Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK

Aims Polypharmacy is increasingly common in older adults, placing them at risk of medication-related harm (MRH). Patients are particularly vulnerable to problems with their medications in the period following hospital discharge due to medication changes, and poor information transfer between hospital and primary care. The aim of this study was to investigate the incidence, severity, preventablitiy and cost of medication-relate harm (MRH) in older adults in England post-discharge. Methods An observational multicentre prospective cohort study recruited 1280 older adults (median age 82 years) from five teaching hospitals in Southern England, UK. Participants were followed up for eight weeks by senior pharmacists, using 3 data sources (hospital readmission review, participant telephone interview and primary care records), to identify MRH and associate health service utilisation. Results Four hundred and thirteen participants (37%) experienced MRH (556 MRH events per 1000 discharges). Three hundred and thirty-six (81%) cases were serious, and 214 (52%) potentially preventable. Four participants experienced fatal MRH. The most common MRH events were gastrointestinal (n=158, 25%) and neurological (n=111, 18%). Medicine classes associate with the highest risk of MRH were opiates, antibiotics, and benzodiazepines. Three hundred and twenty-eight (79%) participants with MRH sought healthcare over the eight-week follow-up. The incidence of MRH associated hospital readmission was 78 per 10000 discharges. Post-dischare MRH in older adults is estimated to cost the National Health Service £396 million annually, f which £243 million is potentially preventable. Conclusions MRH is common in older adults following hospital discharge, and results in substantial use of healthcare resources

Prescribing indicators at primary health care centers within the WHO African region: a systematic analysis (1995-2015)

Abstract Background Rational medicine use is essential to optimize quality of healthcare delivery and resource utilization. We aim to conduct a systematic review of changes in prescribing patterns in the WHO African region and comparison with WHO indicators in two time periods 1995–2005 and 2006–2015. Methods Systematic searches were conducted in PubMed, Scopus, Web of science, Africa-Wide Nipad, Africa Journals Online (AJOL), Google scholar and International Network for Rational Use of Drugs (INRUD) Bibliography databases to identify primary studies reporting prescribing indicators at primary healthcare centres (PHCs) in Africa. This was supplemented by a manual search of retrieved references. We assessed the quality of studies using a 14-point scoring system modified from the Downs and Black checklist with inclusions of recommendations in the WHO guidelines. Results Forty-three studies conducted in 11 African countries were included in the overall analysis. These studies presented prescribing indicators based on a total 141,323 patient encounters across 572 primary care facilities. The results of prescribing indicators were determined as follows; average number of medicines prescribed per patient encounter = 3.1 (IQR 2.3–4.8), percentage of medicines prescribed by generic name =68.0 % (IQR 55.4–80.3), Percentage of encounters with antibiotic prescribed =46.8 % (IQR 33.7–62.8), percentage of encounters with injection prescribed =25.0 % (IQR 18.7–39.5) and the percentage of medicines prescribed from essential medicines list =88.0 % (IQR 76.3–94.1). Prescribing indicators were generally worse in private compared with public facilities. Analysis of prescribing across two time points 1995–2005 and 2006–2015 showed no consistent trends. Conclusions Prescribing indicators for the African region deviate significantly from the WHO reference targets. Increased collaborative efforts are urgently needed to improve medicine prescribing practices in Africa with the aim of enhancing the optimal utilization of scarce resources and averting negative health consequences

Drug utilization patterns in the global context: A systematic review

Objectives Standard drug use indicators have been developed by the World Health Organization/International Network for Rational Use of Drugs (WHO/INRUD). The purpose of this systematic review was to examine and report the current status of health facilities in different regions of the world in terms of drug use based on WHO/INRUD core drug use indicators. Design Systematic review of the literature following PRISMA guidelines. Methods The INRUD bibliography, WHO archives, Google Scholar, Medline, PubMed, SpringerLink, ScienceDirect and Management Sciences for Health (MSH) resource databases were searched between 1985 and 2015 for studies -containing 12 WHO/INRUD core drug use indicators. Secondary data sources were also searched. Results Four hundred and sixty three studies were retrieved and 398 were excluded as they did not provide relevant information or fulfill the selection criteria. Sixty articles met the criteria and were selected for final review. With respect to prescribing indicators, studies of “drug use” showed mixed patterns across geographic regions. Overall trends in “patient-care” and “facility-specific” indicators were similar across most of the World Bank regions. However, based on the Index of Rational Drug Use (IRDU) values, East Asia and the Pacific region demonstrated relatively better drug use practices compared with other regions. Conclusions This systematic review revealed that the drug use practices in all regions of the world are suboptimal. A regulated, multi-disciplinary, national body with adequate funding provided by governments throughout the world are a basic requirement for coordination of activities and services, to improve the rational use of drugs at a local level

Die Funktion von Laktat bei synaptischer Übertragung, die Regenerierung von Ionen Gradienten und der Erhalt von epilepsieartigen Aktivitäten im Hippocampus der Ratte und humanen neokortikalen Schnitten

