Differential diagnosis in pharmacy practice: Time to adopt clinical reasoning and decision making

The delivery of healthcare in most developed countries is under increasing pressure. Ageing populations with increasingly complex needs, coupled with financial constraints and imbalances in workforce, mean that healthcare policies look to contain cost and utilise resource as effectively as possible. Self-care is now widely advocated as a mechanism to manage acute presentations with pharmacy identified as a key resource to support such policy. Pharmacy teams are ideally positioned to facilitate the management of patients who present with acute illness. However, current evidence suggests that patient assessment and establishing a differential diagnosis could be better. It appears that how pharmacists are taught at Schools of Pharmacy adopts a protocol driven approach, which assumes presentation of low acuity conditions, and we argue that this method must be replaced with a curriculum that adopts clinical reasoning. This paper sets out the process of clinical reasoning and how the profession could embrace this as a better model in establishing a diagnosis.     

Pharmacists’ advice and clinical reasoning in relation to cardiovascular disease risk factors – A vignette case study

BackgroundPharmacists are increasingly providing public health services like the screening and monitoring for cardiovascular disease risk factors. Information on risk factors should be integrated into an assessment of absolute cardiovascular disease risk. Limited information is available on how pharmacists interpret test results and information related to cardiovascular disease risk factors.ObjectiveTo investigate the potential advice to clients featured in vignette case studies and reasoning of pharmacists in relation to multiple cardiovascular disease risk factors.MethodsThree vignette case studies representing clients with varying degrees of absolute cardiovascular disease risk who requested blood pressure and cholesterol level testing and related advice were designed and distributed to practicing pharmacists. Vignettes contained all necessary information for absolute cardiovascular disease risk assessment. Two open ended questions asked what advice pharmacists would provide and what influenced their decisions to give specific advice. Responses were analysed using content analysis and assessed for appropriateness in relation to cardiovascular guidelines.ResultsReplies of twenty-nine pharmacists were analysed. Advice to hypothetical clients was mainly appropriate when it concentrated on lifestyle modifications. Pharmacists’ reasoning indicated a focus on individual risk factors in their decision making on advice rather than consideration of absolute cardiovascular disease risk, which resulted in inappropriate recommendations of referral and follow up.ConclusionAdvice provided in relation to case studies and underlying clinical reasoning indicate potential knowledge gaps, anchoring bias and a framing effect in how pharmacists interpret multiple cardiovascular disease risk factors.     

The utility of a computerised clinical decision support system intervention in home medicines review: A mixed-methods process evaluation

BackgroundUse of high-risk medications is common and associated with adverse effects in older adults, including those living with dementia. A Computerised Clinical Decision Support System (CCDSS) called G-MEDSS© (Goal-directed Medication Review Electronic Decision Support System) contains tools that identify medications with anticholinergic and sedative effects and align older adult's health and medication goals of care with medication management strategies.ObjectivesTo describe the utility of a CCDSS called G-MEDSS in Home Medicines Review (HMR) by an accredited clinical pharmacist (ACP) using a mixed-methods process evaluation method.MethodsA mixed-methods process evaluation was conducted as part of a nation-wide cluster-randomised clinical trial evaluating the effectiveness of implementing G-MEDSS in HMR. Data were collected from ACPs and HMR recipients (the patient) using a feedback survey (ACPs and HMR recipients) and one-on-one telephone interviews (HMR recipients). Quantitative and qualitative data were combined at the start of analysis. Content analysis of the qualitative data was conducted, and emerging categories were linked to quantitative data.ResultsFeedback surveys were completed by eight ACPs and 26 HMR recipients; 11 HMR recipients completed one-on-one telephone interviews. Overall, ACPs and HMR recipients who received the intervention reported a positive attitude towards the utility of G-MEDSS in HMR. ACPs reported that G-MEDSS enhanced their ability to make evidence-based recommendations about anticholinergic and sedative medications, and to better align HMR recommendations with HMR recipients’ goals of care. However, ACPs described that it was difficult to obtain goals of care from HMR recipients. HMR recipients gave mixed reports about the ACPs consultations: some HMR recipients reported that they were engaged in discussions about their views on medications, whilst other participants reported that discussions about their concerns towards medications and goals was limited.ConclusionsThis study suggests that a CCDSS, such as G-MEDSS, demonstrates good utility to assist ACPs to identify and assess anticholinergic and sedative medications. Given the mixed feedback from the ACPs on the different components of the G-MEDSS, further refinement of these tools and their use in combination in practice may be needed.     

