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Diabetes along with related comorbidities associated with high disability rates severely threatens human health. The etiology of diabetes is complex. Genetics, environmental factors, eating habits, drug usage, aging, and lack of movement play important roles in the development of diabetes. Intestinal flora is reportedly closely related to the occurrence and development of type 2 diabetes. Herein, we review changes in abundance and proportion of intestinal flora in patients with type 2 diabetes and regulation of intestinal flora through diet, drugs, and surgery to prevent and treat type 2 diabetes. A more appropriate clinical diagnosis and treatment plan could be made considering changes in intestinal flora in the future.

Introduction: Physiological alterations during pregnancy as well as the bio- conversion of compounds can significantly influence the teratogenic effects of drugs and chemicals by affecting absorption, body distribution, the active form(s), and excretion of the compound. Certain medications may cause harm to the foetus due to their potential teratogenic effects and the physiological adjustments occurring in the mother during pregnancy. Prescription of drug used by pregnant women should be viewed as one of a public health issue. This study aware health care workers on harmful drugs prescription to pregnant women and helps in understanding the type of medication used during pregnancy and safety of drugs used during pregnancy, thereupon this study was ascertain drug usage pattern and potential teratogenicity risk among pregnant women attending maternal and child health clinic of Mettu Karl Referral Hospital. Methods: A hospital-based cross-sectional study design was carried out from April 13/2021 to June 15/2021. Data was collected through employing semi-structured questioner, and then the collected data was cleared, coded and analyzed by statistical packages for social sciences 25.0 version statistical software. Descriptive statistics were used to describe the data. P value 35 years (AOR=4.05, 95%CI:1.274-1.903; p=0.001), urban residents (AOR=2.72, 95%CI:2.524-3.927; p=0.035), and pregnant women during second trimester (AOR=1.79, 95%CI:3.926-9.406; p=0.013) were significantly associated with MCH follow up. Conclusion and recommendation: From the drug prescribed, majority of pregnant women were taken antibiotics followed by 18(11.5%) NSAID, iron sulfate, and proton pump inhibitors. Among the dosage form, above half of the participants were taken the tablet dosage form followed by capsule and gels dosage form. Health care workers should have to brought good care for pregnant women, since they perhaps vulnerable to drug teratogenesity

During flight, passengers may experience aviation-related symptoms such as headache, nausea, respiratory failure, and panic disorders. To treat patients with these symptoms, emergency drugs are prepared in the cabin and crews treat patients according taking into account usage and dose guidelines described on the drug containers. However, certain types of drugs are limited and not adequately prepared in the cabin. The aim of this study was to examine (1) emergency drugs used during flight and frequency of symptoms experienced in passengers and (2) cognizance of drug usage among crews was also determined in low-cost carriers. Most frequent symptoms recorded were headache (74.1%), abdominal pain (72.3%), nausea (70.5%), and ear pain (60.7%). Panic disorder (50.9%) is the fifth frequent syndrome in passengers, but emergency drugs are not available for this condition in the cabin. The cognizance survey showed that 21% of crews out of 112 who responded were not interested in usage guidelines of emergency drugs or simply ignored. Thirty-seven percent of crews failed to pay attention to drug expiration dates. Our findings suggest that crews need to be better trained for preparation and usage of emergency drugs in the cabin for passengers suffering from various symptoms. Further, it is recommended that airline companies need to consider to improve the emergency drug management system by requesting training from pharmacists and doctors for safe drug usage.

Introduction Medication use in older people is complex. Consequently, regular medication reviews as an integral part of healthcare provision for older people are necessary. Patients attending consultant-led, multidisciplinary, day hospital clinics have specialist medication reviews undertaken by our senior clinical pharmacist. “Pharmacy Interventions” (PIs) are suggested and typed prior to physician-led patient review. Method Data collected by our senior clinical pharmacist were reviewed including patient demographics, clinical characteristics, types of prescribed drugs and PIs. Clinical severity of PIs was assessed using the NCC MERP Medication error index and American Journal Health-Syst Pharm Medication error index. Scores, ranging in clinical severity from A-I (A = capacity to cause error, I = may have contributed to death) and 0–10 (0 = no potential effect, 10 = death) were assigned by the pharmacist and two physicians. Results 100 patients were included, mean age 82y (range 65-99y). 62% were female and 63% were first time attenders. Mean number of regularly prescribed medications was 7.2 (range 1–16), 10% reported compliance issues. The most commonly prescribed drugs belonged to the “Alimentary tract and metabolism” class (24%), including PPIs, laxatives and blood-glucose lowering medications. 16% and 15% were on regularly prescribed neuroactive and psychoactive medications, respectively. Of suggested PIs, 46% were acted upon during physician review, a further 4% were acknowledged in clinical notes. PIs covered many prescribing issues including drug–drug interactions, incorrect dosing, drug monitoring and administration timing. The average PI scores assigned by the pharmacist, physicians 1 and 2 differed, at 6.4, 3.2 and 4.8, respectively. Conclusion PIs suggested at senior pharmacy level are an important component of the comprehensive geriatric assessment, highlighting multiple complex prescribing issues. Clinical severity of PIs was scored lower by physicians, perhaps indicating an underestimation of prescribing errors. Senior pharmacy involvement in the care of frail older outpatients is an invaluable resource.

Glucose-6-phosphate dehydrogenase G6PD is a cytoplasmic enzymes that are found in all cells of the human body, it plays an essential and vital role in preventing cellular damage from reactive oxygen radicles ROS. Pharmacist can play a major role in providing G6PD deficient patients with the useful information about medications that needs to be avoided in such conditions. Therefore, this study was conducted to assess the pharmacist knowledge about medications use in G6PD deficient patients. Study’s results showed that most of the pharmacists were able to define G6PD deficiency correctly. However, majority were not able to identify risk factors for hemolysis correctly. With regards to the pharmacists’ knowledge about drug usage pattern in G6PD deficient patients, they showed an overall good knowledge as they were able to correctly identify the contraindicated and used with caution medications. Pharmacists should use continuous pharmaceutical education to keep up with updated evidence based information regarding medication use in specific population such as G6PD deficient individuals especially in G6PD prevalent regions.

Background and Objectives: Injection drug usage is a major public health issue. The study is aimed to find the clinical profile and trends of injection drug usage in young people who attended de-addiction services at a tertiary care center in North India. Methods: This retrospective record review analyzed data from consecutive young-aged people attending de-addiction services at a tertiary care hospital in North India between 2015 and 2019. The sociodemographic data and clinical and injection-related characteristics were discerned from the data. Results: Out of 135 patients included in the analysis, 132 (97.8%) were male. There was a 13-fold rise in treatment seeking over the past 5 years (2015: 7 vs. 2019: 98). One hundred and thirty-two (97.8%) were male. High Risk behavior was present such as sharing of needles in 31 (22.9%), paraphernalia sharing in 24 (17.8%), 6 (4.4%) reported ever-having symptoms of sexually transmitted infection, 13 (9.6%) had sex with sex worker, 9 (6.7%) reported ever-having HIV screening, 6 (4.4%) reported having HIV positive status. Thirty-two (23.7%) reported having previous treatment for drug abuse and 13 (9.6%) reported previously being hospitalized for drug abuse. Heroin usage has been present in 96 (71.1%) followed by pentazocine usage in 19 (14.1%). Conclusion: Our findings revealed that treatment-seeking young age population (the WHO defined age group 15–24 years) from the defined geographical location has been showing an increasing trend in injecting drug user usage along with greater injection and sexual risk behaviors associated with it. This can be used to design the public health strategy to educate regarding avoiding injection drug-related practices.

