Primary malignant melanoma of brainstem medulla mimicking as cavernoma

Aim of this case report is to present a rare case of primary malignant melanoma of brain stem at the region of medulla oblongata mimicking as cavernoma. 40-year-old male presented with vertigo, headache, dizziness for 1 month. MRI showed pear shaped T1 hyperintense lesion at medulla oblongata and predominantly hypointense on T2 with focal area of hemorrhage. Lesion showed diffuse enhancement on postcontrast images. On plain CT lesion was Hyperdense. It was initially reported as Cavernoma. Surgical excision of lesion was done with per-op findings of solid, dark maroon colored lesion with hemorrhage. Histopathology showed neoplastic lesion with abundant melanin pigment deposition. The lesion was finally diagnosed as Malignant neoplasm with features favoring Malignant Melanoma

Religious tourism and mass religious gatherings — the potential link in the spread of COVID-19. Current perspective and future implications

COVID-19 has exposed the fragility and preparedness of healthcare systems around the globe. Various countries have widely adopted preventive measures, such as social distancing, face masks, frequent hand wash/sanitizer and lock downs. The pandemic with shifting epicentres from Wuhan to Iran and Italy presents two relevant questions for any next outbreak or epicentre in future: a) How did COVID-19 travel from one country to another? b) To what extent are countries prepared in context of preventive measures in mass gatherings in future

A systematic review and meta-analysis of the impact of collaborative practice between community pharmacist and general practitioner on asthma management

Objective: To evaluate the impact of collaborative practice between community pharmacist (CP) and general physician (GP) in asthma management. Method: An extensive search was carried out in 10 databases (PubMed, Medline/Ovid, CINAHL, Scopus, Web of Science, Cochran central register of controlled trials, PsycARTICLES®, Science Direct, Education Resource Information Centre, PRO-Quest), and grey literature using selected MeSH and key words, such as '' community pharmacist'', ''general physician'' ''medicine use review''. After screening, 23 studies were used for evidence synthesis. The risk of bias was assessed by Cochrane risk of bias tool (EPOC). Studies were included only if there was a definite evidence of collaborative practice between CPs and GPs in management of asthma, such as CPs conducting medications reviews, or providing education and counselling. The studies need to report at least one of the outcomes which include clinical, humanistic, and economical. Results: A total of 23 studies (6 RCTs, 4 C-RCT, 3 controlled trials, 3 case control, and 7 pre-post) were included for meta-analysis. The collaboration between CP and GP has shown consistently improvements in: medication use, inhalation techniques, diseases knowledge, control of asthma, and quality of life However, clinical finding on lungs functions were not significantly improved. The collaboration was shown to be value for money, but the economic outcomes lacked RCT s designs and thus the evidence may not be considered as strong as it was for clinical and humanistic outcomes. Conclusion: The findings from this review established a strong evidence in approval of the positive impact of collaborative practice between CP and GP in the management of asthma

Level of agreement among various health care stakeholders on collaboration between community pharmacist (CP) and general practitioner (GP) for a ″collaborative medication therapy management″ (CMTM) model for chronic diseases (CDs) in Malaysia: a Delphi study

Objective: Current study is the first attempt to build consensus and appraise the level of agreement (or disagreement) among various health care stakeholders on the possibilities of a CMTM model for CDs in Malaysia through Delphi technique. Method: This Delph study was conducted as per the COSRT guidelines (Diamond 2014). Based on a systematic literature search, an online survey was designed on QuestionPro (an online survey tool). After face and content validity of the survey, an expert panel was constructed by inviting various health care stakeholders in different organizations and professional bodies which represent GPs, CPs, and Nurses, across Malaysia. Survey had 96 statements to rate using 5-point Likert scale (strongly agree to strongly disagree) and 36 ranking statements where experts were asked to rank in terms of feasibility of various aspects of the CMTM model. Consensus was pre-defined to be the point where >85% of the respondents falls in either agree or disagree category for each statement. Delphi operates in a reiterative fashion in rounds, where at the end of each round aggregate response (pooled opinion in the form of percent agreement among panel members) is presented to all experts and asked to reconsider their response in the light of the reasoning of other experts and aggregate response, if it appeals to them. This reiteration continues till there is a stability (no change) in the response of experts in two consecutive rounds. Response rate was 70.73% and 100% for 1st and 2nd round respectively. Results: The percentages, Median and IQR were calculated on the responses of experts at the end of the first round and it revealed that consensus was achieved on 105 statements and there was conflict over 27 statements. In round-2, 14 statements out of 27 conflicted statements reached the consensus after due considerations of the experts, while, 13 statements failed to stretch up to consensus. No further round was executed, as after round-2 stability in response of experts reached to 100% (Wilcoxon Signed Rank test). The inter-rater agreement was computed in both rounds using Intra-class correlation coefficient (ICC) (Two-way mixed model-absolute agreement, p < 0.001) that is interpreted to be in between good to excellent level of agreement. Further subgroup analysis based on profession (GP, CP, Nurses) was carried out using Kruskal Wallis H-test (p < 0.01), while differences in response based on experience and education were analyzed using Mann-Whitney U-test (p < 0.017). Conclusion: This study demonstrates a significant level of agreement among different health care professionals for a future role of CPs in CMTM model of CDs. Generally, there is a consensus to at least run a pilot trial of this CMTM model in major cities of Malaysia. It also highlights certain flash points where there were differences. However, study holds importance for policy makers, as the agreements or disagreements expressed in the survey may be utilized to foresee and generate guidelines, and strategies to lay the foundation of a CMTM model for CDs in Malaysi

