Effectiveness of a medication reconciliation project conducted by PharmD students

Objectives

This study evaluated the effectiveness of a medication reconciliation program conducted by doctor of pharmacy (PharmD) students during an advanced pharmacy practice experience.

Methods

Patients admitted to medicine or surgery units at 3 hospitals were included. Students were instructed to interview each patient to obtain a medication history, reconcile this list with the medical chart, and identify and solve drug-related problems.

Results

Eleven students reconciled medications for 330 patients over 10 months and identified 922 discrepancies. The median number of discrepancies found per patient was 2, and no discrepancies were found in 25% of the cases. In cases in which discrepancies were identified, a greater number of medications had been prescribed for the patient (7.9 ± 4.0 medications compared to 5.4 ± 3.9 medications; p < 0.05). The students completed 59 interventions. Differences were found in the numbers of discrepancies and drug-related problems that different students at different sites identified (p < 0.05).

Conclusions

Pharmacy students provided a valuable service to 3 community hospitals. The students improved the quality of patient care by identifying and solving significant drug-related problems, identifying drug allergy information, and resolving home and admission medication discrepancies.     

Pilot of a National Inpatient Medication Chart in Australia: improving prescribing safety and enabling prescribing training

AIMS

To establish whether a standard national inpatient medication chart (NIMC) could be implemented across a range of sites in Australia and reduce frequency of prescribing errors and improve the completion of adverse drug reaction (ADR) and warfarin documentation.

METHODS

A medication chart, which had previously been implemented in one state, was piloted in 22 public hospitals across Australia. Prospective before and after observational audits of prescribing errors were undertaken by trained nurse and pharmacist teams. The introduction of the chart was accompanied by local education of prescribers and presentation of baseline audit findings.

RESULTS

After the introduction of the NIMC, prescribing errors decreased by almost one-third, from 6383 errors in 15 557 orders, a median (range) of 3 (0–48) per patient to 4293 in 15 416 orders, 2 (0–45) per patient (Wilcoxon Rank Sum test, P < 0.001). The documentation of drugs causing previous ADRs increased significantly from 81.9% to 88.9% of drugs (χ² test, P < 0.001). The documentation of the indication for warfarin increased from 12.1 to 34.3% (χ² test, P = 0.001) and the documentation of target INR increased from 10.8 to 70.0% (χ² test, P < 0.001) after implementation of the chart.

CONCLUSIONS

National implementation of a standard medication chart is possible. Similar reduction in the rate of prescribing errors can be achieved in multiple sites across one country. The consequent benefits for patient care and training of staff could be significant.     

A categorization scheme for assessing pharmacy students' levels of reflection during internships

Objective

To test the reliability, feasibility, and responsiveness of a categorization scheme for assessing pharmacy students'' levels of reflection during internships.

Methods

Pharmacy interns at Uppsala University were asked to write a reflective essay about patient counseling at the start and end of their internships. A modified version of Kember''s categorization scheme for assessing the level of reflection was used to evaluate these essays.

Results

Based on their essay scores, the students'' levels of reflection increased during the internship course (p < 0.001) The mean time for categorization was 3 minutes per essay. The interrater reliability of the 182 essays was κ = 0.63.

Conclusions

The evaluation of the categorization scheme showed that it has good interrater reliability, feasibility, and responsiveness. This scheme might be useful in pharmacy practice educational settings, but needs further validation.     

eDrugCalc: an online self-assessment package to enhance medical students' drug dose calculation skills

AIMS

Dose calculation errors can cause serious life-threatening clinical incidents. We designed eDrugCalc as an online self-assessment tool to develop and evaluate calculation skills among medical students.

METHODS

We undertook a prospective uncontrolled study involving 1727 medical students in years 1–5 at the University of Edinburgh. Students had continuous access to eDrugCalc and were encouraged to practise. Voluntary self-assessment was undertaken by answering the 20 questions on six occasions over 30 months. Questions remained fixed but numerical variables changed so each visit required a fresh calculation. Feedback was provided following each answer.

