Availability and price changes of potential medicines and equipment for the prevention and treatment of COVID-19 among pharmacy and drug stores in Bangladesh; findings and implications

Objective: There are concerns with increased prices and drug shortages for pertinent medicines and personal protective equipment (PPE) to prevent and treat COVID-19 enhanced by misinformation. Community pharmacists and drug stores play a significant role in disease management in Bangladesh due to high co-payments. Consequently, a need to review prices and availability in the pandemic. Materials and Methods: Multiple approach involving a review and questionnaire among pharmacies and stores early March to end May 2020. Results and Discussion: 170 pharmacies and drug stores took part, giving a response rate of 63.9%. Encouragingly, no change in utilization of antimalarial medicines in 51.2% of stores despite global endorsements. However, increased utilisation of antibiotics (70.6%), analgesics (97.6%), vitamins (90.6%) and PPE (over 95%). Encouragingly, increases in purchasing of PPE. No increase in prices among 50% of the stores for antimalarials, with a similar situation for antibiotics (65.3%), analgesics (54.7%), and vitamins (51.8%). However, price increases typically for PPE (over 90% of stores). Shortages also seen for medicines and PPE, again greater for PPE. Conclusions: The pandemic has impacted on the supply and prices of medicines and PPE in Bangladesh. Key stakeholder groups can play a role addressing misinformation, with enhanced local production helping address future shortages and prices. Bangladesh Journal of Medical Science Vol.19(0) 2020 p. S 36-S 50

Lessons from the failure of implementing the 'Better Care Better Value' prescribing indicator for renin-angiotensin system drugs in England: a qualitative study of general practitioners' perceptions using behavioural change framework

OBJECTIVES

To explore reasons for the lack of uptake of 'Better Care Better Value (BCBV)' prescribing indicators for renin-angiotensin-aldosterone system (RAAS) inhibitors and identify learning lessons to inform the implementation of future prescribing policies.

DESIGN

In-depth, semistructured interviews to explore: general practitioners' (GPs) experiences in prescribing RAAS, perceptions of the BCBV policy and potential barriers to policy implementation and suggestions for improving future policy implementation. Interviews were audio recorded, transcribed verbatim and analysed thematically, then mapped onto behavioural change frameworks (the Capability, Opportunity, Motivation and Behaviour) model and Behaviour Change Wheel (BCW)).

SETTING

Primary care setting in England PARTICIPANTS: Interviews were conducted with 16 GPs recruited from a purposive sample of 91 GP practices in three English counties.

RESULTS

Four factors/barriers, related mainly to GPs' psychological capability and reflective motivation, emerged as the possible barriers for the BCBV's lack of uptake, including: lack of the policy awareness, negative attitude to the policy, lack of incentives and GPs' reluctance to switch patients from angiotensin receptor blockers (ARBs) to ACE inhibitors (ACEIs). The participating GPs proposed interventions to improve future BCBV implementation and they were related to six intervention/policy functions of the BCW, addressing the four identified barriers: education/communication (increase GPs' awareness) and environmental restructuring/regulations (provide GPs with reminding alerts); incentivisation/fiscal (provide GPs with financial incentives); enablement/guidelines-regulations (provide GPs with benchmarking against peers) and enablement/regulations and education/guidelines (facilitate switching from ARBs to ACEIs).

CONCLUSIONS

The main reason underpinning the low uptake of the BCBV indicator appears to be lack of a proactive implementation strategy. This case study demonstrated that passively disseminating policy without an effective implementation strategy results in low uptake. Furthermore, multifaceted implementation strategies are necessary to influence complex clinical decision making in a time-limited environment, such as prescribing behaviours. These findings suggest that effective policy implementation requires the application of a systematic comprehensive behaviours change framework.

Real-world evaluation of the impact of statin intensity on adherence and persistence to therapy: A Scottish population-based study

Aim

To assess associations between statin intensity and adherence, persistence and discontinuation of statin therapy in Scotland.