AIMS: To describe trends in pediatric in-hospital cardiac arrest drug administration and to assess temporal associations of the Pediatric Advanced Life Support (PALS) guideline changes with drug usage.METHODS: Pediatric patients RESULTS: A total of 6107 patients were analyzed. The adjusted odds of receiving lidocaine (0.33; 95% CI, 0.18, 0.61; p CONCLUSIONS: Changes to the PALS guidelines for lidocaine and bicarbonate were not temporally associated with acute changes in the use of these medications; however, better alignment with these updates was observed over time. A minor update to the language surrounding atropine in the PALS text was associated with a modest acute change in the observed use of atropine. Future studies exploring other factors that influence prescribers in pediatric IHCA are needed.

OBJECTIVE: Drug utilization habits of the pregnant are a critical aspect of rational use of the medicine (RUM). This study aimed to analyze the RUM related attitudes and the behaviors of women during their pregnancies. METHODS: The data were collected between May 2016–October 2016 by conducting surveys to 71 pregnant women admitted to the private and governmental hospitals in five districts of Northern Cyprus. The sociodemographic characteristics of the pregnant as well as their attitudes and behaviors concerning drug use were evaluated. RESULTS: The mean age and the gestational week of the patients was 29.7±4.3 years and 25.7±11.2 weeks, respectively. Planned pregnancies constituted 71.8% of all. The percentage of patients with an unplanned pregnancies who were using drugs at the time of the survey (25.0%) was lower than that in those with planned pregnancies (49.0%, p

Background: In India, asthma imposes a substantial burden; though the disease still remains under-recognized, underestimated and under-treated in masses.With a global need of promoting rational drug use in healthcare, drug utilization pattern studies could provide feedback to prescribers and help in fostering rational drug usage. The present study was planned to study the drug utilization pattern in patients of asthma in a tertiary care set-up in eastern India and to evaluate it with respect to GINA guidelines. Materials and Methods: The study was carried out over a period of one year where cases with confirmed diagnosis of asthma, who gave informed consent to participate were included.Drug usage pattern was determined in the light of drugs prescribed, mean drugs per prescription, percentage of drugs prescribed in generic name and having conformation to national essential drug list. Percentage of inhalational, injectable, fixed dose combination and antibiotics per prescription were noted. Data were checked for completeness and statistically analysed. Results: The present study included 370 participants. A total of 1514 drugs were prescribed, with 4.09 drugs per prescription. 12.55% of drugs prescribed were from national essential drug list. A total of 1031 anti-asthma drugs were prescribed with 2.8 anti-asthma drugs per prescription. Among the various classes of anti-asthma drugs, maximum prescribed were inhalational corticosteroids, followed by long acting inhalational beta 2 agonist and anti-leukotriene drugs. 96.5% of total patients were on inhalational drugs, with budesonide and formeterol being majorly prescribed. Conclusion: The usage pattern as assessed in our study was in conformation to GINA guidelines. Guidelines like GINA have enlightened physicians about the rational prescribing in asthmatic patients.

Effective case management is central for malaria control, but not all of those affected by malaria have access to prompt, effective treatment. In Kenya, free malaria treatment has been implemented since 2006. However, questions remain regarding effective treatment. We conducted cross-sectional epidemiological and questionnaire surveys in four counties in western Kenya in 2004, 2010, and 2016, and antimalarial availability surveys in 2016. We found a significant decline in self-reported malaria cases and an improvement in knowledge of malaria prevention and treatment since 2004. Parasite prevalence declined significantly from 2004 to 2010; however, it has remained unchanged since then. Artemisinin-based combination therapies (ACTs) and sulfadoxine-pyrimethamine (SP) drugs were widely available everywhere. The proportion of ACT usage increased from none in 2004 to 48% and 69%, respectively, in 2010 and 2016, whereas SP drug usage declined from 88% in 2004 to 39% in 2010 and 27% in 2016. During the 2016 survey, non-intermittent preventive treatment in pregnancy use of SP was common (20.9% of all surveyed individual treatments). In 2004, 27.2% (168/617) of households sought hospital treatment alone, and this number increased to 50.6% in 2016. The key factors affecting treatment-seeking behavior were education level, wealth index, household size, and distance to hospitals. Our results indicated that gaps in malaria case management remain and out-of-policy treatment is still a concern.

Summary Background The present study has the objective to assess the zinc (Zn), copper (Cu), and oxysterols plasma levels in type 1 (DM1) (n = 26) and type 2 (DM2) (n = 80) diabetes patients, as compared to healthy controls (n = 71), in order to testify whether metal levels may have a significant impact on the association between oxysterols and diabetes. Methods Plasma trace elements and plasma oxysterols were assessed using atomic absorption spectrometry and LC-MS/MS, respectively. Lifestyle, smoking status, alcohol intake, and drug usage, as well as microvascular complications, were also monitored and reported. Results The obtained data demonstrated that both DM1 and DM2 patients were characterized by significantly elevated HbA1c, FBG, TC, LDL-C, VLDL-C, and TG levels as compared to controls. Plasma Zn levels and Zn/Cu ratio in DM1 and DM2 patients were about 3- and 2-fold lower than controls. No significant differences in plasma Cu levels were reported. The 7-ketocholesterol (7-kchol) levels in DM1 and DM2 patients exceeded these values in healthy individuals by 2.5 and 5-fold, respectively. Similarly, cholestan-3β, 5α, 6β-triol (chol-triol) levels were more than 3- and 6-fold higher when compared to the respective values in non-diabetic controls. In regression models decreased plasma Zn and elevated oxysterol levels were significantly associated with HbA1c and fasting plasma glucose levels, after adjustment for anthropometric and clinical variables, as well as routine biochemical markers. Conclusions Plasma Zn concentration is inversely associated with both 7-kchol and chol-triol levels. Assessment of Zn and oxysterol levels may be used both for risk assessment and as targets for the treatment of diabetes mellitus.

Background/Introduction The novel coronavirus disease (COVID-19) inpatient mortality rate is approximately 20% in the United States. Reports have described a wide pattern of abnormalities in echocardiograms performed in patients admitted with COVID-19. The role of premorbid transthoracic echocardiogram (TTE) in the prediction of COVID-19 severity and mortality is yet to be fully assessed. Purpose To assess whether a pre-COVID TTE can identify patients at high risk of adverse outcomes who are admitted with COVID-19. Methods All patients who underwent a TTE from one year to one month prior to an index inpatient admission for COVID-19 were retrospectively enrolled across five clinical sites. Demographic information, medical history, and laboratory data were included for analysis. Echocardiograms were analyzed by an observer blinded to clinical data. Linear and logistic regressions were performed to detect the association of variables with death, invasive mechanical ventilation, initiation of dialysis, and a composite of these endpoints during the COVID-19 admission. Outcomes were then adjusted for a risk score using inverse propensity weighting incorporating age, sex, diabetes, hypertension, obstructive sleep apnea, history of atherosclerotic cardiovascular disease, atrial fibrillation, diuretic use, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use. Results There were 104 patients (68±15 years old, 49% male, BMI 31.4±9.1kg/m2) who met inclusion criteria (baseline characteristics in Table 1). Mean time from TTE to positive SARS-CoV-2 PCR test was 139±91 days. Twenty-nine (28%) participants died during the index COVID-19 admission. There was no association of pre-COVID echocardiographic measures of systolic ventricular function with any endpoint. Diastolic function, as assessed by LV e', was associated with mortality (Table 2). There were 25 patients (24%) with a normal lateral e' (≥10cm/s); none died. There were 35 (34%) patients with LV e' lateral velocity Conclusion In patients with an echocardiogram prior to COVID-19, impaired diastolic function as represented by an abnormal LV e' lateral velocity was associated with both inpatient COVID-19 mortality and a composite outcome of death, mechanical ventilation, and initiation of dialysis, even after adjustment for multiple co-morbidities and medication use. Knowledge of the pre-COVID TTE results may help clinicians identify patients at higher risk of adverse outcomes during an admission for COVID-19. Funding Acknowledgement Type of funding sources: None.

