Vitamin supplements in type 2 diabetes mellitus management: A review

Type 2 diabetes mellitus (T2DM) is a major public health challenge that affects countries across the world. The use of pharmacological therapy is often limited in some patients due to a loss of effect over time or development of adverse effects such as weight gain or hypoglycaemia. This has prompted searches into the role of non-pharmacological therapies in T2DM. The availability and use of vitamin supplements in developed countries have increased significantly and there is evidence that certain vitamins may have roles in the management of T2DM. This review examines the literature assessing the use of vitamins A, C, E, D, K and the B group vitamins (B1, B3, B7, B6, B9, B12) in the management of T2DM. No clear evidence supporting the beneficial role of any specific vitamin in the treatment of T2DM was found. Thus, it is recommended that until further studies are conducted to clarify the role of such vitamins in T2DM management, they should not be routinely recommended in clinical practice.

An audit of adherence to heart failure guidelines in an Australian hospital: A pharmacist perspective

RATIONALE, AIMS, AND OBJECTIVES

The Australian National Heart Foundation Guidelines have been developed to guide clinicians on how to best manage chronic heart failure (CHF) patients according to the current best available evidence. The primary aim of this study is to evaluate the proportion of patients prescribed evidence-based therapy (EBT) for CHF on discharge at this Australian metropolitan hospital and factors affecting its prescribing. The secondary aims are to examine the proportion of patients prescribed EBT on discharge on cardiac wards compared to medical wards and to explore the role of the pharmacist in the management of these patients.

METHOD

A retrospective audit of patients' medical notes who were admitted consecutively for CHF management was conducted over 6 months to examine their management.

RESULTS

The results showed at discharge, a total of 52% of patients were discharged on angiotensin converting enzyme inhibitors/angiotensin receptor blockers, 49% were discharged on β-blockers, 15% were on Aldosterone receptor antagonists, 90% were discharged on diuretics, and 29% were discharged on Digoxin. The main determinants of prescribing EBT on discharge were the presence of prescribing contraindications and patients' comorbidities. Patients discharged from cardiac wards were more likely to be prescribed EBT than if discharged on medical wards. Furthermore, in the subset of the cohort who was reviewed by a pharmacist during admission, a higher percentage of patients were discharged on EBT compared with those who did not have a pharmaceutical input.

CONCLUSION

This study highlighted existing gaps between the National CHF Guidelines and clinical prescribing practice in this hospital. Patients who were discharged from cardiac wards were more likely to be prescribed medications concordant with the guidelines, and there is further opportunity for pharmacists to assist in closing gaps in prescribing practice by the promotion of adherence to these guidelines.

Diabetes microvascular complications-A clinical update

BACKGROUND

The purpose of this study is to summarise the empirical evidence addressing diabetes microvascular complications and management. The effects of diabetes mellitus include long-term damage, dysfunction and failure of various organs. Microvascular disease tends to occur predominantly in tissues where glucose uptake is independent of insulin activity because these tissues are exposed to glucose levels that correlate very closely with blood glucose levels. These metabolic injuries cause altered blood flow and changes in endothelial permeability, extravascular protein deposition and coagulation resulting in organ dysfunction which in turn lead to microvascular complications.

METHOD

A systematic search of the literature from 2000 to 2016 was conducted using four databases (Medline, Pubmed, Cochrane central and Google scholar) using search terms such as diabetic microvascular complications', pathogenesis, screening, risk factors, pharmacological and non-pharmacological interventions and management.

RESULTS

The current evidence supports a direct relationship between blood pressure (BP) and glycaemic control and progression of nephropathy and retinopathy. These are now considered as independent risk factors for microvascular disease progression. New fields of research addressing new drugs as potential therapeutic targets of the future will be presented.

CONCLUSION

The prevention of microvascular disease involves paying attention to aggravating risk factors and implementing screening programmes to improve early detection.

Medication safety programs in primary care: a scoping review

BACKGROUND

Medication safety plays an essential role in all healthcare organizations; improving this area is paramount to quality and safety of any wider healthcare program. While several medication safety programs in the hospital setting have been described and the associated impact on patient safety evaluated, no systematic reviews have described the impact of medication safety programs in the primary care setting. A preliminary search of the literature demonstrated that no systematic reviews, meta-analysis or scoping reviews have reported on medication safety programs in primary care; instead they have focused on specific interventions such as medication reconciliation or computerized physician order entry. This scoping review sought to map the current medication safety programs used in primary care.

