An exploration of health professionals’ experiences of medicines management in elderly,hospitalised patients in Abu Dhabi

Background Given the multiplicity of issues relating to medicines in the elderly, the structures and processes of medicines management should be clearly defined and described to optimise patient outcomes. There is a paucity of research which provides an in-depth exploration of these elements of medicines management for elderly patients. Objectives This study explored health professionals’ experiences of medicines management for elderly, hospitalised patients in Abu Dhabi. Setting The research was conducted in five major hospitals in Abu Dhabi, the United Arab Emirates. Method Responses to an online sampling questionnaire were used to purposively select nurses, pharmacists and physicians for interview. A semi-structured interview schedule was developed with reference to normalization process theory (NPT) and the theoretical domains framework (TDF) to explore issues of medicines management structures, processes and outcomes. Face-to-face interviews of 20–30 min were audio-recorded, transcribed verbatim and analysed using the Framework Approach. Main outcome measures Health professionals’ in-depth experiences of structures, processes and outcomes relating to medicines management. Results Saturation of themes was deemed to occur at interview 27 (7 nurses, 13 pharmacists, 7 physicians). Six key themes and several subthemes emerged from the qualitative analysis, which pertained to the need for: appropriate polypharmacy; a systematic approach to medicines history taking; improved communication and documentation; improved patients’ adherence to medicines; guidelines and policies to support medicines selection, and an educated and trained multidisciplinary team. The most dominant TDF behavioural determinants were issues around: professional role and identity; beliefs about capabilities; beliefs about consequences; environmental context and resources; knowledge, and goals. NPT construct identified little evidence of coherence, cognitive participation, collective action and reflexive monitoring. Conclusion The key themes identified in this research indicate the need to develop a more structured approach to medicines management in elderly hospitalised patients in Abu Dhabi. The NPT constructs and the TDF behavioural determinants can be utilised as part of service development and implementing change.     

Improving shared decision-making in adolescents through antibiotic education

Background Shared decision-making is vital in achieving desired drug therapy goals, especially with antibiotics, in view of the potential long-term reduction in drug resistance. However, shared decision-making is rarely practiced with adolescent patients. Objectives The aim of the study was to identify the effect antibiotic education has on willingness to engage in shared decision-making among adolescents in Malaysia. Setting Participants from secondary schools in Malaysia were enrolled with ethical approval. Method The adolescents answered a validated questionnaire, which included demographics, antibiotic knowledge, attitude towards antibiotic use, and the Control Preference Scale, which measures willingness to engage in shared decision-making. Afterwards, antibiotic education was delivered to participating students. Main outcome measure Knowledge about and attitude toward antibiotics were investigated. Results A total of 510 adolescents participated in the study. Knowledge of antibiotics significantly increased post education (pre 3.2 ± 1.8 vs. post 6.8 ± 2.1, p < 0.001), as did attitude score (pre 3.3 ± 1.7 vs. post 5.4 ± 1.9, p = 0.003). Interestingly, adolescents were less likely to be passively involved in shared decision-making post education (χ = 36.9, df = 2, p < 0.001). Adolescents who were more collaborative in shared decision-making had a significantly higher total antibiotics knowledge and attitude scores compared to those who were not collaborative (p = 0.003). Conclusion The present work demonstrates that antibiotic education improves knowledge, attitude, and willingness to engage in shared decision-making among adolescents. Antibiotic education can therefore be introduced as a strategy to reduce inappropriate antibiotic use.     

Improving the provision of OTC medication information in community pharmacies in Poland

Background An informed or shared decision-making model is desirable to support the choice of over-the-counter (OTC) medications in pharmacies: it respects patient empowerment in self-medication. Such a model is achievable provided that pharmacists are a credible, competent information source open to patient needs. Objective To study the dependencies among selected factors that may influence the provision of OTC medication information. The study was conducted from the perspective of a community pharmacist. Method The study consisted of an auditorium survey with a self-administered questionnaire. We attempted to determine the relationships among three selected constructs: patient centredness (four items), competence (four items), and provision of OTC medication information (six items) as latent variables. We analysed hypothetical relationships among the observable variables and latent variables using structural equation modelling. Main outcome measure Selected factors that may influence the provision of OTC medication information. Results In all, 1496 pharmacists took part in the study. The model demonstrated adequate fit (χ² = 198.39, df = 64). The patient-centredness construct was demonstrated to have a strong direct positive impact on the provision of OTC medication information construct (β = 0.77, P < 0.05). Provision of OTC medication information was also shown to have a strong direct effect on the competence variable (β = 0.90, P < 0.05). Conclusion If a pharmacist is patient centred, there is a greater possibility that they will provide information about OTC medicines; that may influence the pharmacist’s feelings about their ability to cope with patient initiatives and enhance the pharmacist’s selfperceived competence.     

