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Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433. [ABSTRACT FROM AUTHOR]

A prospective cross-sectional study was conducted to analyse the drugs prescribed to the elderly population with noncommunicable diseases and to determine the polypharmacy at a primary care clinic in Negeri Sembilan, Malaysia. The study was conducted for 6 months at the primary care clinic of Gemas. Geriatric patients above the age of 65 and diagnosed with noncommunicable diseases were included upon providing written informed consent. The majority of the geriatric patients were between 65 and 69 years (mean: 69.72 ± 2.85) and prescribed 4 or more medications (mean: 5.18 ± 0.64, p = 0.007). More than 95% (n = 295) of the geriatrics were found to have multimorbidity, in which around 45% (n = 139) had type-2 diabetes together with hypertension and dyslipidaemia. Combination therapy was prescribed to more than 97% (n = 302) of the elderly, whereas cardiovascular and endocrine medications were the most commonly prescribed. Ten prescriptions were found to have drug-related problems, prescribing cascade (80%), lack of medicine optimisation (10%), and inappropriate prescription (10%). In this study, the majority of the elderly had multimorbidity; polypharmacy was commonly seen among geriatric patients. Polypharmacy is the biggest threat to the elderly population, as it increases the chances of falls and fall-related injuries. Medicine optimisation and deprescribing will reduce the chances of drug-related problems and morbidity and mortality associated with polypharmacy and over-consumption of medications. Hence, the study recommends the health fraternity look for medication optimisation and deprescribing to reduce the future complications associated with polypharmacy. [ABSTRACT FROM AUTHOR]

In this article, we used administrative claims data from the OptumLabs Data Warehouse and American Hospital Association Annual Survey data to examine associations between hospital characteristics and uptake of biosimilar granulocyte colony-stimulating factor treatments. We found that 340B-participating hospitals and non--rural referral center (RRC) hospitals that reported owning rural health clinics were less likely to administer the lower-cost biosimilars, whereas the opposite was true for hospitals that are RRCs. To our knowledge, our study offers a first look at an underappreciated source of disparities in access to lowercost medications such as biosimilars. Results from our study reveal opportunities for targeted policies to encourage adoption of lower-cost treatments, particularly among hospitals that serve rural communities where patients often have fewer choices in care site. [ABSTRACT FROM AUTHOR]

Background: Antiarrhythmic drugs are commonly used to treat arrhythmia. However, data on the usage pattern of antiarrhythmic drugs, associated side effects, and the role of clinical pharmacist interventions in the Middle East are scarce. Objective: The purpose of this study was to describe the usage pattern, side effects, and clinical pharmacist interventions of antiarrhythmic drugs at the Sultan Qaboos University Hospital (SQUH), a tertiary care hospital in Oman. Methods: This retrospective observational study included adult patients (≥18 years) who received at least one dose of antiarrhythmic drugs at SQUH between January 2020 and December 2021. Ethical approval was obtained prior to conducting the study. Results: In total, 400 patients were enrolled in this study. Their mean age was 62.5 ± 16.6 years (range:19-96), and 55.3% (221/400) were male. Atrial arrhythmias were the most commonly observed (344/400, 86.0%). Beta-blockers (337/500, 67.4%) were the most prescribed class of drugs. The most commonly prescribed drugs were bisoprolol (263/400, 65.8%), carvedilol (65/400, 16.3%), and amiodarone (59/400, 14.8%). The majority of patients (300/400, 75.0%) received monotherapy, whereas 25% (100/400) received combination therapy. A total of 109 side effects were reported in 45 patients, resulting in an incidence rate of 11.3 %, with cardiovascular side effects accounting for the majority (41/109, 37.6%) of these. Amiodarone had the highest prevalence of adverse effects (33/109, 30.3%). A total of 122 clinical pharmacist interventions were observed in 13.0 % (52/400) of patients. Beta-blockers were associated with more than half of the interventions (61/122, 50.0%). Age (61.84 years vs. 66.75 years; p=0.047), comorbidities (83.6% vs. 96.2%; p=0.019), renal impairment (19.6% vs. 40.4%; p=0.001, heart failure (11.8% vs. 28.9%; p=0.002), concomitant medications (84.5% vs. 98.1%; p=0.004), polypharmacy (51.1% vs. 69.2%; p=0.022) and duration of therapy of less than one year (9.3% vs. 27.3%; p<0.001) was significantly associated with the need for intervention. Conclusion: Beta-blockers were the most commonly prescribed antiarrhythmic drugs in SQUH. Amiodarone was associated with the highest prevalence of side effects. Clinical pharmacy intervention at the SQUH was mainly related to antiarrhythmic drug selection and dose optimization. [ABSTRACT FROM AUTHOR]

Background: Although polypharmacy is considered a major predictor of irrational use of drugs, little is known about polypharmacy in developing regions. We aimed to indicate the prevalence and correlates of polypharmacy and to determine the medication profile at the population level in southern Iran. Methods: In this cross-sectional study, we analyzed data from participants of the Pars Cohort Study (PCS) (aged above 40 years, N = 9269). Polypharmacy was defined as using five or more medications concurrently. A Poisson multivariable model was applied to estimate the adjusted prevalence ratios (APRs) of various risk factors. The Anatomical Therapeutic Chemical (ATC) classification system was used for classifying medications. Results: Prevalence of polypharmacy was 10.4%, (95% CI: 9.75; 11.08) and it was higher among females (15.0%), older adults (age ≥ 65 years) (16.0%), and individuals with more than two chronic conditions (31%). Being female, educated, married, and not having a low socio-economic class were independently associated with a higher likelihood of polypharmacy. The most prevalent medications among female participants were sex hormones and modulators of the genital system (58.4%), drugs for acid-related disorders (14.6%), and anti-anemic preparations (13.6%,). On the other hand, males were using acid-related disorders (14.6%), anti-inflammatory and anti-rheumatic products (7.8%), and beta-blocking agents (6.3%). Conclusion: The prevalence of polypharmacy in our sample was relatively low, especially among males. Cardiovascular drugs, acid suppressants, hormonal contraceptives, and anti-anemic preparations are drug classes with the highest contribution to polypharmacy. [ABSTRACT FROM AUTHOR]

Background: Drug utilization evaluation (DUE) is defined by the World Health Organization (WHO) and focuses on the medical, social, and economic consequences of pharmaceutical marketing, distribution, prescribing, and usage in society. The WHO recommends a physician to every 1 000 people. According to the recent data from the Health Ministry in 2019, in which 1.16 million doctors are of active population with just 80%, or 0.9 million, practicing. As a result, a ratio of 0.68 doctors for every 1 000 people, which is much below as per the WHO reports. This article describes history, types, WHO guidelines, need and purpose of DUE. Objective: The main aim of this paper is to provide information about the rational use of medication in outpatient and inpatient department with special emphasis of DUEs. It also provides awareness directly to healthcare professionals, researchers, academicians, pharmacist and nurses to reduce the irrationality of medicines. Methods: The method used to compile this review information gathered from websites, Google scholar, PubMed, Research gate, and studies published on DUE from July 20 to Oct 22 were included as source of information. Results: We studied more than 35 published study on DUE, that reveals most of the physicians prescribed branded drugs not generic drugs, but WHO prescribing indicator allows to prescribe generic drugs in the hospital pharmacy to maintain better inventory control. It may also help to prevent pharmacist misunderstanding during dispensing. Conclusion: The use of generic prescription names avoids the possibility of medication product duplication and lowers patient costs. It is important to remember that incorrect medication prescriptions have impact on both patients and their family members. WHO indicators identify irrational prescribing behaviours to make therapy more rational and cost-effective. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate changes in drug utilization pattern of antidiabetic drugs on prospective follow-up of new and recently diagnosed type 2 diabetes mellitus patients along with their 10-year cardiovascular risk assessment. Methods: A prospective observational hospital-based study was conducted among new and recently diagnosed (≤ 6 months) type 2 diabetes patients attending the medicine outpatient department (OPD) at tertiary care teaching hospital, Raipur, after taking written informed consent. Antidiabetic drug prescription and socio-demographic characteristics were noted in the Case Record Form. Recruited patients were followed up at 3, 6, and 9 months. Ten-year cardiovascular risk was determined using the QRISK®3 risk calculator. Result: A total of 90 patients, 48 (53.33%) new and 42 (46.67%) recently diagnosed type 2 diabetes patients, were recruited. An average number of antidiabetic drugs prescribed in patients was 2.1 at the final visit. The average daily dose of antidiabetic drugs was assessed against the WHO/ATC-defined daily dose (DDD). It was decreased for metformin and other antidiabetic drugs, except for glimepiride. More than one-third of patients had a QRISK3 score >10% at each visit. Conclusion: This study highlighted that patient education and periodic review of prescription of new and recently diagnosed diabetic patients play a vital role in managing type 2 diabetes mellitus by tailoring treatment regimen. The present study revealed overtreatment of low-risk groups and under-treatment of high-risk groups based on QRISK3 score and statins. This observation signifies that risk stratification is essential for preventing CVD risks in new diabetic patients. [ABSTRACT FROM AUTHOR]

