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Umaani Rauf,1 Majid Ali,2 Inderpal Dehele,1 Vibhu Paudyal,1 Mohamed Hassan Elnaem,3,4 Ejaz Cheema1 1School of Pharmacy, University of Birmingham, Birmingham, B15 2TT, UK; 2Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia; 3Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia; 4Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, MalaysiaCorrespondence: Ejaz CheemaSchool of Pharmacy, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UKTel +44 121-4146845Email E.Cheema@bham.ac.ukObjective: Mortalities due to fentanyl derivatives are on the rise with novel fentanyl analogues and still emerging on the global illicit drug market. They are highly potent and very fatal in low doses, yet there has been a lack of systematic research surrounding this subject. This review aims to assess the causes, nature, and toxicology of fatalities associated with fentanyl analogues.Methods: Five databases: Scopus, Embase, Medline, PubMed and Google Scholar were searched from inception to October 2020 to identify case studies and case series reporting fentanyl analogue-related fatalities. Two independent reviewers screened and selected the articles followed by the data extraction from each article, which included demography, route of administration, causes and nature of death, and the fentanyl analogue implicated. All articles were then subject to quality assessment tools developed by the Joanna Briggs Institute (JBI). A narrative synthesis was undertaken.Results: The initial data search yielded 834 articles, only 14 of which met the inclusion criteria – this included nine case reports and five case series. Of the 1079 fentanyl-analogue related deaths reported, the majority of them occurred in the US (n=1044, 96.8%). The majority of fatalities were male (n=766, 71%), white (n=884, 87%) and in the age ranges 25– 34 and 35– 44 years (30.5% and 29.6%, respectively). The most common route of administration was intravenous (n=319, 66%) and the manner of death was almost exclusively accidental (99.7%). The predominant cause of death was fentanyl-analogue toxicity (n=292, 85.4%) and involved mixed drug toxicity (n=47, 13.7%). The mean post-mortem fentanyl analogue concentration was 31.6 ng/mL.Conclusion: Most fatalities were reported in the US involving young white males. Overdose through intravenous administration and by mixed drug toxicities with other opioids were the major causes of death. Deaths reported in peer-reviewed literature were relatively less than those reported by real-world data.Keywords: fentanyl-analogues, fatalities, systematic review, case series, case reports

Manar Mosaad,1 Mohamed Hassan Elnaem,2 Ejaz Cheema,3 Ismail Ibrahim,1 Jamalludin Ab Rahman,4 Ahlam Naila Kori,5 How Soon Hin1 1Department of Internal Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia; 2Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia; 3School of Pharmacy, University of Birmingham, Birmingham, B15 2TT, UK; 4Department of Community Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia; 5Haematology Unit, Tengku Ampuan Afzan Hospital, Kuantan, Pahang, MalaysiaCorrespondence: Ejaz CheemaSchool of Pharmacy, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UKEmail manarmosaad@gmail.com; E.Cheema@bham.ac.ukAbstract: Cancer-associated thrombosis (CAT) is a leading cause of death in cancer patients receiving outpatient chemotherapy. The latest guidelines emphasize stratifying the patients in terms of CAT risks periodically. Multiple risk assessment models (RAMs) were developed to classify patients and guide thromboprophylaxis to high-risk patients. This study aimed to discuss and highlight different RAMs across various malignancy types with their related advantages and disadvantages. A scoping review was conducted using predefined search terms in three scientific databases, including Google Scholar, Science Direct, and PubMed. The search for studies was restricted to original research articles that reported risk assessment models published in the last thirteen years (between 2008 and 2021) to cover the most recently published evidence following the development of the principal risk assessment score in 2008. Data charting of the relevant trials, scores, advantages, and disadvantages were done iteratively considering the malignancy type. Of the initially identified 1115 studies, 39 studies with over 67,680 patients were included in the review. In solid organ malignancy, nine risk assessment scores were generated. The first and most known Khorana risk score still offers the best available risk assessment model when used for high-risk populations with a threshold of 2 and above. However, KRS has a limitation of failure to stratify low-risk patients. The COMPASS-CAT score showed the best performance in the lung carcinoma patients who have a higher prevalence of thrombosis than other malignancy subtypes. In testicular germ cell tumours, Bezan et al RAM is a validated good discriminatory RAM for this malignancy subtype. CAT in haematological malignancy seems to be under-investigated and has multiple disease-related, and treatment-related confounding factors. AL-Ani et al score performed efficiently in acute leukemia. In multiple myeloma, both SAVED and IMPEDED VTE scores showed good performance. Despite the availability of different disease-specific scores in lymphoma-related thrombosis, the standard of care needs to be redefined.Keywords: thrombosis, cancer, prophylaxis, risk assessment

