Development of an innovative clinical pharmacy service in a urology surgical unit: a new initiative from Qatar

Purpose

To provide an insight into the role of a clinical pharmacy initiative in a surgical urology unit through evaluating the nature, significance, associated medications, and acceptance rate of pharmacist interventions.

Methods

A cross-sectional study was carried out at the Ambulatory Care Center (ACC), Doha, Qatar. Data related to clinical pharmacist interventions and associated rationale were classified according to the nature of the intervention using an adapted classification system. The assessment of the severity followed the National Patient Safety Agency (NPSA) Risk Matrix. Linear regression, Kruskal-Wallis, and post-hoc analyses were performed to determine the association between patient-related and medication-related characteristics on pharmacist interventions.

Results

A total of 3284 interventions (on 1486 patients) were analysed. Most patients (n = 1105; 74.4%) had 1-2 interventions. Age and gender showed a positive linear correlation with the number of interventions per patient (p < 0.01). Majority of interventions were related to pharmacological strategy (n = 1858; 56.6%) and quantity of drug (n = 821; 25%). Additional drug therapy (n = 748; 22.78%) was the most common subcategory followed by optimum dose/frequency (n = 691; 21.04%) and discontinuation of medications (n = 352, 10.72%). Anti-infectives were the most identified drug category (n = 798, 55.1%). Most interventions (59.4%) were of moderate significance; patients with moderate interventions were found to be older compared to patients with minor interventions (p = 0.032). Prescribers' acceptance rate was high (>90%), with a notable increase of 6.6% from 2021 to 2023.

Conclusion

This study showed that the clinical pharmacy service in the urology surgical field was a fruitful initiative. The clinical pharmacist's role has expanded to include not only therapeutic optimisation while ensuring medication safety across the continuum of perioperative care but also the identification and management of untreated health problems. The dynamic and complexity of the urology patient population challenge clinical pharmacists; however, the practice concepts remain the same as in any other clinical setting.

Outcome evaluation of pharmacist-physician collaborative protocol-based antimicrobial treatment for hospitalized stroke patients with aspiration pneumonia

OBJECTIVES

To evaluate the efficacy and patient outcomes of pharmacist-physician collaborative protocol-based antimicrobial treatment regimens for antimicrobial stewardship.

METHODS

Patients treated for aspiration pneumonia due to stroke within 48 h after admission to Kochi Medical School Hospital (January 2019 to December 2022) were included. Primary outcomes were the cumulative number of days of antimicrobial treatment and length of hospital stay. Secondary outcomes included the percentage of patients under-dosed with first-choice antimicrobial agents and inpatient mortality.

RESULTS

Group A (66 patients) did not receive the antimicrobial treatment protocol, whereas group B (46 patients) did. There were no differences in the patient backgrounds. Group B had a significantly lower percentage of patients who were undertreated with the first-choice antimicrobial agent (9.1 % vs. 42.9 %). There was no significant difference in inpatient mortality between group A and group B (6.1 % vs. 4.3 %). The cumulative number of days of antimicrobial administration and the length of hospital stay were significantly lower in group B: 7.0 days (95 % CI, 6.0-8.0) vs. 9.0 days (95 % CI, 8.0-11.0) for antimicrobial administration, and 28.5 days (95 % CI, 22.0-35.0) vs. 43.0 days (95 % CI, 28.0-55.0) for hospital stay.

CONCLUSIONS

Protocol-based antimicrobial treatment for aspiration pneumonia supports appropriate antimicrobial usage and improves patient quality of life. These findings will assist in the effective treatment of aspiration pneumonia in an aging society.

Community Pharmacists' Readiness for Breast Cancer Mammogram Promotion: A National Survey from Jordan

Purpose

Mammography is the gold standard screening technique for early detection of breast cancer. This study aimed to assess the knowledge of community pharmacists of different aspects emphasized by the JBCP programs. This study also identifies the attitudes and barriers towards promoting early detection services.

Patients and Methods

This study was a cross-sectional survey of community pharmacists in Jordan. Pharmacists were randomly selected and asked to complete an electronic questionnaire. Inclusion criteria: a pharmacist with a bachelor's degree or higher and registered at the JPA working in a community pharmacy. The questionnaire included demographic and socioeconomic information, knowledge, attitudes towards breast cancer screening mammography services, and barriers towards participation in the promotion of these services.

Results

A total of 1,088 community pharmacists were approached, 1,000 (91.8%) completed the questionnaire. Participants had an average age of 34 years ± 10.8 and average experience of 9.1 ± 9.5 years. Only 48 (37.8%) of the female pharmacists aged 40 years or older underwent a mammogram. Knowledge of symptoms of breast cancer was the highest with a score of 755, followed by knowledge of risk factors (670) and finally early detection of breast cancer (540). Many barriers were reported by the community pharmacists including lack of educational materials and time constraints. Pharmacists with higher educational levels (p<0.001), of female gender (p<0.001), attended continuous cancer-related education (p<0.001), encountered a higher percentage of female customers (p<0.001), in a certain geographic location (p=0.003), underwent mammography (p=0.014), and encountered high frequency of inquiries on mammogram by the customers (p<0.001) were all associated with higher knowledge scores.

Conclusion

Despite the reported barriers and insufficient knowledge in certain aspects of early detection of breast cancer, community pharmacists have positive attitudes and can be a valuable asset for awareness-raising efforts.

The effect of pharmacist-led interventions on the appropriateness and clinical outcomes of anticoagulant therapy: a systematic review and meta-analysis

AIM

Although pharmacist-led interventions in anticoagulant (AC) therapy are widely accepted, there is a lack of evidence comparing their effectiveness with usual care in terms of AC therapy appropriateness and clinical outcomes. We aimed to estimate the comparative effectiveness of pharmacist-led interventions on the appropriateness and clinical outcomes of AC therapy.

METHODS AND RESULTS

Adhering to the PRISMA guidelines, we searched PubMed, EMBASE, and Scopus databases to identify randomized controlled trials and quasi-experimental and cohort studies published between 2010 and 2023. A random-effects model was used to calculate pooled intervention effects. We assessed heterogeneity (using Higgins' I2 and Cochran's Q) and publication bias (using Egger's test, the trim-and-fill method, and visualization of the funnel plot). In total, 35 studies involving 10 374 patients in the intervention groups and 11 840 in the control groups were included. The pharmacist-led interventions significantly improved the appropriateness of AC therapy [odds ratio (OR): 3.43, 95% confidence interval (CI): 2.33-5.06, P < 0.01]. They significantly decreased total bleeding [relative risk (RR): 0.75, 95% CI: 0.58-0.96, P = 0.03) and hospitalization or readmission (RR: 0.64, 95% CI: 0.41-0.99, P = 0.04). However, the impact of the pharmacist-led interventions on thromboembolic events (RR: 0.69, 95% CI: 0.46-1.02, P = 0.07) and mortality (RR: 0.76, 95% CI: 0.51-1.13, P = 0.17) was not significant.

CONCLUSION

Pharmacist-led interventions demonstrated superior outcomes in optimizing AC therapy compared with usual care. Further research is needed to evaluate pharmacist-led interventions' cost-effectiveness and long-term sustainability. PROSPERO registration number: CRD42023487362.

Evaluation of hospital quality of care outcomes in a teaching hospital in Ethiopia: a retrospective database study

OBJECTIVES

We aimed to evaluate hospital mortality rates, readmission rates and length of hospital stay (LOS) among adult medical patients admitted to a teaching hospital in Ethiopia.

DESIGN

We performed a retrospective study using routinely collected electronic data.

SETTING

Data were collected from Yekatit 12 Hospital Medical College between January 2021 and July 2023.

PARTICIPANTS

The analysis included 3499 (4111 admissions) adult medical patients with complete data.

OUTCOME MEASURES

We used mortality rates, readmission rates and LOS to measure the quality of the outcomes for the top 15 admission diagnoses. A multivariable Cox proportional hazard model was used to identify the statistically significant predictors of mortality with p values<0.05 and a 95% CI. The Kaplan-Meier curve was used to estimate the failure rate (mortality) of the admitted patients.

RESULTS

The median age of patients was 50 years and men accounted for 1827 (52.3%) of all admitted cases. Non-communicable diseases accounted for 2537 (72.5%) admissions. In descending order, stroke, 644 (18.29%); heart failure, 640 (18.41%); and severe pneumonia, 422 (12.06%) were the three most common causes of admission. The readmission rate was 25.67% (1056/411), and 61.9% of them were readmitted within 30 days of index discharge. The overall median LOS was 8 days. The median LOSs in the index admission (11 vs 8 days, p value=0.001) of readmitted patients was significantly higher than not readmitted. The in-hospital mortality rate was 438 (12.5%), with the highest number of deaths occurred between days 30 and 50 of admission. The mortality rate is significantly higher among patients with communicable diseases (adjusted HR, 1.64, 95% CI: 1.34, 2.10) and elderly patients (≥65 years) (adjusted HR, 1.79, 95% CI: 1.44, 2.22). Septicemia, chronic liver diseases with complications and HIV with complications were the three common causes of death with a proportional mortality rate of 55.2%, 27.93% and 22.46%, respectively.

CONCLUSIONS

Mortality, median LOSs and readmission rate were comparable to other national and international studies. Multicentre compressive research using these three quality patient outcomes is required to establish national standards and evaluate institutional performance.

Breaking bad news: an active learning method for medical students

BACKGROUND

Breaking bad news is one of the most difficult aspects of communication in medicine. The objective of this study was to assess the relevance of a novel active learning course on breaking bad news for fifth-year students.

METHODS

Students were divided into two groups: Group 1, the intervention group, participated in a multidisciplinary formative discussion workshop on breaking bad news with videos, discussions with a pluri-professional team, and concluding with the development of a guide on good practice in breaking bad news through collective intelligence; Group 2, the control group, received no additional training besides conventional university course. The relevance of discussion-group-based active training was assessed in a summative objective structured clinical examination (OSCE) station particularly through the students' communication skills.