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433. [ABSTRACT FROM AUTHOR]

Introduction: The etiology of hypertension in post renal transplant patients is multifold and effective control of blood pressure (BP) contributes towards proper graft functioning and reduces risk of cardiovascular diseases. This prospective observational study was undertaken to evaluate the prevalence of antihypertensive drug use, the prescribing pattern and trends of blood pressure control in a cohort of post renal transplant patients from eastern India. Materials and Methods: Patients who had undergone renal transplant in this public hospital were enrolled as per eligibility criteria. All enrolled patients were on antihypertensive from at least 3months prior to transplant and were followed upto one year post-transplant. Antihypertensive drug (AHD) and immunosuppressant intake, BP recordings and occurrence of major adverse cardiac events (MACE), if any were noted at each visit. Results: 56 patients were enrolled with a mean age of 33.04 ± 9.96 years, 87.5% were male. 75% were hypertensive at discharge (2-3 weeks post-transplant). Percentage of patients on AHD at 3, 6, 9 and 12 months post-transplant were 83.9%, 82.1%, 75% and 71.4% respectively. Amlodipine was the most common prescribed AHD. Target BP control (≤130/80 mm of Hg) was achieved in 62.5% patients at 1year post-transplant. There were no major adverse cardiac events (MACE) during the study period. Conclusion: In our study comprising of a relatively young cohort of transplant patients from India, hypertension control was well achieved in majority of the subjects and no MACE were noted. Amlodipine was the most commonly used AHD either as monotherapy or in combination with beta-blocker. Long term follow up of this cohort shall provide further insights into the trends of such control. [ABSTRACT FROM AUTHOR]

Background: Snake bites are a common cause of morbidity and mortality, especially in tropical countries. Snake bites in any community are managed based on the clinical features and intravenous administration of antisnake venom (ASV). The administration of ASV is either deficient or given in excess based on clinical decisions and whole blood clotting test results. The present study is designed to analyze the level of snake venom component in the blood of snake bite in association with the clinical features. Patients and methods: Blood samples were collected from the patients admitted to Karnataka Institute of Medical (KIMS) hospital with a history of snakebite considering the inclusion criteria. Serum was collected from the blood of snakebite patients before and after ASV and used to assess the level of venom-specific phospholipase A2 (PLA2) enzyme using the enzyme-linked immunosorbent assay (ELISA) method. Results: Quantitative ELISA results revealed that the snake venom-specific PLA2 in the victim's blood was in the range of 0.3-1.27 mg/mL before the administration of ASV. However, the concentration of PLA2 after 24 hours of ASV administration was decreased in most of the patients. Further, it was observed that envenomation complications were directly proportional to the amount of snake venom-specific PLA2 found in the blood of the snakebite patient. Conclusions: The study concludes that snake venom-specific PLA2 in the blood of snakebite patients could be used as a reliable venom marker, which helps in determination of appropriate ASV dosage in snakebite patients. [ABSTRACT FROM AUTHOR]

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433. [ABSTRACT FROM AUTHOR]

Introduction: Urolithiasis causes severe acute pain and is commonly treated with opioid analgesics in the emergency department (ED). We examined opioid analgesic use after episodes of acute pain. Methods: Using data from a longitudinal trial of ED patients with urolithiasis, we constructed multivariable models to estimate the adjusted probability of opioid analgesic use 3, 7, 30, and 90 days after ED discharge. We used multiple imputation to account for missing data and weighting to account for the propensity to be prescribed an opioid analgesic at ED discharge. We used weighted multivariable regression to compare longitudinal opioid analgesic use for those prescribed vs not prescribed an opioid analgesic at discharge, stratified by reported pain at ED discharge. Results: Among 892 adult ED patients with urolithiasis, 79% were prescribed an opioid analgesic at ED discharge. Regardless of reporting pain at ED discharge, those who were prescribed an opioid analgesic were significantly more likely to report using it one, three, and seven days after the visit in weighted multivariable analysis. Among those who were not prescribed an opioid analgesic, an estimated 21% (not reporting pain at ED discharge) and 30% (reporting pain at discharge) reported opioid analgesic use at day three. Among those prescribed an opioid analgesic, 49% (no pain at discharge) and 52% (with pain at discharge) reported using an opioid analgesic at day three. Conclusion: Urolithiasis patients who received an opioid analgesic at ED discharge were more likely to continue using an opioid analgesic than those who did not receive a prescription at the initial visit, despite the time-limited nature of urolithiasis. [ABSTRACT FROM AUTHOR]

Background: Ankle fracture surgery is a common procedure with many patients receiving opioid medications for postoperative pain control. Whether there are factors associated with higher medication quantities or patient-reported outcomes, however, remains largely unknown. Methods: Patients with isolated, rotational ankle fractures who underwent surgical fixation between January 2018 and March 2020 were retrospectively reviewed. Patient demographics, injury characteristics, and preoperative and postoperative opioid prescription information were recorded. Clinical follow-up and Foot and Ankle Ability Measure (FAAM) questionnaires were collected at 6 weeks and 3 months postoperatively. Multiple linear regression was used to examine the influences of age, sex, body mass index (BMI), fracture characteristics, medical comorbidities, and preoperative opioid use (OU) on postoperative opioid morphine milligram equivalent (MME) amount and FAAM scores. Results: A total of 294 patients were included with an average age of 52.11 ± 17.13 years (range, 18-97). Fracture types were proportional to one another. Chronic pain (mean = 145.89, 95% CI = 36.72, 255.05, P = .0009), preoperative OU (mean = 178.22, 95% CI = 47.46, 308.99, P = .0077), psychiatric diagnoses (mean = 143.81, 95% CI = 58.37, 229.26, P = .001), tobacco use (mean = 137.37, 95% CI = 33.35, 229.26, P = .0098), and trimalleolar fractures (mean = 184.83, 95% CI = 86.82, 282.84, P = .0002) were associated with higher postoperative opioid MME amounts. Older age (mean = –0.05, 95% CI = –0.08, –0.02, P = .0014) and higher BMI (mean = –0.06, 95% CI = –0.12, 0.00, P = .048) were both independently associated with lower FAAM scores at 6 weeks. At 3 months, higher BMI (mean = –0.09, 95% CI = –0.13, –0.04, P = .0002), bimalleolar fractures (mean = –1.17, 95% CI = –2.17, –0.18, P = .021), and higher postoperative MME amounts (mean = –0.10, 95% CI = –0.19, –0.01, P = .0256) were each independently associated with lower FAAM scores. Conclusion: In this study, we found that patients with chronic pain, preoperative OU, psychiatric diagnoses, tobacco use, and trimalleolar fractures were more likely to have higher amounts of opioid prescribed following ankle fracture surgery. However, only age, BMI, bimalleolar fractures, and postoperative MME amount were associated with lower FAAM scores postoperatively. [ABSTRACT FROM AUTHOR]

Depression is a prevalent mental health condition treated with antidepressants and other psychotropic medications. This study aimed to assess the utilization pattern of antidepressants among patients visiting the outpatient clinic of the psychiatry department of a tertiary care hospital. The study included the patients who visited the study site and fulfilled the mental and behavioral diagnostic criteria for depression. The demographic and clinical details, including drugs prescribed, were documented in a study-specific data collection form. The ratio of Prescribed Daily Dose to Defined Daily Dose (PDD: DDD) was calculated to assess the adequacy of antidepressant utilization. Data total of 154 patients were collected. A total of 22 psychotropic drugs were used among the study patients as mono (n = 70), dual (n = 69), triple (n = 10), or quadruple therapy (n = 1). Escitalopram was the most often prescribed antidepressant out of the nine antidepressants alone and in combination and was used in slightly high doses (PDD: DDD ratio 1.6). Sertraline, paroxetine, and desvenlafaxine, were used in adequate doses (PDD: DDD between 1 and 1.1), and fluoxetine, duloxetine, amitriptyline, imipramine, and mirtazapine, were used in inadequate doses (PDD: DDD <0.5). Our study findings reveal the need for continuous assessment of antidepressants medications usage in a hospital set up. [ABSTRACT FROM AUTHOR]