OBJECTIVE

The current scoping review sought to examine the characteristics of medication safety programs in the primary care setting and to map evidence on the outcome measures used to assess the effectiveness of medication safety programs in improving patient safety.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

The current review considered participants of any age and any condition using care obtained from any primary care services.

CONCEPT

We considered studies that focussed on the characteristics of medication safety programs and the outcome measures used to measure the effectiveness of these programs on patient safety in the primary care setting.

CONTEXT

The context of this review was primary care settings, primary healthcare organizations, general practitioner clinics, outpatient clinics and any other clinics that do not classify patients as inpatients.

TYPES OF STUDIES

We considered all quantitative studied published in English.

SEARCH STRATEGY

A three-step search strategy was utilized in this review.

DATA EXTRACTION

Data were extracted from the included studies to address the review question. The data extracted included type of medication safety program, author, country of origin, aims and purpose of the study, study population, method, comparator, context, main findings and outcome measures.

RESULTS

The objectives, inclusion criteria and methods for this scoping review were specified in advance and documented in a protocol that was previously published. This scoping review included nine studies published over an eight-year period that investigated or described the effects of medication safety programs in primary care settings. We classified each of the nine included studies into three main sections according to whether they included an organizational, professional or patient component. The organizational component is aimed at changing the structure of the organization to implement the intervention, the professional component is aimed at the healthcare professionals involved in implementing the interventions, and the patient component is aimed at counseling and education of the patient. All of the included studies had different types of medication safety programs. The programs ranged from complex interventions including pharmacists and teams of healthcare professionals to educational packages for patients and computerized system interventions. The outcome measures described in the included studies were medication error incidence, adverse events and number of drug-related problems.

CONCLUSION

Multi-faceted medication safety programs are likely to vary in characteristics. They include educational training, quality improvement tools, informatics, patient education and feedback provision. The most likely outcome measure for these programs is the incidence of medication errors and reported adverse events or drug-related problems.

Professional, structural and organisational interventions in primary care for reducing medication errors

BACKGROUND

Medication-related adverse events in primary care represent an important cause of hospital admissions and mortality. Adverse events could result from people experiencing adverse drug reactions (not usually preventable) or could be due to medication errors (usually preventable).

OBJECTIVES

To determine the effectiveness of professional, organisational and structural interventions compared to standard care to reduce preventable medication errors by primary healthcare professionals that lead to hospital admissions, emergency department visits, and mortality in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trial registries on 4 October 2016, together with reference checking, citation searching and contact with study authors to identify additional studies. We also searched several sources of grey literature.

SELECTION CRITERIA

We included randomised trials in which healthcare professionals provided community-based medical services. We also included interventions in outpatient clinics attached to a hospital where people are seen by healthcare professionals but are not admitted to hospital. We only included interventions that aimed to reduce medication errors leading to hospital admissions, emergency department visits, or mortality. We included all participants, irrespective of age, who were prescribed medication by a primary healthcare professional.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data. Each of the outcomes (hospital admissions, emergency department visits, and mortality), are reported in natural units (i.e. number of participants with an event per total number of participants at follow-up). We presented all outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). We used the GRADE tool to assess the certainty of evidence.