RESULTS

Thirty-one students were included: 17 in Group 1 and 14 in Group 2. The mean (range) score in the OSCE was significantly higher in Group 1 than in Group 2 (10.49 out of 15 (7; 13) vs. 7.80 (4.75; 12.5), respectively; p = 0.0007). The proportion of students assessed by the evaluator to have received additional training in breaking bad news was 88.2% (15 of the 17) in Group 1 and 21.4% (3 of the 14) in Group 2 (p = 0.001). The intergroup differences in the Rosenberg Self-Esteem Scale and Jefferson Scale of Empathy scores were not significant, and both scores were not correlated with the students' self-assessed score for success in the OSCE.

CONCLUSION

Compared to the conventional course, this new active learning method for breaking bad news was associated with a significantly higher score in a summative OSCE. A longer-term validation study is needed to confirm these exploratory data.

Advancements in Modern Treatment Approaches for Central Post-Stroke Pain: A Narrative Review

PURPOSE OF REVIEW

Central post-stroke pain (CPSP) poses a multifaceted challenge in medical practice, necessitating a thorough and multidisciplinary approach for its diagnosis and treatment. This review examines current methods for addressing CPSP, highlighting both pharmacological and non-pharmacological therapies. It covers the mechanisms and clinical effectiveness of these treatments in managing CPSP and emphasizes the importance of personalized treatment plans, given the varied causes of CPSP.

RECENT FINDINGS

Recent advancements have illuminated diverse treatment modalities for CPSP. Pharmacotherapy spans from conventional analgesics to anticonvulsants and antidepressants, tailored to mitigate the neuropathic characteristics of CPSP. Non-pharmacological interventions, including physical therapy and psychological strategies, are pivotal in managing CPSP's chronic nature. For cases resistant to standard treatments, advanced interventions such as nerve blocks and surgical procedures like deep brain stimulation (DBS) or motor cortex stimulation (MCS) are considered. Additionally, innovative technologies such as neuromodulation techniques and personalized medicine are emerging as promising avenues to enhance therapeutic outcomes and improve quality of life for individuals grappling with CPSP.

SUMMARY

Modern approaches in managing CPSP require an interdisciplinary and patient-centric approach. Customizing treatment plans to address the specific etiology and symptoms of CPSP is crucial. Pharmacotherapy remains fundamental, encompassing medications such as anticonvulsants and antidepressants tailored to manage neuropathic pain. Integrating non-pharmacological interventions is crucial for providing comprehensive care. Additionally, investigating innovative technologies and personalized medicine presents promising opportunities to enhance treatment results and elevate the quality of life for those suffering from CPSP. Ultimately, an integrated approach that acknowledges the multifaceted nature of CPSP is essential for effective management and patient well-being.

Association of procalcitonin with voriconazole concentrations: a retrospective cohort study

Inflammation is a potential risk factor of voriconazole (VCZ) overdose, procalcitonin (PCT) is reported to act as a diagnostic marker for bacterial infections. However, the association of PCT with VCZ trough serum concentrations (VCZ-Cmin) is not fully clear. Our study aims to investigate the associations between PCT and VCZ-Cmin. In this retrospective cohort study, we collected the clinical data of 147 patients who received VCZ and monitored the VCZ concentration of them in our hospital from August 2017 to August 2021. All patients underwent routine clinical examinations on the day or the day before VCZ administration. General information and clinical symptoms of these patients were recorded. Multivariate liner analysis showed that PCT was significantly associated with VCZ-Cmin (p < 0.001). Overall, it was shown that VCZ-Cmin was significantly increased by 0.32 µg/mL for each fold increment in PCT in crude model. In the minor adjusted model (Model 1, adjustment for sex, age, albumin, direct bi1irubin, WBC) and fully adjusted model (Model 2, adjustment for sex, age, albumin, direct bilirubin, WBC, AST and ALT), VCZ-Cmin was significantly increased by 0.23 µg/mL and 0.21 µg/mL, respectively, for each fold increment in PCT. In conclusion, this research reveals the correlation between PCT and VCZ-Cmin, indicating that PCT has the potential to serve as a valuable biomarker for drug monitoring in the treatment of VCZ.

Tumor lysis syndrome signal with the combination of encorafenib and binimetinib for malignant melanoma: a pharmacovigilance study using data from the FAERS database

Objective

To investigate the potential association between tumor lysis syndrome (TLS) and drugs for the treatment of malignant melanoma (MM).

Methods

Reports of TLS recorded in the FDA Adverse Event Reporting System (FAERS) (January 2004-2023q3) were identified. Demographic and clinical characteristics were described, and disproportionality signals were assessed through the Reporting Odds Ratio (ROR) and Information Component (IC). The latency of TLS with anticancer drugs was described based on parametric models. Subgroup analysis was conducted to explore the differences of TLS signals in different age and sex.

Results

We found 5 (1.49%), 59 (17.61%), 79 (23.58%), 19 (5.67%), 13 (3.88%), 13 (3.88%), 33 (9.85%), 49 (14.63%), 16 (4.78%) TLS reports with pembrolizumab, nivolumab, ipilimumab, dabrafenib, vemurafenib, dacarbazine, "encorafenib and binimetinib", "nivolumab and ipilimumab", "dabrafenib and trametinib", respectively. The combination of encorafenib and binimetinib showed the strongest signal of TLS (IC025 = 3.98). The median days of latency of TLS with combination of encorafenib and binimetinib is 2 days, which was much shorter than nivolumab (22.0 days) and ipilimumab (21.5 days). TLS cases associated with drugs for MM were predominantly recorded in females and aged 25-65 years. After excluding confounding factors such as pre-existing diseases and co-treated drugs, the disproportionate signal of TLS with "encorafenib and binimetinib" remained strong.

Conclusions

Stronger disproportionate signal of TLS was detected in MM patients using the combination of encorafenib and binimetinib than other drugs. Further research is needed to investigate the underlying mechanisms and identify patient-related predisposing factors to support safe prescribing of the combination of encorafenib and binimetinib.

UPLC-MS/MS method for fluconazole determination in plasma and its application in Mexican patients with candidaemia

Aim: An accurate and fast ultra-high performance liquid chromatography coupled with tandem mass spectrometry analytical method was developed and validated for quantifying fluconazole levels in human plasma according to the US FDA guidelines.Materials & methods: A simple protein precipitation by acetonitrile was employed for the sample preparation. The chromatographic separation was carried out using isocratic elution of water (0.1% formic acid) and acetonitrile on an Acquity ultra-high performance liquid chromatography HSS T3 column. Samples from ten adult patients diagnosed with candidemia who received fluconazole treatment were analyzed.Results & conclusion: The method demonstrated excellent linearity and stability within the 1-50 μg/ml range (r2 >0.999). The intraday and interday precision were determined with coefficient of variation values ranging from 1.4 to 4.38% and 2.8 to 6.6%, respectively. This rapid and selective method has successfully analyzed 27 plasma samples. The straightforward sample preparation in a single step and the reduced analysis time make this method suitable for adult patients with candidemia, leading to improved clinical outcomes.

Evaluation of the drug-drug interactions management system for appropriate use of nirmatrelvir/ritonavir: a retrospective observational study

PURPOSE

While nirmatrelvir/ritonavir (NMV-r) has been positioned as a first-line treatment for mild to moderate COVID-19, it has multiple and significant drug-drug interactions (DDIs). The use of NMV-r in Japan has been limited compared to the United States. This study aimed to describe the distribution of DDIs with NMV-r and their management in patients with COVID-19 under the control of a management system for the appropriate use of NMV-r.

METHODS

A retrospective observational study was conducted at a Japanese university hospital. The management system included a flowchart for selecting antivirals and a list for reviewing DDI management, based on the National Institutes of Health guidelines and the guidance of the Japanese Society of Pharmaceutical Health Care and Sciences. Patients with mild to moderate COVID-19 and prescribed NMV-r or molnupiravir (MOV) were included. The primary outcome was DDI management practices, including the selected COVID-19 medications. The secondary outcome included the distribution of DDI classification and the 30-day all-cause mortality.

RESULTS

This study included 241 patients (median age of 60 years, 112 [46.5%] females), of whom 126 and 115 received NMV-r and MOV, respectively. Of the 241 patients, 145 (60.2%) received concomitant medications that have DDIs with NMV-r. All 30 patients with severe renal impairment or insufficient details on concomitant medications received MOV. Forty-nine patients with concomitant medications required alternative COVID-19 therapy consideration due to DDIs, of whom 42 (85.7%) patients received MOV. Eighty-one patients had concomitant medications requiring temporary adjustment, of whom 44 (54.3%) patients received NMV-r, and 42 of these patients temporarily adjusted these concomitant medications. Five patients with concomitant medications that can continued by monitoring the effects/adverse effects, of whom 4 (80.0%) patients received NMV-r. Seventy-six patients without concomitant medications requiring DDI management, of whom 71 (93.4%) patients received NMV-r. The 30-day all-cause mortality for eligible patients was 0.9% [95% confidence interval, 0.1-3.1].

CONCLUSIONS

Most patients received appropriate antivirals according to the classification of DDIs, and most patients with concomitant medications requiring temporary adjustment received the recommended DDI management. Our management system is effective in promoting the use of NMV-r in the appropriate patients and managing problematic DDIs.

Residual Stroke Risk Among Patients With Atrial Fibrillation Prescribed Oral Anticoagulants: A Patient-Level Meta-Analysis From COMBINE AF

BACKGROUND

Despite oral anticoagulation, patients with atrial fibrillation (AF) remain at risk of ischemic stroke and systemic embolism (SE) events. For patients whose residual risk is sufficiently high, additional therapies might be useful to mitigate stroke risk.