Background: The potential benefit of regional interventions for simple lumpectomy breast cancer surgeries has not been well investigated. Understanding which patients to not offer a regional intervention to can be just as important as knowing which would benefit. It is unclear whether fascial plane blocks, such as serratus anterior plane (SAP) block, should be routinely performed for less extensive breast surgeries. Therefore, our goal in this retrospective cohort study was to evaluate the association of integrating SAP blocks into a standard perioperative multimodal analgesia plan in patients undergoing simple lumpectomies (without node biopsies) with perioperative opioid consumption. As secondary outcomes, we also analyzed postoperative pain scores and post-anesthesia care unit (PACU) length of stay. Methods: This was a single institution retrospective cohort study (surgical site infiltration only versus SAP block cohorts) assessing the association of SAP blocks to our outcomes of interest. In the adjusted analysis, we created matched cohorts using 1:1 (surgical site infiltration only: SAP block) propensity-score matching using nearest neighbor-matching without replacement. To compare the primary and secondary outcomes in the matched cohorts, we used the Wilcoxon signed rank test. A P-value of < 0.05 was considered statistically significant. Results: There were 419 patients included in the analysis, in which 116 (27.7%) received a SAP block preoperatively in addition to our standard perioperative analgesia plan. In an unadjusted analysis, no differences were seen in perioperative opioid consumption, PACU pain scores, and PACU length of stay. Among the matched cohorts, the median [quartile] perioperative opioid consumption in the surgical site infiltration only versus SAP block cohorts were 10 mg [10, 13.25 mg] and 10 mg [7, 15 mg], respectively (P = 0.16). No differences were seen in the other outcomes. Conclusions: In this study, we evaluated the impact of SAP blocks on patients undergoing simple lumpectomies, which are relatively less involved breast surgeries. We concluded that routine use of preoperative regional anesthesia is not beneficial for these specific patients. Future studies should focus on identifying patients that would directly benefit from regional interventions. [ABSTRACT FROM AUTHOR]

Background: Our study objective was to assess if multi-modal analgesia with meperidine-ketorolac combination provides superior analgesia or reduces opioid requirement following surgery compared to meperidine alone. Design: Double-blind randomized controlled trial. Setting: Postoperative pain control in orthopedic ward after spinal anesthesia. Patients: American Society of Anesthesiology (ASA) risk I or II (ASA I/II) patients who had lower limb implant surgery (88) at our center from September 2014 to July 2015. Interventions: Patients were randomly assigned to receive either 1 mg/kg of intravenous (IV) meperidine and 30 mg of IV ketorolac (treatment group) or 1 mg/kg of IV meperidine (control group) post-surgery, administered every hour for the first 6 hours during the first 24 hours post-surgery. In addition, patients received intravenous meperidine on an 'as needed basis' during the first 24 hours of the postoperative period. Measurements: Outcomes were time-to-first analgesia request postoperatively; cumulative opioid dose in first 24 hours post-surgery; frequency of side effects; and patient satisfaction with pain relief using a Likert scale. Numerical rating scale (NRS) pain scores hourly for the first 6 hours, then the 8th, 12th, 16th, 18th and 24th hour post-surgery were assessed. Results: There was a significant delay in time of first request for analgesia (460 min vs 225 min; P=0.03) and a reduction in opioid consumption in 24 hours (299 mg vs 325 mg; P=0.01) in the meperidine/ketorolac group compared with the meperidine alone group which were both statistically significant. Patient satisfaction with pain relief was better in the treatment group (P=0.01). Additionally, there were fewer side effects in the treatment group than in the control group but this was not statistically significant. Conclusions: Adding ketorolac to meperidine reduced postoperative pain, reduced patient daily opioid requirement, increased patient satisfaction with pain relief, without increasing the frequency of side effects. Therefore, IV ketorolac addition to opioids may be a reasonable option in multimodal analgesic protocol. [ABSTRACT FROM AUTHOR]

Background and aims: Coronavirus disease of 2019 (COVID-19) has emerged as a pandemic and increasing numbers of patients are being admitted to dedicated COVID hospitals in a city. Since patients were being prescribed investigational, off label, and some approved drugs, it is important to understand and document prescription and drug utilization patterns. Material and methods: A prospective observational study was conducted on 1164 RT-PCR positive COVID-19 patients admitted to a dedicated COVID-19 tertiary care hospital. Treatment given to patients with COVID-19 was recorded and evaluated with respect to the place of admission, that is, wards or Intensive Care Unit (ICU). Descriptive statistics were used for the evaluation of data. Results: Among the 1164 patients, 670 (57.5%) patients were admitted to the wards while 494 (42.4%) patients were admitted to the ICU. The mortality rate of study participants was 4.1%. Ceftriaxone (39.27%) was the most commonly prescribed antibiotic in the ICU patients while azithromycin (79.10%) was the most prescribed antibiotic in wards patients. 242 (48.98%) patients received dexamethasone whereas methylprednisolone was administered to 88 (17.81%) patients. Remdesivir was administered to 48% of the patients in our study. Conclusion: We observed high rates of mortality in patients with one or more comorbidities having SpO2 less than 65. Concordance and adherence to the line of treatment as recommended by Ministry of Health and Family Welfare/ICMR guidelines were discerned. Rational use of antimicrobials is warranted to curb antibiotic resistance and opportunistic infections since most of the patients received empirical therapy. [ABSTRACT FROM AUTHOR]

Introduction: Due to the abbreviated approval pathway and extrapolation to non-studied indications, an increased importance is placed on post-marketing surveillance of biosimilars to supplement existing evidence and enhance patient and provider confidence. Bevacizumab-awwb (ABP 215, Mvasi) was the first biosimilar approved to bevacizumab (Avastin), a recombinant humanized monoclonal IgG1 antibody that inhibits the vascular endothelial growth factor (VEGF). Purpose: To evaluate utilization, safety, and financial outcomes of bevacizumab-awwb compared to bevacizumab at a national cancer institute (NCI)-designated cancer center. Methods: A single center, retrospective, 1:1 indication-matched cohort study of adult patients who received bevacizumab or bevacizumab-awwb between October 1, 2019 and October 1, 2020 was performed. Thirty-four patients received bevacizumab-awwb during the study period and were matched by indication to 34 randomly selected patients who received bevacizumab. Indications for both groups included: colorectal cancer (n = 19), gynecologic cancer (n = 10), glioblastoma (n = 3), hepatocellular carcinoma (n = 1), and lung cancer (n = 1). Results: Baseline and medication utilization characteristics were similar for this indication-matched cohort of 68 patients receiving bevacizumab-awwb or bevacizumab. Patients in the bevacizumab group had a higher proportion of public payer coverage (64.7% vs 38.2%, P =.029). A higher proportion of patients in the bevacizumab-awwb group remained on active treatment at the end of the study period (52.9%) as compared to the bevacizumab group (35.3%); however, differences in final treatment status and reasons for discontinuation were not statistically significant (P =.218). Rates of worsened hypertension (44.1% vs 44.1%) and worsened proteinuria (38.2% vs 23.5%, P =.077) were common in both groups. Grade 3 adverse drug events in the bevacizumab group included: gastrointestinal perforation (n = 1), gastrointestinal bleed (n = 1), hypertension (n = 2), and venous thromboembolism (n = 2). Grade 3 adverse drug events in the bevacizumab-awwb group included: epistaxis (n = 1), gastrointestinal bleed (n = 1), hypertension (n = 1), intracerebral hemorrhage (n = 1), venous thromboembolism (n = 3), and arterial thromboembolism (n = 1). One patient in the bevacizumab-awwb group experienced grade 4 hypertension. Median drug cost per dose and per milligram for bevacizumab-awwb was less than bevacizumab, representing a 15.8% and 12.1% discount, respectively. Conclusion: Utilization and safety outcomes were similar for this indication-matched cohort of 68 patients receiving bevacizumab or bevacizumab-awwb across a wide range of disease states. [ABSTRACT FROM AUTHOR]