Method

Retrospective cohort study, using linked electronic health records covering a period from January 2009 to December 2016. The study cohort included adult patients (≥18 years) newly initiating statins within Greater Glasgow and Clyde, Scotland. Study outcomes comprised adherence, discontinuation and persistence to treatment, stratified by three exposure groups (high, moderate and low intensity). Discontinuation and persistence were calculated using the refill‐gap and anniversary methods, respectively. Proportion of days covered (PDC) was used as a proxy for adherence. Kaplan‐Meier survival curves and Cox proportional hazard models were used to evaluate discontinuation, and associations between adherence/persistence and statin intensity were assessed using logistic regression.

Results

A total of 73 716 patients with a mean age of 61.4 ± 12.6 years were included; the majority (88.3%) received moderate intensity statins. Discontinuation rates differed between intensity levels, with high‐intensity patients less likely to discontinue treatment compared to those on moderate intensity (prior cardiovascular disease [CVD]: HR 0.43 [95% CI 0.34‐0.55]; no prior CVD: 0.80 [0.74‐0.86]). Persistence declined over time, and high‐intensity patients had the highest persistence rates. Overall, 52.6% of patients were adherent to treatment (PDC ≥ 80%), but adherence was considerably higher among high‐intensity patients (63.7%).

Conclusion

High‐intensity statins were associated with better persistence and adherence to treatment, but overall long‐term persistence and adherence remain a challenge, particularly among patients without prior CVD. This needs addressing.

Evaluation of the prescribing decision support system Synonyms in a primary care setting: a mixed-method study

BACKGROUND

Primary care prescribers must cope with an increasing number and complexity of considerations. Prescribing decision support systems (DSS) have therefore been developed to assist prescribers. Previous studies have shown that although there is wide variance in the different DSS available within primary care, barriers and facilitators to uptake remain. The Drug Synonyms function ('Synonyms') is a DSS inherent in the commercial electronic medical record system EMIS. Synonyms functionality has been further developed by the NHS Greater Glasgow and Clyde (GG&C) Central Prescribing Team to promote safe and cost-effective prescribing; however, it does not support the collection of usage data. As there is no knowledge on the uptake nor on the perceived effect of using Synonyms on prescribing, quantitative and qualitative analyses of Synonyms usage are required to ascertain the impact Synonyms has on primary care prescribers, which will influence the continued maintenance and/or future development of this prescribing DSS.

AIM

To determine the uptake of Synonyms and explore users' perceptions of its usefulness and future development.

DESIGN AND SETTING

An exploratory sequential mixed-method observational study using quantitative questionnaires, followed by semi-structured interviews with primary care prescribers within NHS GG&C.

METHOD

An electronic questionnaire (Questionnaire 1) accessible across 218 EMIS-compliant NHS GG&C GP practices ascertained Synonyms uptake by determining whether prescribers were aware of the DSS, whether they were aware of it and whether they used it. Prescribers who were aware of and used Synonyms were asked to opt in to participating further. This involved answering a second electronic questionnaire (Questionnaire 2), with the option of taking part in an additional one-to-one interview, to investigate their use and perceptions of Synonyms.

RESULTS

Questionnaire 1 was completed by 201 respondents from 43.1% of eligible GP practices: 186 (92.5%) respondents were aware of Synonyms, of whom 163 (87.6%) had used it and 155 (83.3%) continued to use it. Questionnaire 2 was completed by 104 respondents: 90 (86.5%) indicated that Synonyms informed or influenced their choice of drug prescribed; 94 (90.4%) reported that Synonyms changed their prescribing choice towards medication on NHS GG&C formulary, and 104 (100%) reported that they trust Synonyms. Six interviews generated suggestions for improvements, mainly extending the clinical conditions listed.

CONCLUSION

Most respondents were aware of and continued to use Synonyms. Respondents perceived Synonyms to influence prescribing choices towards local formulary medicines and improve adherence to local prescribing guidelines. Respondents trusted the DSS, but there is potential to increase awareness and training amongst non-users to encourage usage. Potentially, the NHS GG&C Synonyms function could be utilised by other health boards with supportive clinical systems.

Translation and Validation of the Farsi Version of the Pain Management Self-Efficacy Questionnaire

Introduction

Pain management is a complex process that is managed through a multi-disciplinary team in which nurses have a significant role. The present study aimed at translating and examining the psychometric properties of the Pain Management Self-Efficacy Questionnaire (PMSEQ) among Iranian nurses.

