicaments to timely diagnosis, drug provision and medical care. Besides, absence of integrated approach to issues of diagnosis and treatment of rare diseases contribute nothing to fast solving of actual problems in this field. Frequently, impossibility to get necessary course of treatment forces patients with orphan diseases to seek for alternative sources. The article assesses current situation with medications support of patients suffering from diseases included in the list of life-threatening and chronic progressive rare (orphan) diseases that result in shortening life-span or disability and diseases included in the Federal Program "The 14 high-cost nosologies". The issues of keeping record of patients and financing medications purchase are touched upon. The study results identified problems of organization of medication support of patients with orphan diseases associated with complexity of accounting their number and absence of integral system of preferential medication support.

Factors Associated with Medication Adherence among Patients with Type 2 Diabetes Mellitus: A Hospital-Based Cross-Sectional Study in Nepal

As diabetes increases globally, high mortality increases due to complications of uncontrolled sugar. Medication adherence is important to control blood sugar and prevent its complications. Objective of the study was to identify factors associated with medication adherence among type 2 diabetes patients. A cross-sectional study was conducted among 343 patients visiting Dhulikhel Hospital, Nepal, for their fasting blood sugar test from September to December 2016. Inclusion criteria: patients with type 2 diabetes, under diabetes medication for past three months (minimum), age ≥ 18 years. The outcome of the study was medication adherence measured using the eight-item Morisky medication adherence scale (MMAS-8) (© 2006 Donald E. Morisky). Multivariate logistic regression was used for the analysis. Results showed that 61% of respondents had high medication adherence; adherence was positively associated with formal education [AOR: 2.43 (95% CI: 1.34, 4.39)] and attendance at diabetes counseling [AOR: 1.76 (95% CI: 1.02, 3.04)] after adjusting for age, occupation, medicine intake duration and diabetes medicine types. The study concluded that formal education and attendance at diabetes counseling positively affected patients' adherence to medicine. We encourage healthcare institutions to provide counseling services to all the patients with type 2 diabetes and focus more on those who are less educated.

Adverse Effects of α-2 Adrenergic Agonists and Stimulants in Preschool-age Attention-deficit/Hyperactivity Disorder: A Developmental-Behavioral Pediatrics Research Network Study

OBJECTIVES

To characterize and compare the type and frequency of a range of common and uncommon adverse effects (AEs) associated with α-2 adrenergic agonist (A2A) and stimulant treatment of attention-deficit/hyperactivity disorder at preschool-age as well as to evaluate the impact of age on common AEs.

STUDY DESIGN

This was a retrospective electronic medical record review of children <72 months of age (n = 497) evaluated at outpatient developmental-behavioral pediatric practices at 7 US academic medical centers within the Developmental-Behavioral Pediatrics Research Network. Data on AEs were abstracted for children who had treatment initiated by a developmental-behavioral pediatrician with an A2A or stimulant medication between January 2013 and July 2017; follow-up was complete by February 2019.

RESULTS

A2A and stimulants had distinctive AE profiles. A2A compared with stimulants had a greater proportion with daytime sleepiness and headaches; stimulants had significantly greater proportions for most other AE, including moodiness/irritability, difficulty with sleep, appetite suppression, stomachaches, skin picking/repetitive behaviors, withdrawn behavior, and weight loss. Younger age was associated with disruptive behavior and difficulty with sleep.

CONCLUSIONS

Stimulants had a greater rate of most AEs compared with A2A. AE profiles, together with efficacy, should inform clinical decision-making. Prospective randomized clinical trials are needed to fully compare efficacy and AE profiles of A2A and stimulants.

Adverse drug reactions in an ageing PopulaTion (ADAPT) study: Prevalence and risk factors associated with adverse drug reaction-related hospital admissions in older patients

Background: Older people experience greater morbidity with a corresponding increase in medication use resulting in a potentially higher risk of adverse drug reactions (ADRs). Objectives: The aim of this study was to; 1) determine the prevalence and characteristics of ADR-related hospital admissions among older patients (≥65 years) in Ireland; and 2) identify the risk factors associated with ADR-related hospital admissions. Methods: A cross-sectional study of ADR prevalence in patients aged ≥65 years admitted acutely to hospital in Ireland over a 8 month period (November 2016- June 2017). A multifaceted review of each hospital admission was undertaken to assess the likelihood of an ADR being a reason for admission (cause of admission or contributing to admission) in the context of the patient's medication, clinical conditions, comorbidities and investigations. A number of decision aids were applied by two independent reviewers to assess ADR causality, avoidability and severity. A random sample of patients, determined not to have a suspected ADR on screening, were assigned to a non-ADR control group. Multivariable logistic regression was used to assess the association between potential risk factors for ADR-related admissions compared with non-ADR-related admissions. Results: In total, 3,760 hospital admission episodes (in 3,091 patients) were screened and 377 admissions were considered ADR-related (10.0%, 95% CI 9.1%, 11.0%). 219 (58.1%) ADR-related admissions were caused by an ADR, while ADRs contributed to 158 (41.9%) admissions. 268 (71.1%) of all ADR-related admissions were deemed definitely or possibly preventable/avoidable. 350 (92.8%) ADRs were classified as being of moderate severity, with 27 (7.2%) classified as severe. Antithrombotic agents, mainly aspirin and warfarin, were the drugs most frequently associated with ADR-related admissions (gastrointestinal and vascular haemorrhagic disorders). In multivariable analysis, immobility, frailty, having delirium or ulcer disease and taking anticoagulant and antiplatelet medication on admission were significantly associated with an ADR-related hospital admission. Conclusion: One in ten hospital admissions, among those aged 65 + years, were considered ADR-related, with approximately 70% potentially avoidable. Reliable and validated ADR detection and prediction tools are needed to develop prevention strategies.