Consensus among healthcare stakeholders on a collaborative medication therapy management model for chronic diseases in Malaysia; a Delphi study

1.1 Background The general problem is lack of inter-professional collaboration and the way private primary care responds to manage chronic diseases in Malaysia. Absence of prescription review, inadequate patient education, the highest percentage of prescribing errors and half of the chronic disease patients are nonadherent. Medicines are the most common and life long used interventions in chronic diseases. Hence, the need to manage medicine in chronic diseases becomes obligatory. As both general practitioner and community pharmacist can dispense medications, this has resulted in a business rivalry. There is a need to build consensus among various healthcare stakeholders for a collaborative medication therapy management model (CMTM) where community pharmacist has an active role in chronic care. 1.2 Method This study utilized modified e-Delphi method to build consensus. A validated e-Delphi survey was administered to a purposive sample of 29 experts. Consensus was pre-defined to be the point where >85% of the experts fall in either agree or strongly agree category for each statement. The inter-expert agreement was computed in both rounds using Intra-class correlation coefficient and Kendall's W. Delphi operates in an iterative fashion till there comes stability in responses. At the end of each round, experts were provided aggregate response, their own response and choice to change their response in the light of aggregate response. 1.3 Results Response rate was 70.73% and 100% in 1st and 2nd round, respectively. Consensus was achieved on 119/132 statements which mainly referred to the need, structural and regulatory aspects of CMTM model in Malaysia. However, there were some flashpoints on dispensing separation and means to finance this model. Stability in response of experts was achieved after 2nd round; hence, no next round was executed. 1.4 Conclusion Overall, the study findings witnessed the expert panel’s support for the CMTM model. Study helped to sketch CMTM model and facilitated development of some recommendations to the authorities which may help to formulate a policy to bring CPs under a working relationship with GPs. Hence, this study should be taken as a call for redefining of the roles of CPs and GPs in Malaysi

A systematic review and meta-analysis of the impact of collaborative practice between community pharmacist and general practitioner on asthma management

Objective: This systematic review aims to investigate the impact of collaborative practice between community pharmacist (CP) and general practitioner (GP) in asthma management. Methods: A systematic search was performed across 10 databases (PubMed, Medline/Ovid, CINAHL, Scopus, Web of Science, Cochrane central register of controlled trials, PsycARTICLES®, Science Direct, Education Resource Information Centre, PRO-Quest), and grey literature using selected MeSH and key words, such as '' community pharmacist'', ''general practitioner'' ''medicine use review''. The risk of bias of the included studies was assessed by Cochrane risk of bias tool. All studies reporting any of the clinical, humanistic, and economical outcomes using collaborative practice between CPs and GPs in management of asthma, such as CPs conducting medications reviews, patient referrals or providing education and counselling, were included. Results: A total of 23 studies (6 RCTs, 4 C-RCT, 3 controlled interventions, 7 pre-post and 3 case control) were included. In total, 11/14 outcomes were concluded in favor of CP-GP collaborative interventions with different magnitude of effect size. Outcomes, such as asthma severity, asthma control, asthma symptoms, PEFR, SABA usage, hospital visit, adherence and QoL (AQLQ, LWAQ) demonstrated a small effect size (d≥ 0.2) while, inhalation technique, ED visit and asthma knowledge witnessed medium ES (d≥ 0.5). In addition to that, inhalation technique yielded large ES (d≥ 0.8) in RCTs subgroup analysis. However, 3 outcomes, FEV, corticosteroids usage and preventer to reliever ratio did not hold significant ES (d< 0.2) and thus, remain inconclusive. The collaboration was shown to be value for money in the economic studies in narrative synthesis, however, limited number of studies hinder pooling of data in meta-analysis. Conclusion: The findings from this review established a comprehensive evidence base in support of the positive impact of collaborative practice between CP and GP in the management of asthma

A snapshot of the global policies and practices of medicine use reviews by community pharmacist in chronic diseases: a narrative review

Medicine use review is a tool to improve medication adherence and safety. Current narrative review was planned to explore global policies and practices of medicine use review by community pharmacists in chronic diseases and its impact and way forward for low- and middle-income countries. Key words, such as ″medicine use review″, ″medication therapy management″ and ″community pharmacy″ were used for search on PubMed and CINAHL databases for articles published from 2004 to 2019. Medicine use review has opened an avenue of ongoing collaboration between community pharmacists and general practitioners. High-income countries have witnessed a gradual yet cautious adoption of these services through effective policy shift. In terms of practices and impact, the situation in high-income countries was promising where on an average ″type-II″ medicine use review was widely in practice and had improved clinical, humanistic and economic outcomes in chronic disease. However, in low- and middle-income countries, a paucity of effective policies was noted. Nevertheless, an emergent recognition of the potential of community pharmacists to contribute to the management of chronic diseases was eviden