Methods

This was a cross-sectional, methodological study conducted in 2019 among nurses working in two teaching hospitals in Sanandaj (Tohid and Kosar). The participants were selected using a convenience sampling method. Responsiveness; interpretability; and face, content, and construct validities were examined using exploratory and confirmatory factor analyses. In addition, internal consistency and stability were examined using the Cronbach’s alpha and test-retest, respectively.

Results

Overall, 410 nurses (210 for the EFA and 200 for the CFA) were included in the sample. In the exploratory factor analysis, two factors of comprehensive pain assessment and pain management with eigenvalues of 6.36 and 1.91, respectively, were extracted. The two factors together explained 56.64% of the variance of nurses’ pain management self-efficacy. The confirmatory factor analysis indicated that the model had a moderate fit to the data (RMSEA: 0.12; NFI: 0.84; NNFI: 0.86; CFI: 0.88; IFI: 0.88; RFI: 0.81; GFI: 0.76; AGFI: 0.69; PGFI: 0.59; RMR: 0.09; standardized RMR: 0.09). Total questionnaire and the two factors (i.e. comprehensive pain assessment and pain management) had internal consistency coefficients of 0.891, 0.876, and 0.803, respectively.

Conclusion

The Farsi version of PMSEQ had good internal consistency and reliability, as well as content and construct validity, and can be used in future studies.

Use of record linkage to evaluate treatment outcomes and trial eligibility in a real-world metastatic prostate cancer population in Scotland

Purpose

New treatments are introduced into standard care based on clinical trial results. However, it is not clear if these benefits are reflected in the broader population. This study analysed the clinical outcomes of patients with metastatic castration‐resistant prostate cancer, treated with abiraterone and enzalutamide, within the Scottish National Health Service.

Methods

Retrospective cohort study using record linkage of routinely collected healthcare data (study period: February 2012 to February 2017). Overall survival (OS) was analysed using Kaplan‐Meier methods and Cox Proportional Hazard models; a subgroup analysis comprised potentially trial‐eligible patients.

Results

Overall, 271 patients were included and 73.8% died during the study period. Median OS was poorer than in the pivotal trials, regardless of medication and indication: 10.8 months (95% confidence interval [CI] 8.6‐15.1) and 20.9 months (95% CI 14.9‐29.0) for abiraterone, and 12.6 months (95% CI 10.5‐18.2) and 16.0 months (95% CI 9.8—not reached) for enzalutamide, post and pre chemotherapy, respectively. Only 46% of patients were potentially “trial eligible” and in this subgroup OS improved. Factors influencing survival included baseline performance status, and baseline prostate‐specific antigen, alkaline phosphatase, and albumin levels.

Conclusions

Poorer prognostic features of non‐trial eligible patients impact real‐world outcomes of cancer medicines. Electronic record linkage of routinely collected healthcare data offers an opportunity to report outcomes on cancer medicines at scale and describe population demographics. The availability of such observational data to supplement clinical trial results enables patients and clinicians to make more informed treatment decisions, and policymakers to contextualise trial findings.

Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future

Background

There has been an appreciable increase in the number of people in Africa with metabolic syndrome and Type 2 diabetes (T2DM) in recent years as a result of a number of factors. Factors include lifestyle changes, urbanisation, and the growing consumption of processed foods coupled with increasing levels of obesity. Currently there are 19 million adults in Africa with diabetes, mainly T2DM (95%), estimated to grow to 47 million people by 2045 unless controlled. This has a considerable impact on morbidity, mortality and costs in the region. There are a number of issues to address to reduce the impact of T2DM including improving detection rates and current access to services alongside addressing issues of adherence to prescribed medicines. There are also high rates of co-morbidities with infectious diseases such as HIV and tuberculosis in patients in Africa with T2DM that require attention.

Objective

Document ongoing activities across Africa to improve the care of patients with T2DM especially around issues of identification, access, and adherence to changing lifestyles and prescribed medicines. In addition, discussing potential ways forward to improve the care of patients with T2DM based on ongoing activities and experiences including addressing key issues associated with co-morbidities with infectious diseases.