Optimization of Process Parameters for Formulation of Ayurvedic Fermented Medicine <Emphasis Type="Italic">Arjunarishta</Emphasis> by Response Surface Methodology

Purpose

Utilization of traditional medicines increased worldwide. However, lack of modern technology creates problems for rejection of such preparations. Good manufacturing practices (GMPs) advocate uniformity and stability in the development of modern pharmaceuticals. Implementation of appropriate formulation strategies may enhance regulatory acceptance of complementary medicines. Herewith an attempt has been made to identify the impact of process parameter temperature, pH, and yeast cell number (inoculum volume) on manufacturing of ayurvedic fermented cardiotonic—arjunarishta.

Method

Optimization of the selected three process parameters was carried out for maximum production of alcohol in arishta using Box–Behnken design of response surface methodology with support of Design Expert software. Alcohol produced in formulation was detected after solvent extraction by dichromate oxidation method.

Result

Quadratic model was found significant with sum of squares 86.76 and F value 250.60. The incubation temperature 33.33 °C, pH 4.73, and inoculum volume 3.25 ml (4?×?10⁷ yeast cells/ml) have been identified as the best for maximal production of alcohol. It shows 7.68 % (v/v) production of alcohol which is identified by dichromate oxidation method. Presence of gallic acid also detected in optimized formulation by HPTLC with concentration 0.296 % (w/v).

Conclusion

This kind of study will definitely make formulation of arishta easier with higher consistency; moreover, manufacturing is possible in any season at any place.

     

Identification of structural requirements of estrogen receptor modulators using pharmacoinformatics techniques for application to estrogen therapy

In this study, we explored the structural requirements of known estrogen receptor modulators for biological activity using pharmacoinformatics approaches to elucidate critical functionalities for new, potent and less toxic chemical agents for successful application in estrogen therapy. For this purpose, a group of nonsteroidal ligands 7-thiabicyclo[2.2.1]hept-2-ene-7-oxide derivatives were collected from the literature to perform quantitative structure–activity relationship (QSAR), pharmacophore and molecular docking studies. The 2D QSAR models (R _α ²  = 0.857, se _α  = 0.370, Q _α ²  = 0.848, R _pred?α ²  = 0.675, s _pα  = 0.537; R _β ²  = 0.874, se _β  = 0.261, Q _β ²  = 0.859, R _pred?β ²  = 0.659, s _pβ  = 0.408) explained that hydrophobicity and molar refractivity were crucial for binding affinity in both α- and β-subtypes. The space modeling study (R _α ²  = 0.955, se _α  = 1.311, Q _α ²  = 0.932, R _pred?α ²  = 0.737, s _pα  = 0.497; R _β ²  = 0.885, se _β  = 1.328, Q _β ²  = 0.878, R _pred?β ²  = 0.769, s _pβ  = 0.336) revealed the importance of HB donor and hydrophobic features for both subtypes, whereas HB acceptor and aromatic ring were critical for α- and β-subtypes, respectively. The functionalities developed in the QSAR and pharmacophore studies were substantiated by molecular docking studies which provided the preferred orientation of ligands for effective interaction at the active site cavity.     

The impact of cardiovascular medication use on patients’ daily lives: a cross-sectional study

Background The management of multiple long-term medicines of patients with chronic diseases creates a burden for patients. However, limited research is performed on its impact on patients’ daily lives. Objective The aim of this study was to explore the impact of cardiovascular medication on different daily life aspects and to examine differences of these aspects between adherent and non-adherent patients. Setting Two community pharmacies in the Netherlands. Method In this cross-sectional study patients (≥ 45 years) using cardiovascular medication participated. Two equally group sized samples of patients non-adherent as assessed with pharmacy refill data, and patients adherent were selected. Main outcome measure Data were collected by means of the Living with Medicines Questionnaire measuring the impact of medicines use on patients’ daily lives. Results In total, 196 patients participated, including 96 non-adherent patients. Substantial proportions of patients experienced medication-related burden on different daily life aspects. This burden was mainly related to the acceptance of long-term medicine use, medication-related concerns or dissatisfaction, the interference of medicines with social and daily lives, and the interaction and communication with health care providers. No statistically significant results were found when comparing the impact on patients’ daily lives between adherent and nonadherent patients. Conclusion Health care providers should acknowledge the impact of multiple long-term medicines on patient’s daily lives and should make an effort to diminish patients’ medication-related burden by improving patient–provider relationships and by providing adequate treatment information incorporating patients’ individual circumstances. This may facilitate the integration of long-term medicine use in patients’ daily lives.     