Objective. To investigate the patients with stable chronic obstructive pulmonary disease (COPD) to understand the use of double bronchodilator therapy and influencing factors. Methods. The patients with stable COPD who used double bronchodilators were continuously enrolled in our hospital. The information of demographic characteristics, medical history, physical examination, drug use, and correct treatment methods after using inhaled drugs were collected by standardized questionnaire. Measurement data between groups were compared by using the independent sample t-test, and counting data between groups were compared by using the chi-square test. Results. A total of 102 patients were included in the analysis. The proportion of patients with stable COPD who correctly used dual bronchodilators was 59.8% (61 patients). In the GOLD classification, the correct use rate of C-level patients was 69.8%, which was significantly higher than the used correct rate of D-level patients (49.0%) (P = 0.032). In the age group, the correct use rate of patients <65 years old was 72.1%, which was significantly higher than that of patients ≥65 years old (50.8%) (P = 0.031). In addition, education level, duration of drug use, and drug type may also affect the correct use of drugs, but no significant statistical significance was found between the groups of these three factors (P > 0.05). Conclusion. There is still a gap between the treatment of dual bronchodilators in patients with stable COPD and the guidelines, so the management of COPD should be strengthened. Besides, the correct use rate could be affected by the GOLD classification and age. [ABSTRACT FROM AUTHOR]

The article presents the discussion on hospital-based opioid stewardship program focusing on improving the prescribing, utilization, and monitoring of opioids. Topics include resulting in increased risk of various harms in the community such as development of an opioid use disorder, overdose, or opioid-induced hyperalgesia; and several consulting services operating within the hospital for addressing issues related to pain and addiction.

Background: Immediate postoperative pain in the postanesthesia care unit (PACU) is common. Titration of opioid is the most popular strategy for controlling early postoperative pain. ABO blood group has been found to be associated with pain perception. We aimed to find the factors including ABO blood group for predicting the amount of opioid requirement in PACU. Methods: This prospective cohort study was performed in 3316 patients who underwent various kinds of anesthetic techniques and received immediate postoperative care in PACU. Preoperative, intraoperative and PACU data were collected. A directed acyclic graph (DAG) representing the hypothesized causal pathways of preoperative, intraoperative and PACU data were compiled prior to conducting multinomial logistic regression analysis. Statistical significance in all models was defined as a P-value < 0.05. Results: Female sex, body mass index, preoperative use of gabapentin, preoperative anxiety score, anesthetic techniques, type of operation, amount of consumed intraoperative opioids, intraoperative use of paracetamol, parecoxib and ondansetron, duration of anesthesia and surgery, amount of blood loss, pain upon PACU arrival, use of paracetamol and parecoxib in PACU were found to be factors influencing amount of opioid consumption in PACU. ABO blood group was not associated with early postoperative opioid requirement. Conclusions: A significant number of factors are related to amount of opioid requirement in PACU. Some factors can be adjusted to provide better pain relief in early postoperative period. However, ABO blood group is not identified to be a predictive factor for early postoperative opioid consumption in PACU. [ABSTRACT FROM AUTHOR]

Information on the burden of healthcare-associated infections (HAIs) and patterns of antibiotic use are prerequisites for infection prevention and control (IPC) and antibiotics stewardship programmes. However, a few studies have been reported from resource-limited settings and many of them have not used standard definitions to diagnose HAI precluding benchmarking with regional or international data. This study aims to estimate the prevalence of HAIs and antibiotic use in our centre. We conducted a point prevalence survey in a 350-bed university hospital in Kathmandu, Nepal in April 2019. We reviewed all patients aged ⩾ 18 years admitted to the hospital for at least two calendar days and evaluated for the three common HAIs—pneumonia, urinary tract infection and surgical site infection. We used the clinical criteria by the European Center for Disease Prevention and Control to diagnose the HAIs. We also collected information on the antibiotics used. Of 160 eligible patients, 18 (11.25%) had HAIs and 114 (87.5%) were on antibiotics, with more than half of them (61/114 patients, 53.5%) receiving two or more antibiotics. This highlights the need for effective implementation of IPC as well as antibiotics stewardship programmes in our centre. [ABSTRACT FROM AUTHOR]

Background: Children are dependent on their parents for medication administration. Parents' attitudes and behaviors toward the use of medicine affect their children's diseases and treatment processes. This study aimed to determine parental attitudes and behaviors toward the rational use of medicines in primary school children. Methods: It was conducted at a primary school located in XX between September and November 2018. The study sample included parents of 371. Study data were collected using a Sociodemographic Information Form and the Rational Use of Medicine Questionnaire. Results: Of the parents, 44.5% used non-prescription medications when their children became sick. Based on the parents' education levels, there were statistically significant differences among parents' status of reading the package insert of the medicine, checking the expiration dates of the medicine stored at home, increasing or reducing the medication dosage provided by a physician without consulting them, and using antibiotics without prescriptions. Conclusions: The parents were found to exhibit irrational behavior in the use of medicines with their children. Therefore, parents should be provided with educational training about rational medication usage in primary health care organizations. It is also recommended to provide health education for parents on rational drug use. [ABSTRACT FROM AUTHOR]

To investigate the association between a recorded procedure code for a medication review and adequate drug treatment management, and to explore factors associated with this code. Cross-sectional study; two primary health care centres, in Region Västra Götaland, Sweden. A total of 302 consecutive patients (≥65 years old, 59% female; median number of drugs: six) requiring a non-urgent consultation with a physician in October–November 2017. Adequate drug treatment management (treatment that did not require any further action), determined in consensus by two specialists in family medicine blinded to the medication review code. Adequate drug treatment management was, overall, less common in those with a recorded medication review over the last year: 63% versus 73% (p = 0.047). This negative association was evident among patients aged 65–74 years: 49% versus 74% (p = 0.003), but absent in those ≥75 years old: 67% versus 70% (p = 0.77). Recommendations from consensus included the search for additional information to be able to make a decision regarding initiation or withdrawal of a drug (n = 53), withdrawal of a drug (n = 41), or ordering a laboratory test (n = 25). Factors associated with a recorded procedure code included age above the remuneration limit of 75 years (odds ratio: 9.8; 95% confidence interval 5.0–19), type 2 diabetes (3.0 (1.5–6.2)), hypertension (2.4 (1.2–4.8)), and depression (2.5 (1.02–6.0)). The presence of a recorded medication review was not positively associated with adequate drug treatment management but was associated with the age limit for remuneration, and some chronic diseases. To improve drug treatment in older people in primary care, a remuneration system linked to recorded medication reviews has been introduced. In this study, fewer patients with than without a recorded medication review (63% versus 73%) had adequate drug treatment management. A recorded medication review was ten times more common in those ≥75 years, that is, the age limit for remuneration. Recorded codes for medication reviews were also common in those with type 2 diabetes, hypertension, and depression. [ABSTRACT FROM AUTHOR]

Background In May 2011, the Portuguese Government signed a Memorandum of Understanding with the European Commission, the European Central Bank and the International Monetary Fund, including detailed measures to control health costs, allowing Portugal to receive a financial rescue package. This study aims to investigate medicines utilization in the outpatient sector during Troika's financial rescue. Methods Using Defined Daily Dose per million inhabitants per year as a measurement unit, we compared medicines utilization with other relevant indicators over 5-year intervals for a total period of 20 years, based on a built-in inventory of national outpatient drug use using the Intercontinental Medical Statistics Health and Anatomical Therapeutic Chemical index of the World Health Organization databases. The calculation was made on the basis of both compound and year-on-year growth rates. Results With the exception of the interval 2009–11, an absolute rise in consumption was observed over the 20-year period. The downturn occurred prior to financial rescue, when expenditure management mechanisms were already in place, and coincided with an increase in out-of-pocket spending. With the decline of cost for patients, the access trend returned to being positive, but at a slower pace. Conclusion The rise in out-of-pocket and austerity measures may have led to decreased access to medicines. The findings of this study suggest that this impact was influenced by public cost-saving policies implemented even before the financial rescue. The results show that price reduction attenuated the repercussion of the measures. [ABSTRACT FROM AUTHOR]