RESULTS

Final-year students had a significantly higher mean score in test 6 compared with test 1 [16.6, 95% confidence interval (CI) 16.2, 17.0 vs. 12.6, 95% CI 11.9, 13.4; n = 173, P < 0.0001 Wilcoxon matched pairs test] and made a median of three vs. seven errors. Performance was highly variable in all tests with 2.7% of final-year students scoring < 10/20 in test 6. Graduating students in 2009 (30 months'' exposure) achieved significantly better scores than those in 2007 (only 6 months): mean 16.5, 95% CI 16.0, 17.0, n = 184 vs. 15.1, 95% CI 14.5, 15.6, n = 187; P < 0.0001, Mann–Whitney test. Calculations based on percentage concentrations and infusion rates were poorly performed. Feedback showed that eDrugCalc increased confidence in calculating doses and was highly rated as a learning tool.

CONCLUSIONS

Medical student performance of dose calculations improved significantly after repeated exposure to an online formative dose-calculation package and encouragement to develop their numeracy. Further research is required to establish whether eDrugCalc reduces calculation errors made in clinical practice.     

Does a physician's specialty influence the recording of medication history in patients' case notes?

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

• Physicians undertake the documentation of medication history during clerking; where all the necessary information that guides the diagnostic and patient management tasks are obtained.
• Medication histories documented by physicians are often incomplete and generally sketchy; however, the impact of a physician''s specialty on the frequency and depth of medication history they document has not been studied.

WHAT THIS STUDY ADDS

• The depth and frequency of medication history documented by physicians is significantly influenced by their specialties.
• Physicians appear more interested in documenting more frequently and in greater depth medication history information that appears to aid diagnostic tasks in their specific specialty.

AIMS

To determine the impact of a physician''s specialty on the frequency and depth of medication history documented in patient medical records.

METHODS

A cross-sectional assessment of the frequency and depth of medication history information documented by 123 physicians for 900 randomly selected patients stratified across Cardiology, Chest, Dermatology, Endocrine, Gastroenterology, Haematology, Neurology, Psychiatry and Renal specialties was carried out at a 900-bed teaching hospital located in Ibadan, Nigeria.

RESULTS

Four hundred and forty-three (49.2%) of the cohort were males and 457 (50.8%) were females; with mean ages 43.2 ± 18.6 and 43.1 ± 17.9 years respectively. Physicians'' specialties significantly influenced the depth of documentation of the medication history information across the nine specialties (P < 0.0001). Post hoc pair-wise comparisons with Tukey''s HSD test showed that the mean scores for adverse drug reactions and adherence to medicines was highest in the Cardiology specialty; while the Chest specialty had the highest mean scores for allergy to drugs, food, chemicals and cigarette smoking. Mean scores for the use of alcohol; illicit drugs; dietary restrictions was highest for Gastroenterology, Psychiatry and Endocrine specialties respectively. Physicians'' specialties also significantly influenced the frequency of documentation of the medication history across the nine specialties (P < 0.0001).

CONCLUSIONS

Physicians appear to document more frequently and in greater depth medication history information that may aid the diagnostic tasks in their specific specialty. Researchers and other users of medication history data documented in patients'' medical records by physicians may want to take special cognizance of this phenomenon.     

Pharmacy-Based Medication Reconciliation Program Utilizing Pharmacists and Technicians: A Process Improvement Initiative

Background:

Pharmacists and pharmacy technicians have an opportunity to impact the quality of the medication histories and improve patient safety by ensuring accurate medication lists are obtained and complete reconciliation has occurred with the admission medication orders by owning the admission medication reconciliation process.

Objective:

To compare the quality of a pharmacy-based medication reconciliation program on admission utilizing pharmacists and technicians to the usual multidisciplinary process.

Methods:

This was a retrospective chart review process improvement study at a 186-bed tertiary care inpatient facility. Primary outcomes included both the accuracy of pre-admission medications listed and the reconciliation of those medications with admission inpatient orders. Technicians obtained patient medication histories. Pharmacists checked the technician-obtained medication histories and ensured reconciliation of those medications with admission orders.