Our Approach

Contextualise the findings from a wide range of publications including internet based publications of national approaches coupled with input from senior level government, academic and other professionals from across Africa to provide future guidance.

Ongoing Activities

A number of African countries are actively instigating programmes to improve the care of patients with T2DM starting with improved diagnosis. This recognises the growing burden of non-communicable diseases across Africa, which has been neglected in the past. Planned activities include programmes to improve detection rates and address key issues with diet and lifestyle changes, alongside improving monitoring of care and activities to enhance adherence to prescribed medicines. In addition, addressing potential complexities involving diabetes patients with infectious disease co-morbidities. It is too early to fully assess the impact of such activities.

Conclusion

There are a number of ongoing activities across Africa to improve the management of patients with diabetes including co-morbidities. However, more needs to be done considering the high and growing burden of T2DM in Africa. Ongoing research will help further benefit resource allocation and subsequent care.

Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa; implications for the future

BACKGROUND

Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa.

METHODOLOGY

Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa.

RESULTS

Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care.

CONCLUSION

There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored.

Evaluation of the clinical practice of aminoglycoside use in paediatric patients in Kenya: findings and implications for lower-middle income countries

OBJECTIVES

To evaluate the practice of aminoglycoside use/monitoring in Kenya and explore healthcare worker (HCW) perceptions of aminoglycoside monitoring to identify gaps and opportunities for future improvements, given the low therapeutic index of aminoglycosides.

METHODS

This was a two-phase study whereby we reviewed patients' medical records at Kenyatta National Hospital (October-December 2016) in Phase 1 and interviewed HCWs face to face in Phase 2. Outcome measures included describing and evaluating the practice of aminoglycoside use and monitoring and compliance to guidelines. Data were analysed using descriptive and inferential analysis.

RESULTS

Overall, out of the 2318 patients admitted, 192 patients (8.3%) were prescribed an aminoglycoside, of which 102 (53.1%) had aminoglycoside doses that did not conform to national guidelines. Aminoglycoside-related adverse effects were suspected in 65 (33.9%) patients. Monitoring of aminoglycoside therapy was performed in only 17 (8.9%) patients, with no therapeutic drug monitoring (TDM), attributed mainly to knowledge and skill gaps and lack of resources. Out of the 28 recruited HCWs, 18 (64.3%) needed training in how to perform and interpret TDM results.

CONCLUSIONS

The practice of using and monitoring aminoglycosides was suboptimal, raising concerns around potential avoidable harm to patients. The identified gaps could form the basis for developing strategies to improve the future use of aminoglycosides, not only in Kenya but also in other countries with similar settings and resources.

Antimicrobial point prevalence surveys in two Ghanaian hospitals: opportunities for antimicrobial stewardship

BACKGROUND

Improved knowledge regarding antimicrobial use in Ghana is needed to reduce antimicrobial resistance (AMR). This includes point prevalence studies (PPSs) in hospitals. Objectives were to: (i) provide baseline data in two hospitals [Keta Municipal Hospital (KMH) and Ghana Police Hospital (GPH)] and identify priorities for improvement; (ii) assess the feasibility of conducting PPSs; and (iii) compare results with other studies.

METHODS

Standard PPS design using the Global PPS paper forms, subsequently transferred to their template. Training undertaken by the Scottish team. Quality indicators included: rationale for use; stop/review dates; and guideline compliance.

RESULTS

Prevalence of antibiotic use was 65.0% in GPH and 82.0% in KMH. Penicillins and other β-lactam antibiotics were the most frequently prescribed in both hospitals, with third-generation cephalosporins mainly used in GPH. Antibiotic treatment was mainly empirical and commonly administered intravenously, duration was generally short with timely oral switching and infections were mainly community acquired. Encouragingly, there was good documentation of the indications for antibiotic use in both hospitals and 50.0%-66.7% guideline compliance (although for many indications no guideline existed). In addition, almost all prescribed antibiotics had stop dates and there were no missed doses. The duration of use for surgical prophylaxis was generally more than 1 day (69.0% in GPH and 77.0% in KMH).