Background: Incorrect and unnecessary drug use is a problem that affects health. Irrational drug therapy causes reduced treatment compliance, drug interactions, resistance to some drugs, recurrence of diseases, prolonged treatment, increased frequency of side effects and increased treatment costs. Therefore, it is important to evaluate the rational drug use of patients. Objective: The purpose of the study is to find out the knowledge and behaviors of inpatients in internal medicine clinics about rational drug use. Methods: It is cross-sectional study. The study was conducted in internal medicine clinics of a hospital. The study was conducted with 372 patients in internal medicine clinics between May 2017 and November 2017. Data collected with "Rational Drug Use Inpatient Survey" prepared by the Republic of Turkey. Results: It was determined that 74.2% of the patients in research group had at least one chronic illness, 61% of them used drug consistently, 48.1% of the patients did not read prospectus, 18% of the participant used drug upon the advice of relatives, 21.8% of the person requested the doctor to prescribe analgesic in case, 9.7% of the patients bought a drug in a drugstore without a prescription. The distinction between age, gender, education level, income status, chronic illness, consistently drug use and prospectus reading rate was found statistically significant (p<0.05). There was statistically significant distinction between the rate of buying a drug in a drugstore without a prescription and education level (p<0.05). Conclusion: In the study, it was found that the patients' drug use behaviors were rational, but not in expected levels. [ABSTRACT FROM AUTHOR]

Introduction: The utilization of prescription drugs as off-label is common. While this practice can be beneficial to some patients, it can raise a safety concern when scientific evidence is lacking; hence, this study was conducted to evaluate the off-label drug consumption and its adverse drug reactions (ADRs) in the medical intensive care unit (ICU). Materials and methods: In the prospective cohort study conducted for a duration of 6 months, data pertaining to ICU patients' (age ≥18 years) demography, diagnosis, treatment, and laboratory investigation were collected to assess for off-label use as well as the strength of evidence and the occurrence of ADRs by using MICROMEDEX 2017 version (Healthcare Series Thomson Reuter, Greenwood, CO). Results: Of total 3574 drugs prescribed, 1453 (41%) were off-label indications and 65 (1.81%) were off-label dose. On the evaluation of off-label indication use, 1279 (88%) were evidence-based and 174 (12%) were low/no evidence-based medications (EBMs); 59 (91%) were evidence-based and 6 (9%) were low/no EBMs for off-label dose. Most commonly prescribed evidence-based off-label drug belonged to the gastrointestinal class while low/no evidence drugs were mostly of anti-infective class. A total of 383 ADRs were identified and 139 (36.2%) were implicated due to off-label medications, of which ADRs with evidence off-label medications (87.8%) were higher than low/no evidence off-label medication (12.2%) (P < 0.001). Conclusion: Widespread presence of off-label use was observed in medical ICU. Although incidence of ADRs was similar to the FDA-approved use, ongoing monitoring of such practice is needed. [ABSTRACT FROM AUTHOR]

Background: Few studies have compared clinical outcomes and medication use between obese and nonobese children in the pediatric intensive care unit (PICU). Objectives: The primary objective was to compare clinical outcomes including mortality, PICU length of stay (LOS), and mechanical ventilation (MV) requirement between obese and nonobese children. Secondary objectives included analysis of factors associated with these outcomes and medication use between groups. Methods: This retrospective study included children 2 to 17 years old admitted to the PICU over a 1-year time frame. Patients were categorized as obese, body mass index (BMI) ≥ 95th percentile, and nonobese (BMI < 95th percentile). Three binary regression models assessed the impact of obesity on clinical outcomes. Results : There were 834 admissions, with 22.1% involving obese children. There was no difference in mortality, MV requirement, or PICU LOS between groups. There were no associations with obesity and clinical outcomes found, but an association was noted for medication classes and receipt of continuous infusions on clinical outcomes. There was no difference noted in the median number (interquartile range [IQR]) of medications between obese and nonobese children, 8 (6-13) versus 9 (6-15), P =.38, but there was a difference in patients receiving a continuous infusion between obese and nonobese children, 24.4% versus 8.8%, P <.01. The 15 most used medications in both groups included analgesics, antimicrobials, corticosteroids, bronchodilators, and gastrointestinal agents. Conclusions : One-fifth of all admissions included obese children. Obesity was not associated with mortality, PICU LOS, and MV requirement, but the number of medication classes and continuous infusions were associated with these outcomes. [ABSTRACT FROM AUTHOR]

Purpose. The purpose of this study was to assess the efficacy and safety of intraocular direct cyclophotocoagulation (IDCP) using a 532 nm laser with combination treatment in reducing intraocular pressure (IOP) for patients with advanced neovascular glaucoma (NVG) with angle closure. In addition, we sought to determine the success rate and frequency of complications and explore an optimized solution to reduce the number of topical medications and the pain of patients. Methods. A retrospective case note review of all patients undergoing combined treatment including IVR, phaco, PPV, PRP, and IDCP from January 2017 to June 2018. Results. In total, 24 consecutive patients (25 eyes) were reviewed. The mean IOP was significantly decreased from 42.2 ± 8.5 mmHg preoperatively to 15.56 ± 2.0 mmHg (P < 0.0001), and no neovascularization of the iris (NVI) reoccurred at month 18. The number of medications used was reduced from 2.72 ± 0.45 preoperatively to 0.87 ± 0.40 at month 18 (P < 0.0001). Conclusions. During 18 months of follow-up, the combined treatments were safe and had a significant IOP-lowering effect. This study provides a new method of performing IDCP with a 532 nm laser, allowing for the use of internal cyclophotocoagulation without extra equipment. [ABSTRACT FROM AUTHOR]

Background: Postoperative pain and analgesic use after arthroscopic rotator cuff repair remain important issues that affect rehabilitation and overall outcomes. Purpose: To evaluate the pre- and intraoperative factors that may cause prolonged duration of postoperative pain and analgesic use. Study Design: Case-control study; Level of evidence, 3. Methods: We included 443 patients who underwent arthroscopic rotator cuff repair and subacromial decompression. Visual analog scale (VAS) scores for pain were obtained preoperatively and at 30 and 90 days postoperatively. Patients were divided into a group who had prolonged postoperative pain (duration ≥1 and <3 months; n = 86 patients) and a group with nonprolonged pain (duration <1 month; n = 357 patients). The following factors were compared between groups: age, sex, body mass index, repair technique, tear size, retraction amount, repair tension, tendon degeneration, preoperative pseudoparesis, symptom duration, application of microfracture to the rotator cuff footprint for marrow stimulation, smoking, degree of fatty degeneration, preoperative narcotic analgesic use, diabetes, acromioclavicular joint degeneration, and preoperative Douleur Neuropathique 4 (DN4) and American Shoulder and Elbow Society (ASES) scores. Results: Significant differences were seen between the prolonged and nonprolonged groups regarding the median duration of pain (54 vs 27 days, respectively; P <.001) and analgesic use (42 vs 28 days, respectively; P <.001). Significant differences were noted between the groups for symptom duration (P =.007), smoking status (P =.001), degree of fatty degeneration (P =.009), preoperative narcotic analgesic use (P <.001), preoperative DN4 and ASES scores, 30-day VAS score (P <.001), duration of opioid and nonopioid analgesic use (P <.001), tear size (P =.026), and retraction stage (P =.032). Tear size (P =.009), retraction amount (P =.005), preoperative narcotic analgesic use (P <.001), degree of fatty degeneration (P <.001), and preoperative DN4 score (P =.024) were factors independently associated with prolonged postoperative pain and analgesic use. Conclusion: Patients with larger size tears, retracted tendons, preoperative use of narcotic analgesics, higher tensioned tendon after repair, and Goutallier grade 3 or 4 fatty degeneration faced an increased risk of prolonged postoperative pain and analgesic use after arthroscopic rotator cuff repair. These factors might be mitigated by psychosocial support; gentle, controlled, and individualized postoperative rehabilitation approaches; detailed preoperative evaluation; and closer follow-up of patients who are treated operatively. [ABSTRACT FROM AUTHOR]

We studied variation in perioperative opioid use after total joint arthroplasty with respect to patient and procedure characteristics in order to inform initiatives to optimize pain relief. We recorded perioperative opioid consumption for a cohort of total joint arthroplasty patients to identify factors underlying variation in perioperative opioid use. Younger patient age, tobacco use, greater symptoms of depression, private insurance, and knee arthroplasty were associated with increased opioid consumption. Awareness of the patient characteristics associated with increased perioperative opioid use can help inform implementation of targeted strategies for safe, optimal pain relief and satisfaction. [ABSTRACT FROM AUTHOR]

