Clinical Pharmacist’s Contribution to Medication Reconciliation in Outpatient Specialty Clinics in Iran

Background: The majority of research in medication reconciliation has focused on the inpatient settings, and little is known about the outpatient settings, particularly in developing countries. As such, we conducted this study to evaluate direct clinical pharmacist involvement in medication reconciliation in outpatient specialty clinics in Iran. Methods: This prospective interventional study was conducted from September 2019 to February 2020 in a University-affiliated clinic in Iran. For 196 patients over 18 years of age who were scheduled for an appointment with a physician, medication reconciliation intervention was carried out by a clinical pharmacist. The number and type of unintentional discrepancies, their potential harm to the patients, their correlation with the patients' demographic and clinical characteristics, and the number of accepted recommendations upon the unintentional discrepancies by the clinicians were assessed and recorded. Additionally, patients' understanding of any change made to their current medication regimen was also assessed. The association between the unintentional discrepancies with patients' characteristics was also assessed. Results: Totally, 57.14% of patients had at least one or more unintentional medication discrepancies, with an overall rate of 1.51 (±0.62) per patient. This is while the patient understanding of their medication changes was inadequate in a significant proportion of the study patients (62.2%). Patients with older ages, lower educational levels, and a higher number of medications and comorvidities were at a higher risk of having unintentional discrepancies. The most common type of unintentional discrepancy was the omission of a drug, and almost half of the reconciliation errors might have had the potential to cause moderate or severe harm to the patient. From 145 recommendations suggested by the clinical pharmacist upon unintentional discrepancies, 131 cases (90.34%) were accepted and implemented by the clinicians. Conclusion: These findings further support the need for conducting medication reconciliation in outpatient settings to identify discrepancies and enhance the safety of patient medication use.

Medication Use Reported by Individuals With Tinnitus Who Are Seeking Internet-Based Psychological Interventions

Purpose This study examined medication use by individuals with tinnitus who were seeking help for their tinnitus by means of a psychological intervention. Method This study used a cross-sectional survey design and included individuals with tinnitus enrolled in an Internet-based cognitive behavioral therapy trial ( n = 439). Study participants provided demographic details, completed various structured questionnaires and provided details about the medications used. The self-reported medications were classified using the United States Pharmacopeial Medicare Model Guidelines v7.0. Results Current medication use was reported by 67% ( n = 293) of the study participants. Those currently using medication were older; had consulted their primary care physician, had greater tinnitus severity, depression, anxiety, and insomnia when compared with those not reporting any current medication use. The top 10 medication used included cardiovascular agents ( n = 162; 55.3%), antidepressants ( n = 80; 27.3%), electrolytes/minerals/metals/vitamins ( n = 70; 23.9%), respiratory tract/pulmonary agents ( n = 62; 21.2%), anxiolytics ( n = 59; 20.1%), hormonal agents/stimulant/replacement/modifying (thyroid; n = 45; 15.4%), gastrointestinal agents ( n = 43; 14.7%), analgesics ( n = 33; 11.3%), blood glucose regulators ( n = 32; 10.9%), and anticonvulsants ( n = 26; 8.87%). Some associations between type of medication used and demographic or tinnitus-related variables were noted especially for the cardiovascular agents, electrolytes/minerals/metals/vitamins, and anxiolytics. Conclusions This exploratory study indicated a large percentage of patients using medication and a range of medications. Further studies are required to assess the effects of such medications on the tinnitus percept and concurrent medication moderate treatment effects.

