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Background: Medication reconciliation can significantly reduce clinically important medication errors at hospital discharge, but its impact on post-discharge medication management has not been investigated. We aimed to investigate the incidence of patient-generated medication discrepancies 30 days after hospital discharge and the impact of a pharmacist-led medication reconciliation coupled with patient counselling on clinically important discrepancies caused by patients., Methods: A pragmatic, prospective, controlled clinical trial was conducted at the University Clinic Golnik, Slovenia. Adult patients were divided into an intervention group and a control group. The intervention group received pharmacist-led medication reconciliation at admission and discharge, plus patient counselling at discharge. Medication discrepancies were identified by comparing the therapy prescribed in the discharge letters with the therapy 30 days after discharge, obtained through telephone patient interviews. Discrepancies were classified as intentional or unintentional, and their clinical importance was assessed., Results: The study included 254 patients (57.9% male, median age 71 years), with 136 in the intervention group and 118 in the control group. Discrepancies occurred with a quarter of the medicines (617/2,441; 25.3%) at 30 days after hospital discharge, and patients themselves caused half of the discrepancies (323/617; 52.4%), either intentionally (171/617; 27.7%) or unintentionally (152/617; 24.6%). Clinically important discrepancies occurred in 18.7% of intentional and 45.4% of unintentional patient-generated changes. The intervention significantly reduced the likelihood of clinically important unintentional patient-generated discrepancies (OR 0.204; 95%CI: 0.093-0.448), but not clinically important intentional patient-generated discrepancies (OR 2.525; 95%CI: 0.843-7.563). The latter were more frequent among younger, male patients and patients hospitalized for respiratory diseases., Conclusion: The study emphasizes the importance of addressing discrepancies made by patients after hospital discharge, which can result in potentially harmful outcomes. It also shows that a pharmacist-led hospital intervention can significantly reduce discrepancies in the early post-discharge period. These findings can guide the development of future services to improve patient support for medication management after hospitalization., Competing Interests: LK has received a speaker honorarium from MSD, Pfizer and Roche. MJ received a speaker honorarium from Shire and Takeda. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest., (Copyright © 2024 Jošt, Knez, Kos and Kerec Kos.)

Introduction: Little is known about the cumulative effect of changes in antihypertensive medications on treatment intensity. This study analyzed how changes in antihypertensive medications affect the intensity of antihypertensive treatment at hospital discharge and 30 days afterwards., Methods: A prospective observational study of 299 hospitalized adult medical patients with antihypertensive therapy was conducted. The effect of medication changes on treatment intensity was evaluated by the Total Antihypertensive Therapeutic Intensity Score (TIS)., Results: At discharge, antihypertensive medications were changed in 62% of patients (184/299), resulting in a very small median reduction in TIS of -0.16. Treatment intensity was reduced more with increasing number of antihypertensive medications at admission, whereas it increased with elevated inpatient systolic blood pressure. Thirty days after discharge, antihypertensive medications were changed in 37% of patients (88/239) resulting in a median change in TIS of -0.02. Among them, 90% (79/88) had already undergone a change at discharge. The change in treatment intensity after discharge was inversely correlated with a change at discharge., Discussion: Changes in antihypertensive medication frequently occurred at discharge but had a minimal impact on the intensity of antihypertensive treatment. However, these adjustments exposed patients to further medication changes after discharge, evidencing the need for treatment reassessment in the first month post-discharge., Competing Interests: Author LK has received a speaker honorarium from MSD, Pfizer and Roche. Author MJ has received a speaker honorarium from Takeda. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Japelj, Kerec Kos, Jošt and Knez.)

Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with well-established clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included-225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. Clinical Trial Registration: https://clinicaltrials.gov/search?id=NCT06207500, identifier NCT06207500., Competing Interests: LK has received a speaker honourarium from MSD, Pfizer and Roche. MJ received a speaker honourarium from Shire and Takeda. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest., (Copyright © 2024 Jošt, Kerec Kos, Kos and Knez.)

Objective: To evaluate the possibility of deprescribing proton pump inhibitors in adult inpatients hospitalized in a teaching hospital in Slovenia., Materials and Methods: We conducted a prospective observational clinical study in 120 patients taking a proton pump inhibitor. Data were obtained from hospital medical records and patient interviews. First, treatment compliance with relevant guidelines was assessed, and then the possibility of deprescribing was considered., Results: Treatment with a proton pump inhibitor was in accordance with guidelines in only 39% of the 120 patients. In 24% of patients, the indication for proton pump inhibitor use was invalid, and 22% and 15% of patients were taking a proton pump inhibitor at a higher dose or for a longer period than recommended, respectively. Deprescribing could be undertaken in 61% of patients, as discontinuation in 38%, and dose reduction in 23%. A deprescribing possibility was noted more frequently in patients prescribed proton pump inhibitors for peptic ulcer disease, Helicobacter pylori infection, or without a valid indication (p < 0.001), as well as in patients taking a double or higher dose of a proton pump inhibitor (p < 0.001)., Conclusion: Deprescribing of proton pump inhibitors could be undertaken in nearly 2/3 of our cohort of adult hospitalized patients. Hospitalization may serve as an opportunity to deprescribe proton pump inhibitors.