Background: The inappropriate and/or high prescribing of benzodiazepine and 'Z' drugs (BDZ +) is a major health concern. The purpose of this study was to determine whether physician or pharmacist led interventions or a simple letter or a personalized prescribing report from a medical regulatory authority (MRA) was the most effective intervention for reducing BDZ + prescribing by physicians to patients 65 years of age or older. Methods: This was a four-armed, one year, blinded, randomized, parallel-group, investigational trial in Alberta, Canada. Participants were fully licensed physicians (n = 272) who had prescribed 4 times the defined daily dose (4 + DDD) or more of any BDZ + to an older patient at least once in the 3rd quarter of 2016. All physician-participants were sent a personalized prescribing profile by the MRA. They were then randomized into four groups that received either nothing more, an additional personal warning letter from the MRA, a personal phone call from an MRA pharmacist or a personal phone call from an MRA physician. The main outcomes were prescribing behavior change of physicians at one year in terms of: change in mean number of older patients receiving 4 + DDD BDZ + and mean dose BDZ + prescribed per physician. To adjust for multiple statistical testing, we used MANCOVA to test both main outcome measures simultaneously by group whilst controlling for any baseline differences. Results: All groups experienced a significant fall in the total number of older patients receiving 4 + DDD of BDZ + by about 50% (range 43–54%) per physician at one year, and a fall in the mean dose of BDZ + prescribed of about 13% (range 10–16%). However, there was no significant difference between each group. Conclusions: A personalized prescribing report alone sent from the MRA appears to be an effective intervention for reducing very high levels of BDZ + prescribing in older patients. Additional interventions by a pharmacist or physician did not result in additional benefit. The intervention needs to be tested further on a more general population of physicians, prescribing less extreme doses of BDZ + and that looks at more clinical and healthcare utilization outcomes. [ABSTRACT FROM AUTHOR]

Background: Proton pump inhibitors (PPIs) are the most potent antacids used in clinical practice with greater safety and efficacy. Limited data are available on the usage of PPIs in Indian health-care settings. Our aim was to understand the usage pattern and potential drug interactions with concurrently administered medications employing a single-day cross-sectional study design. Methods: A prospective observational cross-sectional study conducted on a single day, at two tertiary care teaching hospitals in South India. Inpatients of above 18 years of age were included. Case profiles were reviewed and data were collected in predesigned forms and analyzed. Drug interactions were identified using Micromedex and Medscape drug-interaction databases. Results: A total of 797 case profiles screened from both the centers; 714 were prescribed with PPIs. In intensive care units (ICUs), the use of PPIs was highest with 95% of cases getting these drugs. A PPI was seen in about 93% of patients, who had more than or equal to 4 drugs in their prescriptions. Pantoprazole was the mostly prescribed PPI in around 90% of the cases. Around 33% of the PPIs usage was through IV (intravenous) route, and 75% of that use was seen in wards. Around 134 drug interactions were identified, of which 10 were of major severity. Conclusions: Around 90% of inpatients were prescribed with PPIs. Pantoprazole is the most commonly prescribed PPI (90%). The IV administration was seen more in wards than ICUs, and 10 major drug interactions were observed in this single-day study. Careful monitoring is needed to avoid serious drug interactions involving PPIs, and training programs should sensitize the clinicians on the evidence-based use of PPIs. [ABSTRACT FROM AUTHOR]

Objective: To describe the use of amiodarone in critically ill, septic shock patients experiencing new-onset atrial fibrillation (NOAF) during the acute resuscitative phase of septic shock. Methods: Single-center, retrospective review of adult medical or surgical intensive care unit (ICU) patients with septic shock and NOAF. All patients received amiodarone for NOAF during the acute resuscitative phase of septic shock. The cohort was analyzed via descriptive statistics. Associations between amiodarone exposure and clinical outcomes were analyzed via a Cox proportional-hazards model. An a priori defined sensitivity analysis of hospital survivors was also employed. Main Results: A total of 239 patients were included in the analysis. Patients had a median baseline Charlson Comorbidity Index of 4 (interquartile range [IQR]: 2-6) and were acutely ill with a median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 18 (IQR: 13-22) and an incidence of mechanical ventilation of 85%. In-hospital mortality was 56% with median ICU and hospital length of stay (LOS) of 9 and 15 days, respectively. Included patients received a median of 2760 (IQR: 1110-6415) mg of intravenous (IV) amiodarone during their ICU stay. Receipt of more than or equal to 2700 mg of amiodarone was identified as an independent factor associated with longer ICU LOS (hazard ratio [HR]: 1.30; 95% confidence interval [CI], 1.10-2.28). In a sensitivity analysis of hospital survivors (n = 105), receipt of more than or equal to 2700 mg of amiodarone remained independently associated with longer ICU LOS (HR: 1.64; 95% CI, 1.05-2.58). Conclusions: Exposure to more than or equal to 2700 mg of amiodarone in the setting of NOAF and septic shock is positively correlated with longer ICU LOS. Identifying opportunities to limit amiodarone exposure and address/resolve potential precipitating causes of NOAF in this clinical scenario may reduce the morbidity associated with septic shock. [ABSTRACT FROM AUTHOR]

Background Loneliness is common in older adults, and it is associated with unhealthy behaviours, including substance use. We evaluated the association between loneliness and self-reported use of opioids and benzodiazepines in older adults. Methods We used data from the Canadian Community Health Survey's 'Healthy Aging' sub-survey and included adults 65 years or older who administered their own medications. We classified individuals as lonely if they scored 6 or more on the three -item University of California, Los Angeles's Loneliness Scale. We used multinomial logistic regression models, adjusting for demographics and self-reported comorbidities, to describe the association between loneliness and daily or occasional use of opioids, benzodiazepines and non-opioid analgesics. We also explored the association between loneliness and polypharmacy. Results Our cohort included 15,302 older adults, of whom 2,096 (13.7%) were classified as lonely. Daily use of opioids (4.1%) and benzodiazepines (1.7%) were less common than daily use of non-opioid analgesics (33.9%). Lonely older adults had higher daily use of opioids (odds ratio [OR] 1.61, 1.31-1.98) and benzodiazepines (OR 1.66, 1.21-2.28), but not non-opioid analgesics (OR 1.05, 0.92-1.19). Loneliness was not associated with occasional use of opioids, benzodiazepines or non-opioid analgesics in older adults, but was associated with polypharmacy (OR 1.27, 1.06-1.52). Conclusions Loneliness in older adults is associated with increased daily use of opioids and benzodiazepines. Further research should evaluate patient- and physician-level factors that mediate this association, and develop strategies to mitigate loneliness and its attendant adverse outcomes. [ABSTRACT FROM AUTHOR]

Objectives Recent guidelines advise limiting opioid prescriptions for acute pain to a three-day supply; however, scant literature quantifies opioid use patterns after an emergency department (ED) visit. We sought to describe opioid consumption patterns after an ED visit for acute pain. Design Descriptive study with data derived from a larger interventional study promoting safe opioid use after ED discharge. Setting Urban academic emergency department (>88,000 annual visits). Subjects Patients were eligible if age >17 years, not chronically using opioids, and newly prescribed hydrocodone-acetaminophen and were included in the analysis if they returned the completed 10-day medication diary. Methods Patient demographics and opioid consumption are reported. Opioid use is described in daily number of pills and daily morphine milligram equivalents (MME) both for the sample overall and by diagnosis. Results Two hundred sixty patients returned completed medication diaries (45 [17%] back pain, 52 [20%] renal colic, 54 [21%] fracture/dislocation, 40 [15%] musculoskeletal injury [nonfracture], and 69 [27%] "other"). The mean age (SD) was 45 (15) years, and 59% of the sample was female. A median of 12 pills were prescribed. Patients with renal colic used the least opioids (total pills: median [interquartile range {IQR}] = 3 [1–7]; total MME: median [IQR] = 20 [10–50]); patients with back pain used the most (total pills: median [IQR] = 12 [7–16]; total MME: median [IQR] = 65 [47.5–100]); 92.5% of patients had leftover pills. Conclusions In this sample, pill consumption varied by illness category; however, overall, patients were consuming low quantities of pills, and the majority had unused pills 10 days after their ED visit. [ABSTRACT FROM AUTHOR]