Under normal conditions brain energy metabolism relies almost exclusively on the oxidative metabolism of glucose. Lactate, derived from glycolytic metabolism of glial cells, has been speculated to serve as an alternative substrate under specific circumstances. Indeed, lactate was shown to support synaptic transmission, neuronal plasticity and memory consolidation even in the presence of ample glucose. In addition, lactate may also modulate neuronal activity through its own hydroxycarboxylic acid receptor 1 (HCA1). Even though activity dependent extracellular lactate increases are long known, their contribution to neuronal excitability and maintenance of transmembrane ion gradients has barely been studied. Lactate exchange between brain cells and across the blood-brain-barrier is mediated via hemichannels, ion channels and monocarboxylate transporters (MCT 1-4). In chronic epileptic tissue, the expression of MCT1 is reduced on endothelial cells and upregulated on astrocytes, which is in favor of increased extracellular lactate accumulation and impaired clearance to the circulation. Whether this process is pro or anti-ictogenic (due to metabolic support or lactic acidosis, respectively) is currently not known. Here, I determined the contribution of lactate derived ATP to synaptic signaling, ion recovery kinetics and maintenance of pathological network activity in rat hippocampal slices as well as in chronic epileptic tissue resected from patients with temporal lobe epilepsy (TLE). Stimulus induced changes in field potential, extracellular K+, Na+, Ca2+, H+ concentration as well as tissue oxygen level (pO2) were determined in layer V/VI of human neocortex, and rat medial entorhinal cortex (MEC) and hippocampus slices in the presence or absence of the MCT blockers alpha- cyano-4-hydroxycinnamic acid (4-CIN) or D-lactate. Application of 4-CIN reduced stimulus induced oxygen consumption and synaptic transmission and prolonged ion transient recovery time. The effect on synaptic transmission was partly mediated by activation of KATP channels which hyperpolarize neurons during state of ATP depletion, whereas the contribution of HCA1 receptors could be excluded. On the contrary, despite supporting oxidative energy metabolism, lactate uptake inhibitors did not affect field potential responses or decay kinetics of extracellular K+ in chronic epileptic tissue. MCT inhibitors reduced the incidence and duration/amplitude of seizure-like events (SLEs) in rat MEC and in human neocortical slices. The anti-seizure effect of lactate uptake inhibitors was mediated by adenosine A1 receptor and not by changes in pH. In conclusion, lactate contributes to oxidative metabolism and supports synaptic transmission and recovery of ion gradients changes in healthy tissue while it maintains SLEs in pathologic states.Die Energieversorgung des Gehirns beruht unter physiologischen Bedingungen beinahe ausschließlich auf oxidativem Metabolismus von Glukose. Laktat, aus dem anaeroben Metabolismus der Gliazellen, kann unter speziellen Umständen als alternatives Substrat dienen. Tatsächlich wurde nachgewiesen, dass Laktat als Substrat des Energiemetabolismus, die synaptische Übertragung stützen kann, und zudem an neuronaler Plastizität beteiligt und für die Konsolidierung von Gedächtnisinhalten notwendig ist. Zusätzlich kann Laktat durch Aktivierung eines G-Protein gekoppelten Hydroxykarbonsäure-Rezeptors (HCA1) direkt Wirkung auf die neuronale Funktion ausüben. Obwohl der aktivitätsbedingte Anstieg der parenchymalen Laktatkonzentration schon sehr lange bekannt ist, ist die Rolle von Laktat für neuronale Erregbarkeit, sowie für die Wiederherstellung der transmembranären Ionengradienten weitestgehend unerforscht geblieben. Der Laktataustausch zwischen Gehirnzellen und der Blut-Hirn Schranke wird durch Ionenkanäle, Hemikanäle und Monokarboxysäuretransporters (MCT1-4) getragen. In chronisch epileptischem Gewebe wird MCT1 an Endothelzellen vermindert und an Astrozyten vermehrt exprimiert, was wiederum eine Laktatakkumulation im Gehirngewebe mit verringerter Abgabe in die Blutzirkulation zufolge hat. Ob diese Prozesse pro oder antiiktogen wirken (jeweils durch metabolische Unterstützung oder Laktacidose), ist zur Zeit noch nicht bekannt. In dieser Studie habe ich den Beitrag des Laktat-abhängigen Anteils der ATP Synthese zum Energiebedarf der synaptischer Übertragung, zur Aufrechterhaltung von transmembranären Ionengradienten und an pathologischer Netzwerkaktivität in hippokampalen Gehirnschnitten der Ratte und in chronisch epileptischen, kortikalen Gehirnschnitten von Temporallapenepilepsiepatienten untersucht. Stimulus induzierte Änderungen des Feldpotentials, der extrazellulären K+, Na+, Ca2+, H+ Konzentrationen und des Sauerstoffpartialdrucks wurden mit oder ohne Blockade des MCTs durch alpha-Cyano-4-hydroxyzimtsäure (4-CIN) oder D-Laktat gemessen. Die Gabe von 4-CIN führte zur Reduktion des Sauerstoffverbrauchs, zur Verringerung synaptischer Übertragung und Verlangsamung von extrazellulären Ionenänderungen. Der Effekt auf die synaptische Übertragung wurde zum Teil durch die Aktivierung der KATP Kanäle getragen, welche im Falle eines ATP-Mangels die Nervenzellen hyperpolarisieren, während der Beitrag von HCA1 Rezeptoren ausgeschlossen werden konnte. Im Gegensatz dazu, hat die Blockade der Laktat- aufnahme in chronisch epileptischem Gewebe weder die synaptische Übertragung noch die Wiederherstellung transmembranärer Ionengradienten beeinflusst, obwohl die Zellatmung eindeutig durch 4-CIN gehemmt wurde. Gleichzeitig haben die MCT Inhibitoren 4-CIN und D-Laktat jedoch die Inzidenz, Dauer und Amplitude der evozierten anfallsartigen Ereignisse in den kortikalen Gehirnschnitten der Ratte und der Epilepsiepatienten verringert. Diese antiiktogene Wirkung wurde durch die Aktivierung von Adenosinrezeptoren (A1) in Folge der verminderten ATP-Verfügbarkeit und nicht durch Laktazidose ausgelöst. Zusammenfassend konnte ich feststellen, dass Laktat einen wichtigen Beitrag zum Energiebedarf der synaptischen Übertragung und zur Wiederherstellung der Ionengradienten und zum Aufrechterhalten pathologischer anfallsartiger Aktivität leistet

