Health care and pharmacy practice in Jordan

Jordan is an Arab country located in the north of the Arabian Peninsula, west of Asia.1 It occupies an area of about 92 000 km2, with an estimated total population of about 9.5 million, most of whom reside in the capital, Amman. Jordan is renowned for its high-quality health care services and is considered one of the major destinations for medical tourism in the Middle East and North Africa region. This paper aims to describe current health care and pharmacy practice in Jordan. It is part of a series of invited papers on health care systems in countries around the world. The paper is structured according to the building blocks outlined in the World Health Organization’s Health Systems Framework

A program to increase research productivity among hospital pharmacists

Objective: To describe the development, implementation, and outcomes of a structured research training program that aimed to increase the research productivity among hospital pharmacists. Methods: The program was conducted in a step-wise approach and started with educational sessions on evidence-based medicine and research methods. After about a year, pharmacists were trained and mentored on how to conduct and publish a research project. We evaluated the number of research projects and publications for the pharmacy department before and after the implementation of the program. Results: In the 5 years prior to implementing the program, there were a total of 4 institutional review board (IRB) proposals, 4 abstracts, and 2 manuscripts, which had pharmacists as primary investigators. After 5 years of running the program, there were 24 pharmacist-initiated research proposals submitted to the IRB, 29 abstracts, and 11 published manuscripts. The major challenges were the lack of sufficient time and the extensive training and mentorship required. Conclusion: Implementing a structured pharmacy research program at a hospital setting was feasible and was associated with an increase in the pharmacist-led research and publications. The success of such a program requires training and mentorship, strong commitment, and administrative support

Augmented renal clearance in critically ill patients with cancer (ARCCAN Study): A prospective observational study evaluating prevalence and risk factors

Abstract Augmented renal clearance (ARC) is a phenomenon that has been associated with enhanced excretion of renally eliminated drugs, such as antimicrobials, which may result in subtherapeutic levels and potentially therapeutic failure. There has been limited data on ARC in critically ill patients with cancer. This study aimed to evaluate the prevalence of ARC and to identify risk factors associated with ARC in this patient population. This was a prospective study at an oncologic intensive care unit (ICU) which included adult patients with normal renal function, defined as serum creatinine ≤1 mg/dl and urine output >0.5 ml/kg/hr. The 24‐hour creatinine clearance (ClCr) study was used to determine ClCr, starting on day 1 of ICU admission, for 5 days or until ICU transfer or death. ARC was defined as ClCr >130 ml/min/1.73 m2. Univariate and multivariate logistic regression analyses were performed to identify risk factors for ARC. Over the study period, 363 patients were enrolled who completed an average of 2.8 ± 1.5(SD) days in the study and contributed 977 ClCr measurements. The mean age was 52 ± 16(SD) years old, the majority had solid tumors (n = 264, 73%), mean APACHE II was 21 ± 8(SD), and the major admission diagnosis was respiratory failure (n = 165, 45%). ARC was reported in 116 (32%) patients on at least one of the study days. Over the study period, the incidence of ARC ranged between 15.6% and 24.3%. Age was the only risk factor significantly associated with ARC (OR 1.028, 95% CI 1.005–1.051)

Evaluating the Published Critical Care Research from the World Health Organization Eastern Mediterranean Region

Abstract Objectives Evaluation of published research in a region provides insight into relevant aspects of clinical care and research priorities. This study aimed to provide a comprehensive assessment of the type of critical care research published in the World Health Organization Eastern Mediterranean region (EMR) over a 10-year period. Results During the study period (2007–2016), the search strategy revealed 4303 publications, of which 1537 were included in the analysis; studies were excluded for the following reasons: not critical care, conducted in non-EMR countries, editorials, case reports, in-vitro or animal studies, as well as those conducted in multiple countries and those that evaluated foreign military personal. Countries varied in the number of publications produced, ranging from none in Somalia to 620 in Iran. The majority of the studies were observational (78%), evaluated adults (73%), and the most common areas of research were infectious (29%) and respiratory (10%) diseases. Median sample size was 120 and the mean (SD) impact factor of the journals in which the articles were published was 1.02 (0.7)

Fixed-dose combination associated with faster time to smear conversion compared to separate tablets of anti-tuberculosis drugs in patients with poorly controlled diabetes and pulmonary tuberculosis in Qatar

