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The COVID‐19 pandemic exerted a profound impact on health systems worldwide. Moreover, significant concerns were raised in terms of middle‐ and long‐term consequences of postponing care in non‐COVID patients. The primary aim of the study was to describe the remote pharmaceutical care service (telepharmacy) during the COVID‐19 pandemic in the Republic of Srpska (RS), Bosnia and Herzegovina. The secondary aim was to identify service users’ needs and concerns and to describe community pharmacists’ interventions. Ten community pharmacists were appointed by the Pharmaceutical Society of the RS to deliver telepharmacy services. After obtaining users’ verbal permission, pharmacists documented issues discussed with them. The prospective data collection included the period from April 13 to May 21, 2020. Descriptive and statistical analysis was performed using IBM SPSS Statistics software (ver. 22). A total of 71 service users’ charts were analyzed. Telepharmacy users were on average 61.31 ± 13.27 years of age, with almost equal gender distribution. Patients with chronic or acute/subacute conditions were predominant with a share of 84.5%. Chronic diseases were the main reason for searching pharmacists’ consultation (74.6%), 7% had a complaint about worsening of a chronic condition, 9.9% reported only acute/subacute conditions as ambulatory conditions, whereas 15.5% asked information about coronavirus or COVID‐19. The vast majority of patients’ and users’ needs were addressed by a pharmacist during counseling and only 15.5% of the patients required immediate referral to a doctor for refill/prescribing purposes. Remote pharmaceutical care service (telepharmacy) is deemed a convenient model in the RS during the COVID‐19 pandemic. Patients and users presented with explicit and specific needs and concerns, both COVID‐ and non‐COVID‐related, which should not be neglected. Community pharmacists showed a high level of resilience and ability in addressing patients' needs.

Introduction: Pharmacists have a significant role in improving patient inhaler technique (HK. Reddel, et al. Eur Respir J 2008;32: 812; Alismail A, et al. Respir Care 2016;61:593). Hence, it is crucial for pharmacists to develop skills in educating patients on the correct use of inhalers. Aims: The aim of the study was to evaluate the effectiveness of an educational intervention on the pharmacists’ inhaler technique demonstration skills. Methods: The study was performed during the community pharmacists’ training classes in 2019. Demonstration of correct inhaler technique was performed for metered-dose (MDI), dry powder (DPI) and soft mist inhalers (SMI). All participants were instructed about correct technique and given placebo inhalers. After the demonstration, they were assessed on the use of each of these devices. The pharmacists were given a 1-point score for each step (1-preparation, 2-expiration, 3-inhalation, 4-holding breath) performed correctly. Results: All participants (108) showed improved inhaler technique after training (3.8±0.5 points). Friedman test showed a significant difference in achieved score depending on the type of the inhaler (p

Background In the last 30 years, activities of hospital pharmacists have gone through significant changes. Pharmacists are increasingly involved in patient care. Objectives To explore drug-related and logistic problems, interventions, and their outcomes during routine everyday work of hospital pharmacists. Setting Institute for physical medicine and rehabilitation, Banja Luka, Bosnia and Herzegovina. Methods In the period of January 2013-October 2015 a prospective observational study was performed. Medical doctors, nurses, therapists, and patients addressed pharmacists, face-to-face or by telephone, with drug-related problems (DRPs) and/or logistic issues. Main outcome measure Type of DRP or logistic issue, intervention, outcome, initiator and time spent for solving the problem were documented for each consultation. Results Out of 1515 interventions, 48.8% were aimed at solving DRPs. The most common DRPs were the recommendation of a drug or dose and need for additional information about drugs. Drug price and supply were the most prevalent logistic issues. DRPs were more frequently initiated by medical doctors and required more time to solve the problem compared to logistic issues (Mann-Whitney U test, p lt = 0.001, respectively). The acceptance rate of interventions to solve DRPs (83.7%) was lower compared to logistic issues (95.2%; p lt = 0.001). Conclusions Hospital pharmacists were faced with an approximately equal number of DRPs and logistic issues during their routine everyday work. The overall acceptance rate of pharmacists' interventions was high, and the results of our study indicate that there is a need for more involvement of hospital pharmacists in Bosnia and Herzegovina in clinical activities. Impact on practice.