Mohamed Hassan Elnaem, 1, 2 Noha O Mansour, 3 Abdulrahman Fata Nahas, 1, 2 Mohamed Baraka, 4, 5 Ramadan Elkalmi, 6, 7 Ejaz Cheema 8 1Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang; 2Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang; 3Pharmacy Practice Department, Faculty of Pharmacy, Mansoura University, Cairo, Egypt; 4Department of Clinical Pharmacy, College of Pharmacy, Al Ain University, Al Ain, United Arab Emirates; 5Department of Clinical Pharmacy, College of Pharmacy, Al-Azhar University, Cairo, Egypt; 6Department of Clinical Pharmacy and Pharmacotherapeutics, Dubai Pharmacy College, Dubai, United Arab Emirates; 7Department of Pharmacology, Faculty of Medicine, University of Sabha, Sabha, Libya; 8School of Pharmacy, University of Birmingham, Birmingham B15 2TT, UKCorrespondence: Ejaz CheemaSchool of Pharmacy, University of Birmingham, Edgbaston, Birmingham B15 2TT, UKEmail E.Cheema@bham.ac.ukBackground: This study aims to discuss, summarize and compare the renal outcomes associated with non-insulin antidiabetic (AD) pharmacotherapy prescribed for patients with type 2 diabetes mellitus (T2DM).Methods: A systematic search using predefined search terms in three scholarly databases, ScienceDirect, Google Scholar, and PubMed, was conducted. Original research articles published in the English language between 2012 and 2020 that reported renal outcomes associated with the use of non-insulin AD pharmacotherapy were eligible for inclusion. Review articles, meta-analysis studies, and conference proceedings were excluded. A study-specific data extraction form was designed to extract the author’s name, country, publication year, study design, study population, objectives, key findings, and conclusions. A narrative review of the key findings that focused on renal outcomes and renal safety issues was conducted.Results: Of the 18,872 results identified through the initial search, a total of 32 articles were included in this review. Of these, 18 of the included articles reported the renal outcomes of newer antidiabetic medications, eg, SGLT2 inhibitors and GLP-1 agonists. Eight studies focussed on the well-established antidiabetic medications, eg, metformin and sulphonylureas. The review reported three main types of the clinical impact of the prescribed AD on the renal outcomes: “renoprotective effects”, “no additional risk” and “associated with a decline in renal parameters”. Seventeen studies reported the renoprotective effects of AD, including SGLT2i studies (n=8), GLP1 studies (n=6), and DPP4i studies (n=3). The reported renoprotective effects included slowing down the GFR decline, improving albuminuria, and reducing renal adverse events. The “no additional risk” impact was reported in eight studies, including DPP4i studies (n=3), two SGLT2i studies (n=2), metformin studies (n=2), and one study involving pioglitazone. Furthermore, seven studies highlighted the “associated with a decline in renal parameters” effect. Of these, three involved SGLT2i, two with metformin, and one for each DPP4i and sulphonylurea.Conclusion: More than half of the studies included in this review supported the renoprotective effects associated with the use of AD medications, particularly GLP-1A, SGLT2i, and some of the DPP4i. Further studies involving patients with various stages of chronic kidney disease (CKD) are required to compare AD medications’ renal effects, particularly the newer agents.Keywords: hypoglycemic agents, antidiabetic drugs, type 2 diabetes mellitus, renal effects, renal outcomes