METHODS AND RESULTS

Individual patient data from 5 landmark trials testing oral anticoagulation in AF were pooled in A Collaboration Between Multiple Institutions to Better Investigate Non-Vitamin K Antagonist Oral Anticoagulant Use in AF (COMBINE AF). We calculated the rate of ischemic stroke/SE among oral anticoagulation-treated patients with a CHA2DS2-VASc score≥2, across strata of CHA2DS2-VASc score, stroke history, and AF type, as either paroxysmal or nonparoxysmal. We included 71 794 patients with AF (median age 72 years, interquartile range, 13 years, 61.3% male) randomized to a direct oral anticoagulant or vitamin K antagonist, and followed for a mean of 2.1 (±0.8) years. The median CHA2DS2-VASc score was 4 (interquartile range, 3-5), 18.8% had a prior stroke, and 76.4% had nonparoxysmal AF. The overall rate of stroke/SE was 1.33%/y (95% CI, 1.27-1.39); 1.38%/y (95% CI, 1.31-1.45) for nonparoxysmal AF, and 1.15%/y (95% CI, 1.05-1.27) for paroxysmal AF. The rate of ischemic stroke/SE increased by a rate ratio of 1.36 (95% CI, 1.32-1.41) per 1-point increase in CHA2DS2-VASc, reaching 1.67%/y (95% CI, 1.59-1.75) ≥4 CHA2DS2-VASc points. Patients with both nonparoxysmal AF and CHA2DS2-VASc ≥4 had a stroke/SE rate of 1.75%/y (95% CI, 1.66-1.85). In patients with a prior stroke, the risk was 2.51%/y (95% CI, 2.33-2.71).

CONCLUSIONS

AF type, CHA2DS2-VASc score, and stroke history can identify patients with AF, who despite oral anticoagulation have a residual stroke/SE risk of 1.5% to 2.5% per year. Evaluation of additional stroke/SE prevention strategies in high-risk patients is warranted.

Antihypertensive drug-associated adverse events in osteoarthritis: a study of a large real-world sample based on the FAERS database

Background

Hypertension is a common complication in patients with osteoarthritis (OA). There is increasing interest in the relationship between hypertension and OA. However, hypertension has been reported to negatively affect symptoms and quality of life in patients with OA. Therefore, treating hypertension is crucial for patients with OA. However, there is a lack of real-world studies on the effects of medications for treating hypertension on OA.

Methods

Data from the FAERS database from January 2004 to December 2023 were extracted for disproportionality analyses, and proportional reporting ratios (PRRs) were used to assess the association between medications for hypertension and all types of arthritis. Adverse event signals were identified and determined using reporting odds ratios (RORs) Adverse event signals were considered to have occurred if a drug-induced adverse event was recorded more than or equal to 3 and the lower limit of the ROR confidence interval was more than 1. We selected five classes of drugs including, calcium channel blockers (CCBs), angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), thiazide diuretics and β-blockers and representative drugs were analysed for osteoarthritis-related adverse reactions, and age and gender subgroups were analysed for drugs of significance. We also analysed the occurrence of AEs in relation to time using the Weibull distribution.

Results

In terms of overall data, we found significant OA adverse reaction signals only for ARBs among the five drug classes.ARB AEs for spinal osteoarthritis (ROR 4.64, 95% CI 3.62-5.94), osteoarthritis (ROR 3.24 95% CI 2.82-3.72) and gouty arthritis (ROR 3.27 95% CI 1.22-8.75) were the three adverse reactions with the loudest signals. Next, we found that valsartan had strong osteoarthritis adverse reaction signals among the three ARBs, namely, irbesartan, cloxartan, and valsartan. We also analysed age and gender subgroups and found that osteoarthritis signals were strongest in the 18-65 and 65+ population, while females seem to be more prone to valsartan-related OA AEs.

Conclusion

ARBs, especially valsartan, have significant positive signals for OA AEs. Therefore, ARB drugs, especially valsartan, should be used with caution when treating patients with OA combined with hypertension.

Evaluation of Amiodarone Administration in Patients with New-Onset Atrial Fibrillation in Septic Shock

Background and Objective: New-onset atrial fibrillation (NOAF) is a common cardiac condition often observed in intensive care units. When amiodarone is used to treat this condition, either to maintain sinus rhythm after electrical cardioversion or to control heart rate, complications can arise when a systemic pathology is present. Systemic pathology can result in a decrease in cardiac output and blood pressure, making the management of NOAF and septic shock challenging. Limited international research exists on the coexistence of NOAF and septic shock, making it difficult to determine the optimal course of treatment. While amiodarone is not the primary choice of antiarrhythmic drug for patients in septic shock, it may be considered for those with underlying cardiac issues. This paper aims to investigate the safety of administering amiodarone to patients with septic shock and explore whether another antiarrhythmic drug may be more effective, especially considering the cardiac conditions that patients may have. Materials and Methods: To write this article, we searched electronic databases for studies where authors used amiodarone and other medications for heart rate control or sinus rhythm restoration. Results: The studies reviewed in this work have shown that for the patients with septic shock and NOAF along with a pre-existing cardiac condition like a dilated left atrium, the use of amiodarone may provide greater benefits compared to other antiarrhythmic drugs. For patients with NOAF and septic shock without underlying heart disease, the initial use of propafenone has been found to be advantageous. However, a challenge arises when deciding between rhythm or heart rate control using various drug classes. Unfortunately, there is limited literature available on this specific scenario. Conclusions: NOAF is a frequent and potentially life-threatening complication occurring in one out of seven patients with sepsis, and its incidence is rising among patients with septic shock.

Prospective multicenter study of the epidemiological features of emergency patients with overdose of over-the-counter drugs in Japan

Aim

To investigate the epidemiological characteristics of patients presenting to the emergency department with an overdose of over-the-counter (OTC) drugs.

Methods

A questionnaire survey was conducted to examine the sociodemographic characteristics of patients with OTC drugs overdoses visiting emergency departments at eight sites across the country. The patients were divided into "habitual" and "nonhabitual" groups according to their history of OTC drugs overdose. Student's t-test or Welch's t-test was performed for numerical variables, and Pearson's χ 2 test was performed for dichotomous and nominal variables between the two groups.

Results

Of the 124 patients included in this study, 79% were women. The habitual (26.6%) and the nonhabitual (73.4%) groups showed no differences in sex, occupation, cohabitants, history of mental illness, or history of alcohol consumption or smoking; however, those in the habitual group were significantly younger. The proportion of OTC drugs obtained from physical stores was higher in the habitual group, whereas the nonhabitual group used more household medicines. Suicide and self-harm were more common reasons for overdose in the nonhabitual group. Antipyretic analgesics were significantly more common in the nonhabitual group, whereas antitussive expectorants and antihistamines were significantly more common in the habitual group.

Conclusion

This is the first multicenter study to determine the status of OTC drugs overdose patients treated at emergency departments of medical facilities in Japan. To prevent new overdoses of OTC drugs, continued detailed epidemiologic studies of patient backgrounds and drug acquisition routes, and investigation of the components of OTC drugs that cause dependency are necessary.

Drugs with Anticholinergic Properties and Association with Hip Fractures in Older Patients: A Danish Nationwide Cohort-Study

Objectives

Hip fractures (HFx) resulting from falls are a significant health concern, and drugs with anticholinergic properties (DAP) increase the risk of falls. This study aimed to assess the association between use of DAP at hospital admission and HFx risk in older patients.

Methods

This nationwide population-based study included all patients ≥65 years admitted to Danish geriatric wards during 2005-2014. Outcome of interest was first HFx within 2-years follow-up. The Anticholinergic Cognitive Burden (ACB) scale quantified DAP use. Cox regression analysis of data from four national registries was adjusted for activities of daily living, age, marital status, admission year, BMI, fracture history, previous admissions, dementia, anti-osteoporotic drugs, and Charlson comorbidity index.

Results

74,589 patients (62.8% female) were included, 45,463 (60.9%) received DAP at index, and 7,861 HFx occurred during follow-up. Cumulative 2-year HFx hazard was highest for ACB=0 (15.3%). Higher ACB-score was not associated with increased HFx risk in univariable nor multivariable analyses. In sensitivity analysis, use of DAP with high anticholinergic burden (≥2) did not alter results.

Conclusions

In this high-incidence national cohort, higher ACB-score was not associated with increased HFx risk. Our results call for further research on association between specific DAP and risk of HFx.

Biodegradation of non-steroidal anti-inflammatory drug loxoprofen by a hyper lignin-degrading fungus Phanerochaete sordida YK-624 under non-ligninolytic conditions

Loxoprofen has been widely used as a non-steroidal anti-inflammatory drug globally and it can also persist in the environment. Although it is known to be a non-toxic drug, its presence may still pose a potential risk to organisms in the environment. Here, the hyper lignin-degrading fungus Phanerochaete sordida YK-624 was used to study the degradation of loxoprofen. This fungus showed excellent loxoprofen biodegradation ability with 90.4% and 93.4% after one day of incubation at lower concentrations of 0.01 and 0.005 mM, respectively. And at a higher concentration of 0.1 mM, a significant removal of 94.2% was also observed after 10 days of incubation. In this study, four metabolites were isolated and determined by HR-ESI-MS and NMR. Furthermore, LC/MS analysis suggested the presence of intermediate hydroxy loxoprofen. In addition, loxoprofen-OH was also identified as a metabolite of loxoprofen through comparison with the synthesized compounds. In this metabolism of loxoprofen, cytochrome P450 may play a significant role. Interestingly, P. sordida YK-624 showed enantioselectivity in the degradation process of loxoprofen. By these results, three degradation pathways of loxoprofen by P. sordida YK-624 were hypothesized. To the best of our knowledge, this is the first report describing the potential degradation mechanisms of loxoprofen by a white-rot fungus.

An exploration into CTEPH medications: Combining natural language processing, embedding learning, in vitro models, and real-world evidence for drug repurposing

BACKGROUND

In the modern era, the growth of scientific literature presents a daunting challenge for researchers to keep informed of advancements across multiple disciplines.

OBJECTIVE

We apply natural language processing (NLP) and embedding learning concepts to design PubDigest, a tool that combs PubMed literature, aiming to pinpoint potential drugs that could be repurposed.

METHODS

Using NLP, especially term associations through word embeddings, we explored unrecognized relationships between drugs and diseases. To illustrate the utility of PubDigest, we focused on chronic thromboembolic pulmonary hypertension (CTEPH), a rare disease with an overall limited number of scientific publications.