Abstract Background Diabetes is associated with increased risk of tuberculosis (TB) treatment failure, death, and relapse compared to patients without diabetes. Current TB regimens are available as fixed dose combination (FDC) and separate tablets (ST), in which using the former is purported to make it easier to adhere and complete treatment. So far there are no studies assessing the performance of FDC compared to ST in diabetic patients with pulmonary TB. Methodology A retrospective cohort study was conducted, and included eight hospitals in Qatar in which patients diagnosed with pulmonary TB received rifampin, isoniazid, pyrazinamide, and ethambutol (as FDC or ST) given as directly observed therapy. Sputum smears for acid fast bacilli were tested weekly. We included patients admitted between December 2012 and December 2015, ≥18 years old, diagnosed with TB with pretreatment positive sputum smears, and having diabetes. Patients with Mycobacterium tuberculosis that was resistant to any first-line drug were excluded. Blood glucose was monitored closely and controlled to < 180 md/dL using oral hypoglycemic agents and/or insulin. We assessed the effectiveness of TB regimens by comparing time to confirmed negative smears between those treated with FDC or ST, and the impact of adding metformin. Results 103 patients met inclusion criteria. Mean age and body mass index were 45.6 ± 9.1 years and 22.1 ± 3.6 kg/m2, respectively. Fifty-four (52%) patients received the FDC. There was no difference between groups in baseline characteristics and sputum bacillary loads. Patients prescribed FDC showed faster times to sputum smear conversion compared to ST (32 ± 19 vs. 46 ± 31 days, p = 0.01). The difference was greater among patients with pretreatment bacillary load of 3+ (FDC 36.6 ± 19.5 vs. ST 56.1 ± 28.8, p = 0.008). Receipt of metformin≥2000 mg/day altered the difference in time to smear conversion (FDC 30.7 ± 13.4 vs. ST 62 ± 35.5, p = 0.016), which was of greatest difference in those with pretreatment bacillary load 3+ and who received metformin≥2000 mg/day (FDC 36 ± 12.1 vs. ST 92.2 ± 26 days, p = 0.001). Conclusion Patients with diabetes and prescribed FDC showed faster smear conversion during treatment for pulmonary TB compared to ST which was more pronounced in those with 3+ bacillary load pretreatment and which appeared to be modified by higher dose metformin

EFFECT OF NEBULIZED COLISTIN ON THE VENTILATOR CIRCUIT: A PROSPECTIVE PILOT CASE-CONTROL STUDY FROM A SINGLE CANCER CENTER

Nebulized colistin (NC) is used for the treatment of pneumonia due to multidrug-resistant Gram-negative bacteria. In this one-year case-control study, our objective was to evaluate the effect of NC on the ventilator circuit (VC) components. The case group consisted of 25 mechanically-ventilated patients who received NC, while the control group was 25 mechanically-ventilated patients who did not receive NC. Respiratory therapists inspected the VC every 4 hrs and whenever a ventilator alarm was reported. The VC component was changed if the alarm did not subside after necessary measures were performed. Patients from both groups were treated at the adult ICU in King Hussein Cancer Center (KHCC). In the case group, 22(88%) patients required changing at least one of the circuit components (flow sensor, exhalation membrane, or nebulizer kit). The median number of changes (range) per patient of the flow sensor, exhalation membrane, and nebulizer kit were: 2(1-3), 2(1-6), and 1(1-2), respectively. Large amounts of white crystals, which resembled the colistin powder, were reported on the replaced VC components. The flow sensor was changed in 2 control patients, but white crystals were absent. Crystals obtained from one case subject were confirmed to be colistin by chromatographic mass spectroscopy. Further studies are needed to evaluate the effect of crystal formation on the efficacy of NC and clinical outcomes

Bias in artificial intelligence algorithms and recommendations for mitigation

The adoption of artificial intelligence (AI) algorithms is rapidly increasing in healthcare. Such algorithms may be shaped by various factors such as social determinants of health that can influence health outcomes. While AI algorithms have been proposed as a tool to expand the reach of quality healthcare to underserved communities and improve health equity, recent literature has raised concerns about the propagation of biases and healthcare disparities through implementation of these algorithms. Thus, it is critical to understand the sources of bias inherent in AI-based algorithms. This review aims to highlight the potential sources of bias within each step of developing AI algorithms in healthcare, starting from framing the problem, data collection, preprocessing, development, and validation, as well as their full implementation. For each of these steps, we also discuss strategies to mitigate the bias and disparities. A checklist was developed with recommendations for reducing bias during the development and implementation stages. It is important for developers and users of AI-based algorithms to keep these important considerations in mind to advance health equity for all populations. Author summary Though artificial intelligence (AI) algorithms were initially proposed as a means to improve healthcare and promote health equity, recent literature suggests that such algorithms are associated with bias and disparities. Therefore, we outline the various elements of potential bias in the development and implementation of AI algorithms and discuss strategies to mitigate them