Objective. Nurses represent the key persons in the process of organ donation, acting as intermediaries between the patient and the family of a potential donor. The aim of this study was to analyze the factors influencing the attitudes of nurses toward bequeathing and organ and tissue donation. Methods. The research was designed as a cross-sectional study from November 2013 to November 2014 and included a sample of 264 nurses employed in the health system of Serbia. Data were collected using a specific questionnaire of 18 questions referring to the information on sociodemographic characteristics and the knowledge of organ donation. Results. The investigation enrolled 264 participants, of which 78% were women. The majority of study subjects had secondary medical education (64.4%), lived in an urban area (82.6%), were married (56.4%), and were predominantly Orthodox (87.1%) with their work experience between 5 and 10 years (29.9%) and 10 to 20 years (29.5%). The average knowledge score concerning organ donation was 29.03 (SD, 2.33; range, 23-34). There was a statistically significant difference in the scores between 2 groups formed according the length of service (P < .001) and the level of education (P ¼ .019), which showed the strongest influence on nurses’ attitudes toward donation. Conclusion. This investigation showed that nurses did not express strong positive attitude toward this issue. Further education of nurses in the Serbian health care system focusing on transplantation and bequeathing of organs and tissues are warranted. N

Background:The progression of the nonalcoholic fatty liver disease to nonalcoholic steatohepatitis (NASH) is multifactorial, and there is still a lack of approved medications for its treatment. The study aimed to evaluate the impact of combined treatment with Pentoxifylline and Metformin on biochemical parameters in patients with NASH. Setting:Outpatient hepatology clinic.Methods:A prospective trial was conducted. The first cohort included patients with biopsy-proven NASH, while the second cohort consisted of patients with biopsy-confirmed NAFLD. Blood tests were checked at baseline and every three months. Pentoxifylline at a dosage of 400 mgt.i.d. and Metformin at the dosage of 500 mg t.i.d. were introduced for six months in NASH group. The impact of the treatment was assessed based on biochemical results after combined treatment with low-cost medications. Results:All 33 NASH patients completed 24 weeks of treatment. We observed significant improvement (p

Intrahepatic cholestasis of pregnancy (ICP) is a gestation-specific liver disorder, defined most often as the onset of pruritus, usually from the third trimester of pregnancy, associated with abnormal liver test results and/or increased total serum bile acids and spontaneous relief after delivery. The 21-year-old patient was admitted to our ward in the 11th week of pregnancy due to raised liver enzymes. The first onset of pruritus and jaundice appeared a month before hospitalization. Immunology tests and Toxoplasma gondii were negative. We excluded viral etiology, while alpha-1-antitrypsin, serum and urine copper levels, and thyroid hormones were within the reference values. The patient denied she had taken any medicines and herbal preparations before and during pregnancy. Total bile acids in the serum were significantly elevated (242 μmol/L). The abdominal ultrasound revealed a regular finding. Liver biopsy suggested a cholestatic liver disorder. After a presentation of all risks, the patient decided to stop the pregnancy. After a month, the hepatogram was within the reference values. Very rarely an ICP can occur in early pregnancy (first trimester), which calls for close monitoring. The risk of serious adverse fetal outcomes and spontaneous preterm delivery is proportional with increased levels of maternal serum bile acid.

Background and objectives: Data suggests that nearly 30% of the general population have steatosis and up to 5% of this population develops nonalcoholic steatohepatitis (NASH). Liver biopsy is still considered to be the gold standard for the diagnosis of NASH. Great effort is being made toward the identification of sensitive diagnostic tests that do not involve invasive procedures to address a common concern in patients with the nonalcoholic fatty liver disease&mdash, whether they have NASH or simple steatosis. We aimed to investigate the independent predictors and develop a non-invasive, easy-to-perform, low-cost set of parameters that may be used in clinical practice to differentiate simple steatosis from NASH. Methods: А cross-sectional study of nonalcoholic fatty liver disease (NAFLD) patients divided into two groups: group I&mdash, simple steatosis (SS) and group II&mdash, biopsy-proven NASH. Strict inclusion criteria and stepwise analysis allowed the evaluation of a vast number of measured/estimated parameters. Results: One hundred and eleven patients were included&mdash, 82 with simple steatosis and 29 with biopsy-proven NASH. The probability of NASH was the highest when homeostatic model assessment of insulin resistance (HOMA-IR) was above 2.5, uric acid above 380 &micro, mol/L, ferritin above 100 &micro, g/L and ALT above 45 U/L. An acronym of using first letters was created and named the HUFA index. This combined model resulted in an area under the receiver operator characteristic curve (AUROC) of 0.94, provided sensitivity, specificity, positive predictive value and a negative predictive value for NASH of 70.3%, 95.1%, 83.1% and 90.0%, respectively. Conclusion: We suggest a simple non-invasive predictive index HUFA that encompasses four easily available parameters (HOMA-IR, uric acid, ferritin and ALT) to identify patients with NASH, which may reduce the need for a liver biopsy on a routine basis in patients with NAFLD.