RESULTS

Our literature analysis identified key clinical features linked to CTEPH by applying term frequency-inverse document frequency (TF-IDF) scoring, a technique measuring a term's significance in a text corpus. This allowed us to map related diseases. One standout was venous thrombosis (VT), which showed strong semantic links with CTEPH. Looking deeper, we discovered potential repurposing candidates for CTEPH through large-scale neural network-based contextualization of literature and predictive modeling on both the CTEPH and the VT literature corpora to find novel, yet unrecognized associations between the two diseases. Alongside the anti-thrombotic agent caplacizumab, benzofuran derivatives were an intriguing find. In particular, the benzofuran derivative amiodarone displayed potential anti-thrombotic properties in the literature. Our in vitro tests confirmed amiodarone's ability to reduce platelet aggregation significantly by 68% (p = 0.02). However, real-world clinical data indicated that CTEPH patients receiving amiodarone treatment faced a significant 15.9% higher mortality risk (p<0.001).

CONCLUSIONS

While NLP offers an innovative approach to interpreting scientific literature, especially for drug repurposing, it is crucial to combine it with complementary methods like in vitro testing and real-world evidence. Our exploration with benzofuran derivatives and CTEPH underscores this point. Thus, blending NLP with hands-on experiments and real-world clinical data can pave the way for faster and safer drug repurposing approaches, especially for rare diseases like CTEPH.

Comparative effectiveness of sodium-glucose cotransporter-2 inhibitors for new-onset gastric cancer and gastric diseases in patients with type 2 diabetes mellitus: a population-based cohort study

OBJECTIVE

To compare the risks of gastric cancer and other gastric diseases in patients with type-2 diabetes mellitus (T2DM) exposed to sodium-glucose cotransporter 2 inhibitors (SGLT2I), dipeptidyl peptidase-4 inhibitors (DPP4I) or glucagon-like peptide-1 receptor agonists (GLP1a).

DESIGN

This was a population-based cohort study of prospectively collected data on patients with T2DM prescribed SGLT2I, DPP4I or GLP1a between January 1st 2015 and December 31st 2020 from Hong Kong. The outcomes were new-onset gastric cancer, peptic ulcer (PU), acute gastritis, non-acute gastritis, and gastroesophageal reflux disease (GERD). Propensity score matching (1:1) using the nearest neighbour search was performed, and multivariable Cox regression was applied. A three-arm comparison between SGLT2I, DPP4I and GLP1a was conducted using propensity scores with inverse probability of treatment weighting.

RESULTS

A total of 62,858 patients (median age: 62.2 years old [SD: 12.8]; 55.93% males; SGLT2I: n = 23,442; DPP4I: n = 39,416) were included. In the matched cohort, the incidence of gastric cancer was lower in SGLT2I (Incidence rate per 1000 person-year, IR: 0.32; 95% confidence interval, CI 0.23-0.43) than in DPP4I (IR per 1000 person-year: 1.22; CI 1.03-1.42) users. Multivariable Cox regression found that SGLT2I use was associated with lower risks of gastric cancer (HR 0.30; 95% CI 0.19-0.48), PU, acute gastritis, non-acute gastritis, and GERD (p < 0.05) compared to DPP4I use. In the three-arm analysis, GLP1a use was associated with higher risks of gastric cancer and GERD compared to SGLT2I use.

CONCLUSIONS

The use of SGLT2I was associated with lower risks of new-onset gastric cancer, PU, acute gastritis, non-acute gastritis, and GERD after matching and adjustments compared to DPP4I use. SGLT2I use was associated with lower risks of GERD and gastric cancer compared to GLP1a use.

The Effect of Treatment Adherence on Health Status of Outpatients with Chronic Obstructive Pulmonary Disease

Adherence to COPD treatment plays a crucial role in patient health outcomes. Understanding the correlation between treatment adherence and health status is vital for clinicians to develop effective disease management strategies. This study aimed to examine treatment adherence and its impact on the health status of COPD patients, specifically focusing on the effects of adhering to inhaled medications and breathing exercises. A cross-sectional study involving 420 outpatients diagnosed with COPD was conducted. The study encompassed administering questionnaires, observing patient breathing exercises, and measuring ventilatory function. Results showed that only 36.9% of participants adhered to treatment, with 44.7% following inhaler protocols and 36.9% regularly engaging in breathing exercises. The patients who were non-adherent exhibited a 0.3-fold increase in disease severity compared to the adherent group (p = .002). These findings suggest that consistent adherence to treatment, including inhaled medications and breathing exercises, may positively affect health status by reducing disease severity and airway obstruction in COPD patients. To address this, we recommend that home care clinicians implement a post-discharge assessment and intervention program. This program should focus on educating patients about the importance of treatment adherence and promoting behaviors that reinforce adherence to prescribed therapies.

A Biobehavioral Perspective on Caring for Allogeneic Hematopoietic Stem Cell Transplant Survivors with Graft-Versus-Host Disease

Among the potential complications of allogeneic hematopoietic stem cell transplantation (HSCT), graft-versus-host disease (GVHD) is common and associated with significant physical and psychosocial symptom burden. Despite substantial advances in GVHD treatment, the global immune suppression that frequently accompanies GVHD treatment also contributes to high rates of physical and emotional suffering and mortality. The complex manifestations of GVHD and its treatment warrant a multidisciplinary team-based approach to managing patients' multi-organ system comorbidities. A biobehavioral framework can enhance our understanding of the complex association between medications, physical symptoms, and psychosocial distress in patients with GVHD. Hence, for this perspective, we highlight the importance of addressing both the physical and psychosocial needs experienced by patients with GVHD and provide guidance on how to approach and manage those symptoms and concerns as part of comprehensive cancer care.

Community Pharmacist-Centered training program improves confidence in delivering epilepsy care

RATIONALE

Incorporating pharmacists into interdisciplinary healthcare teams can improve patient outcomes across disease states; however, there is little evidence describing pharmacists' contributions to epilepsy care. Previous research from our group revealed that community pharmacists are well positioned to serve as patient advocates, monitor medications, and provide education for people living with epilepsy. However, pharmacists would like to receive additional training in epilepsy management. Advanced training in neurology is not a practical approach for community pharmacists who engage daily with patients having a variety of conditions and medications.

OBJECTIVE

To develop and evaluate a flexible, community pharmacist-centered training program to improve both confidence and competence in delivering epilepsy care.

METHODS

The training program consisted of five 1-hour, self-paced online modules and two 90-minute synchronous virtual sessions. Topics included the classification of the epilepsies, comorbid conditions, antiseizure medicine (ASM) therapy, special populations (pregnancy, people of childbearing potential, older adults), seizure emergencies, and sudden unexpected death in epilepsy (SUDEP), as well as social determinants of health. The training program was delivered over 6 weeks to pharmacists located at two community pharmacies in Washington State. Learning was assessed using a pre- and post-training questionnaire containing questions that evaluated knowledge and confidence in the training material.

RESULTS

The training program did not significantly change pharmacists' mastery of the material. However, the pharmacists' confidence in delivering the material significantly improved in 14 of the 16 areas that were evaluated. Pharmacists' mastery and confidence were strongest in areas around ASM management, SUDEP and seizure emergencies, people of child-bearing potential and older adults with epilepsy, and comorbidities, whereas social health disparities in epilepsy care remained an area that required further training.

CONCLUSION

Our findings support the idea that community pharmacists are well positioned with the knowledge to play an important role in epilepsy care. However, dedicated training tailored to community pharmacists' needs may improve their confidence in providing such care.

Mechanism-based inactivation of cytochromes P450: implications in drug interactions and pharmacotherapy

Cytochrome P40 (CYP) enzymes dominate the metabolism of numerous endogenous and xenobiotic substances. While it is commonly believed that CYP-catalysed reactions result in the detoxication of foreign substances, these reactions can also yield reactive intermediates that can bind to cellular macromolecules to cause cytotoxicity or irreversibly inactivate CYPs that create them.Mechanism-based inactivation (MBI) produces either irreversible or quasi-irreversible inactivation and is commonly caused by CYP metabolic bioactivation to an electrophilic reactive intermediate. Many drugs that have been known to cause MBI in CYPs have been discovered as perpetrators in drug-drug interactions throughout the last 20-30 years.This review will highlight the key findings from the recent literature about the mechanisms of CYP enzyme inhibition, with a focus on the broad mechanistic elements of MBI for widely used drugs linked to the phenomenon. There will also be a brief discussion of the clinical or pharmacokinetic consequences of CYP inactivation with regard to drug interaction and toxicity risk.Gaining knowledge about the selective inactivation of CYPs by common therapeutic drugs helps with the assessment of factors that affect the systemic clearance of co-administered drugs and improves comprehension of anticipated interactions with other drugs or xenobiotics.

Impact of aromatherapy on anxiety among ICU nurses: A randomized, blinded, placebo-controlled trial

PURPOSE

The purpose of this study was to examine the effect of aromatherapy with an essential oil blend containing lavender, bergamot, ylang-ylang, and sweet orange, compared with placebo, on perceptions of anxiety in ICU RNs.

METHODS

Nurses recruited from six adult ICUs and a neonatal ICU participated in this blinded, randomized, placebo-controlled study, which took place over a 30-day intervention period.

RESULTS

Although there were no statistically significant changes in anxiety pre- to postintervention or between the intervention and placebo groups, there were also no adverse events or untoward effects.

CONCLUSION

The results of this study may support aromatherapy as an evidence-based strategy to reduce anxiety in ICU nurses. Additional research is needed.

Comprehensive overview of analytical and bioanalytical methodologies for the opioid analgesics - Tramadol and combinations

Synthetic opioids like Tramadol are used to treat mild to moderate pain. Its ability to relieve pain is about a tenth that of morphine. Furthermore, Tramadol shares similar effects on serotonin and norepinephrine to several antidepressants known as serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine and duloxetine. The present review paper discusses the recent developments in analytical methods for identifying drugs in pharmaceutical preparations and toxicological materials, such as blood, saliva, urine, and hair. In recent years, a wide variety of analytical instruments, including capillary electrophoresis, NMR, UV-visible spectroscopy, HPTLC, HPLC, LC-MS, GC, GC-MS, and electrochemical sensors, have been used for drug identification in pharmaceutical preparations and toxicological samples. The primary quantification techniques currently employed for its quantification in various matrices are highlighted in this research.