Results:

Medication accuracy increased from 45.8% to 95% per patient (P < .001) and medication reconciliation increased from 44.2% to 92.8% (P < .001) and remained above benchmark.

Conclusion:

A pharmacy-based medication reconciliation program utilizing both pharmacists and technicians significantly increased the accuracy and reconciliation of medications on admission. These gains were maintained for the duration of the 6-month period studied and beyond per continued process improvement data collection.     

A pharmacokinetic evaluation of five H1 antagonists after an oral and intravenous microdose to human subjects

AIMS

To evaluate the pharmacokinetics (PK) of five H₁ receptor antagonists in human volunteers after a single oral and intravenous (i.v.) microdose (0.1 mg).

METHODS

Five H₁ receptor antagonists, namely NBI-1, NBI-2, NBI-3, NBI-4 and diphenhydramine, were administered to human volunteers as a single 0.1-mg oral and i.v. dose. Blood samples were collected up to 48 h, and the parent compound in the plasma extract was quantified by high-performance liquid chromatography and accelerator mass spectroscopy.

RESULTS

The median clearance (CL), apparent volume of distribution (V_d) and apparent terminal elimination half-life (t_1/2) of diphenhydramine after an i.v. microdose were 24.7 l h⁻¹, 302 l and 9.3 h, and the oral C_max and AUC_0–∞ were 0.195 ng ml⁻¹ and 1.52 ng h ml⁻¹, respectively. These data were consistent with previously published diphenhydramine data at 500 times the microdose. The rank order of oral bioavailability of the five compounds was as follows: NBI-2 > NBI-1 > NBI-3 > diphenhydramine > NBI-4, whereas the rank order for CL was NBI-4 > diphenhydramine > NBI-1 > NBI-3 > NBI-2.

CONCLUSIONS

Human microdosing provided estimates of clinical PK of four structurally related compounds, which were deemed useful for compound selection.     

High dose methotrexate chemotherapy: pharmacokinetics, folate and toxicity in osteosarcoma patients

AIMS

To investigate the relationships between pretreatment folate concentrations, MTX pharmacokinetics and acute toxicities following high dose methotrexate (HD MTX) therapy.

METHODS

MTX and its major extracellular metabolite 7-OH-MTX were measured in eight serum samples per HD MTX cycle in 65 consecutive osteosarcoma patients (288 cycles) and AUC (area under the blood concentration–time curve) was calculated. Pretreatment concentrations of folate in serum (S) and erythrocytes (ER) were determined. Hepatic, renal and haematological toxicities, assessed by routine laboratory parameters, as well as mucositis were graded according to National Cancer Institute Common Terminology Criteria for adverse events (CTCAE v.3.0). Dermatitis and pleuritis were reported as occurred or not.

RESULTS

S- and ER-folate pretreatment concentrations increased significantly with increasing number of HD MTX cycles (P < 0.001). ER-folate pretreatment concentrations were higher among males (median 610 nmol l⁻¹, 95% CI 550, 680) compared with females (median 465 nmol l⁻¹, 95% CI 430, 520, P < 0.001), but showed no correlation with MTX or 7-OH-MTX pharmacokinetics. We found correlations between alanine aminotransferase peak concentration (ALAT_max) and clearance of MTX (P < 0.001), gender (P < 0.001), age (P < 0.001) and 7-OH-MTX concentrations (P < 0.001), the latter being the main factor influencing ALAT_max.

CONCLUSION

Our results suggest that 7-OH-MTX is involved in the development of HD MTX hepatic toxicity and that young female patients are most affected.     

Prospective analysis of the impact of VEGF-A gene polymorphisms on the pharmacodynamics of bevacizumab-based therapy in metastatic breast cancer patients

AIMS

To test prospectively the impact of VEGF-A gene polymorphisms on the pharmacodynamics of bevacizumab-chemotherapy in breast cancer patients.