Effects of medication intake on the risk of hemorrhage in patients with sporadic cerebral cavernous malformations

Objective

Recurrent intracerebral hemorrhage (ICH) poses a high risk for patients with cerebral cavernous malformations (CCMs). This study aimed to assess the influence of medication intake on hemorrhage risk in sporadic CCMs.

Methods

From a database of 1,409 consecutive patients with CCM (2003-2021), subjects with sporadic CCMs and complete magnetic resonance imaging data were included. We evaluated the presence of ICH as a mode of presentation, the occurrence of ICH during follow-up, and medication intake, including beta blockers, statins, antithrombotic therapy, and thyroid hormones. The impact of medication intake on ICH at presentation was calculated using univariate and multivariate logistic regression with age and sex adjustment. The longitudinal cumulative 5-year risk for (re-)hemorrhage was analyzed using the Kaplan-Meier curves and the Cox regression analysis.

Results

A total of 1116 patients with CCM were included. Logistic regression analysis showed a significant correlation (OR: 0.520, 95% CI: 0.284-0.951, p = 0.034) between antithrombotic therapy and ICH as a mode of presentation. Cox regression analysis revealed no significant correlation between medication intake and occurrence of (re-)hemorrhage (hazard ratios: betablockers 1.270 [95% CI: 0.703-2.293], statins 0.543 [95% CI: 0.194-1.526], antithrombotic therapy 0.507 [95% CI: 0.182-1.410], and thyroid hormones 0.834 [95% CI: 0.378-1.839]).

Conclusion

In this observational study, antithrombotic treatment was associated with the tendency to a lower rate of ICH as a mode of presentation in a large cohort of patients with sporadic CCM. Intake of beta blockers, statins, and thyroid hormones had no effect on hemorrhage as a mode of presentation. During the 5-year follow-up period, none of the drugs affected the further risk of (re-)hemorrhage.

Asthma Medication Regimens in Pregnancy: Longitudinal Changes in Asthma Status

OBJECTIVE

This study aimed to assess the impact of common asthma medication regimens on asthma symptoms, exacerbations, lung function, and inflammation during pregnancy.

STUDY DESIGN

A total of 311 women with asthma were enrolled in a prospective pregnancy cohort. Asthma medication regimen was categorized into short-acting β agonist (SABA) alone, SABA + inhaled corticosteroid (ICS), SABA + ICS + long-acting β agonist (LABA), and no asthma medications (reference). We evaluated asthma control at enrollment (< 15 weeks' gestation) and its change into trimesters 2 and 3, including per cent predicted forced expiratory volume in 1 second (%FEV1) and peak expiratory flow (%PEF), pulse oximetry, fractional exhaled nitric oxide (FeNO), asthma symptoms (asthma attacks/month, night symptoms/week), and severe exacerbations. Linear mixed models adjusted for site, age, race, annual income, gestational age, body mass index, and smoking, and propensity scores accounted for asthma control status at baseline.

RESULTS

Women taking SABA + ICS and SABA + ICS + LABA had better first trimester %PEF (83.5% [75.7-91.3] and 84.6% [76.9-92.3], respectively) compared with women taking no asthma medications (72.7% [66.0-79.3]). Women taking SABA + ICS + LABA also experienced improvements in %FEV1 (+11.1%, p < 0.01) in the third trimester and FeNO in the second (-12.3 parts per billion [ppb], p < 0.01) and third (-11.0 ppb, p < 0.01) trimesters as compared with the trajectory of women taking no medications. SABA + ICS use was associated with increased odds of severe exacerbations in the first (odds ratio [OR]: 2.22 [1.10-4.46]) and second (OR: 3.15 [1.11-8.96]) trimesters, and SABA + ICS + LABA use in the second trimester (OR: 7.89 [2.75-21.47]). Women taking SABA alone were similar to those taking no medication.

CONCLUSION

Pregnant women taking SABA + ICS and SABA + ICS + LABA had better lung function in the first trimester. SABA + ICS + LABA was associated with improvements in lung function and inflammation across gestation. However, both the SABA + ICS and SABA + ICS + LABA groups had a higher risk of severe exacerbation during early to mid-pregnancy.

KEY POINTS

· Medication regimens may affect perinatal asthma control.. · Intensive regimens improved lung function/inflammation.. · Women on intensive regimens had more acute asthma events..

Delirium-associated medication in people at risk: A systematic update review, meta-analyses, and GRADE-profiles

BACKGROUND

Drug-associated delirium is a common but potentially preventable neuropsychiatric syndrome associated with detrimental outcomes. Empirical evidence for delirium-associated medication is uncertain due to a lack of high-quality studies. We aimed to further investigate the body of evidence for drugs suspected to trigger delirium.