Can immature granulocytes and neutrophil-lymphocyte ratio be biomarkers to evaluate diabetic nephropathy?: A cross-sectional study

AIMS

We aimed to examine the role of circulating immature granulocytes (IGs) in assessing Diabetic Nephropathy (DN) mainly and also associations of other leukocyte parameters with DN.

METHODS

In this retrospective cross-sectional study, a total of 164 Diabetes Mellitus patients were grouped as normoalbuminuric and microalbuminuric according to urinary albumin excretion in the course of admission. Neutrophil-lymphocyte ratio (NLR), IG count (IG#) and IG percentage (IG%) levels were compared between the groups. The value of IG# and IG% levels in detecting microalbuminuria was analyzed with the Receiver operating characteristic (ROC) curve.

RESULTS

NLR was remarkably higher in the microalbuminuric group (p = 0.036). Correlation results in the microalbuminuric group were as follows: A feeble positive correlation between neutrophil count (NEU#) and serum creatinine and albumin-to- creatinine ratio (ACR) (p = 0.036, r = 0.261; p = 0.005, r = 0.347, respectively), a feeble positive correlation between lymphocyte count (LYM#) and estimated glomerular filtration rate (p = 0.021, r = 0.285). Correlation results in the normooalbuminuric group were as follows: A feeble positive correlation between NEU# and ACR (p = 0.043, r = 0.204), a feeble negative correlation between LYM# and serum creatinine (p = 0.042, r = -0.205), a poor positive correlation between IG# and ACR and HBA1C% (p = 0.048, r = 0.199; p = 0.004, r = 0.290, respectively), a positive poor correlation between IG% and HBA1C% (p = 0.019, r = 0.235). Area under the ROC curve values for IG# and IG% were not statistically noteworthy in detecting microalbuminuria (p = 0.430; p = 0.510, respectively).

CONCLUSIONS

IG# and IG% values are insufficient to predict immediate microalbuminuria, but could be considered a weak biomarker for renal damage in normoalbuminuric (<30 mg/g) diabetic patients. Further researches are needed for the use of leukocyte parameters in evaluating DN.

Lost and Found: Misdiagnosis of AIDS-Related Bone Marrow Suppression As Neutropenic Fever and Benign Ethnic Neutropenia in a Patient With Congenital HIV

Neutropenia is a relatively uncommon but notable secondary effect of HIV infection. While the various hematopoietic effects of HIV and AIDS are well-described in the literature, high-quality evidence directly linking neutropenia with mortality in HIV-infected patients remains limited. The multifactorial etiology of neutropenia complicates its diagnosis, particularly when it occurs secondary to HIV. We present the case of a 35-year-old African American male with congenital HIV, who presented with severe neutropenia accompanied by a fever in the context of untreated HIV. The initial differential diagnosis was broad, including benign ethnic neutropenia (given the patient's African American ethnicity), tuberculosis (given the potential for anti-tuberculosis therapy to cause neutropenia and its commonality as a co-infection in HIV patients), sepsis-related neutropenia, and AIDS-related bone marrow suppression. However, through further workup, it became apparent that HIV-related bone marrow suppression ultimately led to pancytopenia. This case highlights how HIV patient non-adherence to antiretroviral therapy (ART) and hematologic abnormalities complicate the diagnosis of hematopoietic abnormalities from HIV. It also discusses how vertical transmission and abrupt ART discontinuation create a new phenotype of HIV patients with delayed presentations of AIDS-related complications. This patient's presentation also provides insight into the consequences of untreated HIV following the self-discontinuation of long-term HIV management therapy due to low healthcare literacy and loss of follow-up. The patient's clinical course, laboratory findings, imaging studies, and treatment outcomes are discussed, emphasizing the need for timely diagnosis and a multidisciplinary approach to care while exploring potential barriers to care in different social contexts.

Risk factors for neonatal hypoglycemia: a meta-analysis

OBJECTIVE

This Study aims to investigate the risk factors of hypoglycemia in neonates through meta-analysis.

METHOD

PubMed, Embase, Cochrane library, and Web of science databases were searched for case-control studies on risk factors for neonatal hypoglycemia. The search was done up to 1st October 2023 and Stata 15.0 was used for data analysis.

RESULTS

A total of 12 published studies were included, including 991 neonates in the hypoglycemic group and 4388 neonates in the non-hypoglycemic group. Meta-analysis results suggested caesarean section [OR = 1.90 95%CI (1.23, 2.92)], small gestational age[OR = 2.88, 95%CI (1.59, 5.20)], gestational diabetes [OR = 1.65, 95%CI (1.11, 2.46)], gestational hypertension[OR = 2,79, 95%CI (1.78, 4.35)] and respiratory distress syndrome[OR = 5.33, 95%CI (2.22, 12.84)] were risk factors for neonatal hypoglycemia.

CONCLUSION

Based on the current study, we found that caesarean section, small gestational age, gestational diabetes, gestational hypertension, respiratory distress syndrome are risk factors for neonatal hypoglycemia.

PROSPERO REGISTRATION NUMBER

CRD42023472974.

Comparative Effectiveness and Safety of Off-Label Underdosed Direct Oral Anticoagulants in Asian Patients with Atrial Fibrillation: A Systematic Review and Meta-analysis

INTRODUCTION

Off-label underdosed direct oral anticoagulants (DOACs) are commonly utilised in Asian patients with atrial fibrillation (AF) since they are prone to bleeding with OACs. However, the efficacy and safety of off-label underdosing DOACs are controversial. This study aimed to compare the effectiveness and safety of off-label underdosed DOACs in Asian patients with AF.

METHODS

PubMed, Embase, Cochrane library, and ClinicalTrials.gov were searched from 2010 to July 5, 2024, for randomised controlled trials or observational studies that compared off-label DOACs and on-label/warfarin in Asian patients with AF. The primary outcomes included ischaemic stroke or systemic embolism (ISSE) and major bleeding (MB), while secondary outcomes included all-cause death, gastrointestinal bleeding (GIB), intracranial haemorrhage (ICH), and myocardial infarction (MI). Hazard ratios (HRs) with 95% confidence intervals (CIs) were pooled using random-effects models.

RESULTS

Twenty observational studies were included. Seventeen studies compared off-label underdosed DOACs versus on-label DOACs, whereas five studies compared off-label underdosed DOACs versus warfarin. Off-label underdosed DOACs were associated with higher risk of ISSE (pooled HR [pHR] = 1.17; 95% CI: 1.00-1.38, p = 0.048) and ICH (pHR = 1.27; 95% CI: 1.06-1.52, p = 0.010) versus on-label. Subgroup analysis demonstrated increased ISSE risk with off-label underdosed rivaroxaban compared to on-label (pHR = 1.49; 95% CI: 1.07-2.08). Compared to warfarin, off-label underdosed DOACs were associated with decreased risk of MB (pHR = 0.46; 95% CI: 0.32-0.65, p < 0.001), GIB (pHR = 0.52; 95% CI: 0.29-0.93, p = 0.028), ICH (pHR = 0.60; 95% CI: 0.42-0.86, p = 0.005), and all-cause death (pHR = 0.70; 95% CI: 0.56-0.87, p = 0.001), while illustrating similar ISSE risk.

CONCLUSIONS

Off-label underdosed DOACs, particularly rivaroxaban, was associated with increased ISSE risk but did not decrease bleeding compared to on-label. Adherence to appropriate DOAC doses should be emphasised to achieve the best clinical outcomes for Asian patients with AF.

Development of Simultaneous Drug Concentration Measurement Method Using an Automated Pretreatment Liquid Chromatography/Tandem Mass Spectrometry System for Therapeutic Drug Monitoring

Therapeutic drug monitoring (TDM) is a personalized treatment approach that involves optimizing drug dosages based on patient-specific factors, such as drug plasma concentrations, therapeutic efficacy, or adverse reactions. The plasma concentration of drugs is determined using liquid chromatography/tandem mass spectrometry (LC-MS/MS) or various immunoassays. Compared with immunoassays, LC-MS/MS requires more pretreatment time as the number of samples increases. Recently, fully automated pretreatment LC-MS/MS systems have been developed to automatically perform whole-sample pretreatment for LC-MS/MS analysis. In this study, we developed a method for simultaneous concentration determination of five analytes (clozapine, mycophenolic acid, sunitinib, N-desethylsunitinib, and voriconazole) using LC-MS/MS for clinical TDM using a fully automated LC-MS/MS pretreatment system. In the developed method, the intra- and inter-assay relative error (RE) values ranged between -14.8% and 11.3%; the intra- and inter-assay coefficient of variation (CV) values were <8.8% and <10.5%, respectively. The analytes showed good stability, with RE values ranging between -13.6% and 10.9% and CV values <8.9%. Furthermore, the plasma concentrations in clinical samples using this method and the conventional manual pretreatment method showed similar results. Therefore, the method developed in this study could be considered a useful pretreatment method for routine TDM in patients.

Full green assay of parenteral dosage forms of polymyxins utilizing xanthene dye: application to content uniformity testing

Due to the lack of other treatment options, a rebirth of polymyxins is urgently required. Colistin (also called polymyxin E) and polymyxin B are the only two examples of this antibiotic class that were effectively employed in such critical situations. In the present work, both of the two studied medications were quantified via a simple, green, and non-extracting spectrophotometric approach based on the formation of ion-pair complexes with Erythrosine B. Without using any organic solvents, the pink color of the created complexes was detected at wavelength = 558 nm. To achieve the highest intensity of absorbance, optimum conditions were established by the screening of many experimental factors such as pH, buffer volume, the volume of Erythrosine B, and the time consumed to undergo the reaction. For Colistin and Polymyxin B respectively, Beer-Lambert's law was observed at the concentration ranges of 1-6, 1-9 µg mL- 1. The technique was approved and validated following ICH recommendations. Lastly, the suggested approach has been successfully implemented to quantify the cited medications colorimetrically, for the first time, in their parenteral dosage forms with excellent recoveries. Also, Content uniformity testing was implemented.