METHODS

As part of the single-arm MO19391 trial, 137 women with locally recurrent or metastatic breast cancer receiving first-line bevacizumab-containing therapy were analysed. Patients received bevacizumab associated (76%) or not (24%) with taxane-based chemotherapy. Clinical evaluation included clinical response, time to progression (TTP) and a toxicity score corresponding to the sum of each maximum observed toxicity grade (hypertension, haemorrhage, arterial and venous thrombo-embolism). Functional VEGF-A polymorphisms at position −2578 C > A, −1498 T > C, −1154 G > A, −634 G > C and 936 C > T were analysed by PCR-RFLP (blood DNA).

RESULTS

Overall response rate (complete response (CR) + partial response (PR)) was 61%. Median TTP was 11 months. None of the VEGF-A polymorphisms was significantly linked to clinical response. Analysis of the 936C > T polymorphism revealed that the 96 patients homozygous for the 936C allele exhibited a marked tendency for a shorter TTP (median 9.7 months) than the 32 patients bearing the 936T allele (median 11.5 months, P = 0.022) of which 30 were CT and two were homozygous TT. Other polymorphisms did not influence TTP. VEGF-A−634 G > C was significantly related to the toxicity score with 39%, 49% and 81% of patients with score >1 in GG, GC and CC patients, respectively (P = 0.01).

CONCLUSIONS

The role for VEGF-A 936C > T polymorphism as a potential marker of TTP in breast cancer patients receiving bevacizumab-containing therapy concords with the known impact of VEGF-A 936C > T polymorphism on VEGF-A expression.     

Deaggregators inhibit TNF-a-induced leukocyte adhesion in vitro by breaking up hydrophobic lipophilic interactions

Aim： Deaggregators （deAgrs） are nontoxic organic molecules that possess the ability to deaggregate simple aggregates formed by hydrophobic lipophilic interactions （HLI）. Since HLI-driven organic molecule aggregates may induce leukocyte adhesion, we investigated the influence of deAgrs on TNF-a-mediated leukocyte adhesion in vitro. Methods： For adhesion studies, vascular endothelial cells or smooth muscle cells monolayers were treated with TNF-α （10 μg/L） and deAgrs for 24 h, followed by addition of monocytes or neutrophiis suspension. The non-adherent leukocytes were rinsed, and the number of attached leukocytes was measured using an ELISA plate reader. Simultaneously, fluorescence probes Np-12 and Np-Ch were used to measure the deaggregating efficiencies of these deAgrs. Results： Among the nine deAgrs tested,eight significantly reduced the cell adhesion rates with the order of efficiencies： 260〉160〉568〉ZPMOP〉R68〉640〉TB6PMOP〉CNS, but TBHQ had no effect. The deAgrs for deaggregating an aggregated probe （Np-12 or Np-Ch） exhibited a similar order of efficiencies： 260〉160〉568〉ZPMOP〉R68〉640〉TB6PMOP〉CNS〉12-AA〉11-AA〉TBHQ. Spearman correlation coefficient analyses indicated that the adherent rates of leukocytes to endothelial cells or smooth muscle cells treated with deAgrs had significantly negative correlation to their deaggregating abilities. Conclusion： DeAgrs effectively inhibit TNF-α-mediated leukocyte adhesion in vitro by breaking up hydrophobic lipophilic interactions, thus may be further tested for blocking atherogenesis.     

Exploring epistatic relationships of NO biosynthesis pathway genes in susceptibility to CHD

Aim:

To assess the epistatic relationships of nitric oxide (NO) biosynthesis pathway genes in susceptibility to coronary heart disease (CHD).

Methods:

A total of 2142 subjects enrolled in two case-control studies was genotyped for 7 single-nucleotide polymorphisms (SNP) within NO biosynthesis pathway genes using TaqMan assays. The association analyses were performed at both SNP and haplotype levels. Two-way SNP-SNP interactions and high-order interactions were tested using multiple unconditional logistic regression analyses and generalized multifactor dimensionality reduction (GMDR) analyses, respectively.