CONCLUSIONS

These two hospitals were the first in Ghana to use the Global PPS system. We found the PPS was feasible, relatively rapid and achieved with limited training. Targets for improvement identified included reduction of broad-spectrum antibiotics and duration of treatment.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use.Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known.Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals.Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored.

Antibiotic Prescribing Patterns at a Leading Referral Hospital in Kenya: A Point Prevalence Survey

Objective:

Antibiotics are essential with inappropriate use leading to antimicrobial resistance (AMR). Currently, little is known about antibiotic use among hospitals in Kenya, which is essential to tackle as part of the recent national action plan addressing rising AMR rates. Consequently, the objective was to overcome this gap in a leading referral hospital in Kenya. The findings will subsequently be used to develop quality improvement programs for this and other hospitals in Kenya.

Methods:

This was a point prevalence survey. Data on antibiotic use were abstracted from patient medical records by a pharmacy team.

Findings:

The prevalence of antibiotic prescribing was 54.7%, highest in the intensive care unit and isolation wards. Most antibiotics were for treatment (75.4%) rather than prophylaxis (29.0%). The majority of patients on surgical prophylaxis were on prolonged duration (>1 day), with only 9.6% on a single dose as per current guidelines. Penicillins (46.9%) followed by cephalosporins (44.7%) were the most prescribed antibiotic classes. The indication for antibiotic use was documented in only 37.3% of encounters. Generic prescribing was 62.5% and empiric prescribing was seen in 82.6% of encounters. Guideline compliance was 45.8%.

Conclusion:

Several areas for improvement were identified including addressing prolonged duration for prophylaxis, extensive prescribing of broad-spectrum antibiotics, high rates of empiric prescribing, and lack of documenting the indication for antimicrobials. Initiatives are ongoing to address this with pharmacists playing a key role.

Proactive risk assessment of vincristine use process in a teaching and referral hospital in Kenya and the implications

INTRODUCTION

The chemotherapy use process is potentially risky for cancer patients. Vincristine, a "High Alert" medicine, has been associated with fatal but preventable medication errors. Consequently, there is a need to improve the use of vincristine especially in lower- and middle-income countries where there are constraints with resources and often a lack of trained personnel to administer cancer medicines. However, where there is a rising prevalence of cancer cases. These concerns can be addressed by performing proactive risk assessments using Healthcare Failure Mode Effect Analysis (HFMEA) and implementing the findings.

METHODS

A multidisciplinary health team driven by pharmacists identified and evaluated potential failure modes based on a vincristine use process flow diagram using a hazard scoring matrix in a leading referral hospital in Kenya.

RESULTS

The processes evaluated were: prescribing, preparation and dispensing, transportation and storage, administration and monitoring of the use of vincristine. Seventy-seven failure modes were identified over the three-month study period, of which 25 were classified as high risk. Thirteen were adequately covered by existing control measures while 12 including one combined mode required new strategies. Two of the failure modes were single-point weaknesses. Recommendations were subsequently made for improving the administration of vincristine.

CONCLUSIONS

HFMEA is a useful tool to identify improvements to medication safety and reduction of patient harm. The HFMEA process brings together the multidisciplinary team involved in patient care in actively identifying potential failure modes and owning the recommendations made, which are now being actively followed up in this hospital. Pharmacists are a key part of this process.

Prescribing trends of inhaler treatments for asthma and chronic obstructive pulmonary disease within a resource-constrained environment in the Scottish national health service: findings and implications

Background: There is an increasing prevalence of asthma and chronic obstructive pulmonary disease (COPD) worldwide, leading to increased inhaler use. However, there are concerns with inhaler compliance resulting in different patented inhalers and longer-acting formulations. As a result, inhalers are now among the highest expenditure items in ambulatory care in Scotland leading to multiple initiatives to keep within budget without compromising care. Method: This study assesses inhaler utilization and expenditure between 2001 and 2017 alongside health authority initiatives. Results: There was an increase by 137% in inhaler utilization between 2001 and 2017, and a two-fold increase in expenditure, driven by the increasing use of patented combination inhalers to address concerns. This is very different to the oral markets where expenditure on proton pump inhibitors, statins, and antihypertensives have fallen considerably recently despite increased volumes due to the increasing use of low-cost generics. However, inhaler expenditure has started to fall with an increasing use of lower cost combinations and initiatives to reduce the steroid burden alongside monitoring patient care. Conclusion: Challenges with using and changing inhalers has meant this market has not followed other high-volume drug classes following patent loss. This is starting to change, with the situation monitored to enhance efficient prescribing alongside continued good quality care.