Psychometrics properties of type 2 diabetes treatment adherence questionnaire (DTAQ): a study based on Pender's health promotion model

BACKGROUND

Management of type 2 diabetes (T2D) as a chronic disease requires treatment adherence such as controlling the blood glucose level and adopting a healthy lifestyle. The present study aimed to develop and psychometrically evaluate a questionnaire based on the Pender's Health Promotion Model (HPM) to measure treatment adherence and the associated factors among T2D patients.

METHODS

The present study was conducted in qualitative and the quantitative phases between March 2022 and March 2023. The participants were T2D patients visiting Shahid Mohammadi hospital Diabetes Clinic in Bandar Abbas in the south of Iran. The first draft of items was extracted from the qualitative phase. The present study used interviews with T2D patients, item construction, validity and reliability evaluation of the instrument, and the relevant statistical analyses. It emphasized the significance of content, face, and construct validity, along with reliability testing using Cronbach's alpha and test-retest method. Data were analyzed using SPSS software, V16 and AMOS, V23.

RESULTS

A 97-item questionnaire was developed through the qualitative phase and, after content validity, it was reduced to 86 items. Five items were removed in face validation, and after the test-retest method, 79 items were retained. The confirmatory factors analysis confirmed a 65-item model with appropriate fitness of data. Cronbach's alpha coefficient showed an acceptable reliability of the diabetes treatment adherence questionnaire (α = 0.92).

CONCLUSION

The questionnaire developed based on the HPM model provides a standard and comprehensive measurement of the degree of adherence to treatment and the associated factors among Iranian T2D patients. This is especially valuable in the Iranian healthcare context, where effective management of chronic diseases such as diabetes is of a top priority. Questionnaires can help identify barriers and facilitators of treatment adherence to inform systematic and goal-oriented interventions. The proposed questionnaire had good psychometric properties, and can be used as a valid and practical instrument to measure the factors related to treatment adherence behaviors.

Associated factors with voriconazole plasma concentration: a systematic review and meta-analysis

Background: Voriconazole plasma concentration exhibits significant variability and maintaining it within the therapeutic range is the key to enhancing its efficacy. We conducted a systematic review and meta-analysis to estimate the prevalence of patients achieving the therapeutic range of plasma voriconazole concentration and identify associated factors. Methods: Eligible studies were identified through the PubMed, Embase, Cochrane Library, and Web of Science databases from their inception until 18 November 2023. We conducted a meta-analysis using a random-effects model to determine the prevalence of patients who reached the therapeutic plasma voriconazole concentration range. Factors associated with plasma voriconazole concentration were summarized from the included studies. Results: Of the 60 eligible studies, 52 reported the prevalence of patients reaching the therapeutic range, while 20 performed multiple linear regression analyses. The pooled prevalence who achieved the therapeutic range was 56% (95% CI: 50%-63%) in studies without dose adjustment patients. The pooled prevalence of adult patients was 61% (95% CI: 56%-65%), and the pooled prevalence of children patients was 55% (95% CI: 50%-60%) The study identified, in the children population, several factors associated with plasma voriconazole concentration, including age (coefficient 0.08, 95% CI: 0.01 to 0.14), albumin (-0.05 95% CI: -0.09 to -0.01), in the adult population, some factors related to voriconazole plasma concentration, including omeprazole (1.37, 95% CI 0.82 to 1.92), pantoprazole (1.11, 95% CI: 0.17-2.04), methylprednisolone (-1.75, 95% CI: -2.21 to -1.30), and dexamethasone (-1.45, 95% CI: -2.07 to -0.83). Conclusion: The analysis revealed that only approximately half of the patients reached the plasma voriconazole concentration therapeutic range without dose adjustments and the pooled prevalence of adult patients reaching the therapeutic range is higher than that of children. Therapeutic drug monitoring is crucial in the administration of voriconazole, especially in the children population. Particular attention may be paid to age, albumin levels in children, and the use of omeprazole, pantoprazole, dexamethasone and methylprednisolone in adults. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023483728.

Population pharmacokinetics study of tacrolimus in liver transplant recipients: a comparison between patients with or without liver cancer before surgery

Background and Objective

The main challenge for immunosuppressive therapy using tacrolimus in liver transplantation is the considerable variability in its oral bioavailability and the narrow treatment range. Many population pharmacokinetic (PopPK) models have been established to precisely estimate the PK variability of tacrolimus in liver transplant recipients. However, it remains unclear whether there is a significant difference in the PK behavior of tacrolimus between patients with or without liver cancer before surgery. Therefore, we aimed to compare the differences of PK parameters and simulate exposures of tacrolimus between populations preoperatively diagnosed with liver cancer or not by PopPK modeling.

Methods

In total, 802 blood concentrations of tacrolimus from 196 patients (118 liver cancer and 78 non-liver-cancer samples) were included in this study. Demographic data and clinical parameters were integrated to perform a PopPK analysis using the nonlinear mixed-effects modeling approach. Potential covariates were evaluated by using a stepwise method. Goodness-of-fit plot and bootstrap were performed to assess the model stability and predictive performance. Simulations were introduced to optimize dosing regimens of both the liver cancer and non-liver-cancer groups according to the guidance.

Results

The PK of tacrolimus was best described by a one-compartment model with first-order absorption and linear elimination, with weight and direct bilirubin as the significant covariates. In the process of constructing the basic model, we tried to separately estimate the PK parameters in liver cancer and non-liver-cancer populations. The results showed that the PK parameters in the two populations were similar, and the individual variation in Ka in non-liver-cancer subjects was large. Hence, the final model did not distinguish between the two populations. Moreover, a minor increase of less than 10% was observed in the simulated exposure in the patients preoperatively diagnosed with liver cancer compared with that in non-liver-cancer groups.

Conclusion

The established PopPK model was capable of optimizing tacrolimus dosing in whole populations who underwent liver transplantation. Although a minimal difference was found in tacrolimus exposure between the liver cancer and non-liver-cancer groups, more research is warranted to explore the differences between the two populations in the future, given the potential limitations of this study.

Pharmacokinetic/pharmacodynamic analysis of vancomycin in patients with Enterococcus faecium bacteraemia: a retrospective cohort study

OBJECTIVES

The trough concentration of vancomycin and the area under the concentration-time curve (AUC)/minimum inhibitory concentration (MIC) ratio are crucial in determining vancomycin efficacy against methicillin-resistant Staphylococcus aureus. However, the use of similar pharmacokinetic principles in determining antibiotic efficacy against other gram-positive cocci is lacking. We performed a pharmacokinetic/pharmacodynamic analysis (association of target trough concentration values and AUC/MIC with therapeutic outcome) of vancomycin in patients with Enterococcus faecium bacteraemia.

METHODS

Between January 2014 and December 2021 we performed a retrospective cohort study of patients with E. faecium bacteraemia treated with vancomycin. Patients who received renal replacement therapy or had chronic kidney disease were excluded. Clinical failure, the primary outcome, was defined as a composite of 30-day all-cause mortality, vancomycin-susceptible infection requiring change of treatment, and/or recurrence. AUC24 was estimated using a Bayesian estimation approach based on an individual vancomycin trough concentration. The MIC for vancomycin was determined using a standardised agar dilution method. Additionally, classification was used to identify the vancomycin AUC24/MIC ratio associated with clinical failure.

RESULTS

Of the 151 patients identified, 69 were enrolled. All MICs of vancomycin for E. faecium were ≤1.0 µg/mL. The AUC24 and AUC24/MIC ratio were not significantly different between the clinical failure group and the clinical success group (432±123 µg/mL/hour vs 488±92 µg/mL/hour; p=0.075). However, 7 of 12 patients (58.3%) in the clinical failure group and 49 of 57 patients (86.0%) in the clinical success group had a vancomycin AUC24/MIC ratio ≥389 (p=0.041). No significant association between trough concentration or AUC24 ≥600 µg/mL×hour and acute kidney injury was observed (p=0.365 and p=0.487, respectively).

CONCLUSION

The AUC24/MIC ratio is associated with the clinical outcome of vancomycin administration in E. faecium bacteraemia. In Japan, where vancomycin-resistant enterococcal infection is rare, empirical therapy with a target AUC24 ≥389 should be recommended.

Effect of mean heart rate on 30-day mortality in older patients with sepsis: Data from the MIMIC-IV database

BACKGROUND

Sepsis is a critical condition with a significant risk of mortality. Advanced age is one factor in increasing mortality in intensive care.

OBJECTIVES

The aim of this study is to investigate the association between mean heart rate (MHR) and 30-day mortality among older patients with sepsis in the intensive care unit (ICU).

METHODS

All older patients (age 65 or older) with sepsis for first time in ICU admission in Medical Information Mart for Intensive Care-IV (MIMIC-IV) were included in this retrospective study. The effect of MHR within 24 h of ICU admission on 30-day mortality was assessed according to multivariable Cox regression models, restricted cubic splines and two-piecewise Cox regression models.

RESULTS

The total number of participants was 6598 (mean heart rate, 83.8 ± 14.3 bpm). A total of 1295 (19.6%) patients died within 30 days after ICU admission. MHR within 24 h of admission was associated with 30-day mortality (J-shaped association) in older patients with sepsis in the ICU, with an inflection point at about 74 bpm and a minimal risk observed at 73 to 82 bpm of MHR.

CONCLUSIONS

In this retrospective cohort study, there was a J-shaped association between MHR and 30-day mortality in older patients with sepsis admitted to the ICU and a minimal risk observed at 73 to 82 bpm of MHR. If further confirmed, this association may provide a theoretical basis for formulating the target strategy of heart rate therapy for these patients.

