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IntroductionSickle cell disease (SCD), an inherited haemoglobinopathy, has important impact on morbidity and mortality, especially in paediatrics. Previous systematic reviews are limited to adult patients or focused only on few therapies. We aim to synthesise the evidence on efficacy and safety of pharmacological interventions for managing SCD in children and adolescents.Methods and analysisThis systematic review protocol is available at Open Science Framework (doi:10.17605/OSF.IO/CWAE9). We will follow international recommendations on conduction and report of systematic reviews and meta-analyses. Searches will be conducted in PubMed, Scopus and Web of Science (no language nor time restrictions) (first pilot searches performed in May 2022). We will include randomised controlled trials comparing the effects of disease-modifying agents in patients with SCD under 18 years old. Outcomes of interest will include: vaso-occlusive crisis, haemoglobin levels, chest syndrome, stroke, overall survival and adverse events. We will provide a narrative synthesis of the findings, and whenever possible, results will be pooled by means of pairwise or Bayesian network meta-analyses with surface under the cumulative ranking curve analyses. Different statistical methods and models will be tested. Dichotomous outcomes will be reported as OR, risk ratio or HR, while continuous data will be reported as standard mean differences, both with 95% CI/credibility interval. The methodological quality of the trials will be evaluated using the Risk of Bias 2.0 tool, and the certainty of the evidence will be assessed with the Grading of Recommendations Assessment, Development and Evaluation approach.Ethics and disseminationThis study refers to a systematic review, so no ethics approval is necessary. We intent to publish our findings in international, peer-reviewed journal. Data will also be presented to peers in scientific events. Additionally, the results obtained in this study may contribute towards the update of therapeutic guidelines and for the development of health policies for SCD.PROSPERO registration numberCRD42022328471.

Owing to advances in pharmacotherapy, older people are increasingly likely to be prescribed multiple medicines. Prescribing is largely based on single-disease evidence-based guidance, which does not generally take account of multimorbidity, which is now the norm in those over 65 years of age.1 Consequently, patients are prescribed several medicines recommended by disease-specific guidelines, which is potentially harmful for this specific population and challenging for them to manage. Inappropriate polypharmacy and medication non-adherence are two key inter-related problems in elderly multimorbid patients, with negative effects on health outcomes. Multimorbidity is associated with increased use of healthcare services (twice as high as non-multimorbid) and hospitalisation (three times higher).2 ‘Polypharmacy’, the prescribing of multiple medicines, has been described as one of the most pressing prescribing challenges.3 Among Scottish patients with two clinical conditions, 20.8% were receiving four to nine medicines, and 10.1% were receiving 10 or more medicines.4 Polypharmacy increases the likelihood of adverse effects, impacting significantly on health outcomes and healthcare resources.5 Notably, most adverse effects are preventable through appropriate medicine selection, monitoring and review.6 Such effects in older people may arise from many inter-related factors including: age-related physiological changes (eg, reduced renal and hepatic function); multimorbidities; prescribing of multiple medicines; and confusion over medicine taking. While, traditionally, polypharmacy has been described as prescribing of four or five medicines, it has been suggested that, given the emphasis on evidence-based practice, there should be a change in focus from inappropriate polypharmacy (inappropriate prescribing of too many medicines) to optimal polypharmacy (appropriate prescribing of many medicines).7 It is commonly accepted among healthcare providers that polypharmacy is an issue. However, an agreed concept and definition of polypharmacy does not exist. A person with multiple morbidities usually requires multiple medicines to control his/her conditions. Some medical conditions, such as cardiovascular … Correspondence to Alpana Mair, Healthcare Quality and Strategy Directorate, Scottish Government, Edinburgh EH1 3DG UK; Alpana.Mair{at}gov.scot

ObjectivesThe integration of community pharmacy services (CPSs) into primary care practice can be enhanced by assessing (and further addressing) the elements that enable (ie, facilitators) or hinder (ie, barriers) the implementation of such CPSs. These elements have been widely researched from the perspective of pharmacists but not from the perspectives of other stakeholders who can interact with and influence the implementation of CPSs. The aim of this study was to synthesise the literature on patients’, general practitioners’ (GPs) and nurses’ perspectives of CPSs to identify barriers and facilitators to their implementation in Australia.MethodsA meta-synthesis of qualitative studies was performed. A systematic search in PubMed, Scopus and Informit was conducted to identify studies that explored patients’, GPs’ or nurses’ views about CPSs in Australia. Thematic synthesis was performed to identify elements influencing CPS implementation, which were further classified using an ecological approach.ResultsTwenty-nine articles were included in the review, addressing 63 elements influencing CPS implementation. Elements were identified as a barrier, facilitator or both and were related to four ecological levels: individual patient (n=14), interpersonal (n=24), organisational (n=16) and community and healthcare system (n=9). It was found that patients, nurses and GPs identified elements reported in previous pharmacist-informed studies, such as pharmacist’s training/education or financial remuneration, but also new elements, such as patients’ capability to follow service's procedures, the relationships between GP and pharmacy professional bodies or the availability of multidisciplinary training/education.ConclusionsPatients, GPs and nurses can describe a large number of elements influencing CPS implementation. These elements can be combined with previous findings in pharmacists-informed studies to produce a comprehensive framework to assess barriers and facilitators to CPS implementation. This framework can be used by pharmacy service planners and policy makers to improve the analysis of the contexts in which CPSs are implemented.

