Ability to detect potentially inappropriate prescribing in older patients: comparative analysis between PIM-Check and STOPP/STARTv2.

Potentially inappropriate prescribing (PIP) is a source of preventable adverse drug events. The objective of this study was a comparative analysis (quantitative and qualitative) between two tools used to detect PIP, PIM-Check and STOPP/START. First, a qualitative analysis (QAC) was conducted to evaluate the concordance between the criteria, which constitute PIM-Check and the gold standard STOPP/START. Second, a retrospective comparative and observational study was performed on the list of treatment at the admission of 50 older patients hospitalized in an acute geriatric ward of a university hospital in Switzerland in 2016 using both tools. The QAC has shown that 50% (57 criteria) of STOPP/START criteria are fully or partially concordant with those of PIM-Check. The retrospective study was performed on 50 patients aged 87 years, suffering from 5 co-morbidities (min-max 1-11) and treated by of 8 drugs (min-max 2-16), as medians. The prevalence of the detected PIP was 80% by PIM-Check and 90% by STOPP/START. Medication review shows that 4.2 PIP per patient were detected by PIM-Check and 3.5 PIP by STOPP/START among which 1.9 PIP was commonly detected by both tools, as means. PIM-Check detected more PIP related to cardiology, angiology, nephrology, and endocrinology in older patients but missed the PIP related to geriatric syndromes (e.g., fall, dementia, Alzheimer) detected by STOPP/START. By using PIM-Check in geriatric settings, some PIP will not be detected. It is considered as a limitation for this tool in this frail population but brings a certain complementarity in other areas of therapy not covered by STOPP/START

Adverse drug events associated with vitamin K antagonists: factors of therapeutic imbalance

Nancy El-Helou, Amal Al-Hajje, Rola Ajrouche, Sanaa Awada, Samar Rachidi, Salam Zein, Pascale SalamehClinical and Epidemiological Research Laboratory, Faculty of Pharmacy, Lebanese University, Beirut, LebanonBackground: Adverse drug events (ADE) occur frequently during treatment with vitamin K antagonists (AVK) and contribute to increase hemorrhagic risks.Methods: A retrospective study was conducted over a period of 2 years. Patients treated with AVK and admitted to the emergency room of a tertiary care hospital in Beirut were included. The aim of the study was to identify ADE characterized by a high international normalized ratio (INR) and to determine the predictive factors responsible for these events. Statistical analysis was performed with the SPSS statistical package.Results: We included 148 patients. Sixty-seven patients (47.3%) with an INR above the therapeutic range were identified as cases. The control group consisted of 81 patients (54.7%) with an INR within the therapeutic range. Hemorrhagic complications were observed in 53.7% of cases versus 6.2% of controls (P < 0.0001). No significant difference was noticed between cases and controls regarding the indication and the dose of AVK. Patients aged over 75 years were more likely to present an INR above the therapeutic range (58.2%, P = 0.049). Recent infection was present in 40.3% of cases versus 6.2% of controls (P < 0.0001) and hypoalbuminemia in 37.3% of cases versus 6.1% of controls (P < 0.0001). Treatment with antibiotics, amiodarone, and anti-inflammatory drugs were also factors of imbalance (P < 0.0001).Conclusion: Many factors may be associated with ADE related to AVK. Monitoring of INR and its stabilization in the therapeutic range are important for preventing these events.Keywords: adverse drug events, vitamin K antagonists, bleeding risks, therapeutic imbalanc

Knowledge of pharmacists and parents towards antibiotic use in pediatrics: a cross-sectional study in Lebanon

