Pancreatitis, familial hypertriglyceridemia, and pregnancy

Interrelationships between pregnancy, hypertriglyceridemia, and pancreatitis were assessed in three women with familial hypertriglyceridemia. One subject had known familial hypertriglyceridemia, familial type V hyperlipoproteinemia, prior to conception. In this woman a progressive increase in triglyceride levels to more than 3,000 mg/dl during the first two trimesters required dietary intervention and hospitalization at 28 weeks' gestation. Use of an isocaloric National Institutes of Health type V diet reduced triglyceride levels to less than 900 mg/dl; the pregnancy was uneventful with term delivery of a healthy neonate. The familial hypertriglyceridemia was covert in the other two women until term. In one subject, subsequently shown to have familial type V, acute hemorrhagic pancreatitis with a pancreatic pseudocyst, shock, and hypocalcemia developed at 39 weeks' gestation; the neonate was safely delivered, and the mother survived. In the second, entirely asymptomatic subject, triglyceride levels greater than 5,000 mg/dl were discovered incidentally at term cesarean section during delivery of a healthy neonate. With a fat restricted diet, plasma triglyceride levels abruptly fell post partum to less than 500 mg/dl, and subsequent studies revealed familial type III hyperlipoproteinemia. Routine quantitation of plasma cholesterol and triglyceride levels or simple visual examination of fasting plasma for triglyceride-induced opacity or "milky" appearance should be done during early pregnancy. This would allow the obstetrician to identify women with severe familial hypertriglyceridemia prior to the superimposition of the physiologic hyperlipidemia of pregnancy upon familial hypertriglyceridemia with resultant, and often catastrophic, acute pancreatitis.

Cholesterol-free diet and the physiologic hyperlipidemia of pregnancy in familial hypercholesterolemia

Longitudinal studies of the effects of a cholesterol-free diet and a less rigid 300 mg/day low cholesterol diet, both with a polyunsaturated to saturated fatty acid ratio of 1.8/1, were carried out preconception, during gestation, and postpartum in a women heterozygous for familial hypercholesterolemia. On the cholesterol-free diet, during weeks 8-14 of gestation, plasma cholesterol was lowered 25% (from 310 to 230mg/dl), and plasma low density lipoprotein cholesterol (C-LDL) (from 240 to 160 mg/dl), 33%. The 25% reduction in plasma cholesterol was slightly more than previously reported decrements of 19% in 14 normal women during pregnancy, also receiving a cholesterol-free diet. The 300 mg cholesterol diet was not as hypocholesterolemic as the cholesterol-free diet. Its maintenance throughout gestation limited the within-pregnancy increments of total plasma cholesterol and C-LDL to 21% (352-426 mg/dl) and 14% (286-326 mg/dl) respectively. Both the cholesterol-free and the 300 mg cholesterol diet were well tolerated, and should be nutritionally adequate for pregnant women, since they contain more than the recommended amounts of high quality protein, vitamins, minerals, and calories for pregnant women. Cholesterol restricted diets during pregnancy in familial hypercholesterolemics should reduce the physiologic hypercholesterolemia of pregnancy, and potentially reduce the increased risk of coronary heart disease relative to the degree and duration of elevations of total and LDL cholesterol.

Impact of pharmacist services on economic, clinical, and humanistic outcome (ECHO) of South Asian patients: a systematic review

BACKGROUND

Pharmacists in high-income countries routinely provide efficient pharmacy or pharmaceutical care services that are known to improve clinical, economic, and humanistic outcomes (ECHO) of patients. However, pharmacy services in low- and middle-income countries, mainly South Asia, are still evolving and limited to providing traditional pharmacy services such as dispensing prescription medicines. This systematic review aims to assess and evaluate the impact of pharmacists' services on the ECHO of patients in South Asian countries.

METHODS

We searched PubMed/Medline, Scopus, EMBASE, CINAHL, and Cochrane Library for relevant articles published from inception to 20th September 2021. Original studies (only randomised controlled trials) conducted in South Asian countries (published only in the English language) and investigating the economic, clinical (therapeutic and medication safety), and humanistic impact (health-related quality of life) of pharmacists' services, from both hospital and community settings, were included.