Multi-Trait Genomic Risk Stratification for Type 2 Diabetes

Type 2 diabetes mellitus (T2DM) is continuously rising with more disease cases every year. T2DM is a chronic disease with many severe comorbidities and therefore remains a burden for the patient and the society. Disease prevention, early diagnosis, and stratified treatment are important elements in slowing down the increase in diabetes prevalence. T2DM has a substantial genetic component with an estimated heritability of 40–70%, and more than 500 genetic loci have been associated with T2DM. Because of the intrinsic genetic basis of T2DM, one tool for risk assessment is genome-wide genetic risk scores (GRS). Current GRS only account for a small proportion of the T2DM risk; thus, better methods are warranted for more accurate risk assessment. T2DM is correlated with several other diseases and complex traits, and incorporating this information by adjusting effect size of the included markers could improve risk prediction. The aim of this study was to develop multi-trait (MT)-GRS leveraging correlated information. We used phenotype and genotype information from the UK Biobank, and summary statistics from two independent T2DM studies. Marker effects for T2DM and seven correlated traits, namely, height, body mass index, pulse rate, diastolic and systolic blood pressure, smoking status, and information on current medication use, were estimated (i.e., by logistic and linear regression) within the UK Biobank. These summary statistics, together with the two independent training summary statistics, were incorporated into the MT-GRS prediction in different combinations. The prediction accuracy of the MT-GRS was improved by 12.5% compared to the single-trait GRS. Testing the MT-GRS strategy in two independent T2DM studies resulted in an elevated accuracy by 50–94%. Finally, combining the seven information traits with the two independent T2DM studies further increased the prediction accuracy by 34%. Across comparisons, body mass index and current medication use were the two traits that displayed the largest weights in construction of the MT-GRS. These results explicitly demonstrate the added benefit of leveraging correlated information when constructing genetic scores. In conclusion, constructing GRS not only based on the disease itself but incorporating genomic information from other correlated traits as well is strongly advisable for obtaining improved individual risk stratification.

Clinician attitude towards safety in medication management: a participatory action research study in an emergency department

ObjectivesEdication management is a process in which medications are selected, procured, delivered, prescribed, reviewed, administered and monitored to assure high-quality patient care and safety. This paper explores clinicians’ attitudes towards medication management which is both open to influence and strongly linked to successful changes in mediation behaviour. We aimed to investigate effects of engaging in participatory action research to improve emergency medicine clinicians’ attitudes to safety in medication management.SettingEmergency department of one university affiliated hospital.ParticipantsA total of 85 clinicians including nurses and physicians partook as participants. Eight managers and clinicians participated as representatives.DesignData are drawn from two-cycle participatory action research. Initially, a situation analysis on the current medication management and clinician views regarding medication management was conducted using three focus groups. Evaluation and reflection data were obtained through qualitative interviews. All qualitative data were analysed using content analysis.ResultsClinicians initially expressed negative attitudes towards existing and new plans for medication management, in that they were critical of current medication-related policy and procedures, as well as wary of the potential relevance and utility of potential changes to medication management. Through the action research, improvement actions were implemented including interprofessional courses, pharmacist-led interventions and the development of new guidelines regarding medication management. Participants and their representatives were engaged in all participatory action research stages with different levels of involvement. Extracted results from evaluation and reflection stages revealed that by engaging in the action research and practice new interventions, clinicians’ attitude towards medication management was improved.ConclusionsThe results support the impact of participatory action research on enhancing clinicians’ positive attitudes through their involvement in planning and implementing safety enhancing aspects of medication management.

Robot-Assisted Surgery Adopting Artificial Intelligence Procedures

Surgery is a methodology done in current medication to distinguish, keep away from and fix any approaching affliction which could genuinely influence the presence of any living being. Henceforth medical procedures structure a basic piece of people/creatures in guaranteeing life or improvement in the current condition to lead a cheerful and sound life. The utilization of Artificial Intelligence as a piece of choice decision supportive networks (AI) to work on the exhibition of explicit undertakings (by clinical robots) is standing out enough to be noticed as a piece of mechanical mediation in medical services. This paper endeavours to feature the advancement, restriction, openings and difficulties in utilizing AI-based innovations in robot-assisted medical procedures. We additionally propose an AI-based system for abnormality discovery and situating of the careful apparatus dependent on the information got from the processed pictures. Keywords: Artificial Intelligence, Medical Robot, Medical Image Processing, Surgery

Idiopathic Cd4+ Lymphocytopenia In Overlap Syndrome (Systemic Sclerosis With Dermatopolimyositis)