MAIN RESULTS

We included 30 studies (169,969 participants) in the review addressing various interventions to prevent medication errors; four studies addressed professional interventions (8266 participants) and 26 studies described organisational interventions (161,703 participants). We did not find any studies addressing structural interventions. Professional interventions included the use of health information technology to identify people at risk of medication problems, computer-generated care suggested and actioned by a physician, electronic notification systems about dose changes, drug interventions and follow-up, and educational interventions on drug use aimed at physicians to improve drug prescriptions. Organisational interventions included medication reviews by pharmacists, nurses or physicians, clinician-led clinics, and home visits by clinicians.There is a great deal of diversity in types of professionals involved and where the studies occurred. However, most (61%) of the interventions were conducted by pharmacists or a combination of pharmacists and medical doctors. The studies took place in many different countries; 65% took place in either the USA or the UK. They all ranged from three months to 4.7 years of follow-up, they all took place in primary care settings such as general practice, outpatients' clinics, patients' homes and aged-care facilities. The participants in the studies were adults taking medications and the interventions were undertaken by healthcare professionals including pharmacists, nurses or physicians. There was also evidence of potential bias in some studies, with only 18 studies reporting adequate concealment of allocation and only 12 studies reporting appropriate protection from contamination, both of which may have influenced the overall effect estimate and the overall pooled estimate. Professional interventionsProfessional interventions probably make little or no difference to the number of hospital admissions (risk ratio (RR) 1.24, 95% confidence interval (CI) 0.79 to 1.96; 2 studies, 3889 participants; moderate-certainty evidence). Professional interventions make little or no difference to the number of participants admitted to hospital (adjusted RR 0.99, 95% CI 0.92 to 1.06; 1 study, 3661 participants; high-certainty evidence). Professional interventions may make little or no difference to the number of emergency department visits (adjusted RR 0.71, 95% CI 0.50 to 1.02; 2 studies, 1067 participants; low-certainty evidence). Professional interventions probably make little or no difference to mortality in the study population (adjusted RR 0.98, 95% CI 0.82 to 1.17; 1 study, 3538 participants; moderate-certainty evidence). Organisational interventionsOverall, it is uncertain whether organisational interventions reduce the number of hospital admissions (adjusted RR 0.85, 95% CI 0.71 to 1.03; 11 studies, 6203 participants; very low-certainty evidence). Overall, organisational interventions may make little difference to the total number of people admitted to hospital in favour of the intervention group compared with the control group (adjusted RR 0.92, 95% CI 0.86 to 0.99; 13 studies, 152,237 participants; low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce the number of emergency department visits in favour of the intervention group compared with the control group (adjusted RR 0.75, 95% CI 0.49 to 1.15; 5 studies, 1819 participants; very low-certainty evidence. Overall, it is uncertain whether organisational interventions reduce mortality in favour of the intervention group (adjusted RR 0.94, 95% CI 0.85 to 1.03; 12 studies, 154,962 participants; very low-certainty evidence.

AUTHORS' CONCLUSIONS

Based on moderate- and low-certainty evidence, interventions in primary care for reducing preventable medication errors probably make little or no difference to the number of people admitted to hospital or the number of hospitalisations, emergency department visits, or mortality. The variation in heterogeneity in the pooled estimates means that our results should be treated cautiously as the interventions may not have worked consistently across all studies due to differences in how the interventions were provided, background practice, and culture or delivery of the interventions. Larger studies addressing both professional and organisational interventions are needed before evidence-based recommendations can be made. We did not identify any structural interventions and only four studies used professional interventions, and so more work needs to be done with these types of interventions. There is a need for high-quality studies describing the interventions in more detail and testing patient-related outcomes.

Medications affecting healing: an evidence-based analysis

The purpose of this arm of the study was to investigate the impact of medication on healing times of the various wound types, including acute wounds and leg ulcers. A prospective longitudinal study design was used, with de-identified data collected using an electronic mobile wound care database system. Three main categories of data were collected, including patients' demographics, wounds types and treatment characteristics. For acute wounds, there was a total of 1732 patients with 2089 acute wounds. The average healing time was about 35 days. The only significant association was with chemotherapy, which increased healing time by 21 days (P = 0·048). There were non-significant trends towards reduced healing times with antibiotics (0·5 days; P = 0·853), anticoagulants (1·7 days, P = 0·673) and corticosteroids (4·98 days, P = 0·303). Non-steroidal anti-inflammatory drugs (NSAIDs) were associated with a non-significant increase in healing time (2·17 days, P = 0·707). For leg ulcers, there was a total of 264 patients with 370 leg ulcers. We only examined the impact of antibiotics, anticoagulants, corticosteroids and NSAIDs on healing times as they had an adequate number of wounds to analyse. The average healing times of leg ulcers were found to be 73 days. None of the classes of medications had any significant impact on healing time. Both anticoagulants and NSAIDs increased healing time by (22·5 days, P = 0·08) and (12·5 days, P = 0·03), respectively. On the other hand, antibiotics and corticosteroids decreased healing times non-significantly by (9·1 days, P = 0·33) and (21·6 days, P = 0·84), respectively.

Fear of Falling in People With Multiple Sclerosis: Which Clinical Characteristics Are Important?