Ejaz Cheema,1 Khalil McGuinness,1 Muhammad Abdul Hadi,1 Vibhu Paudyal,1 Mohammed Hassan Elnaem,2 Abdullah A Alhifany,3 Mahmoud E Elrggal,3 Abdullah Al Hamid1 1School of Pharmacy, University of Birmingham, Birmingham, UK; 2Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University, Kuantan, Malaysia; 3Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Kingdom of Saudi ArabiaCorrespondence: Ejaz CheemaSchool of Pharmacy, University of Birmingham, Room 356, Robert Aitken Building, Edgbaston, Birmingham B15 2TT, UKEmail e.cheema@bham.ac.ukPurpose: Fentanyl poisoning has been widely reported, yet there is a lack of systematic evaluation of the nature and toxicology of associated deaths in the published literature. This article aims to systematically review the nature, causes, routes of administration and toxicology of fentanyl-associated deaths using case studies and case series in peer-reviewed published literature.Methods: Four electronic databases including Embase, Medline (via Ovid), Scopus and Google Scholar were searched from inception until October 2019 to identify the studies reporting fentanyl related deaths. Two independent reviewers screened and selected the titles and then evaluated the full texts. Only case studies and case series were included. A structured data extraction tool was used to extract data on the number of deaths, routes of administration, concomitant drug use and toxicological data. The Joanna Briggs Institute quality assessment tool was used to evaluate the quality of included studies. Data were synthesized narratively.Results: Of 1251 articles identified during initial search, 8 case reports and 9 case series met the inclusion criteria. A total of 1969 deaths were reported in the included studies. Deaths were concentrated in the north American region (n = 1946) and the Nordic region (n = 22). Reported causes of death included fentanyl overdose (n = 321, 56.4%), mixed drug toxicity (n = 196, 34.5%), natural (n = 28, 4.9%), other drug toxicity (n = 10, 1.8%), fentanyl and ethanol intoxication (n = 8, 1.4%), incidental (n = 5, < 1%) and aspiration (n = 1). Most common routes of use were intravenous (70.5%) and transdermal routes (23.0%). Deaths came swiftly via the intravenous route. Mean level of blood fentanyl amongst all reported deaths was 0.024 μg/mL.Conclusion: Literature related to fentanyl-associated deaths predominantly come from North America. Deaths are comparatively lower or not reported in peer-reviewed publications from the rest of the world. Abuse through intravenous administration, mixed drug toxicities and self-treatment of breakthrough pain are mainly responsible for majority of the reported deaths.Keywords: fentanyl, death, nature, cause, toxicology

Mohamed Hassan Elnaem,1,2 Nor Afifah Irwan,1 Usman Abubakar,1 Syed Azhar Syed Sulaiman,3 Mahmoud E Elrggal,4 Ejaz Cheema5 1Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia; 2Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia; 3Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia; 4Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia; 5School of Pharmacy, University of Birmingham, Edgbaston, Birmingham B15 2TT, UKCorrespondence: Ejaz CheemaSchool of Pharmacy, University of Birmingham, Edgbaston, Birmingham B15 2TT, UKTel +44-121-4146845Email E.Cheema@bham.ac.ukBackground: This study aims to identify interventions used to reduce medication regimen complexity and to assess their impact on medication adherence and clinical outcomes.Methods: A literature search was conducted using pre-defined search terms in three scientific databases, including ScienceDirect, ProQuest and MEDLINE. Original research articles published in English between 2009 and 2020 that assessed the impact of medication regimen simplification on medication adherence in patients with long-term medical conditions were eligible for inclusion. Review articles, meta-analysis studies and conference proceedings were excluded. Data charting was done in an iterative process using a study-specific extraction form.Results: Of the 684 studies identified through initial searches, 17 studies were included in the review. Nine studies involved simplification of medication regimen related to HIV, while three studies focused on patients with diabetes with or without coronary artery disease. The remaining five studies included medications used among elderly patients or medications related to hypertension, psychiatric disorders, glaucoma and kidney diseases. Three medication regimen simplification strategies were identified; fixed-dose combination (n = 7), once-daily dosing (n = 4) and the combination of both fixed-dose and once-daily dosing (n = 6). Overall, most of the regimen simplification strategies (14 out of 17) were found to be useful in improving medication adherence. There was no assessment of clinical outcomes in four out of 17 studies. Furthermore, more than half of the studies that assessed clinical outcomes did not show any additional impact on clinical outcomes.Conclusion: The findings suggest that there was an equal utilization of the three main approaches of regimen simplifications; fixed-dose combination, once-daily dosing and a combination of both. Overall, most of the regimen simplification strategies were found to be effective in improving medication adherence. However, the associated improvement in medication adherence did not extend to improvement in the clinical outcomes.Keywords: medication adherence, regimen simplification, clinical outcomes, review