Results:

Two alleles (rs1049255*C and rs841*A) were identified that were significantly associated with increased risk of CHD after adjusting for all confounders (OR=1.21, 95% CI: 1.06−1.39, combined P=0.001, P_corr=0.007 and OR=1.30, 95% CI 1.12−1.50, combined P<0.001, P_corr<0.001, respectively). Significant two-way SNP–SNP interactions were found between SNP rs2297518 and these two significant polymorphisms, affecting the risk of CHD (P<0.001 for both). No significant high-order interactions were identified.

Conclusion:

The results suggested that two-way SNP–SNP interactions of polymorphisms within NO biosynthesis pathway genes contribute to CHD risk.     

Lack of effect of genetic polymorphisms of SLCO1B1 on the lipid-lowering response to pitavastatin in Chinese patients

Aim:

To investigate the SLCO1B1 388A>G and 521T>C polymorphisms in hyperlipidemia patients and evaluate the effect of the two polymorphisms on the lipid-lowering efficacy of pitavastatin.

Methods:

The functional polymorphisms of SLCO1B1 (388A>G and 521T>C) were genotyped in 140 Chinese patients with essential hyperlipidemia using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and one-step tetra-primers ARMS-PCR. Eighty-five patients were enrolled in the clinical trial and given 2 mg of pitavastatin daily for 8 weeks. Total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) serum levels were measured at baseline, after 4 weeks and after 8 weeks of treatment.

Results:

The allele frequencies of SLCO1B1 388A>G and 521T>C in essential hyperlipidemia patients were 71.1% and 11.1%, respectively. The 4- and 8-week treatment with pitavastatin significantly reduced TC, TG, and LDL levels, but there was no statistical difference among patients with wild type, SLCO1B1 388A>G or SLCO1B1 521T>C in the lipid-lowering efficacy of pitavastatin.

Conclusion:

The present study found that the allele frequencies of SLCO1B1 388A>G and 521T>C in Chinese patients with essential hyperlipidemia are comparable to those in healthy Chinese population. SLCO1B1 388A>G and 521T>C do not affect the lipid-lowering efficacy of pitavastatin.     

Pulse pressure amplification in relation to body fatness

AIMS

Arterial pressure transfer to the periphery is accompanied by pulse pressure amplification (PPA). Pulse pressure is influence by body fat. The purpose of the present study was to evaluate any possible inter-relation between body fatness and PPA in healthy subjects.

METHODS

Haemodynamic and wave reflection indices were estimated by pulse wave analysis. Body fat was measured by bio-impedance.

RESULTS

A total of 367 healthy volunteers (136 men and 231 women) was studied. Pulse pressure amplification correlated significantly with percentage of body fat (r = −0.53, P < 0.0001), age (r = −0.62, P < 0.0001), height (r = 0.43, P < 0.0001), heart rate (r = 0.28, P < 0.0001) and mean blood pressure (r = −0.29, P < 0.0001). The association of PPA with body fat was also significant in a multiple linear regression model. Age was an independent predictor of PPA and analysis of study subjects subdivided into two groups, those <50 years and those >50 years showed that body fatness correlated inversely and significantly with PPA in individuals both younger and older than 50 years (r = −0.44, P < 0.0001, r = −0.37, P < 0.0001 respectively). Augmentation pressure was also associated significantly with percentage of body fat in both subgroups (r = 0.48, P < 0.0001 and r = 0.49, P < 0.0001 respectively).

CONCLUSIONS

This study performed on healthy subjects showed that pulse pressure amplification is related to body fatness over a wide age range. Percentage body fat is significantly associated with augmentation pressure, a component of central pulse pressure.     

Paradoxical relationship between RAVE （relative activity versus endocytosis） values of several opioid receptor agonists and their liability to cause dependence

Aim:

To examine the relationship between the RAVE (relative activity versus endocytosis) values of opiate agonists and their dependence liability by studying several potent analgesics with special profiles in the development of physical and psychological dependence.

Methods:

The effects of (−)-cis-(3R,4S,2′R) ohmefentanyl (F9202), (+)-cis-(3R,4S,2′S) ohmefentanyl (F9204), dihydroetorphine (DHE) and morphine on [³⁵S]GTPγS binding, forskolin-stimulated cAMP accumulation, and receptor internalization were studied in CHO cells stably expressing HA-tagged μ-opioid receptors (CHO-HA-MOR). cAMP overshoot in response to the withdrawal of these compound treatments was also tested.

