Combining and Using the Utrecht Method and the Analytic Hierarchy Process to Facilitate Professional and Ethical Deliberation and Decision Making in Complementary and Alternative Medicine: A Case Study among a Panel of Stakeholders

Background. In daily practice, healthcare practitioners face many challenges in ethical and professional decision making. Currently, little is known on the ethical and professional deliberations and weighing benefits against risks in daily complementary and alternative medicine (CAM) practice. The aim of this study was to combine the Utrecht method and the Analytic Hierarchy Process (AHP) in deliberations, weighing benefits against risks of using ginger for a pregnant woman suffering nausea and vomiting of pregnancy (NVP) along with other comorbidities. Methods. A hypothetical case was constructed using the twelve tips for constructing dilemma case-based assessment. Three CAM practitioners, two physicians, three pharmacists, and two patients were recruited, and the Utrecht and the AHP methods were combined and used to deliberate and weigh benefits against risks of using ginger for the presented case. Results. Responses from the ten panelists were obtained. Priority ratings showed significantly higher scores (p-value < 0.001) for alleviating symptoms of NVP (30.7%  ± 16.6%) compared to other potential benefits. Increasing the risk of bleeding was given significantly higher (p-value < 0.0001) weight scores (24.7%  ± 13.5%) than other potential side effects. Potential risk of spontaneous abortion and risk of impairment of fetal development were given higher (p-value < 0.001) weight scores than risk of fetal hypoglycemia. When benefits were compared against side effects and risks to the fetus and pregnancy, potential benefits were given higher (p-value < 0.001) weight scores (72.3%  ± 5.2%). Conclusions. Considering the anticipated benefits and risks, a shared decision was made to use ginger in the case presented. The woman should also be informed of the potential side effects and risks of using ginger. The use of this combined method might promote openness and transparency in making shared decisions for healthcare providers and patients

Quality Indicators of Pharmaceutical Care in Palestinian Integrative Healthcare Facilities: Findings of a Qualitative Study among Stakeholders

Background. Recently, there has been shifts from providing large volumes to providing higher quality of healthcare services. This qualitative exploratory study was conducted to explore the views of different stakeholders on activities and services that could serve as quality indicators of pharmaceutical care in Palestinian integrative healthcare facilities. Methods. A judgmental sampling technique was used to invite and recruit stakeholders for this study. Semistructured in-depth interviews were conducted with the stakeholders. Data collected during the interviews were qualitatively analyzed using the interpretive description methodology. Themes, subthemes, and patterns were recognized using the Qualitative Analysis Guide of Leuven. The data were coded using RQDA software. Results. Interviews (n = 22) were conducted with 9 complementary and alternative medicine practitioners, 8 pharmacists, 2 physicians, 2 nurses, and 1 risk/quality assurance manager. The interview median duration was 41 with an IQR of 22 min. Following the thematic analysis adopted to achieve the objectives of this study, six major themes emerged from the data collected from the interviews. The themes emerged from the data were (1) provision of collaborative, direct, and comprehensive patient care services; (2) common services and activities at the time of admission, during stay, at transition between wards/services/hospitals, and at discharge to home or community care; (3) screening for, identifying, and resolving problems; (4) collaboration with other healthcare providers; (5) professional development; and (6) performance and efficiency. Conclusions. Quality indicators are invaluable for informing decisions relevant to justifying allocation of scarce resources, securing funds, and demonstrating value in activities and services within integrative healthcare facilities. Further studies are still needed to develop a set of measurable indicators to measure the impact of pharmaceutical care in integrative healthcare facilities

Quality Indicators of Pharmaceutical Care for Integrative Healthcare: A Scoping Review of Indicators Developed Using the Delphi Technique

Background. Recently, measuring and benchmarking provision of healthcare services has drawn a considerable attention. This scoping review was conducted to identify, describe, and summarize studies in which the Delphi technique was used to develop quality indicators of pharmaceutical care. The study also aimed to identify activities and services that could be used to capture the impact of pharmacist in integrative medicine. Methods. Databases were searched from inception to February 2020 using key terms that were combined using Boolean operators. Studies were included if they were relevant to development of quality indicators of pharmaceutical care with regard to medications or complementary and alternative medicine (CAM) modalities. Full text of the selected studies was imported into EndNote. Studies were screened and data were extracted into a standard extraction form. Results. Data were extracted from 31 studies. Of those, 24 (77.4%) were related to provision of pharmaceutical services relevant to medications and 7 (22.6%) were related to provision of care using CAM modalities. Most of the studies (67.7%) were published in 2010 and beyond. Almost half of the studies (48.4%) originated from the United States, United Kingdom, and Canada. A total of 42 different activities and services that could be used as quality indicators were identified from the studies included in this review. Activities and services were related to history taking, performing reconciliations, identifying and resolving therapy problems, providing collaborative care, designing care plans, optimal performance, and continuing education. Conclusions. Although there is an increasing interest in improving healthcare delivery, quality indicators of pharmaceutical services and those relevant to CAM provision in healthcare facilities adopting the integrated healthcare paradigm are still limited. Future studies are needed to develop validated quality indicators that could be successfully used in measuring and benchmarking quality of services in integrated healthcare facilities