Background: Data suggest cystatin C (CysC) levels and hepatic artery resistive index (HARI) correspond to the progression of chronic liver disease. We aimed to evaluate the clinical significance of these parameters in assessment of fibrosis in patients with liver cirrhosis. Methods: The cross-sectional study included 63 patients with liver cirrhosis. A control group consisted of 30 age- and gender-matched healthy persons. Results: We confirmed significantly higher values of CysC in patients with cirrhosis compared to control group (p = 0.036). Average value of HARI in the examined group was increased (0.72 ± 0.06) and there was the statistically significant difference compared to controls (0.66 ± 0.03) (p < 0.001). We found statistically significant correlation between HARI and CysC in the study group. Analyzing the possibility of distinguishing healthy subjects from patients with fibrosis, we have found that the area under the curve is far greater in the HARI index than CysC. Comparison of CysC among Child–Pugh stages and correlation with a model for end-stage liver disease (MELD) score showed statistically significant results. Conclusion: We confirmed HARI is a more accurate parameter than CysC in discriminating healthy subjects from patients with fibrosis, while CysC could be a better indicator of the stage of liver cirrhosis.

BACKGROUND: During the initiation of treatment of a chronic disease, patients may have varying interests, expectations, concerns, and reasons to stop treatment, influencing compliance with prescribed treatment. Thus, healthcare professionals are expected to integrate these needs into medicines management.OBJECTIVES: To determine what information is important to patients; assess predictors of patients' interests, expectations, concerns, reasons to stop therapy; evaluate drug-related problems following initiation of therapy and summarize how pharmacists resolve them during patient-pharmacist counselling.METHODS: In 2014, a four-month study was performed in Serbian community pharmacies, as part of the Pharmaceutical Care Quality Indicators Project led by the European Directorate for the Quality of Medicines & Healthcare. Seventy community pharmacists were asked to participate in the study. Pharmacists recruited adult patients who consented to participate in the study and who initiated treatment, lasting at least six months. Patients completed an open-ended questions form. After two-to-four weeks, a patient-pharmacist consultation was performed.RESULTS: Forty-four community pharmacists (response rate 62.9%) sent back the completed forms from 391 patients (response rate 67.1%). The total number of dispensed drugs was 403. In terms of drug safety, 29.4% of patients sought information, 32.5% expressed concerns, and 28.1% of patients cited it as a reason to discontinue treatment. During the first weeks of therapy, 18% of patients experienced practical problems, while 27.3% reported adverse drug reactions.CONCLUSION: Safety issues are a major focus of patients' prescribed new medicines for long-term treatment.

Objective To evaluate elderly polypharmacy patients’ needs and concerns regarding medication through the Structured Patient-Pharmacist Consultation (SPPC). Methods Older patients on chronic treatment with ≥5 medications were asked to fill in the SPPC form at home. A consultation with the community pharmacist, structured according to patient’s answers, followed within 2–4 weeks. Logistic regression associated patients’ individual treatment with care issues and consultation outcomes. Results Out of 440 patients, 39.5% experienced problems, and 46.1% had concerns about medication use. 122 patients reported reasons for discontinuing treatment. The main outcome of the consultation was a better understanding of medication use (75.5%). Side effects and/or non-adherence were identified in 50% of patients, and 26.6% were referred to the doctor. Atrial fibrillation, COPD, anticoagulants, benzodiazepines, and beta agonists/corticosteroids were associated with problems during medication use. Patients with diabetes improved their understanding of medication use significantly. Conclusion Patients on benzodiazepines, anticoagulants, and beta agonists/corticosteroids, with atrial fibrillation and/or COPD, may have a higher potential for non-adherence. Counseling patients based on the SPPC model may be particularly useful for patients with diabetes. Practice Implications The SPPC model is a useful tool for counseling based on patient needs.

Background: The superiority of dabigatran has been well proven in the standard dosing regimen in prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) and extended venous thromboembolism (VTE) treatment. Dabigatran, an anticoagulant with a good safety profile, reduces intracranial bleeding in patients with atrial fibrillation and decreases major and clinically relevant non-major bleeding in acute VTE treatment. However, several important clinical issues are not fully covered by currently available directions with regard to dabigatran administration. The prominent one is reflected in the fact that dynamic impairment in renal function due to dehydratation may lead to haemorragic complications on the one hand, while on the other hand glomerular hyperfiltration may be a possible cause of dabigatran subdosing, hence reducing the drug's efficacy. Furthermore, limitations of the Cockcroft-Gault formula, considered a standard equation for assessing the renal function, may imply that other calculations are likely to obtain more accurate estimates of the kidney function in specific patient populations. Method and Conclusions: Although not routinely recommended, a possibility of monitoring dabigatran in special clinical settings adds to optimization of its dosage regimens, timely perioperative care and administration of urgently demanded thrombolytic therapy, therefore significantly improving this drug's safety profile. Despite the fact that dabigatran has fewer reported interactions with drugs, food constituents, and dietary supplements, certain interactions still remain, requiring considerable caution, notably in elderly, high bleeding risk patients, patients with decreased renal function and those on complex drug regimens. Additionally, upon approval of idarucizumab, an antidote to dabigatran solution, hitherto being a major safety concern, has been finally reached, which plays a vital role in life-threatening bleeding and emergency interventions and surgery.