METHODS

A systematic update review and meta-analyses of prospective studies presenting drug associations with incident delirium in adult study populations was conducted. Two authors independently searched MEDLINE, PsycINFO, Embase, and Google Scholar dated from October 1, 2009 to June 23, 2020, after screening a previous review published in 2011. The most reliable results on drug-delirium associations were pooled in meta-analyses using the random-effects model. Quality of evidence was assessed using the GRADE-approach. This study is preregistered with OSF (DOI https://doi.org.10.17605/OSF.IO/4PUHY).

RESULTS

The 31 eligible studies, presenting results for 24 medication classes were identified. Meta-analyses and GRADE level of evidence ratings show no increased delirium risk for Haloperidol (OR: 0.96, 95% CI 0.72-1.28; high-quality evidence), Olanzapine (OR: 0.25, 95% CI 0.15-0.40), Ketamine (OR: 0.72, 95% CI 0.35-1.46) or corticosteroids (OR: 0.69, 95% CI 0.32-1.50; moderate quality evidence, respectively). Low-level evidence suggests a three-fold increased risk for anticholinergics (OR: 3.11, 95% CI 1.04-9.26). Opioids, benzodiazepines, H₁ -antihistamines, and antidepressants did not reach reliable evidence levels in our analyses.

CONCLUSION

We investigated the retrievable body of evidence for delirium-associated medication. The results of this systematic review were then interpreted in conjunction with other evidence-based works and guidelines providing conclusions for clinical decision-making.

Indian Psychiatric Society multicentre study: Diagnostic patterns, comorbidity and prescription practices for patients with Dementia

BACKGROUND

There are more than 5 million people with dementia in India. Multicentre studies looking at details of treatment for people with dementia In India are lacking. Clinical audit is a quality improvement process which aims to systematically assess, evaluate, and improve patient care. Evaluating current practice is the key to a clinical audit cycle.

AIM

This study aimed to assess the diagnostic patterns and prescribing practices of psychiatrists for patients with dementia in India.

METHOD

A retrospective case file study was conducted across several centers in India.

RESULTS

Information from the case records of 586 patients with dementia was obtained. Mean age of the patients was 71.14 years (standard deviation = 9.42). Three hundred twenty one (54.8%) were men. Alzheimer's disease (349; 59.6%) was the most frequent diagnosis followed by vascular dementia (117; 20%). Three hundred fifty five (60.6%) patients had medical disorders and 47.4% patients were taking medications for their medical conditions. Eighty one (69.2%) patients with vascular dementia had cardiovascular problems. Majority of the patients (524; 89.4%) were on medications for dementia. Most frequently prescribed treatment was Donepezil (230; 39.2%) followed by Donepezil-Memantine combination (225; 38.4%). Overall, 380 (64.8%) patients were on antipsychotics. Quetiapine (213, 36.3%) was the most frequently used antipsychotic. Overall, 113 (19.3%) patients were on antidepressants, 80 (13.7%) patients were on sedatives/hypnotics, and 16 (2.7%) patients were on mood stabilizers. Three hundred nineteen (55.4%) patients and caregivers of 374 (65%) patients were receiving psychosocial interventions.

CONCLUSIONS

Diagnostic and prescription patterns in dementia which emerged from this study are comparable to other studies both nationally and internationally. Comparing current practices at individual and national levels against accepted guidelines, obtaining feedback, identifying gaps and instituting remedial measures help to improve the standard of care provided.

Developing and piloting a cross-sectoral hospital pharmacist intervention for patients in transition between hospital and general practice

Background

Healthcare is challenged by a rapidly growing group of patients with multi-morbidity and polypharmacy. Increasing activity and specialization puts pressure on healthcare sectors. Medication errors in cross-sectoral transition of patients are often seen. The aim of the study was to explore drug-related problems (DRPs) in the transition of patients between sectors and to develop and pilot-test a cross-sectoral hospital pharmacist intervention to overcome some of these problems.

Methods

DRPs in cross-sectoral transitions were explored from four perspectives; the literature, the primary and secondary healthcare sector and the patients. An intervention was developed from the findings through co-creation between pharmacists, doctors and a nurse. The intervention was piloted and evaluated from data on the included patients and the activities performed.

Results

DRPs in transitions from general practice (GP) to hospital were caused by inadequate focus on updating the Shared Medication Record (SMR). For patients being discharged, DRPs were described with multiple facets; for example, missing information on medication changes, lacking patient involvement and problems with dose-dispensed medicine or electronic prescriptions. An intervention with a pharmacist in a shared employment between Hospital Pharmacy and GP was developed and piloted. The intervention included medication reconciliation and updating SMR for patients referred to hospital; and medication review, overview of medication changes and follow-up telephone calls for patients discharged from hospital. The intervention identified and solved several DRPs; in this way, medication errors were avoided. Access to health records in both sectors was important in the identification and resolution of DRPs.

Conclusion

DRPs in cross-sectoral transitions are multifaceted and the experiences depend on the point of view. The cross-sectoral hospital pharmacist intervention identified and solved several DRPs and medication errors were avoided. The intervention made sense to both healthcare sectors and patients. Shared employment and unique access to health records in both sectors showed to be of importance in the identification and resolution of DRPs.