Substance abuse is a growing public mental health issue. Recent data from Global Burden of Disease study demonstrate that age standardized DALYs rate attributed to drug use disorders has increased by 25% in age group of 25-49 years during 1990-2019 (Lancet 2020; 396 1204-22). Standardized DALY rate due to alcohol use disorders reduced by 1/5 in this age group during the last 30 years, however it remains among the top 20 causes leading to greatest losses of DALYs in this age group. European countries persist to have high burden of diseases due to substance abuse. Social ecological model enables to structure individual, family, community and broader societal risk factors for substance abuse in specific groups within society. Some European countries (e.g. Germany) face increased migration especially from the war affected countries like Syria. Respective refugees and migrants may demonstrate higher substance abuse (alcohol and drug abuse) prevalence as an outcome of traumatic exposures and reflect the attempts to escape past and present experiences. In other countries (e.g. Lithuania), who still reflect transitional societies, substance abuse rates remain high due to psychosocial stress and structural barriers to implement effective prevention. Identification of risk factors may alleviate targeted and tailored prevention. The aim of the workshop is to systematize substance abuse risk factors in specific population groups based on socio-ecological framework applying different methodological approaches. There is a knowledge gap in culturally sensitive and translated into different languages instruments which assess substance use in refugee populations, especially from the Arabic countries. Therefore, a systematic review results on culturally sensitive substance abuse screening and assessment instruments among refugee populations will be presented. The qualitative study conducted in Germany will provide findings and insights on substance abuse perceptions among Syrian migrants and refugees. Understanding the explanatory model of Syrian refugees could inform future interventions to prevent substance abuse and design tailored interventions. Assessment of the behavioral risk factors related to injecting dug use in Lithuanian population using respondent driven sampling technique will be presented. Identifying individual and social risk factors may lead to targeted and effective prevention. Key messages Context specific knowledge of substance use is necessary for prevention including past and present factors. As refugee populations continue to grow, adequate screening instruments for substance abuse/dependence are needed.

Background Addiction to illicit drugs is considered as medical condition requiring effective measures to prevent the disease and minimize harms of this addiction. Injecting drug use increases the risk for acquiring blood-borne infections among people who inject drugs (PWID). The aim of the study was to assess the risk behavior related to the use of intravenous narcotic and psychotropic substances among PWID in Lithuania. Methods A cross sectional survey using respondent driven sampling (RDS) of active intravenous drug users (n = 369) in Lithuania has been conducted in 2018-2019. RDS is a peer-referral sampling methodology applied to estimate characteristics of underserved populations that cannot be sampled randomly. 8 seeds were selected in 5 different sites across the country to recruit the study subjects. Descriptive statistics and logistic regression were conducted. Results Data collection was completed using 4 waves. Each seed yielded 3 to 24 eligible recruits. 80% of the sample were males, 20% - females. Age mean is 36.8 years, SD-7.69. The age of debut injecting drugs was 13 years, average age 20 years, SD 4.8. Average injecting duration was 12 years. 76% were incarcerated during their lifetime. 59% of PWID reported injecting heroin, 39% phentanyl, 13% amphetamines. 79% reported using sterile needles and syringes while injecting the last time and 21% were not. 17% were sharing non sterile injecting equipment during the last 30 days. Conclusions Younger age when started injecting drugs, duration of injecting drugs and imprisonment increased the risk of using unsterile needles and syringes and sharing injecting equipment. Main messages Behavioural risk factors are related to higher risks of drug use related infectious diseases. Targeted psychosocial interventions are needed to prevent the behavioural risks of injecting drug use.

Background In South Africa, increasing illicit opioid use and associated health challenges can be managed with opioid substitution therapy (OST), like methadone, provided it is prescribed at the recommended dose and duration. The Community Oriented Substance Use Programme (COSUP) provides free methadone to patients with Opiod Use Disorder across Tshwane, South Africa on need-based criteria. Methods A retrospective cohort using secondary data of patients treated with methadone at eight COSUP sites. The factors associated with the retention of 575 participants for the period December 2016 to September 2018 were analysed. Results Participants on lower methadone doses had decreased odds of being retained (0 to 20mg: adjusted odds ratio (aOR) 0.25, p-value (p)=0.002, 95% Confidence Interval (CI) 0.10 - 0.61; 20 to 40mg: aOR 0.20, p Conclusions Methadone doses above 50mg, access to free methadone, accessing care within the inner-city and the white population group were positively associated with retention. Injecting drug use was negatively associated. Key messages Provision of free methadone at adequate doses can aid in retaining patients within an outpatient OST programme.

Background Erectile Dysfunction (ED), is a common complication in type 2 diabetic men. Present study was undertaken to investigate the association between demographic factors, metabolic parameters and medication use with ED among type 2 diabetics. Methods This was a cross-sectional study. Married men aged 20-60 years with a diagnosis of type 2 diabetes attending the outpatient unit of Department of Endocrinology at PSG Hospitals during the months of May and June 2019 were enrolled. The severity of erectile function was assessed using the validated International Index of Erectile Function (IIEF-5) questionnaire. All subjects were evaluated based on demographic factors, clinical parameters and medications used. Results Out of the 204 patients enrolled, 65 (31.86%) were found to have ED. ED was significantly associated with patients who were having less physical activity, hypertension, obesity and diabetic retinopathy. A significant increase in the prevalence of ED with duration of diabetes was observed. In patients with diabetes, for 1-5, 6-10 and 11-30 years, the prevalence was 24.1%, 27.7% and 53.1% respectively. Conclusions For type 2 diabetes, increasing duration of diabetes poses a greater risk for ED. Hypertension, less physical activity and some medications increase the prevalence of ED. Key messages Our results suggest that health care providers who address sexual dysfunction issues with their diabetic patients early may be able to reduce the severity or delay the onset of ED by implementing intensive lifestyle changes as the first step management for type 2 diabetes.

What is known and objective: Every prescriber knows that patients often do not take their medicines as prescribed. Hippocrates, the wise man of Kos, knew over two millennia ago. Our objective is to comment on the types of studies aimed at understanding and optimizing drug usage and to draw attention to the need to seek approval before using or citing the Morisky adherence scale. Comment: The study of prescribing and how patients use their medicines is important. As part of this effort, the results of investigations of how patients adhere to drug prescriptions can be informative. However, the results are meaningful only if the methods used for doing the measurements are valid and made explicit. We were surprised when a team of our authors were threatened with legal action for citing the Morisky Adherence Scale and explaining how some authors had obtained their adherence scores. Adherence studies are but one facet of the study of prescribing aimed at improving clinical outcomes. Other aspects include investigating the quality of prescribing, and how unnecessary medicines can be deprescribed to improve the quality of care and reduce the risk of adverse effects. What is new and conclusion: The study of optimal prescribing is an important endeavour and adherence studies are but one aspect. We report that using and citing the Morisky Adherence scale in any detail is a risky business. Prior approval is required unless one is prepared to pay up, retrospectively. We require all authors to certify they have no conflicts of interest with respect to the scale.