RESULTS

The electronic search yielded 430 studies, of which 20 relevant ones were included in this review. Most studies were conducted in India (9/20), followed by Pakistan (6/20), Nepal (4/20) and Sri Lanka (1/20). One study showed a low risk of bias (RoB), 12 studies showed some concern, and seven studies showed a high RoB. Follow-up duration ranged from 2 to 36 months. Therapeutic outcomes such as HbA1c value and blood pressure (systolic blood pressure and diastolic blood pressure) studied in fourteen studies were found to be reduced. Seventeen studies reported humanistic outcomes such as medication adherence, knowledge and health-related quality of life, which were found to be improved. One study reported safety and economic outcomes each. Most interventions delivered by the pharmacists were related to education and counselling of patients including disease monitoring, treatment optimisation, medication adherence, diet, nutrition, and lifestyle.

CONCLUSION

This systematic review suggests that pharmacists have essential roles in improving patients' ECHO in South Asian countries via patient education and counselling; however, further rigorous studies with appropriate study design with proper randomisation of intervention and control groups are anticipated.

Types and outcomes of pharmacist-managed travel health services: A systematic review

BACKGROUND AND AIM

Pharmacists have an important role in providing travel health services and medications to travelers. However, given the limited literature on this topic, the aim of this study is to systematically review the types and outcomes of pharmacist-managed travel health services.

METHODS

A comprehensive literature search was performed in four electronic databases, namely Scopus, Web of Science, PubMed and ProQuest to identify studies published in English from 1999 to July 2022. The inclusion criteria included the studies that reported an experience of providing dedicated travel health services by pharmacists and reported the outcomes and/or evaluation of these travel health services.

RESULTS

Nine studies were identified from the literature and included in the review. The pharmacists have provided a wide range of general and specialized travel health services including pre-travel risk assessment, routine and travel-related vaccination service, prescribing or recommending medications for travel-related illnesses, counseling and travel health advice. Overall, 94-100% of the patients were satisfied or very satisfied with pharmacist-managed travel health services. In addition, a good acceptance rate of pharmacist recommendations for vaccines and travel-related mediations was reported with most studies reporting an overall acceptance rate of ≥75% (acceptance rate range: 48%-94.2%). In addition, high rates of acceptance of other nonpharmacological advices were noted.

CONCLUSION

Pharmacists with training in travel medicine have successfully provided a wide range of general and specialized travel health services. Most travelers were highly satisfied with the pharmacy-based travel health services and accepted the pharmacist recommendations.

Medication use problems among older adults at a primary care: A narrative of literature review

Appropriate medication use is one of the most significant challenges among the older population. Although medication use problems are well documented at the secondary and tertiary health care level, the evidence at the primary care level of OECD region is limited. A narrative review of existing literature was conducted through a nonsystematic search for original articles through electronic search databases, Ovid Medline, Google Scholar from 2001 to 2021, and a combination of citation references. Medication use problems are prevalent in older adults at the primary care level. The main issues of medication use identified were as follows; nonadherence, adverse drug events, accessibility, polypharmacy, inappropriate medications, belief about medications, lack of knowledge and awareness, and lack of deprescribing. In addition, the current review has identified the possibilities of the problems: many medications, forgetfulness, lack of deprescribing, lack of communication, poor understanding, and limited awareness of inappropriate medications. This review found that various medication use problems subclusters were identified to impact the health care need among older adults. Therefore, effective interventions targeting these issues need to be developed to reduce medication use problems among older adults at a primary care level.

Combatting opioid misuse, overuse and abuse: a systematic review of pharmacists' services and outcomes

Aim: To examine the range of services pharmacists provide and their impact on patient outcomes, harm reduction, and appropriate opioid use.Methods: Six databases were searched (MEDLINE, EMBASE, Scopus, PsycINFO, CENTRAL and Cochrane Methodology Register) from inception to March 2023. The protocol was registered in PROSPERO (CRD42023401895).Results: Twenty-nine studies identified five key areas of pharmacist interventions in opioid management-naloxone programs and opioid de-escalation, patient and primary healthcare providers' education and motivational interview, prescription monitoring and opioid risk screening, clinical pharmacy interventions (pharmacotherapy, medication review, prescribing, adherence monitoring), and collaborative healthcare approaches to promote optimal opioid use. Outcomes assessment indicated harm reduction, improved safety, increased non-opioid analgesic use, decreased opioid consumption, and enhanced pain management.Conclusion: This review underscores pharmacists' vital role in tackling opioid misuse, overuse and abuse, providing a foundation for evidence-based policies to minimize harm and promote optimal opioid use.

Medication use problems and factors affecting older adults in primary healthcare

BACKGROUND

As the largest demographic group utilizing primary healthcare facilities, older adults often face the challenge of managing multiple chronic illnesses, leading to numerous medications.

OBJECTIVE

The present study aims to assess medication use problems among older adults and explore the factors affecting them in primary healthcare settings.