Mohamed Hassan Elnaem,1,2 Nor Fatin Farahin Rosley,1 Abdullah A Alhifany,3 Mahmoud E Elrggal,3 Ejaz Cheema4 1Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia; 2Quality Use of Medicines Research Group, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia; 3Department of Clinical Pharmacy, College of Pharmacy, Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia; 4School of Pharmacy, University of Birmingham, Birmingham B15 2TT, UKCorrespondence: Ejaz CheemaSchool of Pharmacy, University of Birmingham, Edgbaston, Birmingham B15 2TT, UKTel +44-121-4146805Email E.Cheema@bham.ac.ukBackground: The aim of this study was to provide a scoping review of the impact of pharmacist-led interventions on medication adherence and clinical outcomes in patients with hypertension and hyperlipidemia.Methods: A scoping review was conducted using pre-defined search terms in three scientific databases, including Google Scholar, ScienceDirect, and PubMed. A multi-stage screening process that considered relevancy, publication year (2009– 2019), English language, and article type (original research) was followed. Review articles, meta-analysis studies, and conference proceedings were excluded. Data charting was done in an iterative process using a study-specific extraction form.Results: Of the initially identified 681 studies, 17 studies with 136,026 patients were included in the review. Of these, 16 were randomized controlled trials, while the remaining study was a retrospective cohort study. The majority of pharmacist-led interventions were face-to-face counseling sessions (n=8), followed by remote- or telephone-based interventions (n=5) and multi-faceted interventions (n=4). The majority of the studies (n=7) used self-reported adherence measures and pharmacy refill records (n=8) to measure the rate of adherence to prescribed medications. Eleven of the included studies reported a statistically significant (P< 0.05) impact on medication adherence. Overall, twelve studies assessed the effect of the interventions on the clinical outcome measures; of these, only four studies were associated with significant impact.Conclusion: Pharmacist-led interventions were associated with improved patients’ adherence to their medications but were less likely to be consistently associated with the attainment of clinical outcomes. Face-to-face counseling was the most commonly used intervention; while, the multi-faceted interventions were more likely to be effective in improving the overall outcome measures. The rigorous design of targeted interventions with more frequent follow-ups, careful consideration of the involved medications, and patients’ characteristics could increase the effectiveness of these interventions.Keywords: adherence, hyperlipidemia, antihypertensive, pharmacists, intervention, pharmacy services