Urate lowering therapy in patients starting hemodialysis limit gout flares occurrence: ten years retrospective study

BACKGROUND

Uncontrolled gout can cause articular impairment but is also associated with a global and cardiovascular excess mortality, especially in dialysis population. Data documented within existing research is not conclusive regarding gout flares evolution during hemodialysis and their control by urate lowering therapy (ULT). Without clear guidelines concerning hemodialysis patients management with chronic gout, this study proposes to investigate whether gout flare incidence reduction could be observed on this population treated by urate lowering therapy versus patients without treatment.

METHODS

We performed a retrospective cohort study in two hemodialysis centers in France. Were selected patients over 18 years old with a gout history who started hemodialysis between January 2005 and September 2015. Demographics and clinicals data were recorded at hemodialysis start and throughout 5 years of follow up. Gout flare was defined as presence of uric acid crystal in joint punction or clinically diagnosed as such with a colchicine prescription. All statistical analysis were performed in SAS® version 9.4 (SAS Institute Inc., Cary, NC).

RESULTS

One hundred eighty-one patients have been included, mean age at dialysis initiation was 68.6 years (± 12.4) with 72% of men, 54% were treated by ULT: 89.7% by allopurinol and 9.3% by febuxostat. One patient received both treatments successively. After hemodialysis initiation, 35.36% patients had experienced at least one gout flare. The appearance of at least one gout flare concerned 50% of patients in no ULT group and 22.68% patients in ULT group (p = 0.0002). Dialysis efficiency was measured at regular interval during follow-up and was similar in both groups. To study the association strength between clinical factors and gout flares occurrences, a Cox model was performed; ULT is a protector factor of gout flare (HR:0,42, CI 95: 0,25-0,71). The proportion of serum urate values within the target (median 53% vs 29.3%, p < 0.0001) was significantly higher in ULT group versus no ULT group (median 53% vs 29.3%, p < 0.0001).

CONCLUSION

Urate lowering therapy limit new gout flares occurrence in hemodialysis patients with gout historyCollaboration between rheumatologists and nephrologists may help to update guidelines for urate-lowering therapies in patients on dialysis.

The Infusion of Piperacillin/Tazobactam with an Elastomeric Device: A Combined 24-H Stability Study and Drug Solution Flow Rate Analysis

Bacterial respiratory tract infections (e.g., in patients with cystic fibrosis) may be treated with the intravenous infusion of a piperacillin/tazobactam (P/T) solution through an elastomeric device. In the present work, we combined a 24-h drug stability study with an assessment of the drug solution flow rate during an in vitro simulated infusion. Experiments were performed in triplicate with two excipient-free generic P/T solutions and an excipient-containing proprietary P/T solution in saline (all 50/6.25 mg/mL) released from an elastomeric infusion device at 32 °C. The P/T solutions' stability was assessed by an HPLC-UV assay, pH and osmolality measurements, a visual assessment, and particle counting. Before these analyses, a forced degradation study was performed. To assess the flow rate, a precision scale was used to weigh the solution collected at the infusion line outlet. The stability criteria were <10% degradation and a flow rate within ± 15% of the nominal value over the 24-h infusion period: all three P/T solutions were found to be stable. The actual flow rate was lower than the expected flow rate; this difference was probably due to the drug solution's high viscosity and must be taken into account in clinical use.

Outcomes and Practices of Endotracheal Intubation Using the Glasgow Coma Scale in Acute Non-Traumatic Poisoning: A Systematic Review and Meta-Analysis of Proportions

BACKGROUND

Acute poisoning often results in decreased consciousness, necessitating airway assessment and management. Existing literature in the trauma setting suggests the importance of airway protection in unconscious patients to prevent complications, including aspiration. Practices for endotracheal intubation in non-traumatic acute poisoning are poorly described and variable, particularly regarding the use of a Glasgow Coma Scale (GCS) ≤ 8 threshold for intubation.

METHODS

A systematic review and meta-analysis of proportions was conducted to evaluate intubation rates and outcomes in patients presenting for acute non-traumatic poisoning. Studies were excluded if the primary indication for intubation was not airway protection. We analyzed rates of intubation, mortality, and aspiration by subgrouping patients into GCS ≤ 8, GCS 9-15, or mixed GCS. Common and random-effects analysis were used, supplemented by subgroup analyses.

RESULTS

39 studies were included in the analysis, involving 15,959 patients. Random-effects pooled intubation rates varied significantly across GCS categories: GCS ≤ 8 (30.0%, I2 = 92%, p < 0.01), GCS 9-15 (1.0%, I2 = 0%, p = 0.91), and mixed GCS (11.0%, I2 = 94%, p < 0.01), p-value <0.01 for subgroup difference. Aspiration rates also varied: GCS ≤ 8 (19.0%, I2 = 84%, p < 0.01), GCS 9-15 (4.0%, I2 = 78%, p < 0.01), and mixed group (5.0%, I2 = 72%, p < 0.01), p-value <0.01 for subgroup difference. Mortality rates remained low across all groups: GCS ≤ 8 (1.0%, I2 = 0%, p = 0.62), GCS 9-15 (1.0%, I2 = 0%, p = 0.99), and mixed group (2.0%, I2 = 68%, p < 0.01).

CONCLUSION

The conventional "less than 8, intubate" approach may not be directly applicable to acute poisoning patients due to heterogeneity in patient presentation, intubation practices, and low mortality. Therefore, a nuanced approach is warranted to optimize airway management strategies tailored to individual patient needs.

The causality between use of glucocorticoids and risk of pancreatitis: a Mendelian randomization study

Background and aim

To date, the association between glucocorticoid use and the risk of pancreatitis remains controversial. The aim of this study was the investigation of this possible relationship.

Methods

We carried out a two-sample Mendelian randomization (MR) analysis using GWAS data from European ancestry, East Asian descendants and the FinnGen Biobank Consortium to evaluate this potential causal relationship. Genetic variants associated with glucocorticoid use were selected based on genome-wide significance (p < 5×10-8).

Results

Our MR analysis of European ancestry data revealed no significant causal relationship between glucocorticoid use and AP (IVW: OR=1.084, 95% CI= 0.945-1.242, P=0.249; MR-Egger: OR=1.049, 95% CI= 0.686-1.603, P=0.828; weighted median: OR=1.026, 95% CI= 0.863-1.219, P=0.775) or CP (IVW: OR=1.027, 95% CI= 0.850-1.240, P=0.785; MR-Egger: OR= 1.625, 95% CI= 0.913-2.890, P= 0.111; weighted median: OR= 1.176, 95% CI= 0.909-1.523, P= 0.218). Sensitivity analyses, including MR-Egger and MR-PRESSO, indicated no evidence of pleiotropy or heterogeneity, confirming the robustness of our findings. Multivariable MR analysis adjusted for alcohol consumption, BMI, cholelithiasis and C-reactive protein levels supported these findings. Replicated analysis was performed on datasets from the FinnGen Biobank Consortium and East Asian descendants, and similar results were obtained.

Conclusions

This MR analysis suggests that there is no causal association between glucocorticoid use and the risk of pancreatitis.

Common Mistakes in Managing Patients with Inflammatory Bowel Disease

Introduction: Errors are very common in medical practice and in particular, in the healthcare of patients with inflammatory bowel disease (IBD); however, most of these can be prevented. Aim: To address common errors in the management of IBD. Methods: Our approach to this problem consists in identifying mistakes frequently observed in clinical practice (according to our experience) in the management of patients with IBD, then reviewing the scientific evidence available on the subject, and finally proposing the most appropriate recommendation for each case. Results: The most common mistakes in the management of IBD include those related to diagnosis and differential diagnosis, prevention, nutrition and diet, treatment with different drugs (mainly 5-aminosalicylates, corticosteroids, thiopurines, and anti-TNF agents), extraintestinal manifestations, anemia, elderly patients, pregnancy, and surgery. Conclusions: Despite the availability of guidelines for both disease management and preventive aspects of IBD care, a considerable variation in clinical practice still remains. In this review, we have identified common mistakes in the management of patients with IBD in clinical practice. There is a clear need for a greater dissemination of clinical practice guidelines among gastroenterologists and for the implementation of ongoing training activities supported by scientific societies. Finally, it is desirable to follow IBD patients in specialized units, which would undoubtedly be associated with higher-quality healthcare and a lower likelihood of errors in managing these patients.

Efficacy and safety of minodronate in the treatment of postmenopausal osteoporosis with low back pain: a single-centre, randomized and open-label controlled trial

BACKGROUND

Low back pain is one of the most common symptoms of osteoporosis. The pain can seriously affect patients' mood and quality of life; it can also further aggravate bone loss, causing a serious social burden. Minodronate is an oral bisphosphonate that needs to be administered daily. It significantly reduces levels of bone turnover markers (BTMs) and rapidly improves symptoms of low back pain in patients with osteoporosis. Osteoporosis requires long-term treatment, and daily dosing reduces patient compliance. Minodronate has a better safety profile than other bisphosphonates. The objective of the trial is to explore the efficacy and safety of minodronate in the treatment of low back pain in postmenopausal osteoporosis patients.

METHODS

This is a single-centre, randomized, open-label controlled trial with a 24-week duration. Seventy-two eligible patients will be randomly divided into 4 groups. Subjects will be randomized at a 1:1 ratio to receive either minodronate (1 mg/day) or alendronate (10 mg/day) every day; senior women (≥ 75 years old) and older women (< 75 years old) will be at a ratio of 1:2. The primary outcome is the time required for the visual analogue scale (VAS) score to decline by ≥ 10 from baseline. The secondary outcome is the changes in VAS scores from baseline, the frequency and dosage of rescue medication, BTMs, bone mineral density (BMD), and variations in upper gastrointestinal (GI) symptom scores from baseline (including heartburn, pain, and bloating).

DISCUSSION

This study will provide objective evidence for the efficiency and safety of minodronate. Furthermore, it will be helpful to evaluate the quantitative relationship between BTMs and BMD in patients with osteoporosis under different ages.

TRIAL REGISTRATION

This study protocol has been registered with ClinicalTrials.gov ID NCT05645289 ( https://clinicaltrials.gov/search?term=NCT05645289 ) on December 8, 2022. The registry name is Peking University Third Hospital. This study protocol was reviewed and approved by the Peking University Third Hospital Medical Science Research Ethics Committee (M2022465, 2022.08.09, V2.0). The results will be published in scientific peer-reviewed journals.