Knowledge, Attitude and Practice of Adverse Drug Reaction Reporting among Health Professionals in Southwest Ethiopia

AIM: Adverse drug reaction is noxious and unwanted reaction to drugs at dose used in humans for diagnosis, treatment or prophylaxis. Adverse drug reaction monitoring is an area of drug information that has been given little attention yet. Spontaneous reporting is currently the major back bone for the detection of adverse drug reactions. The objective of this study was to assess the knowledge, attitude and practices of adverse drug reaction reporting among health professionals in selected health facilities in southwest Ethiopia. METHOD: A cross-sectional study design was used among health professionals in selected health facilities in January 2010. Prescribers other than physicians, junior pharmacy technicians and also health assistants were excluded. Data was collected using self administered questionnaires from volunteered physicians (Medical interns and above), nurses (Diploma and above) and Pharmacy professionals (Diploma and above) and analyzed using SPSS version 16.0. RESULTS: A total of 82 health professionals were participated in the study. From those 82 participants, only 19 (23.17%) and 21 (25.61%) knew the existence of national reporting system and a yellow card of adverse drug reaction reporting form. Thirteen (15.85%) participants encountered adverse drug reaction in the past 12 months in their clinical activities, but none of them reported to responsible body. Even though the participants’ knowledge and practice were inadequate, most of the respondents 47 (57.31%) agreed that adverse drug reaction reporting is part of duty of them and important to the public in general and to the patient in particular. CONCLUSION: There was no documentation and reporting of adverse drug reaction, which might partly be explained by lack of knowledge and misconceptions about spontaneous reporting. Our study strongly suggests that there is a great need to create awareness and to promote the reporting of adverse drug reaction amongst health professionals, which will lay a solid foundation for healthcare professionals to be diligently involved in quality pharmacovigilance and spontaneous reporting in their future practices. [TAF Prev Med Bull 2012; 11(4.000): 397-406

Antimicrobial Use-Related Problems and Predictors among Hospitalized Medical In-Patients in Southwest Ethiopia: Prospective Observational Study.

BACKGROUND:The spread of antimicrobial resistance in developing countries is associated with complex and interconnected factors, such as excessive and unnecessary prescribing of antimicrobials, increased self-prescribing by the people and poor quality of available antimicrobials. Moreover, the failure to implement infection control practices and the dearth of routine susceptibility testing and surveillance magnify the problems. This may spread the inappropriateness of prescribing, ending up with the spread of antimicrobial resistance. OBJECTIVE:The aim of this study was to assess antimicrobial use related problems and associated factors among patients admitted at Jimma University specialized hospital. METHODS:A hospital based prospective observational study design was employed at medical wards of Jimma University specialized hospital, Ethiopia. Data collected from patient medication charts and from the patients was analyzed using SPSS, version 16.0. Logistic regression was used to determine the associations between variables. Statistical significance was considered at p-value <0.05. RESULTS:Out of 152 study participants, at least one antimicrobial use problem was identified among 115(75.7%). Accordingly, additional antimicrobials were needed by 45(29.6%) of the patients, whereas they were unnecessary among 44(28.9%). Similarly, 17% of the patients were noncompliant to at least one antimicrobial therapy, while 8.6% experienced at least one type of adverse drug reaction. On the other hand, the coverage of the infectious medical condition in the national guidelines (AOR = 4.888) and the duration of hospital stay (AOR = 3.086) were the determinants of the antimicrobial use problems. CONCLUSION:Most of the antimicrobial use problems identified were related to delay of initiation of effective antimicrobials and excessive use; use without indication or using duplicates of broad spectrum antimicrobials or use for longer duration than recommended. The coverage of the infectious medical condition in the national treatment guidelines and the duration of hospital stay were the determinants of the antimicrobial use problems