Muhammad Abdul Hadi,1 Chin Fen Neoh,2 Rosdi M Zin,3 Mahmoud E Elrggal,4 Ejaz Cheema4 1School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, UK; 2Collaborative Drug Discovery Research Group, Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam, Salangor, 3Pharmacy Department, Malacca Hospital, Malacca, Malaysia; 4Faculty of Pharmacy, Umm-Al-Qura University, Makkah, Saudi Arabia Abstract: Globally, adverse drug reactions (ADRs), one of the leading causes of morbidity and mortality, will continue to pose a threat to public health as long as drugs are being used to treat various ailments. Prompt ADR reporting is crucial in ensuring drug safety. The aim of this narrative review was to highlight the role of pharmacists in pharmacovigilance and to identify barriers and facilitators toward ADR reporting documented in the literature. The perspective of pharmacy students on pharmacovigilance and ADR reporting has also been discussed with an aim to highlight the need to improve content related to ADR reporting and pharmacovigilance in undergraduate pharmacy curriculum. Globally, although the role of pharmacists within national pharmacovigilance systems varies, it is very well recognized. In general, pharmacists acknowledge that ADR reporting is part of their professional responsibility and have a positive attitude toward reporting ADRs. However, current research evidence suggests that there are still critical knowledge gaps with regard to ADR reporting among pharmacists, especially in countries where the role of pharmacists within the health care system is limited. These knowledge gaps can be fulfilled through continuous professional development programs and reinforcing theoretical and practical knowledge in undergraduate pharmacy curriculums. Without adequately identifying and fulfilling training needs of pharmacists and other health care professionals, the efficiency of national pharmacovigilance systems is unlikely to improve which may compromise patient’s safety. Keywords: pharmacist, adverse drug reaction, pharmacovigilance, patient safety

Background: Adverse Drug Reactions (ADRs) are a major public health problem. Prompt reporting of suspected ADRs is fundamental in the post-marketing surveillance of medicines and helps in ensuring medicine safety. However, fewer ADRs are reported in general and in particular by community pharmacists. There is limited knowledge about the factors which are preventing community pharmacists in the UK from reporting an ADR. Objectives: To identify the barriers to ADR reporting among community pharmacists practicing in the UK. Methods: A cross sectional study using a 25-items questionnaire (both online and paper based) including 10 barriers to ADR reporting was conducted from 1st April 2012 to September 2012. Community pharmacists practicing in the West Midlands, UK, were approached for the participation in this study. Chi-Square and regression were applied to identify covariates for the barriers to ADR reporting. A significant value of 0.05 was assigned for analysis. Results: Of the 230 invited community pharmacists, 138 pharmacists responded (response rate 60%). The median age of respondents was 31 years. All pharmacists reported that they would report both serious and mild ADRs from drugs with black triangle among children as well as adults. About 95% (n=131) of the pharmacists were familiar with the paper based ADR reporting system. Store-based pharmacists were more likely to be more confident about which ADRs to report [0.680, 95% Confidence Interval 0.43-3.59]. Lack of time 46.4% (n=64), and pharmacists perception that ADR is not serious enough to report (65.2%; n=90) were identified as barriers to ADR reporting. Majority 63.0% (n=87) of the pharmacists identified training and information about what to report and access to Information Technology (IT) (For example access to internet connection) 61.6% (n=85) as facilitators to ADR reporting process. Conclusion: Lack of time and ADRs considered not serious enough by pharmacists to report were barriers to ADR reporting. Further training and education about the types of ADRs to be reported can help to improve the reporting of ADRs.