Background Guidelines recommend multidisciplinary models for the management of infective endocarditis but have failed to incorporate the unique challenges of treating drug-use associated infective endocarditis (DUA-IE). Given the drug use and overdose epidemic with rising cases of DUA-IE, we created a multidisciplinary Drug Use Endocarditis Team (DUET), which convened monthly case conferences among the specialties involved, including Infectious Diseases, Cardiothoracic Surgery, Cardiology and Addiction Medicine. Objective: To conduct a retrospective cohort study of the patients presented at the DUET conferences from August 2018 to February 2020 to (1) assess clinical and demographic characteristics and (2) describe clinical outcomes. Methods A retrospective chart review was conducted to analyze 57 patient cases, including descriptive statistical analyses of demographics, clinical characteristics, and outcomes. Results Among our DUET cohort, 43.8% represented isolated right-sided endocarditis, and 84% involved native valve. Methicillin-susceptible Staphylococcus aureus was the most common microorganism isolated. ID was consulted in 94.7% of cases and overall 43.9% completed the planned antimicrobial course. The 7 patients who developed relapse/recurrent IE were initially managed medically, and 5 did not complete the initial antimicrobial course. Formal cardiothoracic surgery consultation was obtained in 57.9% and 24.6% were managed operatively. Of the patients managed operatively, 64.3% completed the antimicrobial course. The rate of antibiotic completion was higher among patients managed operatively but did not reach statistical significance (p=0.08). Formal addiction medicine consultation was obtained in 85.9% of cases, with 63.1% discharged on medications for opioid use disorder (MOUD). The rate of MOUD on discharge was not significantly different between patients managed operatively and non-operatively. Figure 1: Patient Characteristics Figure 2: Infection Characteristics Figure 3: Outcome Analyses Conclusion ID is nearly universally involved in the care of patients with DUA-IE, but this patient population requires input from numerous sub-specialties. Multidisciplinary care teams provide a promising framework for DUA-IE to enhance and integrate nuanced decision-making. Disclosures Sarah E. Wakeman, MD, Celero Systems (Advisor or Review Panel member)Optum Labs (Grant/Research Support)UpToDate (Other Financial or Material Support, Author)

Despite its long history of untoward side effects of a systemic autoimmune disease, drug-induced lupus can be difficult to recognize because of the disconnect between chronic drug usage and onset of symptoms. In this case, the patient was treated with hydralazine for two years when symptoms were initially reported, but a diagnosis of hydralazine-induced lupus was not considered for another half year. Despite treatment with steroidal and nonsteroidal anti-inflammatory medications during this period, rheumatologic symptoms and signs continued to deteriorate, consistent with the diagnosis of systemic lupus erythematosus. Not until the patient voluntarily discontinued hydralazine did symptoms begin to improve, fully resolving over the subsequent 6–12 months largely in the absence of anti-inflammatory medication. This patient demonstrates that failure to recognize a drug-induced disease etiology can result in substantial worsening of rheumatologic symptoms over the subsequent six months, ultimately satisfying criteria for systemic lupus erythematosus. While symptoms and signs largely normalized, some laboratory abnormalities and occasional arthralgia remained two years after discontinuing hydralazine, suggesting smoldering inflammatory disease.

Antimicrobial resistance (AMR) has developed as one of the major urgent threats to public health causing serious issues to successful prevention and treatment of persistent diseases. In spite of different actions taken in recent decades to tackle this issue, the trends of global AMR demonstrate no signs of slowing down. Misusing and overusing different antibacterial agents in the health care setting as well as in the agricultural industry are considered the major reasons behind the emergence of antimicrobial resistance. In addition, the spontaneous evolution, mutation of bacteria, and passing the resistant genes through horizontal gene transfer are significant contributors to antimicrobial resistance. Many studies have demonstrated the disastrous financial consequences of AMR including extremely high healthcare costs due to an increase in hospital admissions and drug usage. The literature review, which included articles published after the year 2012, was performed using Scopus, PubMed and Google Scholar with the utilization of keyword searches. Results indicated that the multifactorial threat of antimicrobial resistance has resulted in different complex issues affecting countries across the globe. These impacts found in the sources are categorized into three different levels: patient, healthcare, and economic. Although gaps in knowledge about AMR and areas for improvement are obvious, there is not any clearly understood progress to put an end to the persistent trends of antimicrobial resistance.

Introduction: To provide an overview of drug use in palliative care worldwide and to identify the most commonly used medicines in palliative care settings. Methods: Quasi–systematic review. Search strategy: Medline/PubMed, Embase, SCOPUS and Google Scholar were searched utilizing the selected MeSH terms: palliative care, hospice, drug utilization, and prescription patterns. Results: Overall, it is apparent that there is a significant lack of published literature outlining drug usage in palliative care settings. Twelve sources of information were reviewed from 9 different countries including Austria (n = 1), Brazil (n = 1), Canada (n = 1), Germany (n = 1), Italy (n = 2), Netherlands (n = 2), Norway (n = 1), Switzerland (n = 1) and USA (n = 3), as well as a multinational study comparing 11 European countries. Medication use between countries was similar. The most commonly prescribed classes of medicines included non-opioid analgesics, opioids, laxatives, sedatives and antipsychotics and the most commonly prescribed individual drugs comprised morphine, haloperidol, laxatives and paracetamol. Conclusions: The literature identifies that there is insufficient evidence to describe and compare what drugs are currently used in palliative care settings worldwide. This is attributed to the lack of recently published articles leading to a large gap in knowledge in understanding drug utilization practices in palliative care. Further research is required to address these gaps in knowledge, and identify medication management issues in palliative care and determining whether there are significant differences in drug management practices. Palliat Med Pract 2019; 13, 3: 134–141

Introduction. The ways of usage of pharmacological drugs during the festering setptic diseases are different. Today the most effective is endolymphatic, which influencies causative agent and toxins directly in the lymphatic system before they enter the blood circle. Endolymphatic method of drug usage allows to reate and support therapeutic concentrated doses of antibiotics in the lymphatic system. Thus this method can be used in a complex treatment of peritonitis.Aim of research. Our aim is to improve the results of a complex treatment with endolymphatic combined therapy (ECT) for patients with acute peritonitis.Materials and methods. 37 patients, aged 19-72 with acute peritonitis have been examined. These patients were treated at the surgical department of Uzhhorod regional hospital in the period of 2015-2019. There were two groups of patients: main group with 22 patients and control group with 15 patients. Only main group of patients used endolymfatic combined therapy (ECT). To asses the level of endogenic intoxication we determined the level of middle molecular mass blood serum and made calculation of leucocyte index of intoxication. To assess the activity of non-specific defense of the body we determined body resistance index.Results and discussion. The analyses of the received data show that the usage of endolymfatic combined therapy (ECT) within the complex treatment of peritonitis leads to fast elimination of endogenous intoxications phenomena. Namely, leucocytes are 25% less, rod-core neutrophils are 35% less, leucocyte intoxication index is 25% less, level of peptides with middle molecular mass is 20% less, index of a body resistance is 25% higher, are this leads to a quick recovery of the body defence forces in comparison to a control group patients.Conclusion. Clinicaly enabled us to establish that in case of the complex treatment of peritonitis the endolymphatic combine therapy diminishes endogenic intoxication contributes rapid normalisation of the immunologic findings and rapid restored protective function of organism.

Background: This is the first detailed Indian electronic medical record (EMR)-based real-world observational study to understand the clinical characteristics, associated comorbidities/risk factors and treatment(s) of CAD patients across India.Methods: EMR data of adult Indians (aged ≥ 18 years) diagnosed with CAD was retrospectively analyzed.Results: The majority of the participants had stable IHD (93%), were men (68.5% in ACS, 59.8% in stable IHD), most common age group was 40-64 years in ACS (56.6%) and stable IHD (51.4%). Both are common in metros (ACS 52%, 62% stable IHD). There is a high frequency of hypertension (38.2% in ACS, 59% in stable IHD) and diabetes mellitus (32.3% in ACS, 57.6% in stable IHD). Most common treatments are antiplatelet drugs and lipid-lowering drugs (96%).Conclusions: In India, stable IHD is the most prevalent form in vast majority of patients. The patients with CAD are mostly males, are mainly located in metros and majority fall between the age group of 40-64. The major comorbidities are hypertension and diabetes mellitus. Sociodemographic and clinical characteristics for CAD in India may not be similar to what is reported from the west. There is a significant difference in drug usage and adherence to guidelines in India for CAD.

Objective: The objective of the research was to examine and evaluate rational drug uses of patients over 65 years of age referring to Primary Care Center. Methods: A questionnaire on the drug usage habits of elder patients prepared by making literature scanning and taking expert view was applied in the study to the participants accepting to join the study among patients over 65 years of age applying to Family Health Center. Results: A total of 291 patients including 127 males (43.6%) and 164 females (56.4%) over 65 years of age were included in the study. Mean age of the participants was found 72.76. Leftover drug keeping ratio of the participants at home was found as 53.3% (n=155). When unprescribed drug usage conditions of the participants were questioned, 60.8% (n=177) stated that they didn't use unprescribed drugs. Conclusions: Polypharmacy is an important health problem for elder individuals with the lengthening of average duration of life and increase in the prevalence of chronic diseases. Drug use for a wrong time and dose may cause conditions such as the lack of the effect which should be provided by the drugs, or occur more than expected or unexpected drug-nutrient interactions. Primary care physicians have an important role in disease and health phases of elder patients. Keywords: Aging, Drug therapy, Drug misuse, Continuous...