Results:

All four agonists exhibited the same rank order of activity in stimulation of [³⁵S]GTPγS binding, inhibition of adenylyl cyclase (AC) and induction of receptor internalization: DHE>F9204>F9202>morphine. Based on these findings and the previous in vivo analgesic data obtained from our and other laboratories, the RAVE values of the four agonists were calculated. The rank order of RAVE values was morphine>F9202>F9204>DHE. For the induction of cAMP overshoot, the rank order was F9202≥morphine>F9204≥DHE.

Conclusion:

Taken in combination with previous findings of these compounds'' liability to develop dependence, the present study suggests that the agonist with the highest RAVE value seems to have a relatively greater liability to develop psychological dependence relative to the agonist with the lowest RAVE value. However, the RAVE values of these agonists are not correlated with their probability of developing physical dependence or inducing cAMP overshoot, a cellular hallmark of dependence.     

Association of serum omentin-1 levels with coronary artery disease

Aim:

Omentin-1, a novel adipokine expressed in visceral adipose tissue, is negatively correlated with insulin resistance and obesity. Decreased omentin-1 expression has been found in many chronic inflammatory diseases. However, the role of omentin-1 in coronary artery disease (CAD) has not been elucidated. The aim of the present study was to determine whether serum concentration of omentin-1 was independently associated with CAD.

Methods:

One hundred and fifty five patients with CAD were divided into two groups: acute coronary syndrome (ACS) and stable angina pectoris (SAP). A total of 52 healthy participants served as controls. Serum concentrations of omentin-1 and interleukin-6 (IL-6) were measured using ELISA. The association of omentin-1 with CAD and cardiovascular disease risk factors was evaluated.

Results:

Serum omentin-1 levels were lower in patients with ACS or SAP compared with controls (ACS, 113.08±61.43 ng/mL; SAP, 155.41±66.89 ng/mL; control, 254.00±72.9 ng/mL; P<0.01). Patients with ACS also had lower serum concentrations of omentin-1 compared with patients with SAP (P<0.01). Serum concentration of omentin-1 was negatively correlated with body mass index (r=−0.17, P<0.05) and serum IL-6 concentration (r=−0.19, P<0.05). Furthermore, multiple logistic regression analysis showed that serum omentin-1 concentrations were independently correlated with CAD.

Conclusion:

The findings suggest that serum concentrations of omentin-1 are related to CAD.     

Drug Burden Index and physical function in older Australian men

AIMS

This study evaluated the associations of physical performance and functional status measures with the Drug Burden Index in older Australian men. The Drug Burden Index is a measure of total exposure to anticholinergic and sedative medications that incorporates the principles of dose–response and maximal effect.

METHODS

A cross-sectional survey was performed on community-dwelling older men enrolled in The Concord Health and Ageing in Men Project, Sydney, Australia. Outcomes included chair stands, walking speed over 6 m, 20-cm narrow walk speed, balance, grip strength and Instrumental Activities of Daily Living score (IADLs).

RESULTS

The study population consisted of 1705 men (age 76.9 ± 5.5 years). Of the 1527 (90%) participants who reported taking medications, 21% were exposed to anticholinergic and 13% to sedative drugs. The average Drug Burden Index in the study population was 0.18 ± 0.35. After adjusting for confounders (sociodemographics, comorbidities, cognitive impairment, depression), Drug Burden Index was associated with slower walking speed (P < 0.05), slower narrow walk speed (P < 0.05), balance difficulty (P < 0.01), grip weakness (P < 0.01) and poorer performance on IADLs (P < 0.05). Associations with physical performance and function were stronger for the sedative than for the anticholinergic component of the Drug Burden Index.

CONCLUSIONS

Higher Drug Burden Index is associated with poorer physical performance and functional status in community-dwelling older Australian men. The Drug Burden Index has broad applicability as a tool for assessing the impact of medications on functions that determine independence in older people.