Background : Idiopathic CD4 T cell lymphocytopenia (ICL) is a rare syndrome with varied clinical manifestation, characterized with lymphopenia and decreased in CD4 level without HIV infection or other possible cause of immunodeficiency state. Autoimmune diseases might be a clinical manifestation of ICL. However, it is not known whether ICL triggered an autoimmune diseases, or it is a complication of said diseases. Objective : Awareness of ICL in patient with known autoimmune diseases whom admitted to the hospital for severe infection. Methods : This case report showed a 24-years old woman with prolonged fever since 4 moths ago. It was accompanied with oral ulcers, skin rash in face and trunks, and weakness of lower extremities. She was diagnosed with systemic sclerosis since 2016 and routinely came to rheumatology outpatient clinic in Hasan Sadikin Hospital but stopped coming for past 4 months since pandemic. Her current medication was only 4 mg of methylprednisolone. Results : She had high temperature (38.5 degree Celsius) and tachycardia. Physical examination revealed a single lymphadenopathy at neck. Raynaud phenomenon, calcinosis, and sclerodactyly was found in lower extremities. Dermatomyositis was diagnosed based by heliotropic skin rash. Laboratory tests showed leukopenia, absolute lymphocyte count 135.2 cell/mm3, absolute CD4 39/uL, CK level of 3296 and nonreactive anti-HIV. The patient underwent empirical antibiotic treatment, but unfortunately passed away. Conclusion : ICL is a rare case, following an infection, autoimmune diseases, or unspecified malignancy. Clinician’s awareness toward ICL could prevent fatal opportunistic infection which often happens to patients with immunodeficiency state.

Elevated risk thresholds predict endocrine risk-reducing medication use in the Athena screening registry

Risk-reducing endocrine therapy use, though the benefit is validated, is extremely low. The FDA has approved tamoxifen and raloxifene for a 5-year Breast Cancer Risk Assessment Tool (BCRAT) risk ≥ 1.67%. We examined the threshold at which high-risk women are likely to be using endocrine risk-reducing therapies among Athena Breast Health Network participants from 2011–2018. We identified high-risk women by a 5-year BCRAT risk ≥ 1.67% and those in the top 10% and 2.5% risk thresholds by age. We estimated the odds ratio (OR) of current medication use based on these thresholds using logistic regression. One thousand two hundred and one (1.2%) of 104,223 total participants used medication. Of the 33,082 participants with 5-year BCRAT risk ≥ 1.67%, 772 (2.3%) used medication. Of 2445 in the top 2.5% threshold, 209 (8.6%) used medication. Participants whose 5-year risk exceeded 1.67% were more likely to use medication than those whose risk was below this threshold, OR 3.94 (95% CI = 3.50–4.43). The top 2.5% was most strongly associated with medication usage, OR 9.50 (8.13–11.09) compared to the bottom 97.5%. Women exceeding a 5-year BCRAT ≥ 1.67% had modest medication use. We demonstrate that women in the top 2.5% have higher odds of medication use than those in the bottom 97.5% and compared to a risk of 1.67%. The top 2.5% threshold would more effectively target medication use and is being tested prospectively in a randomized control clinical trial.

Needs Assessment for the Development of an Electronic Cross-Facility Health Record (ECHR) for Pediatric Palliative Care: A Design Thinking Approach

Background: Pediatric palliative care (PPC) is characterized by years of multisectoral and multi-professional care. Sharing information between PPC professionals is, therefore, essential for quality care. The evidence shows that electronic cross-facility health records (ECHRs) provide useful support in this context. To our knowledge, no ECHRs have been developed through a user-centered approach for this specific setting in Germany. Methods: Guided by design thinking, first, qualitative interviews were conducted to assess the needs of PPC professionals. Second, the elicited needs were specified in focus groups (FGs). Based on the needs stated in the interviews, prototypes of the ECHR were developed and discussed in the FGs. The indicated needs were supplemented and specified in an iterative process. The prototypes were further adapted according to these results. The unified theory of acceptance and use of technology was the basic model in the evaluation of needs. Results: Across seven main categories, past and current medication, emergency view, and messaging functions were identified as the participants’ desired core components of an ECHR. Utilizing design thinking facilitated the explicit articulation of user needs. Conclusions: Developing an ECHR with the content identified would allow for real-time data during emergencies, tracking what other PPC professionals have done, and making the applied treatments visible to others. This would offer a broader picture of the complex conditions common to PPC.