Background Non-adherence to combined anti-retroviral treatment (cART) is one of the key factors leading to treatment failure, higher morbidity, mortality, and health costs. Tools to evaluate adherence are beneficial since they allow health care workers to focus on patients with adherence problems. “Beliefs about Medicines Questionnaire” (BMQ) is a tool that evaluates the patient’s awareness of the “need” for and “concerns” about their medicines. Purpose To evaluate whether the findings of the BMQ questionnaire correlated with adherence in HIV patients. Material and methods BMQ was applied to HIV-infected patients on cART with three or more pharmacy visits who gave informed consent. Adherence was evaluated through refill date records. Results Of a total of 175 patients, 80 (45.7%) were women, 97 (55.4%) were previously treatment-naive, and the median age was 44 years old. Average BMQ-specific “need” and “concerns” scores were 22.6 [Standard Deviation (SD) = 2.7] and 18.6 [SD = 5.0], respectively. The average difference between “need” and “concerns” scores (N-C) was 4.0 [SD = 6.1]. Average refill adherence was 101% [SD = 9.1%] with values between 59% and 129%. The majority of patients (86.3%) had refill adherence between 80% and 110%, and 2.3% had refill adherence below 80%. Although we observed a tendency for higher values of N-C in patients with higher refill adherence, it was not possible to establish a correlation due to lack of statistical significance. Conclusion It wasn’t possible to correlate the results of the BMQ-specific questionnaire with adherence, probably due to the fact that there was a high proportion of treatment-naive patients. We observed higher refill adherence rates in treatment-naive patients, which may be due to the fact that these patients are most likely to be aware of the “need” for cART. It’s possible that the BMQ-specific questionnaire is more useful in treatment – experienced patients in order to identify causes of non-adherence. References and/or Acknowledgements No conflict of interest.

Background Beatriz Ângelo Hospital (HBA) is 424-bed district hospital (210-bed Medical Specialties, 90-bed Surgical Specialties, and 22-bed Intensive/Intermediate care unit, among others). All prescriptions are validated by a pharmacist at the Department of Pharmacy (DP), and it is always possible to access the electronic medical record of each patient to consult clinical data and record any suggestions or interventions. For the purposes of this study, pharmaceutical interventions (PIs) are defined as contact with other healthcare providers in order to prevent any medicines-related problems (MRPs). Purpose To quantify and characterise PIs at HBA following the identification of any risks of MRPs during prescription validation. Materials and Methods Prospective data collection from 1 July to 30 September and subsequent entering of the data into a PIs database created by the HBA’s DP according to a protocol developed by the DP of Hospital da Luz and Faculdade de Farmacia da Universidade de Lisboa. Results During the period of analysis, 914 PIs were recorded for a total of 280 patients (an average of 3.3 PIs per patient), with the following distribution: 242 PIs in Intensive Care units, 400 in the Medical Specialties, 214 in the Surgical Specialties and 58 in other units. The most frequent causes of PIs were: unsuitable use of medicine due to the renal function (n = 420 [46.0%]); potential adverse effect/toxicity (n = 139 [15.2%]); and lack of therapeutic efficacy (n = 112 [12.3%]). The most frequent PIs were therapeutic drug monitoring (n = 343 [37.5%]); suggestions regarding parameters found in blood tests (n = 241 [26.4%]); adjustments to dose and frequency of administration (n = 106 [11.6%]); adjustments to route of administration and medicine formulation (n = 07 [11.7%]). As for the expected effects of PI, the most frequent were: increased effectiveness (n = 548 [60.0%]); reduced drug toxicity (n = 205 [22.4%]); reduced risk associated with route of administration (n = 104 [11.4%]). Concerning the results of PI, the most frequent were: no clinical improvement/no clinical aggravation (n = 289 [31.6%]); problem prevented (n = 248 [27.1%]); clinical improvement (n = 238 [26.0%]). Of all PIs, 813 (88.9%) were accepted, and 328 (35.9%) of all PIs were recorded in the patient’s electronic medical record. Conclusions The high acceptance of PIs confirms the interdisciplinary cooperation of all the healthcare providers within the institution. The results show that PI is fundamental in promoting the good use of medicines and preventing MRPs. The development of a software application integrated in the electronic medical record will allow us to be more agile in documentation and to quantify the pharmacist’s contribution within the clinical team. No conflict of interest.