Objectives: to assess the knowledge of both parents and community pharmacists regarding antibiotics use and resistance in pediatrics in Lebanon. Methods: A cross-sectional study was conducted between June and August 2017 in community pharmacies. A pre-established questionnaire targeting knowledge of parents and pharmacists regarding antibiotics use/misuse was carried out. An index of knowledge was computed to assess factors associated with good knowledge on antibiotics use/misuse. Results: The study showed that 28.7% of pharmacists did not know which factors may contribute to antimicrobial resistance. Concerning the misuse of antibiotics, pharmacists blamed at first parents (90.1%), at second level physicians (72.8%), and third themselves (59.4%). Furthermore, pharmacists believed that the socioeconomic problems of the country (86.1%), the level of resistance to the molecule of choice (80.8%), the lack of consultation time (71.2%) and the lack of national guidelines/recommendations (66.3%) might be additional factors contributing to antimicrobial resistance. In case of acute otitis media, the majority of pharmacists chose the correct treatment, dose and duration according to international guidelines; this was in contrast to the results obtained in case of pharyngitis. Female pharmacists had a significantly higher knowledge score compared to their male counterparts (ORa=2.51). Half of parents (42.6%) declared that antibiotics act against both viruses and bacteria, 55.9% still believe that the presence of fever requires the administration of antibiotics, 50% didn’t know the consequences of antibiotics misuse, 58.4% said that it is okay to give their child antibiotics without a physician's advice or based on a pharmacist’s recommendation, and 66.7% trusted the pharmacist in the antibiotic prescription. Parents with a university level of education or a master’s degree had significantly better knowledge compared to illiterate ones (ORa=9.04 and ORa=16.46, respectively). Conclusions: Based on the results obtained, it would be necessary to implement educational campaigns in order to increase awareness on antibiotics misuse and resistance in pediatrics

Evaluation of medication adherence among Lebanese diabetic patients

Background: Diabetes type 2 is considered one of the main public health concerns. Lack of adherence to treatment leads to poor therapeutic outcome, poor glycemic control, and high risk for developing diabetes complications. Objectives: The aim of this study is to evaluate adherence to oral antidiabetic medication in Diabetes type 2 Lebanese patients, and to evaluate factors leading to low adherence. Methods: A cross-sectional study was conducted in outpatients endocrinology clinics of two hospitals and four private clinics located in Beirut-Lebanon. Data was collected using a well-structured questionnaire by trained pharmacists. Adherence level was measured by the Lebanese Medication Adherence Scale (LMAS-14). Bivariate and multivariate analyses were conducted using SPSS version 20. Results: Overall, 245 patients were included in the study with the majority being females (54.3%) and obese (47.8%). Only 29% of the participants had controlled glycemia (HbA1c <7%) with 31.8% of subjects had high adherence to their medication compared to 68.2% with low adherence. Increased working hours/day was associated with a decrease in adherence to oral antidiabetic medication (OR=0.31; 95% CI 0.11:0.88; p=0.029). Other factors significantly associated with decreased adherence to treatment were forgetfulness, high drug costs, complex treatment regimens, experiencing side effects, and perception of treatment inefficacy. Postponing physician office visits also decreased the probability of being adherent to oral antidiabetic medication (OR=0.36; 95% CI 0.15:0.86; p=0.022). Skipping or doubling the dose in case of hypo/hyperglycemia and the sensation of treatment burden also decreased medication adherence (OR=0.09; 95% CI 0.02:0.34; p=0.001, and OR=0.04; 95% CI 0.01:0.13; p<0.001 respectively). Conclusions: Adherence to oral antidiabetic medication is low for Lebanese patients, which leads to a poor glycemic control and increases the diabetes complications. Intervention programs including patient education strategies are essential to improve medication adherence

Visualization and suppression of interfacial recombination for high-efficiency large-area pin perovskite solar cells

The performance of perovskite solar cells is predominantly limited by non-radiative recombination, either through trap-assisted recombination in the absorber layer or via minority carrier recombination at the perovskite/transport layer interfaces. Here, we use transient and absolute photoluminescence imaging to visualize all non-radiative recombination pathways in planar pin-type perovskite solar cells with undoped organic charge transport layers. We find significant quasi-Fermi-level splitting losses (135 meV) in the perovskite bulk, whereas interfacial recombination results in an additional free energy loss of 80 meV at each individual interface, which limits the open-circuit voltage (V) of the complete cell to ~1.12 V. Inserting ultrathin interlayers between the perovskite and transport layers leads to a substantial reduction of these interfacial losses at both the p and n contacts. Using this knowledge and approach, we demonstrate reproducible dopant-free 1 cm perovskite solar cells surpassing 20% efficiency (19.83% certified) with stabilized power output, a high V (1.17 V) and record fill factor (>81%)

Clinical and economic impacts of explicit tools detecting prescribing errors: A systematic review.