Outcomes of Care Among Patients with Gout in Europe: A cross-sectional survey

Objective To assess health- and patient-centered outcomes in gout across Europe, and explore patient-, care-, and country-level characteristics associated with these outcomes. Methods Patients with self-reported physician-diagnosed gout from 14 European countries completed an online survey. Multivariable mixed-effect logistic and linear regressions were computed for health outcomes (gout flare recurrence) and patient-centered outcomes (patient satisfaction with current medication, and unaddressed goals), accounting for clustering within countries. The role of patient-, care- and country-level factors was explored. Results 1029 patients, predominantly diagnosed by a general practitioner, participated. One or more gout flares were reported by 70% of patients and ≥3 flares by 32%. Gout patients reported 1.1±1.2 unaddressed goals, and 80% were satisfied with current medication. Patients with ≥3 and ≥1 flares were less likely to be treated with urate-lowering therapy (ULT) [OR:0.52(0.39-0.70) and OR:0.38(0.28-0.53), respectively], but more likely to have regular physician visits [OR:2.40(1.79-3.22) and OR:1.77(1.30- 2.41)]. Three or more gout flares were also associated with lower satisfaction [OR:0.39(0.28-0.56)], and more unaddressed goals [B:0.36(0.19-0.53)]. Notwithstanding, the predicted probability of being satisfied was still between 57% and 75% among patients with ≥3 flares but who were not receiving ULT. Finally, patients from wealthier and Northern European countries more frequently had ≥3 gout flares. Conclusion Across Europe, many gout patients remain untreated despite frequent reported flares. Remarkably, a substantial proportion of them were still satisfied with gout management. A better understanding of patients' satisfaction and its role in physicians' gout management decisions is warranted to improve quality of care and gout outcomes across Europe.

Clozapine & constipation: an audit of bowel habit monitoring and laxative prescribing in inpatients on clozapine

AimsTo establish how often bowel habits are monitored in inpatients on clozapineTo determine how many of these patients are prescribed laxatives and whether these are utilisedBackgroundIt's estimated that 30-60% of patients will suffer from constipation whilst on clozapine; this can lead to ileus, intestinal obstruction and bowel ischaemia, all of which can be fatal. Constipation is much more common than clozapine-induced blood dyscrasias, and has a higher mortality rate. Despite this, there is no strict universal framework for bowel habit monitoring equivalent to the compulsory FBC monitoring. Local trust guidance indicates that bowel habits should be monitored regularly, at least at any point of blood sampling. However, monitoring processes across the trust were noted to be variable, as were laxative prescribing practices.MethodThe data sample of current inpatients on clozapine across the trust was identified from pharmacy records. The patient's Rio notes from the preceding 3 months were searched for predetermined terms relating to bowel habits and constipation, and the notes were then analysed for assessment of bowel habit. The number of FBCs collected during this 3 month period was then used to produce comparison with the audit standard. The data on laxative prescribing were collected from current medication lists on EPMA.ResultA data sample of 31 current inpatients was identified. The audit found that only 54.8% (17) of patients had their bowel habits monitored at least with every FBC taken. There was significant variability between different wards, with the best performing ward having 100% adherence to the audit standard, and the worst performing having 0%. In terms of laxative prescribing, it was found that 87.1% (27) of patients had at least 1 regular or 1 PRN laxative prescribed. Regular laxatives were prescribed for 61.2% (19) of patients, whereas only PRN laxatives were prescribed in 25.8% (8) of patients. Of those prescribed only PRN laxatives, only 50% (4) ever utilised this medication.ConclusionBowel habits are not consistently monitored across the trust in inpatients on clozapine, leaving room for potentially life-threatening side effects to be missed. Additionally, regular laxative prescribing is not standard throughout the trust, which could further add to the potential for significant constipation-related morbidity to occur. A standard method of monitoring bowel habits throughout the trust, as well as a trust laxative prescribing policy, could be a way of remedying this issue and preventing harmful outcomes for our patients on clozapine.