头孢特仑新戊酯的药动学和临床评价进展

头孢特仑新戊酯是90年代上市的一种口服三代头孢菌素,具有广谱抗菌活性,对细菌产生的β-内酰胺酶稳定,目前常见的致病菌很少对其耐药。本文综述了头孢特仑新戊酯的药动学和临床评价的进展,为临床合理使用提供依据。     

临床药学工作模式在妇科治疗团队的构建及其成效评价

构建临床药师在妇科治疗团队的工作模式,不仅有效改善了临床药师和医护间沟通效率,而且面对面的药学服务形式明显提高了患者用药的依从性。在本研究过程中,临床药师选取了妇科手术常见病种卵巢囊肿和子宫肌瘤作为切入点,开展围术期预防用药监测,并以此作为本模式的成效评价依据。结果提示,该模式的建立使围术期预防用药更加趋于合理,用药疗程明显缩短,无指征换药和出院带药均明显减少。     

地方性医学高校临床教学督导评价结果分析研究

目的 分析地方性高校教学督导现状及临床教师课堂教学评价结果.方法 收集2014年9月至2015年12月第二临床医学院临床教学督导结果,汇总建立数据库,分析教学督导现状,对不同专业技术职称临床教师课堂教学评价进行差异性分析.结果 共收集第二临床医学院临床教师教学督导评价表38份,分布于13门临床课程,其中医学影像学督导6次,内科学、传染病学各督导5次,儿科学、急诊医学各督导1次.按专业技术职称分类,中级、副高级、正高级临床教师人数分别为22、10、6人,中级职称临床教师数最多,占57.9％.中级、副高级、正高级专业技术职称的临床教师教学评价得分分别为(83.5±3.7)分、(85.7±3.3)分、(88.5±2.3)分,3组专业技术职称临床教师教学评分差异具有统计学意义(P=0.008).结论 临床教师教学督导覆盖率有待提高,学校根据发展定位,做好临床教师的教学能力提升工作,充分利用教学督导工作,实现临床教学质量的持续改进.     

Development and evaluation of fundamental education about Kampo medicine adopting an experimental program in clinical pharmacy using team-based format

A model core curriculum was proposed by the government in 2001 that outlined the core structure for undergraduate medical education, in which a Kampo medicine educational program was established. The following year, it was introduced in pharmacy as well as medicine. For fourth-year students at Tokai Medical University, a lecture on Kampo herbal medicine, focusing on clinical pharmacy, was given using team- based learning. Students learned the fundamental mechanism of Kampo medicine through team discussions about their subjective assessment of herbal medicine "Keishito" using their sensory organs and comparing objective analysis data of the main ingredients of Cinnamomi Cortex. They found that knowledge about Kampo medicine can come not only from clinical trials but also from objective observation. Through this educational program, almost all had an increased interest in the possible therapeutic value of herbal medicine. The results of examinations on Kampo herbal medicine showed that this program motivated students, especially those who had less or little interest in Kampo medicine before the lecture. The lecture-style team-based format could also facilitate a mutually supportive atmosphere, because negative feelings and concerns regarding initial traditional medicine can freely be expressed. In future, pharmacists as medical staff will provide preventive and curative primary care; since, for example, the Japanese government is pressing forward to prevent metabolic syndrome, which is related to lifestyle, this project could not have been completed without the cooperation of health professionals such as pharmacists. The present educational program in Kampo medicine may also be recommended for clinical pharmacy education.     