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Daiichi Sankyo Europe GmbH Background Direct oral anticoagulants (DOACs) have been shown to be non-inferior to vitamin K antagonists (VKA) regarding both efficacy and safety outcomes in patients with atrial fibrillation (AF). However, elderly are underrepresented in the underlying clinical trials. Purpose The aim of this study was to compare risks of major bleeding events and compare healthcare resource utilization (HRU) between AF patients treated with edoxaban or VKA in elderly. Methods A cohort study was conducted using claims databases of Caserta and Palermo Local Heath Units in Italy. AF patients starting use of edoxaban or VKA between August 1st, 2016 and December 31st, 2018 were included. Date of the first dispensing was defined as the index date. The study population was matched based on a propensity score based on factors associated with the outcome. We restricted to patients aged ≥65, ≥1 year database history, and no use of the index drug in the year before index date. Incidence rates of bleeding outcomes and rates of HRU were assessed per 1,000 and 100 person-years follow-up (PY), respectively. Cox regression analyses to adjust for baseline covariates were used for comparisons of incidence rates of bleeding outcomes among all edoxaban and VKA users. Poisson regression analyses were used for comparisons of rates of HRU among all edoxaban and VKA users. Both analyses were adjusted for age. Sex, region and year of index date were considered for the adjusted models as well, using a backward stepwise approach to select eligible variables. Results 1,317 edoxaban users and 2,924 VKA users were included in the matched population. Mean age was 79 in both treatments groups, and 43% of the edoxaban users and 45% of the VKA users was male. Bleeding risks were significantly lower among edoxaban users compared to VKA users aged ≥65 (adjusted HR 0.39 (95% CI 0.19-0.83)) and among patients aged ≥75 (adjusted HR 0.37 (95% CI 0.16-0.86)). Among patients aged ≥65, edoxaban users were significantly less often hospitalised (RR 0.56 (95% CI 0.46-0.68)) and the total number of hospitalised days were also significant lower (RR 0.58 (95% CI 0.42-0.80)) compared to VKA users. Among patients aged ≥75, similar results were observed for the number of hospitalisations. Edoxaban users had significant less out-patient visits compared to VKA users (among patients aged ≥65 the RR was 0.44 (95% CI 0.39-0.50) and among patients ≥75 this was 0.40 (95% CI 0.35-0.47). Use of out-patient medication use was significantly lower among edoxaban users compared to VKA users among patients aged ≥65 (adjusted RR 0.91 (95% CI 0.88-0.95)) as well as among patients aged ≥75 (adjusted RR 0.91 (95% CI 0.87-0.95)). Conclusion Study results show a decreased bleeding risk of edoxaban compared to VKA in both age groups of patients with AF. Hospital based HRU has shown to be lower among edoxaban users compared to VKA users in both age groups. Out-patient HRU was also lower among edoxaban users.

Background and Aims Posttransplantation diabetes Mellitus (PTDM) is one of the major medical problems in renal transplant recipients (RTRs). Diuretic-induced hyperglycemia and diabetes have been described in the general population. We aimed to investigate whether diuretics also increase PTDM risk in RTRs. Method We included 486 stable outpatient RTRs (with a functioning graft ≥1 year) without diabetes from a prospective longitudinal study (the Transplantlines Food and Nutrition Study [NCT02811835]). Participants were classified as diuretic users and non-diuretic users based on their medication use recording at baseline. PTDM was defined according the American Diabetes Association’s diagnostic criteria for diabetes. Multivariable Cox proportional-hazards regression analyses were performed to assess the prospective association between diuretic use and the risk of PTDM development. Results Median time since transplantation was 5.4 (2.0-12.2) years and 168 (35%) RTRs were taking diuretics. After 5.2 (IQR, 4.0 5.9) years of follow up, 54 (11%) RTRs developed PTDM. In Kaplan-Meier (log-rank test, p Conclusion This study demonstrates that diuretics overall, associated with the risk of developing PTDM in RTRs, independent of established risk factors for PTDM development. The association was consistent for thiazide and loop diuretics.

Background/Aims Polymyalgia rheumatica (PMR) is one of the commonest indications for long term glucocorticoid (GC) use, leading to an increased risk of osteoporosis and fragility fractures. Clinical guidelines recommend prescribing medication including vitamin D, calcium and anti-resorptives, such as bisphosphonates. The aim of this study was to examine the association of reported falls and prescriptions of medications for osteoporosis with future fragility fractures in a cohort of people with PMR. Methods 652 people with an incident diagnosis of PMR responded to a baseline survey between June 2012 and June 2014. This included data on general health, sociodemographics, history of falls and medication. Data on fractures and prescriptions were collected at 12 and 24 months. Fragility fractures were defined as fractures of the hip, wrist or spine. Logistic regression models were used to assess the association between baseline characteristics and fractures at 12 and 24 months. Analysis was conducted unadjusted and adjusted for age, gender, reported medication use and falls history. Results 112 (17.2%) baseline respondents reported a previous fragility fracture. 60 (83.3%) of the 72 respondents who reported a fragility fracture between baseline and month 12 also reported a fragility fracture at baseline. 49 (79.1%) of the 60 respondents who reported a fragility fracture at between the month 12 and 24 also reported a fragility fracture at baseline. Falls before baseline was the most significant predictor of fragility fracture at 12 (OR 2.35 95% CI 1.35-4.12) and 24 (OR 1.91 95% CI 1.05-3.49) months. Fewer than 50% of respondents were ever prescribed treatment for osteoporosis. Being prescribed treatment for osteoporosis was associated with a reduced incidence of fragility fractures at 24 months (adjusted OR 0.28 95% CI 0.10-0.80), but an increased incidence at 12 months (adjusted OR 2.10 95% CI (1.3-3.48). Calcium and vitamin D prescription, gender and age were not significantly associated with fracture outcome. Conclusion Despite guidelines, fewer than 50% of patients were prescribed medications for osteoporosis. This data highlights the risks of fractures in PMR patients who have experienced previous falls. Over a period of two years, medication for osteoporosis was significantly protective, hence more needs to be done to encourage adherence to guidelines. Further studies need to address reasons for non-adherence to guidelines and the effects of long-term treatment. Disclosure B. Sokhal: None. S.L. Hider: None. Z. Paskins: None. C.D. Mallen: None. S. Muller: None.

Objectives:Elderly-onset rheumatoid arthritis (EORA) is reported to differ from young-onset rheumatoid arthritis (YORA) with regard to patient background and drug treatment. We examined the amount of drug administered to patients who achieved low disease activity (LDA) for rheumatoid arthritis at our hospital., Methods:Demographics, clinical history, and treatments were compared between patients with EORA (n = 70) and YORA (n = 190)., Results:There was a significant difference in the average age (73.8 vs. 57.8 years), disease duration (6.66 vs. 14.7 years), and sex (62.9% males vs. 83.7% females), but no difference in rheumatoid factor positivity (85.3% vs. 80.7%), anti-citrullinated peptide antibody positivity (86.5% vs. 87.7%), simplified disease activity index (4.28 vs. 4.59), or disease activity score 28-CRP (1.99 vs. 2.04) in the EORA and YORA groups, respectively. There were also no significant differences in prednisolone use (37.1% vs. 36.3%), amount of methotrexate administered (MTX) (1.45 vs. 1.41 mg), and MTX use (55.7% vs. 65.3%). However, the MTX dose (2.89 vs. 4.09 mg/week, p = .011) and overall biologics use (32.9% vs. 56.3%, p = .0012) were significantly lower in patients with EORA than in those with YORA., Conclusion:Patients with EORA may be able to achieve LDA with lower drug dosage than those with YORA.