METHODS

A mixed-method study was conducted to establish a baseline understanding of the perspectives and challenges faced by older adults, with regards to medication use. Translated Medication Use Questionnaire (MedUseQ), a patient-centered tool, was distributed to older adults above 60 in primary healthcare settings to assess their frequency of problems related to medication use. Fifteen semi-structured interviews were conducted to explore this topic in depth. Descriptive and inferential analyses were conducted with quantitative data. Interviews were transcribed verbatim, and thematic analysis was conducted. Quantitative and qualitative findings data were triangulated.

RESULTS

The study involved 393 participants. The most common problems with regards to medication use were polypharmacy (55.4%), administration difficulties (48.4%), limited awareness about adverse drug events (47.3%), issues with adherence (46.5%), and accessibility to primary healthcare (42.7%). Approximately 55% were satisfied with the older adult-centered medication use services by pharmacist and doctors. The qualitative findings showed that major factors affecting medication use were forgetfulness, language barriers, lack of awareness, transportation problems, long waiting times, and multiple visits to healthcare facilities.

CONCLUSION

The findings of this study reveal that a significant proportion, around 50%, of the older adult population face challenges with medication use in Penang. These difficulties mainly stem from medication administration, adherence, accessibility, polypharmacy, and inadequate medication knowledge. The qualitative analysis further highlighted several factors that contribute to such medication-related problems. Given the rapidly aging Association of Southeast Asian Nations (ASEAN) population, it is essential to devise effective solutions and strategies to tackle medication use-related issues among older adults.

Medication Use Questionnaire for Older Adults in Malaysia: Translation, Cultural Adaptation, and Reliability

OBJECTIVES

This study aimed to translate the Medication Use Questionnaire into a Malay version, adapt it to Malaysia's culture, and verify its reliability among Malaysia's older adults.

METHODS

Methodological approaches were used to translate, validate, and modify the questionnaire. The subjects were older adults aged ≥ 60 years in primary care settings in Penang, Malaysia. Two forward translations (English to Malay) were developed, reviewed, and back translated to English. The reconciliation phase was conducted to compare the translated and original questionnaires. Five older adults were then interviewed for the cognitive debriefing of the reconciled questionnaire to assess the linguistic and cultural equivalence. Two experts assessed content validity, and the translated questionnaire was proofread and finalized. After that, pilot test was done to examine the internal consistency among 20 older adults.

RESULTS

Translation of the questionnaire was done with no major disagreements. The main issues identified in cognitive debriefing and content validity were terms, number of questions, and phrases used in the questionnaire. Most participants reported that the questionnaires were not difficult to complete during the cognitive debriefing phase. The issues were then judged and revised accordingly. Further pilot testing on 20 older adults demonstrated good internal consistency reliability, Cronbach α (0.902).

CONCLUSIONS

This study findings suggest promising data supporting the use of translated version of the Medication Use Questionnaire that can be used to identify medication use problems among older adults in Malaysia.

Assessing feasibility of conducting medication review with follow-up among older adults at community pharmacy: a pilot randomised controlled trial

BACKGROUND

Medication review with follow-up is essential for optimising medication utilisation among the older adult population in primary healthcare.

AIM

This study aimed to evaluate the feasibility of implementing medication reviews with follow-up for older adults in community pharmacies and examined potential outcomes on medication use.

METHOD

A pilot randomised controlled trial was conducted with 4 cluster-randomised community pharmacies to assess the feasibility of the intervention. Two community pharmacies served as intervention and control groups. Both groups recruited older adults over 60 who were followed over 6 months. The translated Medication use Questionnaire (MedUseQ) was administered at baseline and 6 months for both groups. The outcomes were to assess the feasibility of conducting medication review with follow-up and the probable medication use outcomes from the intervention.

RESULTS

The intervention and control groups comprised 14 and 13 older adults. A total of 35 recommendations were made by pharmacists in the intervention group and 8 in the control group. MedUseQ was easily administered, providing some evidence the feasibility of the intervention. However, there were feasibility challenges such as a lack of pharmacists, collaborative practice, difficulties with the tool language, time constraints, and limited funds. Questionnaire results provided a signal of improvement in medication administration, adherence, and polypharmacy among intervention participants. The incidence of drug related problems was significantly higher in the control group (median = 1) after 6 months, U = 15, z = - 2.98, p = 0.01.

CONCLUSION

Medication review with follow-up is potentialy practical in community pharmacies, but there are feasibility issues. While these challenges can be addressed, it is essential to study larger sample sizes to establish more robust evidence regarding outcomes.

CLINICAL TRIAL REGISTRY

ClinicalTrials.Gov NCT05297461.