西安三级甲等教学医院临床一线医护人员临床决策能力现状及其影响因素分析

目的 调查西安三级甲等教学医院临床一线医护人员临床决策能力现状,分析其影响因素。方法 2021年10—12月,按照随机数字表法选取西安交通大学第一附属医院、西安交通大学第二附属医院和西北妇女儿童医院的507名三级甲等教学医院临床一线医护人员为研究对象,其中医生192名,护士315名。采用一般资料调查表、临床决策量表和综合决策风格量表进行调查研究,回收有效答卷493份。用单因素分析及多元线性回归等方法分析三级甲等教学医院临床一线医护人员临床决策能力影响因素。结果 三级甲等教学医院临床一线医护人员临床决策能力总分为（164.40±18.92）分,达到临床决策能力高水平标准（146.68～200.00分）范围。Pearson相关性分析显示：临床决策能力的总得分及各维度的得分结果与理智型决策风格得分结果均呈正相关关系（P<0.05）;寻找信息或新信息维度的得分情况与直觉-冲动型决策风格的得分情况呈负相关关系（P<0.05）;回避型决策风格与寻找信息或新信息、明确目标和价值、临床决策能力总分、寻找可选择的方案维度等得分均呈负相关关系（P<0.05）。多元线性回归结果显示：理智型...     

Healthcare professionals' perceptions related to the provision of clinical pharmacy services in the public health sector: A case study

Background

In Mexico, the Modelo Nacional de Farmacia Hospitalaria (MNFH, or National Hospital Pharmacy Model), published in 2009, mainly aims to promote the provision of clinical pharmacy services in private and public hospitals. However, there is little scientific documentation about the quality of these services.

Clinical pharmacy definition,required education,training and practice in Saudi Arabia: A position statement by the Saudi society of clinical pharmacy

The Saudi Society of Clinical Pharmacy (SSCP) is a scientific and professional society in the field of clinical pharmacy that operates under the Saudi Commission for Health Specialties governance. The SSCP believes that there is a need to define and describe many aspects related to the clinical pharmacy profession in Saudi Arabia. Moreover, there is an increasing demand for promoting the concept of clinical pharmacy and developing a consensus regarding the scope of practice and clinical pharmacist's required postgraduate education and training in Saudi Arabia. This paper is intended to present several position statements by the SSCP that define the concept of clinical pharmacy, describe the required education and training, and highlight clinical pharmacists' scope of practice in Saudi Arabia. This paper calls for further investigations that examine the impact of clinical pharmacists on individual and population health levels.     

Development of orally dissolving films for pediatric-centric administration of anti-epileptic drug topiramate – A design of experiments (DoE) study

Children have often been treated as small adults in relation to drug formulation, but research has now shown this not to be the case. Therefore, there is a push from regulatory bodies to provide drug formulations specifically tailored towards the needs of this fragmented population. Orally dissolving films (ODFs) have been identified as an emerging opportunity, to bridge this gap. Therefore, the aim of this study was to prepare ODFs containing topiramate, an antiepileptic drug, using solvent casting method as a potential alternative to oral tablets/powders for paediatrics. For this purpose, a Design of Experiment (DoE) was employed to optimise formulation parameters. 24 formulations were prepared by changing the polymer type (HPMC, Guar-Gum or PEO), concentration (0.4%-1.2%w/v); plasticizer type (glycerol\sorbitol) and concentration (0.1–0.3%w/v). Disintegration time, content-uniformity, film quality and thickness uniformity were the responses. Surface and molecular profiling were conducted on the optimal formulation (N4). TGA and XRD results demonstrated the stability of materials upon production into films, while the SEM images showed smooth films that proved to be resilient due to good mechanical properties. HPMC-glycerine based ODFs are presented as an effective dosage form to enhance the ease of administration and patient compliance of topiramate, specifically for paediatric patients.     