This study was aimed to evaluate the impact of community pharmacy (CP)-based medication therapy management (MTM) program on clinical and humanistic outcomes in patients with uncontrolled diabetes. An open label, parallel-group randomised controlled trial was undertaken at a community pharmacy in Riyadh city, Kingdom of Saudi Arabia. Patients with a diagnosis of uncontrolled diabetes (HbA1c of ≥ 8%) meeting the eligibility criteria were randomised to receive either the MTM programme provided by pharmacists or standard care. The primary outcome was change in HbA1c over 6 months. Secondary outcomes included: changes in clinical parameters (blood pressure (BP), lipid profile, serum creatinine (SCr) and albumin-to- creatinine ratio (ACR)), types of drug-related problems (DRPs), health service utilization (HSU), adherence, diabetes distress and overall patient satisfaction with the service at 6-month. A sufficiently powered sample of 160 participants with a mean age was 50 years (SD ± 11.9) was recruited. The majority of the patients (68.1%) were male and had diabetes for more than eight years [IQR 3, 14]. After adjusting for baseline HbA1c, compared to the control group, the mean HbA1c level was 0.02% (p = 0.929) and 0.2% (p = 0.47) lower in the intervention arm at 3-month and 6-month respectively. However, these differences were not statistically significant. Nonetheless, within each arm, there was a significant improvement in HbA1c from baseline. Furthermore, the intervention arm demonstrated improvement in BP control (SBP lowered by 3.2 mmHg (p = 0.05) and DBP lowered by 3.8 mmHg (p = 0.008)). During the study period, none of the participants in the intervention group reported hospitalization or ER visits compared to 14 patients in the control group [OR 0.069 (95% CI 0.004, 1.3)]. Patient satisfaction as measured by Patient Satisfaction with Pharmacist Services Questionnaire 2.0 (PSPSQ 2.0) was significantly higher among MTM program participants compared to standard care (p = 0.00001). Patients in the MTM program were eight times more likely to be adherent compared to the patients in the standard care [OR 7.89 (95% CI 3.6, 17.4)]. MTM program metrics showed that per patient, the pharmacists spent a median of 35 [IQR 30, 44.5] minutes at the initial visit and 20 [IQR 10, 25] minutes during the 6-month visit. The number of DRPs had significantly dropped in the intervention arm at 3 and 6-month (p = 0.0001). In conclusion, CP-based MTM program can improve health outcomes and prevent hospitalisations in patients with diabetes. These findings support the implementation of CP-based MTM services for patients with diabetes in the Kingdom of Saudi Arabia., (© 2024. The Author(s).)

Background: Understanding patient satisfaction is key to advancing pharmacy services and improving health outcomes. There is a lack of a translated and psychometrically validated tool in the Arabic language to measure patient satisfaction with pharmacy services., Objective: To translate the English version of the PSPSQ 2.0 into Arabic language, culturally adapt, and verify its reliability and validity., Setting: A community pharmacy in Riyadh, Saudi Arabia., Method: A cross-sectional study was conducted between April 2021 and June 2022 among patients with diabetes attending a community pharmacy. The International Society for Pharmacoeconomics and Outcomes Research good practice guidelines for linguistic translation and cultural adaptation were used to translate and culturally adapt the English version of PSPSQ 2.0 into Arabic. The Arabic version of PSPSQ 2.0 was subjected to factor analysis using principal component analysis with varimax rotation to evaluate its validity and Cronbach's alpha was used to assess the reliability of PSPSQ 2.0., Results: A total of 129 (68.2% male, and mean age 50 (SD: 11.9) years) patients with diabetes participated in the study. The analysis was undertaken for the items in each of the three domains of PSPSQ 2.0: quality of care, interprofessional relationship and overall care. Exploratory factor analysis revealed validity of 92.7%, 80.5% and 96.2%, respectively. The Arabic version of PSPSQ 2.0 had high internal consistency with Cronbach's alpha scores 0.99, 0.95 and 0.98 for the three measured domains, respectively. The sample adequacy was 0.924., Conclusion: The PSPSQ 2.0 was successfully translated and culturally adapted into the Arabic language and had acceptable validity and reliability to measure patient satisfaction with services provided by pharmacists in community pharmacies., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Albabtain et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Cardiovascular disease (CVDs) has been perceived as a 'man's disease', and this impacted women's referral to CVD diagnosis and treatment. This study systematically reviewed the evidence regarding gender bias in the diagnosis, prevention, and treatment of CVDs. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. We searched CINAHL, PubMed, Medline, Web of Science, British Nursing Index, Scopus, and Google Scholar. The included studies were assessed for quality using risk bias tools. Data extracted from the included studies were exported into Statistical Product and Service Solutions (SPSS, v26; IBM SPSS Statistics for Windows, Armonk, NY), where descriptive statistics were applied. A total of 19 studies were analysed. CVDs were less reported among women who either showed milder symptoms than men or had their symptoms misdiagnosed as gastrointestinal or anxiety-related symptoms. Hence, women had their risk factors under-considered by physicians (especially by male physicians). Subsequently, women were offered fewer diagnostic tests, such as coronary angiography, ergometry, electrocardiogram (ECG), and cardiac enzymes, and were referred to less to cardiologists and/or hospitalisation. Furthermore, if hospitalised, women were less likely to receive a coronary intervention. Similarly, women were prescribed cardiovascular medicines than men, with the exception of antihypertensive and anti-anginal medicines. When it comes to the perception of CVD, women considered themselves at lower risk of CVDs than men. This systematic review showed that women were offered fewer diagnostic tests for CVDs and medicines than men and that in turn influenced their disease outcomes. This could be attributed to the inadequate knowledge regarding the differences in manifestations among both genders., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Al Hamid et al.)