Relationship between adolescents’ and their parents’ attitudes toward medicines and awareness of the risk of medicines

Background When they reach adolescence, children begin to independently use medicine without their parents’ supervision, but parents usually still want to be involved in their drug therapy. Objective The aim of this study was to investigate how parental attitudes and awareness toward medicine relate to adolescents’ attitudes and awareness. Setting Twelve secondary schools in different regions of the Slovak Republic. Method Adolescents and parents responded to a questionnaire, and the answers were paired and analysed. Parental and adolescents’ attitudes toward medicines and awareness of the risk of medicines were measured using a five-point Likert scale. Main outcome measure The strength of the relationship between parents’ and their adolescent children’s level of agreement with statements about medicines. Results There were significant differences between parents? and adolescents’ mean Likert scores for statements about their attitudes toward medicines and their awareness of the risk of medicines (p?<?0.05). Parents and adolescents were not fully aware of the risks of cough medicine (73.5% and 76.1%), antihistamines (32.7% and 52.1%), painkillers (33.6% and 47%) and combining medicines (25.2% and 40.4%). More than half of the parents and adolescents had a positive perception of the effectiveness of medication and believed that taking medicine would not hurt adolescents. Parents’ and adolescents’ responses to the statements were directly proportional (r?=?0.94, p?<?0.001). Conclusion The analysis revealed a relationship between Slovakian adolescents’ and their parents’ attitudes and awareness toward medicine; it highlighted areas of adolescents’ and parents’ education about the proper use of medications.     

Medicine information leaflets for non-steroidal anti-inflammatory drugs in Thailand

Background The importance of promoting the use of patient-oriented medicines leaflets is recognized in many countries. Leaflets should include basic information plus specific warnings, and be provided with all medicines, but there is little attempt at enforcement of these requirements in Thailand. Objective To determine content and availability of Thai information leaflets for nonsteroidal anti-inflammatory drugs (NSAIDs). Methods Leaflets for all NSAIDs available for purchase from 34 pharmacies in a large city were evaluated against a checklist and number of leaflets assessed against number of medicine packs available in each pharmacy. Results Of the 76 leaflets for ten different NSAIDs, 67 (88 %) were for locally manufactured products. Only 22 % of 76 leaflets were sufficient in number for distribution with medicines, while only 4 % had patient-oriented leaflets. No leaflet covered all topics in the checklist. Less than half included safety information, such as contraindications (46 %), precautions (47 %), and adverse drug reactions (34 %). Locally-produced leaflets provided less information than those for originator products and no leaflet included all the warnings required by Thai regulations. Conclusion This study illustrates the variable availability and quality of NSAID information leaflets. The lack of accessible essential information about medicines in Thailand requires urgent attention to enable patients to minimise adverse reactions.     

Effect of Cd<Superscript>+2</Superscript> on phosphate solubilizing abilities and hydrogen peroxide production of soil-borne micromycetes isolated from <Emphasis Type="Italic">Phragmites australis</Emphasis>-rhizosphere

The aims of this work were to evaluate the phosphate-solubilization and hydrogen peroxide (H₂O₂) production by the soil-borne micromycetes, Aspergillus japonicus, Penicillium italicum and Penicillium dipodomyicola, isolated from Phragmites australis rhizosphere and to study the effect of several concentrations of Cadmium (Cd²⁺) on both variables. Our results showed that P. italicum achieved a higher P-solubilization and H₂O₂ production than A. japonicus and P. dipodomyicola, as only P. italicum showed a positive correlation (R² = 0.71) between P-solubilization and H₂O₂ production. In dose–response assays, P. italicum was also more tolerant to Cd²⁺ (0.31 mM) in comparison to A. japonicus (0.26 mM). Analysis of the 2⁴ factorial experimental design showed that P-solubilization by P. italicum was negatively affected by increases in Cd²⁺ (p = 0.04) and yeast extract (p = 0.02) in the culture medium. The production of H₂O₂ was positively affected only by glucose (p = 0.002). Fungal biomass production was reduced significantly (p = 0.0009) by Cd²⁺ and increased (p = 0.0003) by high glucose concentration in the culture medium. The tolerance and correlation between P-solubilization and H₂O₂ production in the presence of Cd²⁺ was strain and species dependent. The effects of Cd²⁺, glucose, ammonium sulfate and yeast extract on those variables were evaluated through a two-level factorial design. P. italicum is promising for P-solubilization in soils contaminated with Cd²⁺ and may be an alternative for manufacture of biofertilizers to replace chemical fertilizers.     