Many explicit tools have been developed to reduce prescribing errors and ensure patients' safety. The impact of explicit tools is not well studied. The objective of this study was (a) to conduct a systematic review of systematic reviews listing explicit tools developed to detect prescribing errors and (b) to assess their impact on clinical and economic outcomes. This project includes two related parts. First, a systematic review of systematic reviews listing explicit tools dedicated to geriatrics or internal medicine was performed to develop an exhaustive list of explicit tools. Then, using the list compiled in the first step, a systematic review of randomized controlled trials (RCT) assessing clinical or economic impacts of tools was performed to evaluate their usefulness. The systematic review of systematic reviews identified 49 explicit tools. The systematic review of RCT, using one or more of the 49 explicit tools, identified 5 RCT using explicit tools as intervention (3 STOPP/START and 2 FORTA RCT). The 5 studies evaluated clinical impacts with 3 RCT identifying significant clinical impacts (falls, activities of daily living and/or adverse drug reactions) and 2 STOPP/START RCT identifying significant economic impacts. The systematic review of RCT showed that explicit tools can have some effect in improving patients' safety. Further studies are warranted to better characterize their clinical and economic impact

Impact of Pharmaceutical Interventions with STOPP/START and PIM-Check in Older Hospitalized Patients: A Randomized Controlled Trial.

Pharmaceutical interventions can reduce negative outcomes related to potentially inappropriate prescriptions (PIPs). The objective of this study was to compare the impact of interventions on the reduction of PIPs and on different clinical outcomes using two electronic explicit tools. A randomized controlled trial was conducted in patients hospitalized between 2018 and 2019 at the Acute Care for Elders unit at Lausanne University Hospital in Switzerland. A medication review was conducted using PIM-Check in the first arm and STOPP/START in the second arm. Proposed interventions were communicated to the physicians. Clinical outcomes evaluated were incidence of falls, delirium, activities of daily living (ADL), length of stay, number of drugs at discharge and hospital readmission. The 123 included patients (60 in the first arm and 63 in the second arm) were 86.3 ± 6.6 years old, had 3.5 ± 1.7 diseases and were treated by 6.2 ± 2.7 drugs at admission. There was a significant decrease in PIPs in each arm, but no significant difference between arms. The deprescription of nervous system drugs was significantly higher with STOPP/START than with PIM-Check (Chi-square p = 0.025). ADL scores between home and discharge were significantly higher in the STOPP/START arm than in the PIM-Check arm (4.42 vs 3.77; p = 0.040). The predictors of ADL score improvement were the deprescription of nervous system drugs (β = 0.423; 95% CI 0.034-0.812; p = 0.033), the use of STOPP/START (β = 0.798, 95% CI 0.305-1.290; p = 0.002) and a shorter length of hospital stay (β = -0.033, 95% CI - 0.056 to - 0.010; p = 0.005). Although PIM-Check was non-inferior to STOPP/START in reducing the number of PIPs, STOPP/START had a significantly higher impact on ADL. The use of STOPP/START or the deprescription of two nervous system drugs would allow the patient to acquire almost one more basic function of living. On the other hand, a loss of one point on the ADL score was observed per month of hospitalization. NCT04028583

Impact of Pharmaceutical Interventions in Hospitalized Patients: A Comparative Study Between Clinical Pharmacists and an Explicit Criteria-Based Tool.