Plain language summary

Development and pilot-test of a pharmacist intervention for patients in transition between hospital and general practice Background: Healthcare is challenged by a rapidly growing group of patients with multiple chronic diseases treated with several drugs at the same time. The aim of the study was to explore drug-related problems in the transition of patients between the hospital and patients' general practitioner and to develop and pilot-test a pharmacist intervention to overcome some of these problems.Methods: Drug-related problems in patient transitions were explored from the perspectives of the hospital, the general practitioner, the patients and the literature. An intervention was developed from the findings by pharmacists, doctors and a nurse. The intervention was pilot-tested and evaluated from the descriptions of the included patients and activities performed.Results: Drug-related problems in transitions from general practice to hospital were caused by inadequate focus on updating the Shared Medication Record.For patients being discharged, drug-related problems were related to for examplemissing information on medication changessparse involvement of the patient in their own treatmentproblems with medicine dispensed on a dose dispensing machine at the local pharmacy.An intervention with a pharmacist in a shared employment between Hospital Pharmacy and general practice was developed and piloted. The intervention includedtalking to the patient about their medication and updating the Shared Medication Record for patients referred to hospitalmedication review, overview of medication changes and follow-up telephone calls for patients discharged from hospital to general practice.The intervention identified and solved several drug-related problems. Access to health records in both the general practice and at the hospital was important in the identification of drug-related problems.Conclusions: Drug-related problems in cross-sectoral transitions are multifaceted. The pharmacist intervention identified and solved several drug-related problems. The intervention made sense to the general practitioner, hospital and patients. Shared employment and unique access to health records in both the general practice and at the hospital showed to be of importance in the identification of drug-related problems.

Seizure Analysis Presented to Emergency Department in Saudi Arabia: New VS Chronic Cases

Background

Epilepsy, characterized by recurrent unprovoked seizures, poses a significant global burden on individuals and healthcare systems. Accurate identification of underlying causes is vital for optimal intervention. However, studies reveal a lack of standardized approaches, potentially resulting in unnecessary investigations.

Objective

We aimed to highlight the importance of avoiding unnecessary testing to minimize healthcare costs and resource waste.

Methods

In the Emergency Department of King Fahd Hospital of the University (KFUH) in Alkhobar, a retrospective cross-sectional study encompassed 190 patients presenting with seizures from January 1, 2020, to December 31, 2022. The study aimed to elucidate the epidemiological profile and distinguish clinical and demographic factors between new onset seizures and known cases.

Results

The study included 190 epilepsy cases, with 51.1% known and 48.9% new onset. Generalized tonic-clonic seizures were prominent (43.2%), and non-compliance (24.2%) was a leading cause. New onset seizures were associated with abnormal CT findings (p=0.025), drug use (74.2%), and intoxication (6.5%). Demographically, Saudis showed higher new onset prevalence (82.8%, p=0.001).

Conclusion

The average length of stay was 5.93 hours, and the distribution of new vs. known cases was nearly equal among the 190 patients. Laboratory findings showed no significant associations with either group, mostly falling within the normal range. To optimize care further, we recommend continued refinement of protocols, emphasis on medication compliance.

Effect of a Pharmacist-Led Discharge Counseling Service at a Children's Hospital

OBJECTIVE

To evaluate the effect of a pharmacist-led discharge counseling service at a pediatric hospital.

METHODS

This was a prospective observational cohort study. Patients in the pre-implementation phase were identified by the pharmacist at the time of admission medication reconciliation, whereas patients in the pos-timplementation phase were identified at the time of pharmacist discharge medication counselling. Caregivers were contacted within 2 weeks of the patients' discharge date to complete a 7-question telephone survey. The primary objective was to measure the effect of the pharmacist-led service on caregiver satisfaction, using a pre- and post- implementation telephone survey. The secondary objectives were to evaluate the effect of the service on 90-day medication-related readmissions and determine the change in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response (Question 25) regarding discharge medications following implementation of the new service.

RESULTS

A total of 32 caregivers were included in both the pre- and post-implementation groups. The most common reason for inclusion was high-risk medications (84%) in the pre-implementation group and device teaching (62.5%) in the post-implementation group. The primary outcome, the average composite score on the telephone survey, was 30.94 ± 3.50 (average ± SD) in the pre-implementation group and 32.5 ± 2.26 in the post-implementation group (p = 0.038). There were no medication-related readmissions within 90 days in either group. The score on HCAHPS Question 25 was not different between groups (p = 0.761).

CONCLUSIONS

Implementation of a pharmacist-led discharge counseling service in pediatric patients improved caregiver satisfaction and understanding as shown by a postdischarge telephone survey.

Practical recommendations for the management of children after kidney and liver transplantation

The number of pediatric solid organ transplantations is growing. This therapy leads often to better quality of life but also brings some specific complications. Our review summarizes practical recommendations for long-time care of the children after kidney and liver transplantation. The knowledge of the issues related to transplantation is essential for the first contact physicians, whose cooperation with transplant centre contributes highly to adequate management of these children.

Parents' expectation of antibiotic prescriptions for respiratory infections in children: a systematic review and meta-analysis

Objectives

Despite most childhood infections being self-limiting, children are among the leading consumers of antibiotics. Little is known about parental expectations of antibiotics for childhood infections. A comprehensive systematic review and meta-analysis was conducted to explore the nature and extent of parental expectations of antibiotic prescriptions for children with respiratory infections.

Design

Systematic review and meta-analysis.