Objective: This study aimed to evaluate the current practice of community pharmacists from patients' and pharmacists' perspectives in Saudi Arabia. This paper presents the patients' perspective., Methods: A self-administered cross-sectional survey was developed to collect responses from patients in Saudi Arabia from February to April 2021. The questionnaire comprised several statements related to the best practice in community pharmacy. Patients' responses to each statement were scored using a 5-point Likert scale. Higher scores represented the greater extent to which the pharmacists perform the best practice in a community pharmacy setting and vice versa., Findings: The data of 233 participants were included in the analysis. The majority of the participants were female (67%) and Saudi nationals (96%). The minimum mean score was related to the statement: pharmacist discusses with you about herbal medications or vitamin supplements. The maximum mean score was related to the statement: Pharmacist explains to you about the dose of medications and when to take them. Participants who were <20 years old had a significantly highest mean score, whereas those above 40 years old had the least mean score, P = 0.001. Participants from the Eastern region had a significantly highest mean score, compared to South region participants who had the least mean score, P = 0.009., Conclusion: A gap in the current practice and the best practice of community pharmacists was found. The policymakers can utilize these findings to provide targeted professional development opportunities for the practicing community pharmacists to improve the overall service and care for the patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Research in Pharmacy Practice.)

Background: Since 2015, the National Health Service (NHS) has funded pharmacists to work in general practice (GP practice) to ease workload pressures. This requires pharmacists to work in new roles and be integrated effectively in GPs. Independent prescribing is a key part of the GP pharmacist role, but little is known about pharmacists' integration into GP practice as well as patients' perceptions and experiences of the care provided by GP pharmacists. This study aims to explore the perceptions of pharmacist independent prescribers (PIPs) about their integration into GP practice and gain insight into patients' perceptions about the care provided to them by pharmacists., Methods: A mixed-methods study comprising semi-structured interviews with PIPs (n = 13) followed by questionnaire-based assessment of patients' (n = 77) evaluation of pharmacists' care was conducted between December 2019 and March 2020. Quantitative data were analysed using descriptive statistics. Interviews and open comments of the survey were thematically analysed., Results: Pharmacist independent prescribers reported undertaking a range of patient-facing and non-clinical roles. Lack of understanding about PIPs' clinical role and working beyond their clinical area of competence were some of the barriers to their integration into GP practice. Most patients were satisfied with the consultations they received from pharmacists and reported confidence in the pharmacist's recommendations about their health conditions. However, a few patients (14%) felt they would still need to consult a general practitioner after their appointment and 11% were not sure if a further consultation was needed., Conclusions: Pharmacist independent prescribers provide a range of clinical services for the management of long-term conditions which appear to be recognised by patients. However, there is a need to address the barriers to PIPs' integration into GP practice to optimise their skill-mix and patient-centred care., (© 2023. The Author(s).)