Background and Aim The number of elderly patients with ulcerative colitis (UC) is increasing worldwide. The clinical practice of associated treatment is still unclear. Therefore, we aimed to analyze clinical treatment realities and mortality in elderly and non‐elderly patients with UC. Methods We collected UC patients' data using the diagnosis procedure combination (DPC) database system and divided eligible patients into elderly (≥65 years) and non‐elderly (≤64 years) groups. We investigated and compared their therapeutic histories (medical treatments vs. surgery). Logistic regression analysis was conducted to identify clinical factors affecting surgery and in‐hospital death in each group. Results The rates of systemic steroid injection, molecular targeting drug usage, and surgery were not different between the two age groups. Meanwhile, the rate of in‐hospital death in elderly patients was higher than that in non‐elderly patients (2.7% vs. 0.19%, P, The clinical practice of treating elderly patients with ulcerative colitis (UC) is overall not different from treating non‐elderly patients with UC. Although the form of medical treatment and surgery rate for elderly patients with UC may not be significantly different from non‐elderly patients, the rate of in‐hospital death for elderly patients is higher.

Outbreaks of Hepatitis A, caused by the Hepatitis A Virus (HAV), remain a worldwide health concern. We conducted a retrospective chart review to characterize patients with acute HAV during an outbreak at our urban tertiary care center to better characterize patients infected with HAV. We searched our electronic records for patients with positive HAV IgM antibodies during a period of outbreak in Philadelphia, May 2017-December 2019. Characteristics of patients were recorded. We searched an equal period of time prior to the outbreak, September 2014-April 2017, to compare the two patient populations. During the outbreak we diagnosed 205 cases of acute HAV compared to just 23 during an equal time period prior to the onset of the outbreak. When compared to the results reported by the public health department for 2019, this accounted for 39.9% of patients documented in the city. A history of drug use was found in 49.4% of our patients while 19.5% of patients were homeless. Our analysis of homelessness and drug usage among documented cases of HAV during the outbreak period mirrored data reported by the city. Further, our analysis found that 7 zip codes accounted for 60% of our patients. Biochemical measures of liver function were higher in patients examined during the outbreak.

Introduction: Atrial fibrillation increases the risk of stroke 5-fold. The efficacy of endocardial catheter ablation (CA) for drug - refractory persistent and longstanding persistent AF (PsAF) is limited and has led to the development of minimally invasive hybrid epicardial/endocardial ablation technique (hybrid Convergent) to achieve a comprehensive lesion set with durable transmural lesions. The CONVERGE IDE randomized controlled trial prospectively evaluated the effectiveness of Convergent ablation compared to CA for the treatment of PsAF. Methods: PsAF patients, >18 to Results: One hundred fifty-three patients (102 Convergent, 51 CA) with similar baseline characteristics were treated. Body mass index (mean 33.7, range 19.1- 50.1) and years since PsAF diagnosis (mean 4.4 years, range 0.5 - 26.0 years) were high; 42.5% (65/153) patients had longstanding persistent AF. In the Convergent arm, 4 major adverse events (3.9%, 4/102) were reported through the first 7 days and additional 4 events (3.9%) from days 8 - 30. The safety rates were lower than the performance goal of 12%. Rates of freedom from atrial arrythmia stratified by AAD use are included in Table1. Irrespective of the criteria, the hybrid Convergent procedure demonstrated significantly higher treatment success compared to CA (RR 1.28 - 1.67, p Conclusion: The hybrid Convergent procedure combining epicardial and endocardial ablation is safe and has superior effectiveness as compared to the endocardial catheter ablation for the treatment of PsAF, irrespective of AAD use.

Background Epilepsy, which is the most common symptom accompanying gliomas, was reported as an independent favorable prognosis factor for glioma patients. However, the correlation between glioma location and epilepsy prognosis, genesis and genetic phenotypes of the glioma associated seizure (GAS) patients is far from clear, the purpose of the current study was to provide probabilistic radiographic atlases reflecting seizure susceptible regions, relationship between tumor associated biomarkers and seizure initiation and poor epilepsy prognosis areas. Methods Preoperative MRIs were collected from 119 newly diagnosed patients with histologically confirmed gliomas. These samples were analyzed for seizure status and tumor genetic makers (TP53 mutations, MMP-9.PTEN, MGMT, EGFR and IDH1) using a statistical voxel-based lesion-symptom mapping (VLSM) method. Results We found bilaterally that the frontal lobe containing regions were associated with GAS for low grades gliomas, moreover lesions with the PTEN mutation and IDH1 mutation and seizure susceptible regions were located close together and partially overlapped, Patients with preoperative tumor involving the right frontal lobe may have good seizure control; however, for the glioma-infiltrated regions in front of the precentral regions in the left hemisphere, the epilepsy prognosis is poor. Conclusions The current results of seizure associated molecules and specific regions on structural MRI could be used in preoperative surgical planning, seizure prognosis predictions and anti-epilepsy drug usage.

Background High blood lipid levels are known risk factors for atherosclerotic cardiovascular events, but associations between lipid levels and atrial fibrillation (AF) are unclear. Some previous studies have suggested an inverse association between lipid levels and AF referred to as the “cholesterol paradox”. Purpose To examine the prevalence of AF by differing lipid levels in a large population-based study of almost 14,000 adults in Poland. Methods The LIPIDOGRAM 2015 study is a cross-sectional study of adults aged 18 years and older recruited in Poland in 2015/2016 by 438 family physicians. Poisson regression models with robust variance were used to estimate prevalence ratios (PRs) for AF with 95% confidence intervals (CIs) for participants with differing lipid profiles. Lipid measures including low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), total cholesterol (TC) and LDL/HDL ratios were grouped into quartiles with the lowest quartile as the reference group. Models were adjusted for potential confounding factors including age, sex, waist-to-hip ratio, smoking, alcohol intake, regular physical activity, hypertension, antihypertensive medication use and treatment of dyslipidaemia. Results 13,724 participants were recruited to the study, the median (interquartile range: IQR) age was 58.0 (47.7–65.8) years and 5.2% (n=708) had a diagnosis of AF, with a median (IQR) 3 (1–8) years since diagnosis. After adjusting for potential confounding factors, a statistically significant lower prevalence of AF was estimated for participants in the highest quartile for LDL-C (PR (95% CI): 0.60 (0.48, 0.75) p Conclusions The prevalence of AF was lower for people with higher levels of LDL-C, HDL-C, TC and higher LDL/HDL ratios; some of the difference in prevalence was explained by controlling for confounding factors, but in multivariable models the association remained statistically significant. This research adds to the body of evidence which suggests an inverse relationship between cholesterol levels and AF-the “cholesterol paradox” for AF. Funding Acknowledgement Type of funding source: None

In the majority of cases, allergic rhinitis (AR) has its onset in children or adolescents, with the cardinal symptomatology of repeated sneezing, nasal pruritus, discharge, and a blocked nose. The customary way to classify AR is into seasonal and perennial variants, reflecting the allergenic underpinning of the disorder, but the World Health Organisation (WHO), in its Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines, employs a classification scheme dividing AR into intermittent or persistent types, based on the symptomatic duration. The current treatment modalities for AR are nasal steroids, nasal decongestants, anticholinergics, antihistamines, and panthenol. A novel pharmaceutical formulation that provides all the effects of the abovementioned drugs may be unique and has significant benefits such as single drug usage, cost-effectiveness, lesser side effects, etc. The proposed formulation enables to combine the anti-inflammatory, antihistaminic, decongestant, anticholinergic, and hydrating effects of these drugs into a single medicine.