Methods

An extensive literature search using six major scientific databases was conducted for all published articles until 7 December 2022. Primary studies reporting parents' expectations of antibiotics for children with upper respiratory tract infections were included after assessment for quality. Heterogeneity between the studies was assessed using the I² statistic and publication bias was analyzed using funnel plots and Egger regression tests. The primary outcome was a summary estimate of the percentage of parents who expect antibiotics from their physicians when their child presents with an upper respiratory tract infection.

Results

From a total of 4510 studies found in the initial searches, a final pool of 19 eligible studies with 15,664 individuals was included in this meta-analysis. Nine of the 19 studies were from the United States or Saudi Arabia. The pooled prevalence of parental expectations of antibiotics in the population reviewed was 55.78% (95% CI = 44.60-66.41). There was significant heterogeneity between the studies, but funnel plot and meta-regression did not detect any publication bias.

Conclusion

More than half of parents expect antibiotics for their children during consultation for upper respiratory tract infections. Such practices may cause undue side effects among children, contribute to the growing burden of antibiotic resistance, and lead to treatment failure for many common infections in the future. To optimize efforts to tackle antimicrobial resistance, shared decision-making and education emphasizing the proper and judicious use of antibiotics are much needed in pediatric healthcare settings. This can also help to manage parents' expectations when seeking antibiotics for their children. Despite pressure from parents, pediatric healthcare providers should continue to advocate for antibiotic use only when warranted and help improve knowledge and awareness amongst parents.

Registration

The protocol has been registered with PROSPERO (CRD42022364198).

Psychiatric Diagnoses and Medications in Wolfram Syndrome

Background

Wolfram Syndrome is a rare genetic disorder usually resulting from pathogenic variation in the WFS1 gene, which leads to an exaggerated endoplasmic reticulum (ER) stress response. The disorder is typically characterized by diabetes insipidus, diabetes mellitus, optic nerve atrophy, hearing loss, and neurodegenerative features. Existing literature suggests it may also have psychiatric manifestations.

Objective

To examine lifetime psychiatric diagnoses and medication history in Wolfram Syndrome.

Method

Child, adolescent, and young adult Wolfram Syndrome participants (n=39) were assessed by a child & adolescent psychiatrist to determine best estimate DSM-5 lifetime psychiatric diagnoses as well as psychoactive medication history. In addition, the Child & Adolescent Symptom Inventory-5 (CASI-5) Parent Checklist was used to determine likely psychiatric diagnoses based on symptom counts in Wolfram Syndrome patients (n=33), type 1 diabetes (n=15), and healthy comparison (n=18) groups.

Results

Study participants with Wolfram Syndrome had high lifetime rates of anxiety disorders (77%). Also, 31% had an obsessive-compulsive spectrum disorder, 33% had a mood disorder, 31% had a neurodevelopmental or disruptive behavior disorder, and 31% had a sleep-wake disorder. More than half of Wolfram Syndrome participants had taken at least one psychoactive medication, and one third had taken at least one selective serotonin reuptake inhibitor (SSRI). Some individuals reported poor response to sertraline but better response after switching to another SSRI (fluoxetine or citalopram). In general, people with Wolfram Syndrome often reported benefit from psychotherapy and/or commonly used psychoactive medications appropriate for their psychiatric diagnoses.

Conclusions

Wolfram Syndrome may be associated with elevated risk for anxiety and obsessive-compulsive spectrum disorders, which seem generally responsive to usual treatments for these disorders.

Antidepressant Adherence Among Hispanics: Patients in an Integrated Health Care Model

Purpose

We report on antidepressant (AD) adherence among Hispanics seeking mental health services in a community primary care clinic in Texas as an ancillary outcome from a National Institutes of Health-funded study that collected data on Hispanic AD adherence over a period of two years (February 2016-February 2018). Adherence to AD medications was measured throughout the year-long trial and compared across various demographic characteristics. Since Hispanic individuals often experience stigma and cultural barriers related to AD treatment, we sought to understand what factors may increase the likelihood of non-adherence in this population.

Patients and Methods

This study focused on 69 patients who were prescribed AD medications while receiving treatment through an integrated health care model. Adherence was measured with the Patient Adherence Questionnaire, a validated 2-item questionnaire that asks patients about their medication use (missed medications or dosage changes) over the past week. We looked at patient adherence at two key time points (4-weeks and 13-weeks) and utilized logistic regression to identify factors that may increase or decrease the likelihood of adherence in Hispanic patients at a community primary care clinic.

Results

Non-adherence to AD medication was 49.3% at 4-weeks and 57% at 13-weeks post-treatment initiation. Logistic regression analyses revealed that age was the only significant predictor of AD non-adherence. As age increased, the likelihood of adherence increased by 12.2% at 13-weeks post-treatment initiation and by 11.1% at 4-weeks post-treatment initiation.

Conclusion

The likelihood of Hispanic patients to adhere to AD therapy increased with the age of the patient. Since primary care is the most likely place to be prescribed an AD for Hispanic patients, further research to better understand adherence is essential. Integrated health care interventions designed to help identify, reduce, or eliminate barriers to adherence and improve cultural understanding may help address issues of non-adherence in primary care settings.

Digital Medicine System in Veterans With Severe Mental Illness: Feasibility and Acceptability Study

BACKGROUND

Suboptimal medication adherence is a significant problem for patients with serious mental illness. Measuring medication adherence through subjective and objective measures can be challenging, time-consuming, and inaccurate.