Background: The CGRP antagonists offer a novel therapeutic approach in migraine. Their utility in patients with severe forms of chronic migraine is a subject of particular interest. We present outcomes of 9 months of erenumab treatment in a cohort of patients with difficult-to-control chronic migraine, all of whom had prior unsatisfactory response to onabotulinumtoxinA. Methods: We offered erenumab to 98 patients with a prior unsatisfactory response to onabotulinumtoxinA. Eighty of 98 had trialled greater occipital nerve injections (82%), 32/98 peripheral neurostimulation (33%) and 18/98 intravenous dihydroergotamine (18%). Thirty eight of 98 (39%) met the definition of triptan overuse and 43/98 (44%) analgesic overuse. All patients met the EHF criteria for 'resistant migraine'. Outcome measures (recorded monthly) included days with headache limiting activities of daily living ("red"), not limiting ("amber"), headache free ("green"), and requiring triptans or other analgesics. Quality of life scores - headache impact test 6 (HIT-6), patient health questionnaire 9 (PHQ-9) and pain disability index (PDI) - were also measured. Results: Mean number of red days improved by − 6.4 days (SE 0.67, 95%CI − 7.7 to − 5.1, p=0.001) at 3 months; − 6.8 days (SE 0.96, 95%CI − 8.80 to − 4.9, p=0.001) at 6 months and − 6.5 days (SE 0.86, 95%CI − 8.3 to − 4.8, p=0.001) at 9 months. Repeated measures ANOVA confirmed improvements in the number of red (p=0.001), green (p=0.001), triptan (p=0.001) and painkiller days (p=0.001) as well as scores of the HIT-6 (p=0.001), PHQ-9 (p=0.001), and PDI (p=0.001) across the duration of study. Conclusion: We observed improvements in pain, medication use and quality of life in onabotulinumtoxinA-resistant chronic migraine patients following erenumab treatment. [ABSTRACT FROM AUTHOR]

Introduction Antibiotic use drives antibiotic resistance. Reducing antibiotic use through reducing antibiotic course lengths could contribute to the UK national ambition to reduce total antibiotic use. Methods Medical notes were reviewed for patients who had received at least 5 days of antibiotic therapy; had been discharged in January 2019; and were from a 750-bed acute secondary care hospital in England. UK national guidelines were used to determine the excess antibiotic use in common medical infections: community-acquired pneumonia (CAP), hospitalacquired pneumonia (HAP), pyelonephritis, cellulitis, infective exacerbation of chronic obstructive pulmonary disease (IECOPD) and cholangitis. Results Four-hundred and twenty-three patients met the inclusion criteria. Of these, 307 (73%) patient notes were retrieved and reviewed. One-hundred and seventy-three patients met the study case definitions, of which, 137 met short course criteria. Potential antibiotic reductions (measured in defined daily doses) were identified for five of the six infections: 32% in CAP, 20% in HAP, 14% in IECOPD, 11% in cellulitis and 10% in pyelonephritis. These reductions were estimated to reduce total antibiotic use in medical specialties by 12.4%, which equates to 3.6% of the hospital's total antibiotic use. Conclusion Clinical application of the evidence-based guidance for shorter antibiotic course lengths appears to be a valid strategy for reducing total antibiotic consumption. [ABSTRACT FROM AUTHOR]

Objective Although past research has established that men with chronic pain are more likely to misuse prescription pain medications in a myriad of ways compared with women, little is known about men's medication use in the context of their gender role beliefs. The aim of the present study was to examine the role of men's domestic gender role beliefs on their use of prescription pain medication for chronic pain. Methods Using a nationally representative data set with 304 men with chronic pain, this study examined a longitudinal moderated mediation model in which pain interference mediates the longitudinal relationship between somatic amplification and prescription pain medication use, with domestic gender role beliefs as a moderator of the aforementioned mediated relationship. Results Results indicated a significant moderated mediation model in which pain interference fully mediated the relationship between somatic amplification and prescription pain medication use, with men's domestic gender role beliefs moderating this mediated relationship. Specifically, domestic gender role beliefs moderated the relationship between pain interference and prescription pain medication use. Men with higher levels of traditional domestic gender role beliefs strengthened the mediated relationship, contributing to increased prescription pain medication use. Conclusions These findings suggest that although men's perceptions of somatic stimuli through its perceived interference contribute to their medication use, the extent to which they consume prescription pain medication depends on their beliefs in domestic gender roles during chronic pain. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to assess medication use in pregnant women in Malaysia by measuring use, knowledge, awareness, and beliefs about medications. Methods: This was an observational, cross-sectional study involving a total of 447 pregnant women who attended the Obstetrics and Gynecology Clinic, Hospital Kuala Lumpur (HKL), Malaysia. A validated, self-administered questionnaire was used to collect participant data. Results: Most of pregnant women had taken medication during pregnancy and more than half of them (52.8%) showed a poor level of knowledge about the medication use during pregnancy. Eighty-three percent had a poor level of awareness and 56.5% had negative beliefs. Age and education level were significantly associated with the level of knowledge regarding medication use during pregnancy. Multiparous pregnant women, and pregnant women from rural areas were observed to have a higher level of awareness compared with those who lived in urban areas. Use of medication during pregnancy was determined to be significantly associated with education level, and race. Conclusion: Although there was prevalent use of medication among pregnant women, many had negative beliefs, and insufficient knowledge and awareness about the risks of taking medication during pregnancy. Several sociodemographic characteristics were significantly associated with the use (race and education level), level of knowledge (age and education level), awareness (parity and place of residence), and beliefs (race, education level, and occupation status) towards medication use during pregnancy. [ABSTRACT FROM AUTHOR]

Objectives: We sought to assess medications prescribed to patients attending the Dental and Maxillofacial Surgery (DMS) clinic at Sultan Qaboos University Hospital (SQUH), Oman. Methods: This was a retrospective cross-sectional study covering a six-month period from January to June 2018 including a sample of patients attending the DMS clinic. Drug utilization data like drug name, type, administration route, dosage frequency, and anatomical and therapeutic class were assessed. Results: The study included 400 patients, of which 190 (47.5%) were males and 210 (52.5%) were females. A total of 88 different drugs were prescribed. Only 140 (35.0%) patients were prescribed drugs for their dental conditions or other comorbidities per visit, and the rest 260 (65.0%) were not prescribed any drugs. The dentists prescribed drugs only in 116 (29.0%) patients. The most common diagnosis was dental caries (n = 177, 44.3%) followed by chronic gingivitis (n = 15, 3.8%). The most common comorbidities in patients were anemia (n = 45, 11.3%) and diabetes (n = 21, 5.3%). The most common drugs prescribed were chlorhexidine mouthwash (n = 43, 37.1%) and paracetamol (n = 36, 31.0%) followed by ibuprofen (n = 10, 8.6%) and amoxicillin/clavulanate (n = 5, 4.3%). Conclusions: Drugs prescribing pattern was within the international norms. Sixty-five percent of the patients were not prescribed any drug by the dentist. Oral antiseptics, analgesics, and antibiotics were the most common drugs prescribed by dentists. [ABSTRACT FROM AUTHOR]

Multiple sclerosis (MS) is a chronic autoimmune disease that affects the central nervous system causing neurological deterioration over time. The objective of this study was to examine the predictors associated with MS medication use. The categories that were investigated were various alternative treatments such as complementary/alternative medications (CAMs), rehabilitation therapy and psychotherapy services as well as comorbid health conditions. The Survey on Living with Neurological Conditions in Canada (SLNCC) 2011-2012 was used (N = 73 347) to carry out a logistic regression model. Individuals who did not take CAMs were more (OR = 5.44, 95% CI 1.37-9.29) likely to use medications for MS. Having a mood disorder was associated with greater use of MS medications (OR = 5.39, 95% CI 1.60-18.17) while back problems were associated with lower odds of medication use (OR = 0.38, 95% CI 0.15-0.98). These factors need to be taken into consideration when creating effective medication adherence interventions. [ABSTRACT FROM AUTHOR]

Background: Anabolic androgenic steroid (AAS) use is associated with serious mental and physical health problems. Evidence indicates that AAS use among people who use psychoactive substances is higher than in the general population. This study aims to estimate lifetime AAS use among patients in substance use disorder (SUD) treatment, compare characteristics of AAS and non-AAS users and identify whether AAS use was addressed during treatment. Methods: This cross-sectional survey included 563 (142 women, 24.2%) patients in 38 SUD treatment facilities in Norway. Respondents reported on AAS and substance use, and treatment experiences. Results: Lifetime AAS use was reported by 156 (28.3%) SUD patients, thereof 35.6% of the men and 8.0% of the women. Lifetime AAS use was highest among men with stimulants (55.8%) as preferred substance, and lowest among men who preferred alcohol (14.6%). Initiation of AAS use due to getting thinner following substance use was reported by 44.5% of the AAS using men. AAS users reported more severe substance use than non-AAS users. More than half (58%) of all patients had not been asked about AAS use, and 42.4% of those who were asked, experienced that treatment providers lacked expertise about AAS. Conclusion: Lifetime AAS use in this sample of SUD patients is common practice and comprise an underrecognized problem in SUD treatment. Given the deleterious implications to the individual and society that concomitant use of AAS may cause, it would be essential to raise the awareness about AAS use among SUD patients, and the level of competence among health professionals. [ABSTRACT FROM AUTHOR]

