Pharmacists’ role in the management of patients receiving dual or triple antithrombotic therapy

Purpose: Patients on dual and triple antithrombotic therapy present the therapeutic dilemma of mitigating bleed risk while sustaining antithrombotic efficacy. Lack of literature and variability in existing published guidance potentiates inconsistent management of these patients. Furthermore, suboptimal dosing of direct oral anticoagulants is relatively common. One study reported as high as 43% of patients receive higher and 13% receive lower than clinically indicated doses. These findings were associated with a significantly increased risk of major bleeding and incidence of stroke, thus highlighting the importance of selecting an ideal regimen. The purpose of this project is to highlight pharmacists’ role in the optimization of antithrombotic therapy in patients with concurrent indications for antiplatelet and anticoagulant agents. Methods: This was a single center, quality improvement project including adult patients concomitantly receiving at least one antiplatelet agent and a therapeutic-dose anticoagulant between January and March 2021 at Baptist Hospital. Eligible patients were assessed and evaluated on a daily basis. Data collection included indications for prescribed antithrombotic agents and rationale for clinical recommendations. Potential therapeutic de-escalations and/or dose adjustments were communicated with the provider as necessary. The primary outcome of this study was appropriateness of anticoagulant and antiplatelet therapy based on their specific indications. Secondary outcomes included the types of pharmacy interventions made and accepted. Results: A total of 239 patients receiving dual or triple antithrombotic therapy were prospectively reviewed over the 10-week study period. The average age was 74 years, and 56% of patients were male. The majority of regimens reviewed (95.4%) were dual antithrombotic therapy. Overall, 82% of all reviewed regimens were considered appropriate at time of pharmacist review (85% of dual therapy regimens and 27% of triple therapy regimens were appropriate). After pharmacist intervention, regimen appropriateness increased to 97% overall, with dual therapy regimens adjusted to 96.5% appropriate (78% acceptance rate) and triple therapy regimens adjusted to 100% appropriate (100% acceptance rate). The most common intervention was antiplatelet discontinuation (46%), however the most clinically significant intervention was discontinuation of oral anticoagulation (7.8%). Conclusion: Pharmacist intervention resulted in optimization of dual and triple antithrombotic therapies by 15% with an intervention acceptance rate of 83%. Triple antithrombotic regimens had the greatest room for optimization, as was demonstrated by a 73% increase in regimen appropriateness as a result of pharmacist review and intervention

Impact of Midodrine on Optimization of β-blocker Therapy in Patients with Heart Failure with Reduced Ejection Fraction

Introduction: Midodrine, an α-adrenergic agonist approved for orthostatic hypotension, is used off-label for hypotension in patients with heart failure with reduced ejection fraction (HFrEF). However, its prevalence, clinical outcomes, and risks in HFrEF remain unclear. Theoretically, adding midodrine to HFrEF patients’ medication regimens may facilitate up-titration of guideline-directed medical therapy (GDMT) by attenuating its corresponding hypotensive effects. This study aims to assess the concurrent use of midodrine and β-blockers in patients with HFrEF to allow the initiation or up-titration of GDMT. Methods: This was a multisite, retrospective chart review of adult patients with HFrEF who received concomitant treatment with midodrine and a β-blocker from March to June 2022. Patients were excluded if they were pregnant, had a left ventricular ejection fraction (LVEF) ≥ 50%, or received concomitant therapy for less than 48 hours. Primary outcomes included tolerance of β-blocker initiation and up-titration with midodrine. Secondary outcomes included initiation and continuation of midodrine and β-blockers or additional GDMT upon discharge. Results: Twenty-six patients were included. All patients on midodrine were initiated on β-blockers, and 73% (n = 19) tolerated β-blocker dose titration. An improvement in mean systolic blood pressure (SBP) from 104 mmHg to 112 mmHg was observed. Nineteen (73%) patients were discharged on midodrine and β-blockers, while 7 (27%) patients were discharged on β-blockers alone. Discussion: The initiation of midodrine improved mean SBP and enhanced tolerability of β-blockers in HFrEF patients. Further studies with larger sample sizes are necessary to evaluate midodrine\u27s long-term risks and benefits in HFrEF

A survey of fertility preservation options available to cancer patients around the globe

Purpose: Oncofertility focuses on providing fertility and endocrine-sparing options to patients who undergo life-preserving but gonadotoxic cancer treatment. The resources needed to meet patient demand often are fragmented along disciplinary lines. We quantify assets and gaps in oncofertility care on a global scale. Methods: Survey-based questionnaires were provided to 191 members of the Oncofertility Consortium Global Partners Network, a National Institutes of Health–funded organization. Responses were analyzed to measure trends and regional subtleties about patient oncofertility experiences and to analyze barriers to care at sites that provide oncofertility services. Results: Sixty-three responses were received (response rate, 25%), and 40 were analyzed from oncofertility centers in 28 countries. Thirty of 40 survey results (75%) showed that formal referral processes and psychological care are provided to patients at the majority of sites. Fourteen of 23 respondents (61%) stated that some fertility preservation services are not offered because of cultural and legal barriers. The growth of oncofertility and its capacity to improve the lives of cancer survivors around the globe relies on concentrated efforts to increase awareness, promote collaboration, share best practices, and advocate for research funding. Conclusion: This survey reveals global and regional successes and challenges and provides insight into what is needed to advance the field and make the discussion of fertility preservation and endocrine health a standard component of the cancer treatment plan. As the field of oncofertility continues to develop around the globe, regular assessment of both international and regional barriers to quality care must continue to guide process improvements