Pharmacodynamic model for β-lactam regimens used in surgical prophylaxis: model-based evaluation of standard dosing regimens

Background Continual evolution of resistance among bacteria against methods of surgical prophylaxis may make currently used beta-lactam regimens inadequate. Objective To re-evaluate beta-lactam regimens in surgical prophylaxis. Setting A pharmacodynamic Monte Carlo simulation (MCS) model based on a number of patients in China. Methods Pharmacodynamic profiling using Monte Carlo simulation up to 4 hours postinfusion was conducted for standard-dose, short-term (0.5 h) and prolonged (2 to 4 h) infusions of ampicillin, cefazolin, cefotaxime, cefoxitin, cefuroxime, ertapenem, and piperacillin/tazobactam in adult patients with normal renal function. Microbiological data were incorporated. Cumulative fraction of response (CFR) was determined for each regimen against populations of S. aureus, coagulase-negative staphylococci and E. coli. The optimal CFR was defined as?≥?90% response. Main Outcome Measure Cumulative fractions of response of pharmacodynamic target attainment. Results During the first 2 hours postinfusion, piperacillin/tazobactam 3.375 g exhibited consistently optimal cumulative fractions against S. aureus, CoNS and E. coli. Ampicillin 2 g (2 h) also displayed optimal CFRs for S. aureus and E. coli but not for coagulase-negative staphylococci. Cefoxitin 2 g didnot achieve any optimal CFRs, even via 2-h prolonged infusion (maximum 72.8% CFR for S. aureus and 64.5% CFR for E. coli). Cefazolin 2 g (4 h) and cefuroxime 1.5 g (4 h) provided desired CFRs across 4 h postinfusion for S. aureus but provided poor CFRs for coagulase-negative staphylococci and E. coli. Only ertapenem 1 g for E. coli and S. aureus and cefotaxime 1 g for E. coli consistently yielded?≥?90% CFRs for 4 hour postinfusion. Conclusions Certain dosing regimens may warrant adjustment for improved prevention efficiency and enhanced empirical antibiotic regimens for surgical prophylaxis.     

Three new 5,6,7,8-tetrahydroxy-5,6,7,8-tetrahydrochromone derivatives enantiomeric to agarotetrol from agarwood

Agarwood (jinkoh in Japanese) is a resinous wood from Aquilaria species of the family Thymelaeaceae and has been used as incense and in traditional medicines. Characteristic chromone derivatives such as agarotetrol have been isolated from agarwood. In previous study, we isolated two new 2-(2-phenylethyl)chromones together with six known compounds from MeOH extract of agarwood. Further chemical investigation of the MeOH extract led to isolation of eighteen 2-(2-phenylethyl)chromones, including three new 5,6,7,8-tetrahydroxy-5,6,7,8-tetrahydrochromones with stereochemistry enantiomeric to agarotetrol-type, viz. (5R,6S,7S,8R)-2-[2-(3′-hydroxy-4′-methoxyphenyl)ethyl]-5,6,7,8-tetrahydroxy-5,6,7,8-tetrahydrochromone (2), (5R,6S,7S,8R)-2-[2-(4′-methoxyphenyl)ethyl]-5,6,7,8-tetrahydroxy-5,6,7,8-tetrahydrochromone (6), and (5R,6S,7S,8R)-2-[2-(4′-hydroxy-3′- methoxyphenyl)ethyl]-5,6,7,8-tetrahydroxy-5,6,7,8-tetrahydrochromone (13). The absolute configurations of the new compounds were determined by exciton chirality method. All isolated compounds were tested for their phosphodiesterase (PDE) 3A inhibitory activity by fluorescence polarization method. Compounds 8, 12–15, 21–24 showed moderate PDE 3A inhibitory activity.     