Ongoing initiatives within the Scottish National Health Service to affect the prescribing of selective serotonin reuptake inhibitors and their influence

Aim: Increasing use of selective serotonin-reuptake inhibitors (SSRIs) in Scotland, coupled with safety concerns with some SSRIs, and the increasing availability of generic SSRIs, have resulted in multiple initiatives to improve the quality and efficiency of their prescribing in Scotland. Our aim is to assess their influence to provide future direction. Materials & methods: The prescription costs analysis database was used to document utilization and expenditure on SSRIs between 2001 and 2017 alongside documenting the initiatives. Results: Multiple interventions over the years increased international nonproprietary name prescribing up to 99.9% lowering overall costs. This, coupled with initiatives to limit escitalopram prescribing due to concerns with its value, resulted in a 73.7% reduction in SSRI expenditure between 2001 and 2017 despite a 2.34-fold increase in utilization. Safety warnings resulted in a significant reduction in the prescribing of paroxetine, citalopram and escitalopram alongside a significant increase in sertraline Conclusion: Multiple initiatives have increased the quality and efficiency of SSRI prescribing in Scotland providing direction to others.

Prevalence of metabolic syndrome among Iranian women with polycystic ovary syndrome: A systematic review and meta-analysis

Polycystic ovary syndrome (PCOS) is a common endocrine disorder that is associated with an increased the risk of metabolic syndrome (MetS) and hence increased cardiovascular diseases in women. This systematic review and meta-analysis aimed at examining the prevalence of MetS in Iranian women with PCOS. This was a systematic review and meta-analysis of English and Persian studies, using the following keywords: Polycystic Ovary Syndrome, Hyperandrogenism, Metabolic Syndrome,"MetSyn", X Syndrome, and Iran in several national and international databases (Scientific Information Database (SID), Magiran, Web of Science, Google Scholar, PubMed, and Scopus from inception to February 2019. Heterogeneity among the studies was assessed using the Cochran's Q test. The random effects model was then used to estimate the overall prevalence of MetS. ALL the analyses were performed using STATA, version 12. Overall, 10 studies were included in the study. The overall prevalence of MetS among Iranian women with PCOS was 26.6% (95% CI: 16.60-31.70). In addition, the mean body mass index (BMI) was 27.47 (95% CI: 25.46-29.48) and the mean waist circumference was 87.94 (95% CI: 84.28-91.60). According the meta-regression results, there were no significant associations between the prevalence of MetS and sample size, year of publication, waist circumference, BMI, and age. One-fourth of Iranian women with PCOS have MetS. Given the overlap between anthropometric and metabolic abnormalities in PCOS and the features of MetS, accurate identification of patients with MetS is important to ensure early diagnosis and subsequent interventions to effectively manage the condition.

Adverse effects of chemotherapy and their management in Pediatric patients with Non-Hodgkin's Lymphoma in Kenya: A descriptive, situation analysis study

BACKGROUND

Chemotherapy-related side effects and their management in patients with Non-Hodgkin's Lymphoma (NHL) are not well defined in developing countries, including Kenya. This needs addressing considering the high number of patients with cancer in these countries. Consequently, we sought to determine the common side effects of chemotherapy used to treat NHL in pediatric patients and its implications.

METHODS

Observational study conducted at the Kenyatta National Hospital in patients aged ≤15 years. Some data was collected by reviewing patients' records admitted to the pediatric oncology ward, December 2016 to May 2017; and additional data was collected retrospectively (review of patients' records with NHL, January-2014 to May-2017). Data were analyzed descriptively.