Development of Key Performance Indicators for Capturing Impact of Pharmaceutical Care in Palestinian Integrative Healthcare Facilities: A Delphi Consensus Study

Background. The current study was performed to develop a consensus-based core inventory of key performance indicators (KPIs) to be used in capturing the impact of pharmaceutical care in healthcare facilities that employ integrative medicine paradigm in Palestine. Methods. A panel of healthcare professionals and risk/quality assurance managers was composed employing a judgmental sampling technique. The study tool was a questionnaire. Views and opinions of the panelists on the roles of pharmacists in caring for patients admitted to or visiting healthcare facilities that employ integrative medicine were collected using 11 statements. An initial inventory of activities and services that potentially can be used as KPIs was compiled from the literature and interviews with key contact experts in the domain. Three iterative Delphi rounds were conducted among the panelists (n = 50) to achieve formal consensus on the KPIs that should be used. The consensus-based KPIs were ordered by the scores of the panelists. Results. A total of 8 consensus-based KPIs were developed. The KPIs related to the number of problems related to medications and complementary and alternative medicine (CAM) that were resolved by pharmacists and CAM practitioners (p < 0.0001), number of patients for whom reconciliations were documented (p < 0.0001), number of patients receiving direct, comprehensive, and/or collaborative care (p < 0.0001), and number of patients for whom pharmacists and CAM practitioners were involved in implementing a therapeutic plan (p < 0.05) were rated significantly higher than the KPI (#8) related to the participation in multi-healthcare provider discussions/deliberations. Conclusions. Consensus-based KPIs that can be used in capturing the impact of evidence-based CAM and pharmaceutical care of patients in healthcare facilities that employ integrative medicine paradigm were developed. Future studies are still needed to investigate if implementing these KPIs might promote evidence-based CAM and pharmaceutical care in healthcare facilities that employ the integrative medicine paradigm

Expression génomique et protéomique quantitative des transporteurs et des enzymes du métabolisme au niveau de la barrière hémato-encéphalique humaine

Le passage des médicaments dans le cerveau est un processus qui implique souvent des transporteurs éventuellement couplés avec des enzymes du métabolisme. Au niveau de la barrière hémato-encéphalique (BHE), ces transporteurs et enzymes contribuent à modifier la pharmacocinétique cérébrale des médicaments. Leurs activités sont souvent corrélées a leur niveau d expression protéique. Dans la première étude, nous avons réalisé une quantification relativement exhaustive de l expression génomique et protéomique de 71 transporteurs SLC et OST, 34 transporteurs ABC, et 51 enzymes des les phases I et II dans des microvaisseaux cérébraux humain fraîchement isolées. Notre étude a montré que les transporteurs du glucose et des acides aminés sont les principaux transporteurs exprimés. La protéine ABCG2/BCRP était 1,6 fois plus exprimée que l ABCB1/MDR1. Les CYP1B1 et CYP2U1 étaient quantifiables au niveau génomique et protéomique. Les GSTs sont fortement exprimées, dans les microvaisseaux cérébraux alors que les UGTs n ont pu être détectées. Dans la seconde étude, nous avons quantifié l'expression relative des gènes marqueurs de type cellulaire, les transporteurs SLC et ABC, les enzymes de la phase I et la phase II et certains facteurs de transcription dans un modèle in vitro optimisé de la BHE humaine : la lignée hCMEC/D3. Les cellules hCMEC/D3 sont moins fenêstrées par rapport aux cellules non-cérébrales (HUVEC) : en effet, PLVAP, marqueur de la fenestration, est 70,7 fois moins exprimé dans la lignée hCMEC/D3. Comme les microvaisseaux cérébraux humains, les cellules hCMEC/D3 expriment fortement les transporteurs du glucose et des acides aminés. Le traitement avec le chlorure de lithium (LiCl), agoniste de signalisation Wnt/b-caténine, enrichit l'expression de l ABCG2/BCRP et l ABCC5/MRP5 et du CYP1A1 de 5,6 fois, 2,5 fois et 9,1 fois, respectivement. Tout comme les microvaisseaux cérébraux, les cellules hCMEC/D3 expriment fortement les GSTs et le facteur de transcription AhR.Drug entry and distribution into the brain is a delicate process as modulated by the interaction between the drug molecule with influx and/or efflux drug transporters as well as metabolizing enzymes at the blood-brain barrier (BBB). The transport and metabolic activities of transporters and enzymes are often correlated with their protein amounts. In the first study, we are reporting a relatively exhaustive quantitative gene expression and absolute protein quantification of 71 solute carrier (SLC) and organic solute (OST) transporters, 34 ATP-binding cassette (ABC) transporters, and 51 phase I and phase II metabolizing enzymes in freshly isolated human brain microvessels. Our study showed that glucose and amino acid transporters were the main uptake transporters expressed. Interestingly, our study showed that ABCG2/BCRP protein was 1.6-fold more than ABCB1/MDR1. CYP1B1 and CYP2U1 were quantifiable at both gene and protein levels. Interestingly, microvessels highly expressed GSTs, whereas, UGTs were completely absent. In the second study, we quantitatively investigated the gene expression of cell type markers, SLC and ABC transporters, phase I and phase II metabolizing enzymes and some transcriptional factors in an optimized in vitro human BBB model (hCMEC/D3). The hCMEC/D3 cells were less fenestrated as compared to non-cerebral (HUVEC) cells as shown by PLVAP which was less expressed by 70.7-fold in hCMEC/D3 cells. In accordance with human brain microvessels, hCMEC/D3 expressed glucose and amino acids transporters. Treatment with the Wnt/b-catenin agonist, lithium chloride (LiCl), enriched the gene expression of ABCG2/BCRP and ABCC5/MRP5 and CYP1A1 by 5.6-fold, 2.5-fold and 9.1-fold, respectively. Similar to microvessels hCMEC/D3 cells highly expressed GSTs and the transcriptional factor AhR.PARIS-BIUP (751062107) / SudocSudocFranceF