It has been well recognized that pharmaceutical interventions (PIs) can prevent patient harm related to prescribing errors. Various tools have been developed to facilitate the detection and the reduction of inappropriate prescriptions and some have shown benefit on clinical outcomes. The objective of this study was to evaluate the clinical, economical, and organizational impact of interventions generated by clinical pharmacists in hospitalized patients, and to evaluate the performance of an explicit tool, the Potentially Inappropriate Medication Checklist for Patients in Internal Medicine (PIM-Check), in detecting each pharmacist's intervention. A cohort retrospective study was conducted on hospitalized patients. The impact of PIs based on pharmacists' standard examination was evaluated using the Clinical, Economic, and Organizational (CLEO) tool. The performance of PIM-Check in detecting each intervention was assessed by conducting a retrospective medication review based on available information collected from patients' records. A qualitative analysis was also conducted to identify the types of PIs that PIM-Check failed to detect. The study was performed on 162 patients with a median age of 68 years (interquartile range = 46-77 years) and a median hospital stay of 5 days (interquartile range = 4-7 days). The pharmacists generated 1.9 PIs per patient (n = 304) of which 31% were detected by PIM-Check. The acceptance rate of the interventions by physicians was 84% (n = 255). Among the accepted interventions, 53% (n = 136) had a clinical impact graded CL ≥ 2C (moderate or major), whereas the majority of them were not detected by PIM-Check (63%; 86 out of 136). In addition, 46% of accepted interventions (n = 117) were associated with a cost decrease, among which 62% were not detected by PIM-Check (73 out of 117). The qualitative analysis shows that PIM-Check mostly failed to detect PIs related to dose adjustment, overprescribing, and therapy monitoring. According to the CLEO tool evaluation of PIs, our results show that clinical pharmacists' interventions are associated with improved clinical outcomes. In comparison with pharmacists' interventions, PIM-Check failed in detecting the majority of interventions associated with a moderate or major impact

Risky substance exposure during pregnancy: a pilot study from Lebanese mothers

Samar Rachidi,1 Sanaa Awada,1 Amal Al-Hajje,1 Wafaa Bawab,1 Salam Zein,1 Nadine Saleh,1,2 Pascale Salameh1,21Laboratory of Epidemiological and Clinical Research, Lebanese University, Beirut, Lebanon; 2Faculty of Public Health Labanese University, Beirut, LebanonBackground: The harmful effects of medication and licit substance use during pregnancy may potentially constitute a major public health concern. Our study aims to assess risky exposure of Lebanese pregnant women to drugs, tobacco, caffeine, and alcohol, and to determine their effect on postnatal outcomes.Methods: Women at term were addressed after delivery in five university hospitals of Beirut and Mount Lebanon between February and June 2012. A standardized questionnaire was administered to them. Moreover, medical files of both mothers and their respective newborns were checked to confirm information given by mothers, and to assess the health outcome of the babies.Results: Among the interviewed 350 women, active and passive smoking of tobacco (cigarette or water pipe), and consumption of category C, D, and X drugs were common during pregnancy in Lebanon; they were shown to negatively affect the neonatal outcome in multivariate analyses: they significantly decreased Apgar scores and increased the risk of underweight and medical complications of babies (P < 0.05).Conclusion: Our study demonstrated that Lebanese women were exposed during pregnancy to multiple medications and licit substances that affected the neonates&#39; health. Our findings have implications for clinical obstetric practice and prevention programs in Lebanon. Efforts should be made to decrease exposure to harmful substances during pregnancy.Keywords: pregnancy, smoking, cigarette, water pipe, caffeine, alcohol, drugs, Apgar scor

Barriers to Access Multiple Sclerosis Disease-Modifying Therapies in Middle East and North Africa: A Regional Survey-Based Study

International audienceMultiple sclerosis (MS) management varies markedly between different countries of the Middle East and North Africa (MENA) region based on disease-modifying therapies (DMTs) availability, accessibility, and reimbursement. In general, introduction of novel DMTs in most MENA countries is usually delayed, as drug approval can take several months to years once approved for use by the Food and Drug Administration (FDA) or European Medicines Agency (EMA), depending on the country. To our knowledge, there are no published studies assessing the accessibility to DMTs across different countries of the region