BACKGROUND

Fear of falling (FOF) is an important risk indicator for health-related outcomes and quality of life in patients with multiple sclerosis (MS). However, factors associated with FOF in MS are not well investigated.

OBJECTIVES

This study was done to explore predictors of FOF in this population.

METHODS

Seventy relapsing remitting patients with MS were evaluated. Fear of falling was assessed using the Fall Efficacy Scale-International (FES-I). Motor outcomes included: 30-second chair stand test (30s-CST), Berg Balance Scale (BBS), 10-Meter Walk Test (10MWT), and 6-Minute Walk Test (6MWT). Cognitive status was determined using the Montréal Cognitive Assessment (MOCA) and Symbol Digit Modalities Test (SDMT). Affective factors including depression, fatigue, and sleep were also assessed using the Beck Depression Inventory (BDI), Modified Fatigue Impact Scale (MFIS), and Pittsburgh Sleep Quality Index (PSQI), respectively.

RESULTS

Fear of falling was significantly correlated with all motor and affective measures used. However, a stepwise regression found that only BBS from motor measures, MOCA from cognitive measures, and sleep disorders from affective factors were significantly predictive of the FOF.

CONCLUSIONS

Fear of falling in patients with MS is multifactorial and includes motor and nonmotor factors. Thus, therapies that aim to reduce risk of falling in this population should address motor functions, cognitive abilities, and sleep quality.

Living With Parkinson’s Disease: A Jordanian Perspective

Date Presented 3/31/2017

This study explored the lived experiences of Jordanian persons with Parkinson’s disease, both challenges and adaptations. Some of these challenges and adaptations are rooted within the Jordanian Arabic and Islamic culture. It is highly recommended that therapists be aware of these cultural issues.

Primary Author and Speaker: Mohammad Nazzal

Additional Authors and Speakers: Hanan Khalil

A pilot study of a minimally supervised home exercise and walking program for people with Parkinson's disease in Jordan

Aim: This study aimed to evaluate the feasibility and cultural considerations of a minimally supervised, home-based exercise program in Jordan. Methods: Quantitative and qualitative approaches were used. Thirty participants were randomly allocated to either an 8-week intervention group (n = 16), or a standard care group (n = 14). The intervention incorporated the home use of an exercise DVD, walking program and initial instructional sessions and weekly phone calls provided by a physiotherapist. Interviews were used to explore feasibility. Unified Parkinson's disease rating scale (UPDRS-III); balance and walking speed were assessed. Results: The retention rate was 86.7% and mean adherence rate was 77%. Personal and sociocultural barriers of adherence to the exercise program were identified. UPDRS-III at follow-up was lower in the intervention group. Conclusion: A home exercise program was feasible. Sociocultural barriers specific to Arabic culture may affect the uptake of such an intervention in Parkinson's disease in these countries.

Quality of Life after Intestinal Resection in Patients with Crohn Disease: A Systematic Review

BACKGROUND/AIMS

Most patients with Crohn disease (CD) require surgery within 10 years of diagnosis. Intestinal resection is the most commonly performed operation although the effects on health-related quality of life (HRQOL), particularly long-term, are contentious.

METHODS

We conducted a systematic review evaluating the impact of intestinal resection on the HRQOL of CD patients, predictors of postoperative HRQOL, and patient satisfaction with surgery.

RESULTS

Nine studies including 1,108 CD patients undergoing intestinal resection were identified as eligible for inclusion. The median age at surgery was 29-41 years with varying follow-up period (range 30 days-5 years). Ileocolic resection was the most commonly performed operation on an elective basis (range 95-100%). HRQOL improved as early as 2 weeks postoperatively and lasted up to 5 years across both generic and gastrointestinal domains. Gender, smoking, and disease recurrence were potential predictors of postoperative HRQOL. Patient satisfaction is high with regard to surgery, with preference for a laparoscopic approach.

CONCLUSION

Intestinal resection in CD patients improved HRQOL in the short- and long-term and patients describe high satisfaction about their surgery. Further studies are needed to validate potential predictors of postoperative HRQOL in this cohort.