RESULTS

Overall, out of the identified NHL patients (n = 85), 93% (n = 79) had chemotherapy-related side effects. The majority of patients suffered from side effects were managed; apart from 23% to 24% of the documented anemia and hypersensitivity, respectively.

CONCLUSIONS

Whilst the majority of the reported side-effects were being managed, the lack of management of some side effects raises real concerns since this indicates either failure to manage or failure to document their management in patients' records, both of which should be addressed appropriately to improve future care.

Feasibility of using point prevalence surveys to assess antimicrobial utilisation in public hospitals in South Africa: a pilot study and implications

OBJECTIVES

There is currently a lack of data regarding antimicrobial use among public hospitals in South Africa. This is a concern given their growing use and increasing antimicrobial resistance rates in South Africa. Consequently, the objectives of this study were to firstly determine the appropriateness of point prevalence survey (PPS) data collection instruments for performing antimicrobial utilization studies among public sector hospitals in South Africa; secondly, to determine current antimicrobial utilization in a public sector hospital, and thirdly evaluate the prescribing of antimicrobials with those contained within the national Essential Medicines List and Standard Treatment Guidelines (EML/STGs). The findings will be used to guide future activities in South Africa.

METHODS

A PPS was conducted in Dr George Mukhari Academic Hospital. For each in-patient ward, all patients' files were completely surveyed on a single day. The number of patients who were on antimicrobials served as the numerator and the denominator comprised the total number of patients in the ward.

RESULTS

39 wards and 512 patient files were surveyed. The overall prevalence of antimicrobial use was 37.7%, highest in the ICUs. Beta lactamase inhibitors and antimicrobials for tuberculosis were the most prevalent antimicrobials. More than two thirds (83%) of antimicrobial treatment was modified following culture sensitivity test results when requested, and 98% of antimicrobials prescribed were contained within the current EML/STGs. In 10.8% of occasions, antimicrobials appear to have been prescribed other than for treatment, i.e. no systemic infection. There were concerns though with the lack of IV to oral switching.

CONCLUSION

The PPS method offers a standardized tool that can be used to identify targets for quality improvement. However, there were concerns with the time taken to conduct PPS studies, which is an issue in resource limited settings. This is being addressed alongside concerns with the lack of IV to oral switching.

Prevalence of depression among Iranian patients with rheumatoid arthritis: a systematic review and meta-analysis

Patients with rheumatoid arthritis (RA) are prone to depression due to several factors related to their RA, including chronic and persistent pain, functional disability, economic constraints, and the side effects of RA medication. Previous Iranian studies showed conflicting and inconclusive findings regarding the prevalence of depression among RA patients. Therefore, this systematic review and meta-analysis was conducted to estimate the true prevalence of depression in Iranian patients with RA. Search for eligible articles was performed using the keywords of depression, depressive disorder, dysthymic disorder, major depressive disorder, RA, and Iran, and their possible combinations in the following databases: Scientific Information Database, MagIran, Web of Science/ISI, PubMed, and Scopus. The search was restricted to articles published in Persian and English languages. The meta-analysis was performed using the random effects model, and the data were analyzed using the STATA software version 12. Overall, six articles were selected; the overall prevalence of depression among the Iranian patients with RA was 65.58% (95% CI: 56.53%-74.62%). There were no significant relationships between the prevalence of depression and articles' methodological quality and year of publication, participants' age, sample size, and duration of disease. More than half of RA patients suffer from depression. The overlap between the physical symptoms of RA and depression in this group of patients makes it difficult to correctly diagnose depression; therefore, initiative and efforts are required to improve the identification of early depression symptoms in RA patients in order to effectively manage their depression.