Background Hospital-based strategies that link persons with infectious complications of opioid use disorder (OUD) to medications for OUD (MOUD) are of great interest. The objective of this study is to determine whether a hospital-based protocol would increase the use of MOUD and to identify barriers to MOUD during admission and at the time of discharge. Methods This study included participants with a documented or suspected history of injection drug usage receiving care for an infection at the University of Alabama at Birmingham Hospital from 2015 to 2018. The protocol, the intravenous antibiotic and addiction team (IVAT), included Addiction Medicine and Infectious Diseases consultation and a 9-item risk assessment. We quantified MOUD use before and after IVAT and used logistic regression to determine factors associated with MOUD. We explored barriers to MOUD uptake using chart review. Results A total of 37 and 98 patients met criteria in the pre- and post-IVAT periods, respectively. With IVAT, the percentage with OUD receiving MOUD significantly increased (29% pre-IVAT and 37% post-IVAT; P = .026) and MOUD use was higher in “high risk” participants (62%). Clinical and sociodemographic factors were not associated with MOUD receipt. Conclusions A hospital-based protocol may increase the use of MOUD; however, the uptake of MOUD remains suboptimal (

Objective To analyze the prevalence of diabetes mellitus (DM) according to different diagnostic criteria, in the Brazilian adult population, according to laboratory results from the Brazilian National Health Survey. Methods Analysis of laboratory data from the National Health Survey, collected between 2014 and 2015. The prevalence of diabetes was calculated according to different diagnostic criteria. The prevalence of diabetes was calculated according to the criterion of glycosylated hemoglobin ≥ 6.5% or using medication, using Poisson regression and calculating crude and adjusted PR and 95%CI. Results The prevalence of diabetes according to different criteria varies from 6.6 to 9.4%. Intermediate or pre-diabetes hyperglycemia ranged from 6.8 to 16.9%. Considering laboratory criteria or medication use, the prevalence of DM was 8.4 (95%CI 7.65-9.11). The adjusted PR for gender, age, educational level and region was lower for males (PR 0.75; 95%CI 0.63 - 0.89), increased with age: 30 to 34 years (PR 2.32; 95% CI 1.33 - 4.07), 40 to 59 years PR 8.1; 95%CI 4.86 - 13.46), 60 years old or older (PR 12.6; 95%CI 7.1 - 21.0), and higher educational levels was protective (PR 0.8; 95%CI 0.6 - 0.9). Therewas a higher PR in the Central West Region (PR 1.3; 95%CI 1.04 - 1.7), in overweight people (PR 1.8; 95%CI 1.4 - 2.1), and in obese people (PR 3.3; 95%CI 2.6 - 4.1). Conclusions The prevalence of diabetes was higher in females, people over 30 years of age, in populations with low educational levels, and people who were overweight and obese. The study advances in determining the diabetes situation in the country through laboratory criteria. These data demonstrate the importance of controlling hyperglycemia in order to avoid the vascular and systemic effects of DM. Key messages This is the first study to analyze the prevalence of DM using laboratory data from a representative sample of the Brazilian population. The study pointed to a strong association between overweight and obesity and diabetes, showing the importance of public health measures to encourage healthy eating and physical activity.

Background Harm reduction programmes are recommended as an effective HIV prevention among injection drug users by the WHO and UN. Monitoring of clients' risky behaviour is carried out to evaluate the effectiveness of low threshold centres' (LTCs) activity, which allows assessment of services' effect on the public health. Aim Evaluation of effectiveness of LTCs' activity, changing clients' behaviour, during 1997-2019. Methods Analysis of LTCs’ documentation during 1997–2019; survey of the anonymous questionnaire carried out in the LTC of Klaipėda Mental Health Centre in 2019 (sample 130 people), comparison of the data with the results of 2001 survey. Results during 1997-2019 the average number of one client visits to the centre per year increased from 5 to131. The number of means supplied to clients was increasing: the amount of returned used syringes (83% in 1998, 101% in 2019) was increasing in comparison with the amount of issued sterile means. In 2001 58% of respondents who did not attend the centre would hand over used syringes to others while in 2019, after taking the centre services, the number dropped to 13%. A certain number of clients would accept used syringes until coming to the centres (in 2001 25% did not do this), after visits to the centres in 2019 91% did not use used syringes. Clients more often started using condoms with casual partners (17% in 2001, 84% in 2019). The more often clients attend the centres, the more of them take HIV tests (62% in 2001, 96% in 2019). 58% of respondents in 2001 and 97% of respondents in 2019 expressed a wish to give up drug use. Conclusions the activity of the LTCs during 1997-2019 attracted increasing number of drug users. The study demonstrated: activity of LTCs is effective in changing risky behaviour of drug users to a more safe one while injecting drugs and having sexual contacts. Majority of clients have a wish to stop using drugs and the more they attend the LTCs the more realistic possibility to do this they see. Key messages Monitoring of clients‘ risky behaviour is carried out to evaluate the effectiveness of low threshold centres‘ (LTCs) activity, which allows assessment of services‘ effect on the public health. Activity of LTCs is effective in changing risky behaviour of drug users to a more safe one while injecting drugs and having sexual contacts.

Background:Over the counter drug abuse is a growing problem and it needs more recognition. This current study is aimed to assess the pattern of over the counter drug usage among the patients attending Saveetha medical college hospital, Chennai, Tamil Nadu. Method: This cross-sectional questionnaire based study was conducted at Saveetha medical college and hospital, Chennai, Tamil Nadu. The patients who signed the informed consent form were the study participants, a total of 100 patients were involved. The study period lasted from 23rd January 2019 to 30th March 2019. After the data was obtained they wereanalyzed using Microsoft excel. Percentages and frequency were calculated. Result: A total of 100 filled questionnaires were collected from the study participants. Majority of the participants (63%) bought OTC drugs on occasion and the rest (37%) bought them always. Most of them (43%) consumed OTC drugs when the symptoms were minor/manageable, 33% of them whenever they felt sick and 24% when they couldn’t go to a doctor. Many (41%) believed they could relieve fever by using OTC drugs, 20% to relieve nausea and 39% to relieve headache. Antipyretics (47%) were the most commonly consumed OTC drug. Most (38%) common reason for choosing OTC drug was to save time. Conclusion: This study helped gauge the general public’s views on OTC drug usage and gives an idea about the amount of work that is yet to be done or has to be done to bring OTC drug abuse under control. It is almost obligatory to make the patients understand the detrimental effects of OTC misuse and abuse- and the most effective way to achieve this is by making the people aware of them in the first place. Even though OTC drug abuse is a largely recognized problem, we still have a long way to go in terms of actually solving it.

Introduction Nasal decongestants are one of the drugs commonly prescribed by otorhinolaryngologists in their day to day practice. The excessive or inappropriate use of nasal decongestant due to rapid symptomatic relief leads to drug misuse or abuse. Inadequate knowledge about the drug usage leads to inappropriate drug usage. Materials and Methods A cross sectional study was done among 90 patients who were using topical nasal decongestants. A pre tested, pre validated questionnaire was used to assess the patient’s knowledge, the utilization pattern and the attitude towards the drug usage. Results The mean age of presentation in our study was 38.4 years. Only 14.4% of the people knew the appropriate duration of drug usage. Only 33.3% knew about the probable side effects of prolonged drug usage. There was a significant correlation between knowledge and utilisation pattern of topical nasal decongestants usage and the literacy level. Though most of the people (46.7%) started using the drug after being prescribed by a doctor, only 14.3% among them strictly adhered to doctor’s instructions.82% of the users were not much worried about the prolonged usage as 73.3% believed that prolonged use may or will surely improve their symptoms. Though 66.7% users wanted to stop prolonged usage of the drug, 76.9% had varying difficulties in stopping the drug. Conclusion The knowledge and the utilization pattern regarding the drug usage were very low. The same was found to be better with increase in literacy level. Health professionals should play a major role in establishing a rational drug usage.