Background and purpose — Smoking is a modifiable risk factor that may adversely affect postoperative outcomes. Healthcare providers are increasingly denying smokers access to total hip and knee arthroplasty (THA and TKA) until they stop smoking. Evidence supporting this is unclear. We assessed the effect of smoking on outcomes following arthroplasty. Patients and methods — We identified THAs and TKAs from the Clinical Practice Research Datalink, which were linked with datasets from Hospital Episode Statistics and the Office for National Statistics to identify outcomes. The effect of smoking on postoperative outcomes (complications, medications, revision, mortality, patient-reported outcome measures [PROMs]) was assessed using adjusted regression models. Results — We studied 60,812 THAs and 56,212 TKAs (11% smokers, 33% ex-smokers, 57% non-smokers). Following THA, smokers had an increased risk of lower respiratory tract infection (LRTI) and myocardial infarction compared with non-smokers and ex-smokers. Following TKA, smokers had an increased risk of LRTI compared with non-smokers. Compared with non-smokers (THA relative risk ratio [RRR] = 0.65; 95% CI = 0.61–0.69; TKA RRR = 0.82; CI = 0.78–0.86) and ex-smokers (THR RRR = 0.90; CI = 0.84–0.95), smokers had increased opioid usage 1-year postoperatively. Similar patterns were observed for weak opioids, paracetamol, and gabapentinoids. 1-year mortality rates were higher in smokers compared with non-smokers (THA hazard ratio [HR] = 0.37, CI = 0.29–0.49; TKA HR = 0.52, CI = 0.34–0.81) and ex-smokers (THA HR = 0.53, CI = 0.40–0.70). Long-term revision rates were not increased in smokers. Smokers had improvement in PROMs compared with preoperatively, with no clinically important difference in postoperative PROMs between smokers, non-smokers, and ex-smokers. Interpretation — Smoking is associated with more medical complications, higher analgesia usage, and increased mortality following arthroplasty. Most adverse outcomes were reduced in ex-smokers, therefore smoking cessation should be encouraged before arthroplasty. [ABSTRACT FROM AUTHOR]

Objective Although depression and chronic pain often coexist, few studies have examined antidepressant use among people with pain. This study examines the prevalence and characteristics associated with antidepressant use among people prescribed opioids for chronic noncancer pain (CNCP). Design Baseline data from a prospective cohort study. Setting Australian community. Subjects A total of 1166 people prescribed opioids for CNCP. Methods Baseline data collection consisted of a self-completed seven-day medication diary and telephone interview to collect information on sociodemographic characteristics and mental/physical health using validated questionnaires. Logistic regression was used to examine characteristics associated with antidepressant use, reporting adjusted odds ratios (AORs) and 95% confidence intervals (CIs). Results Of the 1166 participants, 668 (57.3%) were female, and the median (interquartile range) age was 59 (49–68) years. About half the cohort (N = 637, 54.6%) used antidepressants. Of these, 329 (51.7%) reported moderate to severe depression. Amitriptyline was the most commonly used antidepressant (17.3%). Factors independently associated with antidepressant use were being female (AOR = 1.47, 95% CI = 1.13–1.92), more years lived in pain (AOR = 1.01, 95% CI = 1.00–1.02), and use of nonopioid analgesics (AOR = 1.34, 95% CI = 1.01–1.78), benzodiazepines and related drugs (AOR = 1.84, 95% CI = 1.36–2.49), antiepileptics (AOR = 1.86, 95% CI = 1.38–2.51), and antipsychotics (AOR = 2.15, 95% CI = 1.22–3.77). Conclusions Antidepressant use is common among people with CNCP prescribed opioids. Those using antidepressants were more likely to use other psychotropic medicines concurrently, highlighting that they are a high-risk population requiring comprehensive assessment to optimize outcomes and reduce potential harms from polypharmacy. [ABSTRACT FROM AUTHOR]

Background: Human albumin is an expensive therapy with inappropriate use in many clinical conditions. Inappropriate use of albumin imposes a substantial economic burden on the healthcare system and society. Drug use evaluation (DUE) is one method of assessing the appropriateness of drug use which has been powered by increasing concern about the cost-effectiveness of drugs. The objective of this study is to systematically review the appropriateness of albumin utilization in Iranian hospitals. Methods: We searched the PubMed, MEDLINE, EMBASE, SCOPUS, and Google Scholar for articles in English and SID, Magiran, Medlib, and Irandoc for articles in Persian from 1997 to 2018. Studies on the DUE of albumin in Iranian hospitals were included in this study. Articles conducted outside Iran, editorials, letters and review articles were excluded. Results: In total, eight studies were selected for the final review. The majority of the papers were conducted in Tehran. In most studies, the highest albumin consumption was related to the intensive care unit. The most frequent reasons for prescribing albumin were edema, hypoalbuminemia, volume expansion after heart surgery, ascites, cardiac surgery and cirrhosis. Of the studies included, five studies evaluated the costs of drug use. Conclusion: Our findings show that inappropriate use of albumin imposes a relatively high additional cost on the society. The included studies show that the percentage of inappropriate use of albumin is relatively high in Iran and this abuse is an essential problem in Iranian hospitals. Prescription based on standard guidelines could improve rational use of albumin and lead to savings in treatment costs. [ABSTRACT FROM AUTHOR]

Background. In developing countries, most maternal deaths are related to the lack of accessibility and availability of reproductive health services. In those nations, emergency contraceptive pills are the most commonly used family planning methods to prevent unintended pregnancy. However, women do not use this family planning method for different reasons. Consequently, women expose to unsafe abortion which results in maternal morbidity and mortality. Objective. To assess the knowledge of and utilization of emergency contraceptive and its associated factors among women seeking induced abortion in public hospitals, Eastern Tigray, Ethiopia, 2017. Methods. Hospital-based cross-sectional study was conducted on 380 women, who came for safe termination of pregnancy from April to July 2017. Systematic random sampling technique was used. Pretested structured questionnaire was used to collect data through interview. Data were entered using Epi Info version 7 and exported to SPSS version 20 for analysis. Data were presented using descriptive statistics. Bivariate and multivariate logistic regression was carried out to see if there was significant association between variables at P<0.05 and 95% confidence interval (CI). Result. Out of the total 369 respondents, 149 (40.4%) had the knowledge about emergency contraceptive pills. The magnitude of utilization of emergency contraceptive among respondents was found to be 45 (12.2%). Protestant in religion (AOR = 60.85, CI (5.34–693.29)), previous utilization of any contraceptive method (AOR = 0.13, CI (0.05–0.36)), and women who were not knowledgeable about emergency contraceptive (AOR = 0.030, CI (0.006–0.14)) were significantly associated with the utilization of emergency contraceptive. Conclusion. Most of the women were not knowledgeable about emergency contraceptive and utilization of emergency contraceptive was also very low. In conclusion, religion, knowledge, and previous utilization of emergency contraceptive were associated with the utilization of emergency contraceptive. [ABSTRACT FROM AUTHOR]

Objectives Febrile seizure is common disorder in childhood, with a prevalence of 2% to 5%. There are many drugs for treatment of this disease; however, the most common prescribed medication in Iran is phenobarbital that is cheap, but it has many side effects. We aimed to compare the cost-effectiveness of topiramate versus phenobarbital in patients with febrile seizure in the south of Iran. Materials & Methods This econometric cost-effectiveness and cost-utility study were conducted on 91 patients with febrile seizure to assess two strategies of oral drug therapy including phenobarbital and topiramate in 2016-2017. Of all, 51 patients were treated with phenobarbital and 40 patients received topiramate. We followed up the patients for six months, using a randomized and single-blinded approach. A decision tree model was used. The outcomes of the model included febrile seizure and utility. The study was conducted from the perspective of the community; therefore, direct and indirect costs were included in the study. Excel and Tree Age software (2011) were used to analyze the results. Results Topiramate was cheaper and more effective than phenobarbital. In patients in the phenobarbital and topiramate groups, the mean costs were $740 and $674 per PPP, utility scores were 0.72 and 0.82, and febrile seizure without side effects were 0.3 and 0.6, respectively. Moreover, one-way sensitivity analysis confirmed the robustness of the results of the study. Conclusion Topiramate in patients with febrile seizure is a fully cost-effective and cost-efficient strategy suggested as a better alternative for children with febrile seizure. [ABSTRACT FROM AUTHOR]