AIM: To evaluate the clinical significance of cystatin C and renal resistive index for the determination of renal function in patients with liver cirrhosis. METHODS: We conducted a study of 63 patients with liver cirrhosis. A control group comprised of 30 age and gender-matched healthy persons. Serum cystatin C was determined in all study subjects and renal Doppler ultrasonography was made. Estimated glomerular filtration rate from serum creatinine (GFR(Cr)) and cystatin C (GFR(Cys)) was calculated. RESULTS: We confirmed significant differences in values of cystatin C between patients with different stages of liver cirrhosis according to Child-Pugh (P = 0.01), and a significant correlation with model of end stage liver disease (MELD) score (r(s) = 0.527, P lt 0.001). More patients with decreased glomerular filtration rate were identified based on GFR(Cys) than on GFR(Cr) (P lt 0.001). Significantly higher renal resistive index was noted in Child-Pugh C than in A (P lt 0.001) and B stage (P = 0.001). Also, a significant correlation between renal resistive index and MELD score was observed (r(s) = 0.607, P lt 0.001). Renal resistive index correlated significantly with cystatin C (r(s) = 0.283, P = 0.028) and showed a negative correlation with GFR(Cys) (r(s) = -0.31, P = 0.016). CONCLUSION: Cystatin C may be a more reliable marker for assessment of liver insufficiency. Additionally, cystatin C and renal resistive index represent sensitive indicators of renal dysfunction in patients with liver cirrhosis.

ObjectivesThe aim of the study was to determine the rate of Potentially Inappropriate Medicines (PIM) and Potential Prescription Omissions (PPO) according to Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment (STOPP/START) criteria.Study designA cross-sectional survey in community pharmacy.MethodA prospective cross-sectional study was performed, during March-May 2012, in five community pharmacies. Patients aged ≥65 years, who collected one or more prescribed medications, were asked to participate in the study, and an interview was scheduled. Patients were asked to provide their complete medical and biochemical record from their general practitioner.Results509 patients, mean age 74.8±6.5 years, 57.4% female, participated in the study. 164 PIM were identified in 139 patients (27.3%). The most common were: long-term use of long-acting benzodiazepines (20.7%), use of non-steroidal antiinflammatory drugs (NSAID) in patients with moderate-severe hypertension (20.1%), use of theophylline as monotherapy for chronic obstructive pulmonary disease (COPD, 15.9%) and use of aspirin without appropriate indication (15.2%). Patients with more than four prescpritions had a higher risk for PIM (OR 2.85, 95% CI 1.97-4.14, pConclusionSTOPP/START criteria may be useful in identifying inappropriate prescribing and improving the current prescribing practices. Pharmacists should focus more on patients with more than four medications and/or patients with gout or pain accompanied with arterial hypertension because those patient may be at higher risk of PIM. Additionlly, patients older than 74 years with diabetes, osteoporosis, myocardial infarction, stroke, angina pectoris and/or COPD may have an increased risk of PPO.