Community pharmacist perceptions of delivering post-hospital discharge Medicines Use Reviews for elderly patients

Background The UK’s Department of Health has recommended that formal communication channels between hospital and community pharmacy should be established so that post discharge Medicines Use Reviews (dMUR) become an integral part of the medicines pathway. Objective To investigate the perspective of community pharmacists on the usefulness of dMUR referrals from hospital, the suitability of patients referred and overall views on the service. Method Self-completed survey distributed to 21 community pharmacists who had received referrals from the hospital during a 9-month randomized controlled feasibility study. Results Nineteen pharmacists (90.4%) returned the survey. Seven (36.8%) felt that it was hard to engage patients with dMURs. Failure or inability of patients to attend the pharmacy were the most common barriers. Reasons for medication changes (n = 5) and indications for new medicines (n = 4) were the most common examples of extra information that would be useful on referral. Community pharmacists held positive opinions on the dMUR service and could see the benefit to patients. Pharmacists wanted more referrals but reported performing few dMURs outside this study. Conclusion This study highlights the need to improve communication between hospital and community pharmacies and to overcome barriers to performing dMURs outside the pharmacy premises in this patient group.     

Regulation of the Human Fc-Neonatal Receptor alpha-Chain Gene <Emphasis Type="BoldItalic">FCGRT</Emphasis> by MicroRNA-3181

Purpose

FCGRT encodes the alpha-chain component of the neonatal Fc receptor (FcRn). FcRn is critical for the trafficking of endogenous and exogenous IgG molecules and albumin in various tissues. Few regulators of FcRn expression have been identified. We investigated the epigenetic regulation of FcRn by two microRNAs (hsa-miR-3181 and hsa-miR-3136-3p) acting on FCGRT.

Methods

The binding of candidate microRNAs to the 3′-untranslated region of FCGRT was evaluated using luciferase reporter constructs in CHO cells. The effect of microRNAs on FCGRT mRNA and FcRn protein expression was evaluated using specific microRNA mimics and inhibitor transfections in A549, HEK293 and HepG2 cells.

Results

Hsa-miR-3181 mimic reduced luciferase reporter activity by 70.1% (10 nM, P <?0.0001). In A549, HEK293 and HepG2 cells, hsa-miR-3181 decreased FCGRT mRNA expression (48.6%, 51.3% and 43.5% respectively, 25 nM, P <?0.05). The hsa-miR-3181 mimic decreased the expression of FcRn protein by 40% after 48 h (25 nM, P <?0.001). The mature form of hsa-miR-3181 was detected in samples of human liver.

Conclusions

These data suggest that hsa-miR-3181 is an epigenetic regulator of FCGRT expression. The identification of this regulator of FCGRT may provide insights into a potential determinant of interindividual variability in FcRn expression.

     

A cross-sectional evaluation of community pharmacists’ perceptions of intermediate care and medicines management across the healthcare interface

Background Despite the importance placed on the concept of the multidisciplinary team in relation to intermediate care (IC), little is known about community pharmacists’ (CPs) involvement. Objective To determine CPs’ awareness of and involvement with IC services, perceptions of the transfer of patients’ medication information between healthcare settings and views of the development of a CP–IC service. Setting Community pharmacies in Northern Ireland. Methods A postal questionnaire, informed by previous qualitative work was developed and piloted. Main outcome measure CPs’ awareness of and involvement with IC. Results The response rate was 35.3 % (190/539). Under half (47.4 %) of CPs ‘agreed/strongly agreed’ that they understood the term ‘intermediate care’. Three quarters of respondents were either not involved or unsure if they were involved with providing services to IC. A small minority (1.2 %) of CPs reported that they received communication regarding medication changes made in hospital or IC settings ‘all of the time’. Only 9.5 and 0.5 % of respondents ‘strongly agreed’ that communication from hospital and IC, respectively, was sufficiently detailed. In total, 155 (81.6 %) CPs indicated that they would like to have greater involvement with IC services. ‘Current workload’ was ranked as the most important barrier to service development. Conclusion It was revealed that CPs had little awareness of, or involvement with, IC. Communication of information relating to patients’ medicines between settings was perceived as insufficient, especially between IC and community pharmacy settings. CPs demonstrated willingness to be involved with IC and services aimed at bridging the communication gap between healthcare settings.