Total HDL cholesterol efflux capacity in healthy children - Associations with adiposity and dietary intakes of mother and child

BACKGROUND AND AIMS

High-density lipoprotein (HDL) cholesterol efflux capacity in adults may be a measure of the atheroprotective property of HDL. Little however, is known about HDL cholesterol efflux capacity in childhood. We aimed to investigate the relationship between HDL cholesterol efflux capacity and childhood anthropometrics in a longitudinal study.

METHODS AND RESULTS

Seventy-five children (mean age = 9.4 ± 0.4 years) were followed from birth until the age of 9 years. HDL cholesterol efflux capacity was determined at age 9 by incubating serum-derived HDL-supernatants with ³H-cholesterol labeled J774 macrophages and percentage efflux determined. Mothers provided dietary information by completing food frequency questionnaires in early pregnancy and then 5 years later on behalf of themselves and their children. Pearson's correlations and multiple regression analyses were conducted to confirm independent associations with HDL efflux. There was a negative correlation between HDL cholesterol efflux capacity and waist circumference at age 5 (r = -0.3, p = 0.01) and age 9 (r = -0.24, p = 0.04) and BMI at age 5 (r = -0.45, p = 0.01) and age 9 (r = -0.19, p = 0.1). Multiple regression analysis showed that BMI at age 5 remained significantly associated with reduced HDL cholesterol efflux capacity (r = -0.45, p < 0.001). HDL-C was negatively correlated with energy-adjusted fat intake (r = -0.24, p = 0.04) and positively correlated with energy-adjusted protein (r = 0.24, p = 0.04) and starch (r = 0.29, p = 0.01) intakes during pregnancy. HDL-C was not significantly correlated with children dietary intake at age 5. There were no significant correlations between maternal or children dietary intake and HDL cholesterol efflux capacity.

CONCLUSIONS

This novel analysis shows that efflux capacity is negatively associated with adiposity in early childhood independent of HDL-C.

Living with Parkinson's disease: A Jordanian perspective

BACKGROUND

Parkinson's disease (PD) has a major impact on mobility, as well as cognition which can consequently impair aspects of individual's lives. Many studies have examined the living experiences of individuals with PD and its impact on their daily lives. None of these studies have explored the life experiences of Jordanian individuals living with PD. Therefore, the purpose of this qualitative study was to describe the daily living experiences and impact on lives of Jordanian individuals with PD.

METHODS

A qualitative phenomenological design was used. Interviews were recorded and transcribed. Transcripts were analysed using thematic analysis.

RESULTS

Experiences of 8 Jordanian individuals with PD who participated in this study can be categorized in the following major themes: (1) challenging perspectives and (2) adaptations. Challenging perspectives included stigma, emotional drainer, and experience of decreased independence and difficulty in occupational performance. Adaptations included embracing early acceptance and intervention, spiritual experience, and family support.

CONCLUSIONS

Study provided a wealth of knowledge related to the effect of PD and its intersection with the Arabic Jordanian culture. Such knowledge should aid healthcare professionals involved with providing services to Jordanian individuals with PD to provide better holistic services.

Parkinson's disease in Jordan: Barriers and motivators to exercise

BACKGROUND

Perceived barriers to engaging in exercise in people with Parkinson's disease (PD) are becoming more defined in countries such as the UK and the US. This, however, may vary by culture and environment. This study aimed to explore the perceptions of exercise and barriers that may affect participation in people with PD from Jordan.

METHODS

Two focus groups and seven individual interviews were conducted with people with PD. Additionally, individual interviews were conducted with two neurologists. Conversations were digitally recorded and transcribed. Transcripts were analyzed using thematic analysis and validated via researcher triangulation and peer checking.

RESULTS

Most of the PD participants lacked previous participation in any disease-specific exercises. Several barriers were perceived by PD participants for such lack of participation. Barriers included difficulty of diagnosis, lack of informational support provided by neurologists, lack of referral to physiotherapy services, disease-specific issues, and setting-related issues. Neurologists indicated a number of barriers in counseling their PD patients on exercise including lack of time and lack of health system resources. Motivators to participate in future exercise included outcome expectations and family support.

CONCLUSIONS

Findings of the study shed light into large areas of unmet needs of supporting exercise and physiotherapy for people with PD in developing countries as per Jordan. For better patient outcomes, findings of the study suggest that it is crucial to raise awareness among all PD-related stakeholders on the benefits of early referrals to physiotherapy and early engagement in exercise programs.