Health-related quality of life in Iranian patients with type 2 diabetes: An updated meta-analysis

Diabetes is the most common metabolic causes of increased mortality rate due to its multiple complications. Diabetes, thus, influences patients' quality of life because of its resultant physical disabilities and mental health problems. This study aimed to investigate health-related quality of life among Iranian patients with type 2 diabetes. In this meta-analysis study, a search was conducted using the keywords: Quality of Life, Health-Related Quality of Life, QoL, HRQoL, Shortform questionnaire 36, SF-36, Diabetes and Iran in the national and international databases such as SID, MagIran, ISI/Web of Science, PubMed [including Medline], and Scopus between 2011 and 2018. Based on the heterogeneity of data, the random effects model was used. Data was analyzed using the Stata software version 14. Overall, 17 studies were eligible, with a total sample size of 5472 patients, and they showed that the mean score of the physical dimension in patients with type 2 diabetes (53.5, 95% CI: 43.1-63.9) was less than the mean of mental dimension score (54.5, 95% CI: 47-61.9). By increasing age of the samples, the mean of the HRQoL score of the Iranian patients with type 2 diabetes was significantly decreased (p = 0.015). The highest and lowest scores for the quality of life subscales were social function and general health, respectively. In conclusion, patients with type 2 diabetes have been shown to have moderate quality of life. Providing solutions to improve the quality of life in this group of patients, especially in the physical aspect, is required.

The use of probiotics as a supplementary therapy in the treatment of patients with asthma: a pilot study and implications

OBJECTIVES

Evaluate the use of probiotics as an additional therapy in the treatment of children and adolescents with asthma in Belo Horizonte, MG-Brazil.

METHODS

A pilot longitudinal, experimental and nonrandomized study with 30 patients from six to 17 years old from Belo Horizonte. In the baseline appointment, all patients received beclomethasone, and one group also received a probiotic containing Lactobacillus reuteri (n=14). The patients were reassessed after at least 60 days with the Asthma Control Test, spirometry and self-report of the symptoms they experienced associated with asthma.

RESULTS

A predominance of male patients (56.7%) and a mean age of 10.6 years were observed. The groups using probiotics did not differ in terms of sex, age or atopy. In the longitudinal evaluation, an increase in the Asthma Control Test scores and a reduction in the number of symptoms were observed in the probiotic group. There was an increase in the peak expiratory flow among those who used probiotics.

CONCLUSIONS

This pilot study supports the hypothesis that the administration of probiotics as a supplementary therapy for the treatment of children and adolescents with asthma improves the clinical condition of the patients. Further studies are needed to confirm the efficacy of probiotics in asthma treatment.

Clinical and Financial Implications of Medicine Consumption Patterns at a Leading Referral Hospital in Kenya to Guide Future Planning of Care

Background: Medicines can constitute up to 70% of total health care budgets in developing countries as well as considerable expenditure in hospitals. Inventory management techniques can assist with managing resources efficiently. In Kenyatta National Hospital (KNH), a leading hospital in Kenya, over 30% of expenditure is currently allocated to medicines, and this needs to be optimally managed.

Objective: To investigate drug consumption patterns, their costs and morbidity patterns at KNH in recent years.

Methodology: Cross-sectional retrospective record review. Inventory control techniques, ABC (Always, Better, and Control), VEN (Vital, Essential, and Non-essential) and ABC-VEN matrix analyses were used to study drug expenditure patterns. Morbidity data was extracted from the Medical Records.

Results: Out of an average of 811 medicine types procured annually (ATC 5), 80% were formulary drugs and 20% were non-formulary. Class A medicines constituted 13.2–14.2% of different medicines procured each year but accounted for an average of 80% of total annual drug expenditure. Class B medicines constituted 15.9–17% of all the drugs procured yearly but accounted for 15% of the annual expenditure, whilst Class C medicines constituted 70% of total medicines procured but only 5% of the total expenditure. Vital and Essential medicines consumed the highest percentage of drug expenditure. ABC-VEN categorization showed that an average of 31% of medicine types consumed an average of 85% of total drug expenditure. Therapeutic category and Morbidity patterns analysis showed a mismatch between drug expenditure and morbidity patterns in over 85% of the categories.

Conclusion: Class A medicines are few but consume the largest proportion of hospital drug expenditure. Vital and essential items account for the highest drug expenditure, and need to be carefully managed. ABC-VEN categorization identified medicines where major savings could potentially be made helped by Therapeutic category and Morbidity pattern analysis. There was a high percentage of non-formulary items, which needs to be addressed. Inventory control techniques should be applied routinely to optimize medicine use within available budgets especially in low and middle income countries.