TRIAL STATUS

The protocol was registered at ClinicalTrials.gov (registration number: NCT05645289). Recruitment has started in January 2023 and is still ongoing.

Validation of a Questionnaire to Assess Patient Satisfaction with an Automated Drug Dispensing System

BACKGROUND AND OBJECTIVES

Automated drug dispensing systems (ADDs) have been introduced to improve the efficiency of dispensing and patient safety. The available questionnaires measure patient satisfaction with particular aspects of ADDs. Also, the level of patient satisfaction with ADDs is not widely established. This study aimed to develop and validate a novel questionnaire to assess patient satisfaction with ADDs.

METHODS

Content and construct validity procedures were used to validate the 20-item questionnaire with four domains, including pharmacy administration, dispensing practice, patient education, and the dispensing system. Two hundred consenting participants took part in this study, from those who visited the outpatient pharmacy in a government hospital.

RESULTS

The internal consistency of all four scale items shows acceptable reliability (>0.7). In the exploratory factor analysis, three items were removed due to poor factor loading and cross-loading. In the confirmatory factor analysis, the model has acceptable fit indices, including the comparative fit index (0.937), Tucker-Lewis's index (0.924), standardized root mean square residual (0.051), root mean square error of approximation (0.057), and χ2/df (1.67). The convergent and discriminant validity were established, since the average variance extracted (AVE) was ≥0.5 and the squared correlation (SC) values of one construct with other constructs were less than the AVE of the specific construct.

CONCLUSION

This study offered a reliable and valid 17-item questionnaire incorporating a multi-dimensional four-factor model to evaluate patient satisfaction with ADDs. The validated questionnaire can be utilized to explore patients' perspectives on ADDs.

The Association between Statin Use and Reduced Migraine Likelihood: A Comprehensive Analysis of Migraine Subtypes and Statin Types in a Nationwide Korean Cohort

Despite growing interest in the preventive effects of statins, as lipid-lowering agents, on migraine attacks, comprehensive nationwide studies comparing migraine likelihood between statin users and controls are lacking. Our nested case-control study within the Korean National Health Insurance Service-Health Screening Cohort (2002-2019) investigated this association using 38,957 migraine patients and 155,828 controls, considering migraine subtypes (with/without aura) and statin types (lipophilic vs. hydrophilic). Using propensity score matching and adjusting for confounders, statin use was linked to reduced migraine likelihood overall (odds ratio (OR) 0.93), particularly for migraines with aura (OR 0.75) and without aura (OR 0.94). Lipophilic statins were effective for both subtypes, while hydrophilic statins mainly reduced the likelihood of migraines without aura. Subgroup analyses showed consistent benefits across demographics, but varied effectiveness based on weight, smoking, alcohol use, hemoglobin levels, and dyslipidemia history. In summary, this nationwide cohort study suggests that statin use may reduce migraine likelihood among Korean adults across diverse demographics and clinical profiles, but varied effectiveness based on certain lifestyle and comorbidity factors underscores the importance of considering individual patient profiles when assessing the potential benefits of statin therapy for migraine prevention.

Characterization of Liquid Dosage Forms of Atenolol and Enalapril Maleate for Oral and Enteral Feeding Administration

The limited availability of pharmaceutical formulations tailored for cardiovascular diseases in both pediatric and geriatric populations generates the need for compounded dosage forms to guarantee precise dosing and medication adherence. This study aimed to analyze the physicochemical properties and stability of formulations of atenolol and enalapril maleate prepared with a proprietary oral vehicle, SuspendIt®. To this end, palatability, injectability, pH, rheological behavior, and physical, microbiological, and chemical stability over a 180-day storage period at 25 °C and 5 °C were evaluated. Injectability tests confirmed the suitable use of both formulations for administration through enteral feeding tubes. By using a potentiometric electronic tongue, it was confirmed that the SuspendIt® vehicle effectively served as a bitter-blocking strategy for atenolol and enalapril maleate. Adequate stability throughout the storage period was confirmed in terms of the mechanical properties, pH, and effectiveness of the preservative system. The atenolol concentration remained above 90% of the initial amount, while the concentration of enalapril maleate decreased to 88% after 90 days of storage at 25 °C. In summary, the atenolol formulation maintained suitable chemical, physical, and microbiological stability after 180 days at both storage temperatures, while the enalapril maleate formulation remained stable up to 60 days at 25 °C and for 180 days at 5 °C.

Intra-hospital microbiome variability is driven by accessibility and clinical activities

The hospital environmental microbiome, which can affect patients' and healthcare workers' health, is highly variable and the drivers of this variability are not well understood. In this study, we collected 37 surface samples from the neonatal intensive care unit (NICU) in an inpatient hospital before and after the operation began. Additionally, healthcare workers collected 160 surface samples from five additional areas of the hospital. All samples were analyzed using 16S rRNA gene amplicon sequencing, and the samples collected by healthcare workers were cultured. The NICU samples exhibited similar alpha and beta diversities before and after opening, which indicated that the microbiome there was stable over time. Conversely, the diversities of samples taken after opening varied widely by area. Principal coordinate analysis (PCoA) showed the samples clustered into two distinct groups: high alpha diversity [the pediatric intensive care unit (PICU), pathology lab, and microbiology lab] and low alpha diversity [the NICU, pediatric surgery ward, and infection prevention and control (IPAC) office]. Least absolute shrinkage and selection operator (LASSO) classification models identified 156 informative amplicon sequence variants (ASVs) for predicting the sample's area of origin. The testing accuracy ranged from 86.37% to 100%, which outperformed linear and radial support vector machine (SVM) and random forest models. ASVs of genera that contain emerging pathogens were identified in these models. Culture experiments had identified viable species among the samples, including potential antibiotic-resistant bacteria. Though area type differences were not noted in the culture data, the prevalences and relative abundances of genera detected positively correlated with 16S sequencing data. This study brings to light the microbial community temporal and spatial variation within the hospital and the importance of pathogenic and commensal bacteria to understanding dispersal patterns for infection control.

IMPORTANCE

We sampled surface samples from a newly built inpatient hospital in multiple areas, including areas accessed by only healthcare workers. Our analysis of the neonatal intensive care unit (NICU) showed that the microbiome was stable before and after the operation began, possibly due to access restrictions. Of the high-touch samples taken after opening, areas with high diversity had more potential external seeds (long-term patients and clinical samples), and areas with low diversity and had fewer (short-term or newborn patients). Classification models performed at high accuracy and identified biomarkers that could be used for more targeted surveillance and infection control. Though culturing data yielded viability and antibiotic-resistance information, it disproportionately detected the presence of genera relative to 16S data. This difference reinforces the utility of 16S sequencing in profiling hospital microbiomes. By examining the microbiome over time and in multiple areas, we identified potential drivers of the microbial variation within a hospital.

The Effect of Thickened Water on Ciprofloxacin Pharmacokinetics: A Comparative Study in Adult Males

Background/Objectives: The use of food thickeners with ciprofloxacin tablets may result in a gelatinous appearance and experience delayed dissolution, which presents a challenge for the drug's efficacy, creating a healthcare economic issue. However, the pharmacokinetic impact of this compound in humans remains uncertain. Therefore, a comparative pharmacokinetic study of ciprofloxacin was conducted on healthy adult Japanese males. Methods: We compared the effects of administering tablets with water or thickened water and crushed tablets mixed with thickened water. The maximum blood concentration (Cmax) of ciprofloxacin determines the drug's efficacy. Results: There were variations in drug absorption across different administration methods. The group who took the tablets immersed in thickened water exhibited different results in the area under the blood drug concentration-time curve (AUC) and Cmax compared to the group who took the tablets in regular water. Notably, the group that consumed the crushed tablets mixed with thickened water demonstrated equivalent results for both AUC and Cmax. Conclusions: Administering crushed tablets in thickened water may yield pharmacokinetics comparable to those of tablets taken with water. However, the process of crushing tablets may result in the loss of active ingredients and compromise the formulation, necessitating a comprehensive assessment before administration.

Adverse Event Profiles of Adalimumab in Children: A Disproportionality Analysis

BACKGROUND

Adalimumab has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult rheumatoid arthritis (RA), and subsequently approved for pediatric treatment of various autoimmune diseases in children of different ages. Due to genetic differences between children and adults in terms of physiology and immunity, there is a need to explore the safety of adalimumab in children in the real world. The aim of this study is to identify potential adverse event (AE) signals associated with the use of adalimumab in pediatric patients (<18 years old) using data from the FDA Adverse Event Reporting System (FAERS).

METHODS

AEs associated with adalimumab in pediatric patients reported in the FAERS database from the first quarter (Q1) of 2017 to the third quarter (Q3) of 2022 were systematically gathered. Reporting odds ratio (ROR), the proportional reporting ratio (PRR), the information component (IC), and the empirical Bayes geometric mean (EBGM) were used to assess the relationship between adalimumab and AEs in children.

RESULTS

Out of 8,363,304 reports collected from the FAERS database during the study period, 3819 reports on children on adalimumab were identified. Adalimumab-related AEs reports were concentrated on 10 toxicity areas and a total of 202 positive signals were detected, of which injection site papule (ROR = 261.97) and intestinal fistula (ROR = 122.09) had the strongest signals. Unexpected significant AEs, including intestinal obstruction, immunodeficiency, abdominal abscess, and Takayasu's arteritis might also occur. In comparison with patients of all ages in the same time window, the median onset time of children was shorter (99 vs. 149 days). Most of the AE cases occurred in children within the first 1 (1.71%), 2 (8.12%), and 3 months (8.39%) and had early failure types after adalimumab initiation. Methotrexate, folic acid, prednisone, azathioprine, and mesalamine were the top five drugs used concomitantly for adalimumab-associated AEs.

CONCLUSIONS

When adalimumab is used in children, especially in the first 3 months of treatment, in addition to the AEs recorded in the drug package insert, close attention should be paid to the new potential AEs off-label to ensure the safety of adalimumab in children.