Background People with chronic liver diseases constitute a group of patients who often have polypharmacy, comorbidities, and pharmacokinetic and pharmacodynamic changes, that cause an increase in the risk of drug-drug interactions. Purpose To identify and describe drug-drug interactions based on their clinical significance and predictors of their occurrence among patients with chronic liver diseases. To compare the results from two available electronic sources for interaction evaluation. Material and methods A study was conducted on a hepatology ward from May to July 2015, at the gastroenterology and hepatology clinic. Data were gathered through a prospective chart review performed by a clinical pharmacist during a 4 h visit once per week. An estimate of whether gender, age, liver disease, comorbidities, use of certain drugs and total number of drugs per patient influenced the occurrence of drug-drug interactions was made, using correlation and binary regression analysis. Two separate drug interaction programs (Lexi-Interact and Epocrates) were applied to provide the analysis. Results From medicines use review of 100 patients with chronic liver diseases, we identified 486 drug-drug interactions (DDIs) using the Lexi-Interact and 293 using the Epocrates database. The most common type of interaction was class C and monitor/mоdify, deemed as clinically significant (367 DDIs; at least one was found in 83.5% of patients). Acetylsalicylic acid had the highest risk of causing potentially serious (class D, major severity; Lexi-Interact) interactions (25.3%). Most common interacting drug pairs were hydrochlorothiazide/bisoprolol, hydrochlorothiazide/ibuprofen and furosemide/spironolactone. Predictors of DDIs were total number of drugs per patient, number of comorbidities and gender. Statistically significant correlation with occurrence of DDIs was observed for the following covariates: total number of drugs per patient (p = 0.049), number of comorbidities (p = 0.023) and patient age (p = 0.039). Conclusion Most DDIs in the study identified the need for monitoring/modifying therapy. Patients on hydrochlorothiazide, furosemide and bisoprolol were more likely to have DDIs. Lexi-Interact was shown to be the more sensitive source. We advocate that on-ward participation of a clinical pharmacist in a hepatology team may prevent/minimise the frequency and severity of DDIs, provide prompt solutions and enhance patient care. References and/or Acknowledgements lexi.com/PDA-Software-for-Pharmacists/Lexi-Drugs-Interact https://online.epocrates.com No conflict of interest.

Background Patient-centred clinical pharmacy is still in its early stages in _, despite its well evidenced positive impact worldwide. Studies show that clinical pharmacists are valuable members of the healthcare team in improving medicines outcomes in patients with liver disease and liver transplant recipients. Purpose To assess the results of the introduction of clinical pharmacy services on the hepatology ward of a tertiary care teaching hospital in _. Material and methods The prospective observational study was conducted on a hepatology ward from March to July 2014, at Gastroenterology and Hepatology Clinic, _. The clinical pharmacist evaluated medicines use during a 4 h visit once per week, and made recommendations to the prescribing physician. The interventions to optimise prescribing were classified according to type and acceptance by the physician. Results A total of 107 medicines-related interventions were made for 57 patients (investigated or treated for alcohol-related liver disease, non-alcohol-related steatohepatitis, viral hepatitis, autoimmune hepatitis, biliary cirrhosis, sclerosing cholangitis, liver transplant recipients), of which the clinical pharmacist initiated 84 (78.5%) interventions, while 23 (21.5%) interventions were initiated by other health care professionals. The most frequent drug related problems requiring interventions were: incorrect dose (14.7%), inappropriate choice of medicine (11.9%), adverse drug reaction (10.1%) and unavailability of necessary drug (8.9%). The most common type of recommendation was dose adjustment (22.7%), change (15.5%) or discontinuation (11.9%) of a drug, followed by a consultation with a healthcare professional regarding potential adverse drug reactions, interactions and other available treatment options (10.7%). Acceptance rate by physicians was 87.3%. Conclusion Involving a clinical pharmacist in a hepatology team led to clinically significant and embraced optimisation of medicines use. This approach may serve as a baseline and the support for further development of clinical pharmacy in References and/or Acknowledgements No conflict of interest.

Background Hospital patients in Serbia receive information about their medicines from physicians and nurses. Pharmacists are not involved in medicines counselling. In countries with developed health care, pharmacists provide counselling to patients at discharge. Purpose To establish which groups of hospital patients got the least information about their medicines, since these patients could profit from additional counselling at discharge, provided by pharmacists. Materials and Methods The study was carried out in five hospitals in Serbia, over a period of 8 weeks. Pharmacists collected clinical data from the patient’s medical notes. Patients’ knowledge of medicines was assessed through an interview using a structured questionnaire, on the morning of discharge. We evaluated 3 groups of patients according to age, length of hospital stay and number of newly-introduced medicines. They were asked seven questions: if they were informed about all medicines, reasons for treatment, the effects of the drug, duration of treatment, posology and method of administration, undesirable effects and interactions. ‘Yes’ was awarded two points, ‘partially’ one and ‘no’ no points. A total ≤10 of all answers per patient was defined as insufficient knowledge. Results 148 patients (mean age 60 years) were interviewed. 74% of patients younger than 65 years and 89% of elder patients showed insufficient knowledge. Length of hospital stay had impact on patient knowledge. 70% who stayed more than 20 days had insufficient knowledge vs. 85% who were hospitalised less than 10 days. Insufficient knowledge increased with number of newly-introduced medicines (80% who had 1 vs. 96% who had ≥5 new drugs on discharge). Conclusions The findings of this study indicate that older patients, those who stay less time in hospital and those who receive more new drugs on discharge need to get more counselling about their treatment. Serbian pharmacists can take a proactive role for these patients. No conflict of interest.