OBJECTIVE

The primary purpose of this feasibility and acceptability study was to evaluate the impact of a digital medicine system (DMS) among Veterans (patients) with serious mental illness as compared with treatment as usual (TAU) on medication adherence.

METHODS

This open-label, 2-site, provider-randomized trial assessed aripiprazole refill adherence in Veterans with schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder. We randomized 26 providers such that their patients either received TAU or DMS for a period of 90 days. Semistructured interviews with patients and providers were used to examine the feasibility and acceptability of using the DMS.

RESULTS

We enrolled 46 patients across 2 Veterans Health Administration sites: 21 (46%) in DMS and 25 (54%) in TAU. There was no difference in the proportion of days covered by medication refill over 3 and 6 months (0.82, SD 0.24 and 0.75, SD 0.26 in DMS vs 0.86, SD 0.19 and 0.82, SD 0.21 in TAU, respectively). The DMS arm had 0.85 (SD 0.20) proportion of days covered during the period they were engaged with the DMS (mean 144, SD 100 days). Interviews with patients (n=14) and providers (n=5) elicited themes salient to using the DMS. Patient findings described the positive impact of the DMS on medication adherence, challenges with the DMS patch connectivity and skin irritation, and challenges with the DMS app that affected overall use. Providers described an overall interest in using a DMS as an objective measure to support medication adherence in their patients. However, providers described challenges with the DMS dashboard and integrating DMS data into their workflow, which decreased the usability of the DMS for providers.

CONCLUSIONS

There was no observed difference in refill rates. Among those who engaged in the DMS arm, the proportion of days covered by refills were relatively high (mean 0.85, SD 0.20). The qualitative analyses highlighted areas for further refinement of the DMS.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03881449; https://clinicaltrials.gov/ct2/show/NCT03881449.

Self-Management of Medication on a Cardiology Ward: Feasibility and Safety of the SelfMED Intervention

An intervention, SelfMED, was introduced to facilitate patient self-management of medication during hospitalization. This study aimed to evaluate the feasibility and safety of the SelfMED intervention. All patients in a cardiology ward in a Belgian regional hospital were assessed for suitability for inclusion, applying an evidence-based stepped assessment tool. Patients eligible for medication self-management and willing to participate were included in the study (i.e., consecutive sampling). Patients who self-managed their medication were closely monitored by nurses. The feasibility of medication self-management was evaluated by implementation and completion rates and the opinions of cardiologists. Safety was evaluated by medication administration errors and errors in patients' registration of intake. Of 159 patients assessed for eligibility to self-manage medication in-hospital, 61 were included. A total of 367 medicines were self-managed. Pill counts showed 3 administration errors (0.8%), and on 6 occasions (1.7%) the patient's registration of the intake was incorrect. SelfMED was deemed feasible within the hospital ward. In cardiologists' opinions, SelfMED requires substantial time investment. In summary, SelfMED facilitated patient medication self-management in-hospital. As an essential step in the preparation for a full trial, this study showed it is feasible and safe to implement the intervention and identified some possibilities for refinement.

Physical Activity Reduces the Risk of Developing Diabetes and Diabetes Medication Use

Diabetes is a global public health challenge, exerting a large socioeconomic burden on healthcare systems. This study aimed to explore Diabetes prevalence and Diabetes medication use in diabetics regarding sex, age group, Physical Activity Level (PAL) and Body Mass Index (BMI) by studying possible differences and calculating the risks of developing Diabetes and Diabetes medication use in the population according to their PAL. A cross-sectional study was conducted using data extracted from the Spanish National Health Survey (ENSE2017). The sample was finally composed of 17,710 participants. A descriptive analysis was performed to characterise Diabetes prevalence and Diabetes medication use (Chi-square test and a z-test for independent proportions). Odds Ratios (OR) and 95% Confidence Intervals (CI) were calculated for Diabetes prevalence and Diabetes medication use according to the participants’ PAL. Both the Diabetes and Diabetes medication use was higher in men than in women, increasing with age and BMI, and decreasing with increasing PAL (p < 0.001). Higher prevalence levels were observed in the inactive group versus very active or active people (p < 0.001). Inactive people had a higher risk of Diabetes and use of Diabetes medication risk compared to the very active and active groups. Prevalence decreased the higher the PAL both in men and women.

Effects of acupuncture in the treatment of occipital neuralgia: A systematic review and meta-analysis

BACKGROUND

Acupuncture is used to treat subjects with occipital neuralgia, which is 1 of the main causes of occipital pain; however, its effect is conflicting. Hence, the current study aims to evaluate the effects of acupuncture in the treatment of occipital neuralgia.

METHODS

In a systematic search of PubMed, Embase, OVID, China National Knowledge Infrastructure, Cochrane Library, Chinese Biomedical Literature Database, Wanfang databases, and Google Scholar until July 2021, 15 studies aimed to evaluate the effects of acupuncture in the treatment of occipital neuralgia were included. Human-related trials were considered in different languages. The size of the study was not considered a limit for its inclusion and the study intervention should focus on comparing the impact of acupuncture in the intervention group compared with the control group.The odds ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were calculated with a random or fixed-effect model for different subgroup analyses. Publication bias was assessed using the Egger test, while the risk of bias was assessed using the Review manager software.