Background and Aims Sleep is considered a basic human need according to Maslow. It helps in the individual‘s physical and psychological recovery. Nowadays, sleep disturbances are an increasingly frequent reality and they interfere negatively with quality of life. Poor sleep quality has a negative impact on the individual’s health (attention, memory, Diabetes, Hypertension, immune system depression, mortality). Peritoneal dialysis (PD) may be an additional insult that is disturbing to its quality. The aim of the study was to assess the quality and health of sleep in PD patients. Method We carried out a single-center study in 35 prevalent PD patients. We used the Pittsburgh Sleep Quality Scale (PSQI), which evaluates seven components (subjective quality, latency, duration, usual efficiency of sleep and sleep changes, medication use and daytime dysfunction) and which considers a good sleep quality when PSQI ≤5. We used a sleep health scale assessed by SATED PT (validated for the Portuguese population) and which considers 0 poor sleep health and 30 good sleep health. Each patient answered both PSQI and SATED-PT questionnaires. Demographic and clinical variables were analyzed. Continuous variables are presented as means (standard deviation) or medians (interquartile range), depending on normality; categorical as frequencies. Univariate analysis was performed. STATA software was used and p Results Our cohort has 18 (51%) women, 34 (97%) Caucasians, mean age 49 ± 15 years, median dialysis time of 20.5 (8-33) months; 4 (11%) had a history of attempted construction of arteriovenous fistula and 7 underwent a short period of hemodialysis before starting PD (median 60 months). Charlson's median score was 4 (2-5). 21 patients (60%) were on automated PD, 14 on manual, 18 on Baxter system and 17 on Fresenius system. Regarding sleep quality, the average obtained on the PSQI scale was 7 ± 3.4 and 60% had values> 5. We found no correlations between these parameters and the demographic and clinical variables studied. We found that 36.4% of patients wake up earlier than expected, 43.8% get up to go to the bathroom, 30% have nightmares, 20% have pain while sleeping, 23.5% depend on sleeping medication, 34.3% have restless legs, all these parameters in a frequency greater than 3x week. Regarding sleep health, the mean of the SATED scale was 22 ± 5.8 and only 2 patients (5.7%) had values None of these scales (and respective sub-scales) correlated with the PD modality. Conclusion In conclusion, the majority of our patients have poor sleep quality but the small sample size limits further conclusions from this study.

Background and Aims In etiological research the aim is to uncover the causal effect of a specific exposure on an outcome. The aim in prediction research is to predict an outcome with the best accuracy, irrespective of possible causality. Although in observational research both types of studies use similar statistical methods (generally multivariable modelling), the interpretation differs. For example, when researching the causal effect of BMI on kidney failure, it is important to correct for confounders such as age (i.e. factors that causally affect both BMI and kidney failure). Judgement of confounders must be made on pre-existing knowledge. If we select confounders based on the data, we might also correct for hypertension and atherosclerosis (as they are associated with BMI and kidney failure). As this correction is in the causal pathway we would erroneously conclude that BMI does not affect the risk of kidney failure. Vice versa, a mortality prediction model for dialysis patients may include antihypertensive medication use as a predictor. It would be wrong to conclude that patients should discontinue this medication to improve prognosis; the medication use is a marker for a certain health status and we cannot interpret it in a causal manner. Similar to these examples, we’ve found that characteristics from etiology and prediction are often confused, leaving us with studies that may be misinterpreted. The aim of the current study is to quantify the amount of confusion between etiology and prediction in clinical observational studies and identify common mistakes that lead to this confusion. Method Studies published in January 2018 in the top journals of four distinct medical fields: General & Internal medicine, Surgery, Cardiology and Nephrology were screened for inclusion. Original research studies on observational cohorts of humans were included. A list of key study characteristics of etiological and prediction research was developed by CLR and MvD in an iterative fashion. From these characteristics signaling questions for confusion were developed to score included studies. Results The developed key study characteristics of etiology and prediction are shown in the table. In total, 286 studies were screened of which 123 were included. Overall, 27% (n=33) of included articles contained some form of confusion between etiology and prediction. In the figure the journal impact factor is mapped against proportion of confusion per included journal. We can see a trend that as impact factors increase the amount of confusion decreases. In etiological studies, the most frequent (n=15) form of confusion was adjustment for variables based on predictive performance in the data, instead of known causal structure. The majority selected ‘confounders’ purely based on p-values and therefore potentially adjusted for intermediate variables, resulting in incorrect effect estimates. Another mistake in etiological studies (n=5) was the reporting of predictive performance measures such as the C-statistic for an etiological model. In prediction studies the most confusion occurred in the discussion (n=14). Seven studies interpreted predictors causally, for example by concluding that these predictors should be modified in order to improve patient outcomes. As the effect estimates of these studies do not account for confounding, this interpretation is invalid. Lastly, seven studies mention residual confounding as a limitation, which is only a problem in etiological research. Conclusion Confusion between etiology and prediction is a wide-spread methodological flaw in medical observational studies, particularly those published in lower impact clinical journals. As confusion may lead to erroneous conclusions, the distinction between causal and predictive research deserves more attention in medical research and scientific education.

BACKGROUND With exponentially higher number of patients being diagnosed with diabetes in India, it has gained an epidemic status here.1,2 Globally, the prevalence of diabetes in 2030 is expected to be almost double that in 2000 with the major contribution being from India, nearly 79.4 million.3,4 The potential burden that diabetes may impose upon India is highly disturbing. It is important to study the factors currently affecting diabetes in India that are making this potential health burden so extreme and to bring about changes. Drug usage studies help to identify the treatment adherence problems and improve proper drug usage. Aim- The aim of this study was to evaluate the usage pattern of anti-diabetic drugs in Type II DM patients in a rural population in Kerala. MATERIALS AND METHODS A prospective observational study was carried out at a tertiary care teaching hospital for a period of 9 months. 1113 patients were screened from which 69 Type II DM patients were included and a structured questionnaire was used to collect data and analysis was done. Patients aged 20 to 80 yrs. who were already following life style modification and diet advice were included in the study. RESULTS The prevalence was about 6.19% and 68.11% of them were 40-60 years of age. Metformin was the most commonly prescribed drug and 21.74% of patients were on monotherapy. Glimepiride and Metformin (33.33%) was the mostly used oral combination followed by Glibenclamide and Metformin (8.69%). Inj. Human Mix insulin with Metformin was used in 27.53%. 15.94% of patients were on statins. The most common comorbid condition was hypertension (21.73%) followed by dyslipidaemia (8.6%). CONCLUSION Both oral hypoglycaemic drugs and insulin were used for proper control of diabetes. Metformin was the most commonly used drug. Statins and low dose ACE inhibitors were used to minimize the complications of DM.

Objective The objective of this study was to determine the pattern of uterotonic drug usage in obstetric units of university-affiliated hospitals in Canada. Methods This was a prospective observational study conducted in the form of an electronic survey. The target group consisted of chiefs or directors of Obstetrics and Anaesthesia at university-affiliated hospitals across Canada. The survey was sent out between November 2016 and January 2017, using the program ‘SurveyMonkey’. Data on institutional obstetric practices and usage of uterotonic agents were collected. Results The survey was sent to 92 obstetricians and anesthesiologists from 46 institutions, of which 33 clinicians from 24 institutions responded. About 65% of clinicians were unaware of the rate of postpartum hemorrhage in their institution. The first-line agent for vaginal deliveries was reported as oxytocin by 94% and carbetocin by 6% of physicians. For women at low-risk for postpartum hemorrhage when undergoing cesarean deliveries (CD), 66% reported oxytocin as the first-line uterotonic, while 34% reported carbetocin. For CDs at high-risk of postpartum hemorrhage, 60% of physicians reported oxytocin and 40% reported using carbetocin initially. The use of second-line uterotonics was also variable. The choice of uterotonic was mainly based on perceived efficacy and Society of Obstetricians and Gynaecologists of Canada guidelines. Conclusion There is a lack of a unified approach to the use of uterotonic drugs for postpartum hemorrhage management in Canada. To improve the management of postpartum hemorrhage due to uterine atony, an evidence-based approach to usage and consensus between obstetricians and anesthesiologists is warranted.