桩核加烤瓷冠修复治疗牙体缺损83例临床观察

目的 观察桩核加烤瓷冠技术在牙体大面积缺损修复中的临床应用疗效。方法 临床为71例患者83个牙体大面积缺损的患牙行桩核加烤瓷冠修复术，观察1～2年，计算成功率和失败率。结果 83个烤瓷冠中79个取得满意的临床效果，成功率为95．18％。失败4例，失败率为4．82％。结论 桩核加烤瓷冠技术在牙体大面积缺损修复中的临床应用是成熟、成功的，保留了许多以前要拔除的牙体大面积缺损的患牙，临床应用很有价值。     

Development of a core set of clinical skills for pharmacist prescribers working in general practice: A Delphi study

BackgroundWith increasing numbers of pharmacists working in general practices and undertaking patient-facing roles, it has been recognised that they must have the necessary clinical skills. However, previous studies have highlighted that practice-based pharmacists (PBPs) do not feel confident regarding their clinical skills, and it is unclear what skills are needed.ObjectiveTo develop a core set of clinical skills (CSs) required for pharmacists who intend to practise as independent prescribers working in general practice/family medicine.MethodsBased on a previous study, 18 CSs were selected for inclusion in a three-round Delphi consensus questionnaire. These skills were rated by a Delphi panel on a 9-point Likert scale (ranging from 1 = limited importance to 9 = critical). The Delphi panel comprised designated leads of pharmacist independent prescribing programmes in each United Kingdom educational provider listed on the General Pharmaceutical Council website. A CS was included in the core set if 80% or more of participants scored between 7 and 9, and 15% or less scored between 1 and 3.ResultsFollowing Round 1, seven CSs met the criteria for inclusion: ‘Measuring heart rate (radial pulse)’, ‘Assessing respiratory rate’, ‘Measuring blood pressure (manual, e.g. with aneroid sphygmomanometer)’, ‘Measuring blood pressure (automated, i.e. electronic blood pressure monitor)’, ‘Measuring peripheral oxygen saturation (using pulse oximeter)’, ‘Measuring temperature’, ‘Measuring Peak Expiratory Flow Rate’. After two further rounds, a further four CSs were included consisting of ‘Undertaking a urinalysis’, ‘Respiratory examination (includes inspection, palpation, percussion and listening to breath sounds)’, ‘Screening for/assessment of depression and anxiety using a validated questionnaire (e.g. Patient Health Questionnaire-9 [PHQ-9] scoring)’, and ‘Patient assessment via National Early Warning Score (NEWS)’. No consensus was reached on nine CSs.ConclusionThis study has produced a core set of CSs for prescribing pharmacists. This study may contribute to standardisation of training and assessment for pharmacist prescribers working in general practice/family medicine.     

养血清脑颗粒治疗紧张型头痛的临床观察

目的观察养血清脑颗粒治疗紧张型头痛的疗效及安全性。方法将120例紧张型头痛患者随机分为治疗组和安慰剂组各60例。治疗组给予养血清脑颗粒治疗;对照组给予安慰剂。结果治疗组和安慰剂组头痛发作次数分别为1.21±1.38次和2.65±3.24次,P〈0.05;头痛持续时间分别为6.55±12.63h和22.72±40.88h,P〈0.01;治疗组的总有效率为93.3%,而安慰剂组为36.7%,P〈0.01;治疗组和安慰剂组的不良反应发生率分别为5.0%和3.3%,P〉0.05。结论养血清脑颗粒治疗紧张型头痛可减少头痛的发作次数、持续时间,是一种治疗紧张型头痛安全有效的药物。     

Investigation of unbound colistin A and B in clinical samples using a mass spectrometry method

Colistin, used as a last-resort drug, has a narrow therapeutic range that justifies therapeutic drug monitoring. Few data are available in the literature regarding the in vivo unbound fraction of colistin. The objectives of this study were to develop a method to isolate unbound colistin in clinical samples by ultrafiltration and to quantify it. The association between unbound colistin and biological parameters (total protein, albumin, alpha-1-acid glycoprotein and creatinine) was investigated. The measured ranges were 0.036–7.160 mg/L for colistin A and 0.064–9.630 mg/L for colistin B. The process of isolation and determination of unbound colistin was applied to clinical samples (n?=?30) within 40 min and no non-specific binding was observed during the ultracentrifugation step. The median unbound fractions of colistin measured were 34.3% (12.8–51.0%) and 53.4% (27.0–77.8%) for colistin A and B, respectively. High interindividual biological variation of binding was observed for colistin A and B that was not explained by the biochemical parameters studied. The method developed could be useful to improve outcomes for patients.     