Which Benefits and Harms of Using Fenugreek as a Galactogogue Need to Be Discussed during Clinical Consultations? A Delphi Study among Breastfeeding Women, Gynecologists, Pediatricians, Family Physicians, Lactation Consultants, and Pharmacists

Background. Breastfeeding women with hypogalactia are commonly recommended to use fenugreek as a galactogogue. This study aimed to achieve formal consensus among breastfeeding women and healthcare providers on which potential harms and benefits of using fenugreek need to be communicated and discussed during clinical consultations. Methods. A two-iterative round Delphi technique was used in two separate panels of breastfeeding women (n=65) and healthcare providers (n=56) to achieve formal consensus on a list of 24 and 16 items related to potential harms and benefits of fenugreek. Results. About 70% of the healthcare providers recommended quite often herbal remedies for breastfeeding women and about 68% of the women had been recommended to use herbal remedies many times by their healthcare providers. Consensus was achieved on 21 potential harms and 14 potential benefits of using fenugreek to enhance human milk supply that need to be discussed with breastfeeding women during consultations. Conclusion. Probably, potential harms and benefits of recommending fenugreek as herbal galactogogue for breastfeeding women seeking recommendations to increase their human milk supply need to be discussed during clinical consultations. Further observational studies are needed to assess what is being discussed in daily consultations when herbal remedies are recommended

Additional file 1: of Ethnopharmacological survey of medicinal plants used by patients with psoriasis in the West Bank of Palestine

Interviewer administered survey of medicinal plants use by psoriasis patients in the West Bank of Palestine. (DOCX 18 kb

Inequalities in health care and behaviour in patients with diabetes and concurrent hypertension in Lahore, Pakistan

The global healthcare delivery system is largely inequitable and patients suffer inequalities in relation to their socioeconomic status (SES). In this study, we applied univariate measures to predict the SES in a sample of patients. We investigated the relationship between patient’s SES, adherence to drug, dietary intake and health behaviour. We also investigated if inequalities exist in physician’s choice on multisource oral solid hypoglycaemic and antihypertensive drugs in a sample of male type II diabetes mellitus patients with concurrent hypertension. Questionnaires were administered on patients (N=500) with diabetes mellitus and concurrent hypertension to determine their SES, prescribed drugs, dietary regime and health behaviour in Lahore, Pakistan. Correlation was determined using chi-square test for category characteristics, Kruskall-Wallis or ANOVA for continuous data variables non-normal or normally distributed data, respectively. The patient’s SES was indicated by univariate like income, occupation, and education. Patients with high SES were more adherent to drug, dietary intake and health behaviour (χ2 =13.16, p<0.001; 34.71, p<0.0001; 79.24, p<0.0001, respectively). Patients with lower SES were prescribed cheaper hypoglycaemic and antihypertensive alternatives than their richer counterparts (p<0.0001). Socioeconomic differentials exist within urban communities; these differentials have direct effects on healthcare delivery and patient health