RESULTS

Acupuncture had a significantly higher effective rate of treatment (OR, 5.40; 95% CI, 2.48 to 11.77, P < .001) compared to control in the treatment of occipital neuralgia and lower visual analogue scale (MD, -2.45; 95% CI, -2.69 to -2.21, P < .001). Acupuncture plus medication had a significantly higher effective rate of treatment (OR, 3.96; 95% CI, 2.10 to 7.47, P < .001) compared to medication in the treatment of occipital neuralgia. Acupuncture analysis for safety issues showed a significant reduction of adverse events compared with the medication group.

CONCLUSION

Acupuncture alone or acupuncture plus medication had a significantly beneficial effect on the effective rate of treatment, safety and visual analog scale compared to medication in the treatment of occipital neuralgia. Further studies are required to validate these findings.

Drug-Related Adverse Events Necessitating Treatment Discontinuation in Pediatric Inflammatory Bowel Disease Patients

OBJECTIVES

Inflammatory bowel disease (IBD) requires long-term drug therapy in most patients, posing a risk for adverse drug events with the need for discontinuation. In this study, we investigated adverse events (AE) necessitating drug discontinuation in pediatric and adolescent IBD patients.

METHODS

We used data prospectively collected from IBD patients below the age of 18 enrolled in the Swiss Inflammatory Bowel Disease Cohort Study (SIBDCS), namely demographic variables, medical characteristics, drug treatments, and related AE. We analyzed the frequency, type, and risk factors for AE necessitating drug discontinuation.

RESULTS

A total of 509 pediatric IBD patients fulfilled the inclusion criteria of which 262 (51.5%) were diagnosed with Crohn disease (CD), 206 (40.5%) with ulcerative colitis (UC), and 41 (8%) with IBD-unclassified (IBD-U). In total, 132 (25.9%) presented with at least 1 drug-related AE that required drug cessation. Immunomodulators [methotrexate 29/120 (24.2%), azathioprine 57/372 (15.3%)] followed by tumor necrosis factor (TNF)-alpha antagonists [adalimumab 8/72 (11.1%), infliximab 22/227 (9.7%)] accounted for the highest proportions of AE necessitating treatment discontinuation. Treatment schemes with at least 3 concomitant drugs significantly amplified the risk for development of drug-related AE [odds ratio = 2.50, 95% confidence interval (1.50-4.17)] in all pediatric IBD patients.

CONCLUSIONS

Drug-related AE necessitating discontinuation are common in pediatric and adolescent IBD patients. Caution needs to be taken in the case of concomitant drug use.

Reported Side or Adverse Effects Associated with Medication Nonadherence Among Adolescents and Young Adults with Attention-Deficit/Hyperactivity Disorder

Background and Objective: The purpose of this study was to determine what side effects were most associated with medication nonadherence as reported by adolescents and young adults with attention-deficit/hyperactivity disorder (ADHD). Methods: A combination of multiple linear regression and chi-square automatic interaction detection techniques were utilized in analyzing the survey data responses of 157 adolescents and young adults with ADHD. Results: The mean number of side effects reported was M = 10.33 side effects with 77% of the sample reporting at least one side effect. In aggregate, the number or severity of side effects were not significantly associated with medication nonadherence. Rather, it was the severity of particular side effects, upset stomach and vomiting, which were significantly associated with medication nonadherence. Conclusions: Health care providers should utilize this information as an indicator that medication nonadherence will be an issue when these side effects are present.

Duration of medication treatment for opioid-use disorder and risk of overdose among Medicaid enrollees in 11 states: a retrospective cohort study

BACKGROUND AND AIMS

Medication for opioid use disorder (MOUD) reduces harms associated with opioid use disorder (OUD), including risk of overdose. Understanding how variation in MOUD duration influences overdose risk is important as health-care payers increasingly remove barriers to treatment continuation (e.g. prior authorization). This study measured the association between MOUD continuation, relative to discontinuation, and opioid-related overdose among Medicaid beneficiaries.

DESIGN

Retrospective cohort study using landmark survival analysis. We estimated the association between treatment continuation and overdose risk at 5 points after the index, or first, MOUD claim. Censoring events included death and disenrollment.

SETTING AND PARTICIPANTS

Medicaid programs in 11 US states: Delaware, Kentucky, Maryland, Maine, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia and Wisconsin. A total of 293 180 Medicaid beneficiaries aged 18-64 years with a diagnosis of OUD and had a first MOUD claim between 2016 and 2017.

MEASUREMENTS

MOUD formulations included methadone, buprenorphine and naltrexone. We measured medically treated opioid-related overdose within claims within 12 months of the index MOUD claim.

FINDINGS

Results were consistent across states. In pooled results, 5.1% of beneficiaries had an overdose, and 67% discontinued MOUD before an overdose or censoring event within 12 months. Beneficiaries who continued MOUD beyond 60 days had a lower relative overdose hazard ratio (HR) compared with those who discontinued by day 60 [HR = 0.39; 95% confidence interval (CI) = 0.36-0.42; P < 0.0001]. MOUD continuation was associated with lower overdose risk at 120 days (HR = 0.34; 95% CI = 0.31-0.37; P < 0.0001), 180 days (HR = 0.31; 95% CI = 0.29-0.34; P < 0.0001), 240 days (HR = 0.29; 95% CI = 0.26-0.31; P < 0.0001) and 300 days (HR = 0.28; 95% CI = 0.24-0.32; P < 0.0001). The hazard of overdose was 10% lower with each additional 60 days of MOUD (95% CI = 0.88-0.92; P < 0.0001).