Background: The European baseline series (EBS) of contact allergens is subject to change. An allergen is considered for inclusion when routine patch testing of patients with suspected contact dermatitis results in ≥0.5% prevalence rate., Objectives: We aimed to determine the frequency of sensitizations to 30 EBS allergens and 10 locally added allergens. Additionally, we assessed the strength and evolution of reactions to all tested allergens and co-reactivity of additional allergens., Methods: Patch testing with our baseline series of 40 allergens was done in 748 consecutive adults. Tests were applied to the upper back and removed by patients after 48 h. Readings were done on Day 3 (D3) and D6 or D7 (D6/7). Positive reactions fulfilled the criteria of at least one plus (+) reaction. A retrospective analysis was done., Results: Eight allergens not listed in the EBS had ≥0.5% prevalence rate (i.e., cocamidopropyl betaine, thiomersal, disperse blue mix 106/124, 2-bromo-2-nitropropane-1,3-diol, diazolidinyl urea, propylene glycol, Compositae mix II and dexamethasone-21-phosphate), and 16.6% of positive reactions would have been missed without D6/7 readings., Conclusion: We propose further studies to evaluate whether cocamidopropyl betaine, disperse blue mix 106/124, 2-bromo-2-nitropropane-1,3-diol, diazolidinyl urea and Compositae mix II need to be added to the EBS., (© 2022 The Authors. Contact Dermatitis published by John Wiley & Sons Ltd.)

Background: Anaphylaxis, which is rare, has been reported after COVID-19 vaccination, but its management is not standardized., Method: Members of the European Network for Drug Allergy and the European Academy of Allergy and Clinical Immunology interested in drug allergy participated in an online questionnaire on pre-vaccination screening and management of allergic reactions to COVID-19 vaccines, and literature was analysed., Results: No death due to anaphylaxis to COVID-19 vaccines has been confirmed in scientific literature. Potential allergens, polyethylene glycol (PEG), polysorbate and tromethamine are excipients. The authors propose allergy evaluation of persons with the following histories: 1-anaphylaxis to injectable drug or vaccine containing PEG or derivatives; 2-anaphylaxis to oral/topical PEG containing products; 3-recurrent anaphylaxis of unknown cause; 4-suspected or confirmed allergy to any mRNA vaccine; and 5-confirmed allergy to PEG or derivatives. We recommend a prick-to-prick skin test with the left-over solution in the suspected vaccine vial to avoid waste. Prick test panel should include PEG 4000 or 3500, PEG 2000 and polysorbate 80. The value of in vitro test is arguable., Conclusions: These recommendations will lead to a better knowledge of the management and mechanisms involved in anaphylaxis to COVID-19 vaccines and enable more people with history of allergy to be vaccinated., (© 2022 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Background: During transitions of care, patient's medications are prone to medication errors. This study evaluated the impact of pharmacist-led medication reconciliation at hospital admission on unintentional medication discrepancies and adverse drug events., Methods: A randomized controlled clinical trial was conducted in 120 adult medical patients hospitalized in a tertiary hospital in Slovenia. In the intervention group, a pharmacist-led medication reconciliation was performed on admission, while the control group received usual care. Patient's drug treatment before admission was compared with their admission and inpatient treatment to identify discrepancies. The intention of discrepancies and related adverse drug events were assessed as a consensus of an expert panel., Results: Included patients were elderly (median 72 years) and treated with polypharmacy (median 7 medications). Upon admission, discrepancies and unintentional discrepancies, representing a medication error, were identified in 61.2% (825/1347) and 18.3% (247/1347) of medications, respectively. In the intervention group, only 29.1% (37/127) of unintentional discrepancies were reported to the physicians in person. The majority of admission discrepancies (88%) persisted through hospitalization. Unintentional discrepancies resulted in 51 adverse drug events even during hospitalization. There were no differences between the intervention and control group in the occurrence of unintentional discrepancies (p = 0.481) or adverse drug events (p = 0.801)., Conclusions: Medication reconciliation at hospital admission failed to reduce unintentional discrepancies and adverse drug events, possibly due to its poor integration into clinical practice. Discrepancies resulted in patient harm even during the short period of hospitalization, which warrants the implementation of medication reconciliation at hospital admission., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)