How Can We Improve Oncofertility Care for Patients? A Systematic Scoping Review of Current International Practice and Models of Care

© The Author(s) 2018. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. BACKGROUND: Fertility preservation (FP) is an important quality of life issue for cancer survivors of reproductive age. Despite the existence of broad international guidelines, the delivery of oncofertility care, particularly amongst paediatric, adolescent and young adult patients, remains a challenge for healthcare professionals (HCPs). The quality of oncofertility care is variable and the uptake and utilization of FP remains low. Available guidelines fall short in providing adequate detail on how oncofertility models of care (MOC) allow for the real-world application of guidelines by HCPs. OBJECTIVE AND RATIONALE: The aim of this study was to systematically review the literature on the components of oncofertility care as defined by patient and clinician representatives, and identify the barriers, facilitators and challenges, so as to improve the implementation of oncofertility services. SEARCH METHODS: A systematic scoping review was conducted on oncofertility MOC literature published in English between 2007 and 2016, relating to 10 domains of care identified through consumer research: communication, oncofertility decision aids, age-appropriate care, referral pathways, documentation, training, supportive care during treatment, reproductive care after cancer treatment, psychosocial support and ethical practice of oncofertility care. A wide range of electronic databases (CINAHL, Embase, PsycINFO, PubMed, AEIPT, Education Research Complete, ProQuest and VOCED) were searched in order to synthesize the evidence around delivery of oncofertility care. Related citations and reference lists were searched. The review was undertaken following registration (International prospective register of systematic reviews (PROSPERO) registration number CRD42017055837) and guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). OUTCOMES: A total of 846 potentially relevant studies were identified after the removal of duplicates. All titles and abstracts were screened by a single reviewer and the final 147 papers were screened by two reviewers. Ten papers on established MOC were identified amongst the included papers. Data were extracted from each paper and quality scores were then summarized in the oncofertility MOC summary matrix. The results identified a number of themes for improving MOC in each domain, which included: the importance of patients receiving communication that is of a higher quality and in different formats on their fertility risk and FP options; improving provision of oncofertility care in a timely manner; improving access to age-appropriate care; defining the role and scope of practice of all HCPs; and improving communication between different HCPs. Different forms of decision aids were found useful for assisting patients to understand FP options and weigh up choices. WIDER IMPLICATIONS: This analysis identifies core components for delivery of oncofertility MOC. The provision of oncofertility services requires planning to ensure services have safe and reliable referral pathways and that they are age-appropriate and include medical and psychological oncofertility care into the survivorship period. In order for this to happen, collaboration needs to occur between clinicians, allied HCPs and executives within paediatric and adult hospitals, as well as fertility clinics across both public and private services. Training of both cancer and non-cancer HCPs is needed to improve the knowledge of HCPs, the quality of care provided and the confidence of HCPs with these consultations

Penilaian Kinerja Keuangan Koperasi di Kabupaten Pelalawan

This paper describe development and financial performance of cooperative in District Pelalawan among 2007 - 2008. Studies on primary and secondary cooperative in 12 sub-districts. Method in this stady use performance measuring of productivity, efficiency, growth, liquidity, and solvability of cooperative. Productivity of cooperative in Pelalawan was highly but efficiency still low. Profit and income were highly, even liquidity of cooperative very high, and solvability was good

Differential cross section measurements for the production of a W boson in association with jets in proton–proton collisions at √s = 7 TeV

Measurements are reported of differential cross sections for the production of a W boson, which decays into a muon and a neutrino, in association with jets, as a function of several variables, including the transverse momenta (pT) and pseudorapidities of the four leading jets, the scalar sum of jet transverse momenta (HT), and the difference in azimuthal angle between the directions of each jet and the muon. The data sample of pp collisions at a centre-of-mass energy of 7 TeV was collected with the CMS detector at the LHC and corresponds to an integrated luminosity of 5.0 fb[superscript −1]. The measured cross sections are compared to predictions from Monte Carlo generators, MadGraph + pythia and sherpa, and to next-to-leading-order calculations from BlackHat + sherpa. The differential cross sections are found to be in agreement with the predictions, apart from the pT distributions of the leading jets at high pT values, the distributions of the HT at high-HT and low jet multiplicity, and the distribution of the difference in azimuthal angle between the leading jet and the muon at low values.United States. Dept. of EnergyNational Science Foundation (U.S.)Alfred P. Sloan Foundatio

Juxtaposing BTE and ATE – on the role of the European insurance industry in funding civil litigation

One of the ways in which legal services are financed, and indeed shaped, is through private insurance arrangement. Two contrasting types of legal expenses insurance contracts (LEI) seem to dominate in Europe: before the event (BTE) and after the event (ATE) legal expenses insurance. Notwithstanding institutional differences between different legal systems, BTE and ATE insurance arrangements may be instrumental if government policy is geared towards strengthening a market-oriented system of financing access to justice for individuals and business. At the same time, emphasizing the role of a private industry as a keeper of the gates to justice raises issues of accountability and transparency, not readily reconcilable with demands of competition. Moreover, multiple actors (clients, lawyers, courts, insurers) are involved, causing behavioural dynamics which are not easily predicted or influenced. Against this background, this paper looks into BTE and ATE arrangements by analysing the particularities of BTE and ATE arrangements currently available in some European jurisdictions and by painting a picture of their respective markets and legal contexts. This allows for some reflection on the performance of BTE and ATE providers as both financiers and keepers. Two issues emerge from the analysis that are worthy of some further reflection. Firstly, there is the problematic long-term sustainability of some ATE products. Secondly, the challenges faced by policymakers that would like to nudge consumers into voluntarily taking out BTE LEI