CONCLUSIONS

Continuation of medication for opioid use disorder (MOUD) in US Medicaid beneficiaries was associated with a substantial reduction in overdose risk up to 12 months after the first claim for MOUD.

Pregnancy outcomes and anxiety in nulliparous women

OBJECTIVE

To examine pregnancy outcomes in women with treated and untreated anxiety in a well-characterized cohort.

STUDY DESIGN

Secondary analysis of the NuMoM2b study, a prospective multi-center cohort of nulliparous women. Anxiety was assessed at 6 weeks 0 days - 13 weeks 6 days using the State Trait Anxiety Inventory (STAI-T). Women were divided into three groups: anxiety and medical treatment, anxiety and no medical treatment, and no anxiety (controls). The primary outcome was a composite of preterm birth, small for gestational age infant, placental abruption (clinically diagnosed), and hypertensive disorders of pregnancy. Multivariable logistic regression was used to adjust for potential confounding variables.

RESULTS

Among 8293 eligible women, 24% (n = 1983) had anxiety; 311 were treated medically. The composite outcome (preterm birth, small for gestational age infant, placental abruption, hypertensive disorders of pregnancy) occurred more often in women with untreated anxiety than controls (28.6% vs 25.9%, p=.02), with no difference between treated anxiety and controls (27.7% vs 25.9%, p=.49). After adjustment for confounders, including controlling for depression, there were no differences in the primary outcome among groups. Untreated anxiety remained associated with increased odds of neonatal intensive care unit admission.

CONCLUSION

Anxiety occurred in almost a quarter of nulliparas. There was no association between treated or untreated anxiety and our primary outcome of adverse pregnancy outcomes after adjustment for confounders. However, neonates born to women with untreated anxiety were at increased risk for NICU admission.

Women's Perceptions of Medication Use During Pregnancy and Breastfeeding in Saudi Arabia

Background Pregnancy is a unique physiological condition in which medication intake offers a challenge and a worry due to changed drug pharmacokinetics and drugs potentially crossing the placenta, such as beta blockers and benzodiazepines. As a result, medication safety during pregnancy has gained global interest, attracting attention from doctors and pregnant women, little of which has been documented regarding the Saudi population. Therefore, this study aimed to assess medication use and perceptions of medication use during pregnancy and breastfeeding among women in Saudi Arabia. Methods This study is a questionnaire-based, cross-sectional study. Data was collected through an online self-administered questionnaire from different regions of Saudi Arabia. Data was then entered and analyzed using SPSS 24.0 version (IBM Inc., Chicago, USA) statistical software. Results A total of 1831 participants were included in the current study. About 835 (45.6%) of the participants were within the age group of 26-35 years old. A total of 602 (32.9%) were using medications on a daily basis or several times a week during pregnancy or breastfeeding. About 1476 (80.6%) participants agreed on medication use during pregnancy. About 66.4% of women would be worried about fetal malformations if they were supposed to take medications during pregnancy. About 940 (51.3%) women think that medication use during early pregnancy is harmful, and 500 (27.3%) think that medication use during breastfeeding trimesters is harmful. Regarding pregnant women's perception of herbal medicines, about (65.4%) of those with low educational levels think that herbal medicines are harmful in early pregnancy. Most participants (63%) within the age group of ≥36 years old think that medications and herbal medicines are harmful in early pregnancy. The vast majority (91%) of the participants would ask the physician working on antenatal care if they had concerns about using certain medications during pregnancy. Conclusion The average use of medication and herbal medicines among pregnant women was noted, although many women had negative beliefs about taking certain medications. Continued effort is essential to support and encourage women to seek out reliable information sources regarding medication use during pregnancy. In addition, healthcare practitioners should be mindful of women's attitudes when counseling them to take medication during pregnancy.

Reducing potential errors associated with insulin administration: An integrative review

RATIONALE, AIMS, OBJECTIVES

Around one-third of medication errors resulting in death within 48 h involve insulin therapy. Despite a growing number of interventional strategies that have been published over the past decade, it remains unclear which of these interventions is effective in reducing insulin errors. Therefore, the study aimed to synthesize interventions to reduce the frequency of insulin errors in either home or health care settings.

METHODS

This integrative review was conducted based on Whittemore and Knafl's four steps, which includes problem identification, literature search, data analysis and presentation. Six databases including Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, PubMed, Scopus, PsychInfo and Cochrane were searched from January 2010 through July 2021. The level of evidence quality was assessed according to the Johns Hopkins Nursing Evidence-Based Practice grading scale.

RESULTS

Sixteen studies meeting inclusion criteria were reviewed. The results provide strong support for teaching patients how to use automated bolus calculators and educating patients to self-administer insulin to prevent insulin errors in the home setting. Computerized protocols, education and double-checking procedures were also found to be effective strategies for minimizing insulin errors in healthcare settings.

CONCLUSION

While the strategies might be effective in reducing insulin administration errors in the home settings, computerized protocols, continuing education and the manual validation of insulin products appear to be the most effective strategies for reducing such insulin errors in healthcare settings. Understanding these findings may help clinicians and patients to decrease the number of insulin errors administration.