Background Antibacterial consumption has been associated with an increase in the growth of resistant bacterial strains. Hospital Pharmacists play an important role in antimicrobial stewardship strategies, by improving compliance with anti-infective prescribing recommendations. Purpose To identify real-world situations in which pharmacists can intervene to improve antibacterial patterns of use in Hospital da Luz, Lisbon, Portugal. Materials and methods Retrospective audit study. All courses of antibacterials for systemic use (therapeutic class J01), prescribed in patients over 18 years-old admitted to Hospital da Luz during January 2011, were extracted from the electronic medical records and analysed. Descriptive statistics were performed. Results A total of 913 patients were admitted to hospital during the study period, being 81.1% (n=740) prescribed 961 antibacterial courses. Surgical prophylaxis represented 63.7% (n=612) of the courses. The following potential improvement areas were identified: ▶In 4.9% (n=47) cases the reason for prescription was not identified. ▶Prophylaxis duration was longer than 48 h in 2.1% and between 24 and 48 h in 10.8% courses. A clear distinction between antibacterials prescribed for prophylaxis and therapy was found, except for second-generation cephalosporins (78.3% vs 21.7%), quinolones (24.6% vs 75.4%), and imidazole derivatives (57.1% vs 42.9%). ▶Only 3.8% (n=12) of the 349 non-surgical prophylactic and therapeutic antibacterial prescriptions were discontinued after microbiological identification and/or antibiotic susceptibility test results. Parenteral administration represented 73.9% (n=258) of these 349 courses, whereas only 8.4% (n=20) were discontinued due to intravenous-to-oral switch. Conclusions After an indepth audit process, the following opportunities for pharmacists9 interventions to improve the antibacterial pattern of use in our hospital were identified: unclear prescription indication, inappropriate extension of surgical prophylaxis duration, inappropriate selection of the prophylactic antibacterial agent, insufficient microbiological identification follow-up, and scarce intravenous-to-oral switch.

Background Currently, no pharmacy services exist in outpatient dialysis centres in Australia, although the literature demonstrates the positive contribution of pharmacists to dialysis patients. Purpose To explore hospital pharmacists9 willingness to implement pharmacy services in outpatient dialysis centres. Materials and methods Qualitative indepth, semistructured interviews were conducted with a convenience sample of hospital pharmacists recruited through the Society of Hospital Pharmacists of Australia Renal Special Interest Group. The interview guide was developed based on the Theory of Planned Behaviour, which explains human behaviour as the result of attitudes, subjective norm, and perceived behavioural control. These components determine behavioural intention which is the immediate antecedent of behaviour. The interviews were recorded, transcribed verbatim, and analysed for thematic content. Results Thirteen renal hospital pharmacists were interviewed. All except one demonstrated high behavioural intention, as a consequence of positive attitudes towards the implementation of the service, favourable subjective norm, and high perceived behavioural control. The expected outcomes of the service perceived by pharmacists included benefits to patients, the renal team and the pharmacy profession, as well as financial savings due to dose optimisation and improvement of patients9 adherence. Subjective norm was favourable meaning that nephrologists, nurses and patients were thought to be receptive towards a future service. Barriers pointed out for the implementation comprised: funding, hospital administrators9 approval, time and staff shortages, academic training, relationship with physicians and attitudes of pharmacists, renal team, and patients. Facilitators included: having an interview room with access to information sources, consent from the team, access to patients9 profiles, and a full-time pharmacist with a clearly-defined role. Conclusions Pharmacists showed high willingness and perceived behavioural control to develop pharmacy services in outpatient dialysis centres. The potential barriers outlined should be taken into account, as well as the holistic approach for the successful implementation of cognitive pharmacy services.

Background Different measurements to assess antibacterial use in hospitals have been described, many of them based on the WHO Defined Daily Dose (DDD) assignments. Although WHO accepts the update of DDDs, ‘changes of DDDs should be kept to a minimum and avoided as far as possible’. Purpose To assess the utility of WHO DDD assignments to: a) measure real-world antibacterial utilisation, and b) label prescribed doses as potentially inappropriate. Materials and methods All courses of antibacterials for systemic use (therapeutic class J01) prescribed for therapeutic purpose in patients over 18 years-old and admitted during January 2011 were extracted from the electronic medical records. ‘Treatment days’ was obtained adding one to the difference between the starting and the ending dates. ‘DDDs used’ per patient were obtained dividing the dose actually used by the WHO DDD assignments. The ratio ‘DDD used’/9treatment days9 was calculated. Outliers for this ratio were estimated by the IQR rule. Results A total of 349 antibacterial courses were analysed comprising 1761.79 DDD, and representing 33.8 DDD/100 beds/day. Mean ratio ‘DDD used’/9treatment days9 was 1.29 (SD=0.76) (range 0.16 to 7.69). This ratio was below one only for penicillins, sulfonamides and lincosamides (doses used were higher than the DDD assignments). IQR for the ‘DDD used’/9treatment days9 ratio was above two for sulfonamides (IQR=2.53) and glycopeptides (IQR=2.09), identifying them as the two classes where WHO DDD assignments are more deviated from the clinical practice in our hospital. Sixteen extreme (>IQR×3) and 12 mild (>IRQ×1.5) outliers were identified, representing potential inappropriate prescriptions. Conclusions Except for sulfonamides and glycopeptides, WHO DDD assignments could be used as an alert-generating system for potentially inappropriate antibacterial prescribed doses in our hospital by identifying the outlier prescribed doses. Further analysis is required to exclude a potential systematic inappropriate dosing for these two classes.