Investigations and feedback on the training mode of professional master’s degree of clinical pharmacy in Peking University and the preliminary exploration of Pharm. D. Education

In order to carry out the comprehensive reform of the professional master’s degree training mode of clinical pharmacy, we carried out interviews among 91 persons on the professional master's degree of clinical pharmacy in Peking University School of Pharmaceutical Sciences and collected extensive feedback. We preliminaries explore the mode of Doctor of Pharmacy (Pharm. D.) Education, laying the foundation for Doctor’s education of professional clinical pharmacy in China. We conducted investigations and interviews among 91 clinical pharmacists and students of Peking University School of Pharmaceutical Sciences on the training of professional master’s degree and Pharm. D. education mode, which includes 67 postgraduates and 24 clinical pharmacists. Respondents put forward the problems of training mode and corresponding suggestions and opinions from different aspects during the investigation and interview. The results mainly divide into four aspects: curriculum setting, clinical practice, assessment system and teaching resources. Respondents put forward effective feedback on the above four aspects, which are beneficial to the comprehensive reform of the training mode of professional master degree in clinical pharmacy and preliminary exploration of Pharm. D. Education in China.     

The impact of using pictorial aids in caregivers’ understanding of patient information leaflets of pediatric pain medications: A quasi-experimental study

IntroductionPatient information leaflets (PILs) are one of the main sources of information for over-the-counter medications (OTCs). This study aimed to assess caregivers'' understanding of instructions in PILs provided with paracetamol medications and the impact of pictograms use.MethodsA quasi-experimental study was conducted among caregivers of children aged < 13 years recruited in pediatric outpatient clinics at University Medical City in Riyadh. The calculated sample size was 128; at least 64 participants were needed in each group (the text-only group and the text-plus pictograms group). Caregivers'' health literacy was assessed using a validated Arabic version of the Newest Vital Sign scale. Participants’ understanding of PILs instructions was assessed using eight questions on the route of administration, minimal hours between doses, max daily dose, shake medication before use, storage, and reporting adverse events; and was rated based on the number of questions correctly understood. Characteristics of participants were compared by Pearson X² and t-test was used to assess the significance of mean score differences between groups.ResultsA total of 130 caregivers participated in the study; almost half of them were mothers (47%, [n = 61]) and 43% (n = 56) have “a possibility of limited health literacy”. The mean number of correct answers to questions assessing the understanding of PILs instructions was significantly higher among the text-plus pictograms group compared to the text-only group (5.25 ± 1.85 vs. 4.38 ± 1.27; p < 0.001). When results were controlled for age and gender, better health literacy was found to be associated with a better understanding of instructions (B = 0.39, 95 %CI 0.23–0.54).ConclusionLimited comprehension of medications instructions was observed; adding pictorial aids to PILs might enhance the comprehension. Differences in health literacy levels of caregivers should be considered when designing PILs.     

A multivariate approach linking reported side effects of clinical antidepressant and antipsychotic trials to in vitro binding affinities

The vast majority of approved antidepressants and antipsychotics exhibit a complex pharmacology. The mechanistic understanding of how these psychotropic medications are related to adverse drug reactions (ADRs) is crucial for the development of novel drug candidates and patient adherence. This study aims to associate in vitro assessed binding affinity profiles (39 compounds, 24 molecular drug targets) and ADRs (n=22) reported in clinical trials of antidepressants and antipsychotics (n>59.000 patients) by the use of robust multivariate statistics. Orthogonal projection to latent structures (O-PLS) regression models with reasonable predictability were found for several frequent ADRs such as nausea, diarrhea, hypotension, dizziness, headache, insomnia, sedation, sleepiness, increased sweating, and weight gain. Results of the present study support many well-known pharmacological principles such as the association of hypotension and dizziness with α₁-receptor or sedation with H₁-receptor antagonism. Moreover, the analyses revealed novel or hardly investigated mechanisms for common ADRs including the potential involvement of 5-HT₆-antagonism in weight gain, muscarinic receptor antagonism in dizziness, or 5-HT₇-antagonism in sedation. To summarize, the presented study underlines the feasibility and value of a multivariate data mining approach in psychopharmacological development of antidepressants and antipsychotics.