Controlling hypertension (HTN) remains a challenge, as it is affected by various factors in different settings. This study aimed to describe the disparities in the prevalence and barriers to hypertension control across countries of various income categories. Three scholarly databases-ScienceDirect, PubMed, and Google Scholar-were systematically examined using predefined search terms to identify potentially relevant studies. Original research articles published in English between 2011 and 2022 that reported the prevalence and barriers to HTN control were included. A total of 33 studies were included in this systematic review. Twenty-three studies were conducted in low and middle-income countries (LMIC), and ten studies were from high-income countries (HIC). The prevalence of hypertension control in the LMIC and HIC studies ranged from (3.8% to 50.4%) to (36.3% to 69.6%), respectively. Concerning barriers to hypertension control, patient-related barriers were the most frequently reported ( n = 20), followed by medication adherence barriers ( n = 10), lifestyle-related barriers ( n = 8), barriers related to the affordability and accessibility of care ( n = 8), awareness-related barriers ( n = 7), and, finally, barriers related to prescribed pharmacotherapy ( n = 6). A combination of more than one category of barriers was frequently encountered, with 59 barriers reported overall across the 33 studies. This work reported disparities in hypertension control and barriers across studies conducted in LMIC and HIC. Recognizing the multifactorial nature of the barriers to hypertension control, particularly in LMIC, is crucial in designing and implementing customized interventions.

Background: The role of pharmacists has evolved over the past few decades from being product-oriented to being service-oriented. Community-pharmacist-led medication review programmes have been commissioned in different countries under different names. The services provided by general pharmacists can have a positive impact on patient health, but the impact of the services offered by community pharmacists is relatively unknown., Objective: To evaluate the effectiveness of community-pharmacist-based medication review programmes among patients with long-term conditions., Methods: The electronic databases Cochrane Library, MEDLINE and Embase were searched from their inception until January 2020 for randomised controlled trials (RCTs) published in the English language assessing the effectiveness of community-pharmacist-led medication review programmes on patients' clinical and healthcare utilisation outcomes. Random-effects meta-analysis was used to pool data statistically, where applicable. The study protocol was published in PROSPERO (ID: CRD42020165693)., Results: Forty-two reports of 40 RCTs were included in the systematic review, and 12 RCTs were included in the meta-analysis. Compared to the control, a significant improvement was noted in the community-pharmacist-based medication review group for the following outcomes: blood pressure (BP) in patients with diabetes (mean difference [MD] in systolic blood pressure [SBP]: 6.82 [95% CI -11.33, -2.32]; MD in diastolic blood pressure [DBP]: 2.13 [95% CI -3.35, -0.92]) and in the hypertension patients (MD in SBP: 6.21 [95% CI -13.26, 0.85]; MD in DBP: 2.11 [95% CI -6.47, 2.26]), HbA1c in patients with diabetes (MD -0.61; 95% CI -0.96, -0.25), and total cholesterol (TC) in patients with hyperlipidaemia (MD -0.18; 95% CI -0.32, -0.05)., Conclusion: Community-pharmacist-led medication review can improve certain clinical and healthcare utilisation outcomes in patients with long-term conditions., (Copyright © 2021 Elsevier Inc. All rights reserved.)

This study aimed to evaluate the current practice of community pharmacists from patients' and pharmacists' perspectives in Saudi Arabia. This paper presents the pharmacist's perspective. A cross-sectional self-administered online survey was designed to collect responses from community pharmacists in Saudi Arabia from February to April 2021. The questionnaire consisted of several statements related to best practice in community pharmacy. Pharmacists' responses to each statement were scored using a 5-point Likert scale. Higher scores represented a greater extent to which they adhered to best practice in the community pharmacy setting and vice versa. Data of 164 participants were included in the analysis. The minimum median score was related to the statement: Pharmacist explains the main side effects. The maximum median score was related to the statement: Pharmacist explains dosage regimen. Pharmacists aged 30 years or above and non-Saudi pharmacists had significantly higher median scores compared with pharmacists less than 30 years of age ( p = 0.016) and Saudi pharmacists, respectively ( p = 0.001). A gap between best practice and current practice of community pharmacists was observed. Policymakers can utilize these findings to provide targeted professional development opportunities for the practicing community pharmacists in order to improve the overall service and care for patients.

Background: This review aimed to conduct an indirect comparison using a Bayesian network meta-analysis of randomized controlled trials (RCTs) to compare the efficacy and safety of delafloxacin versus other single antibiotic regimens for the empiric treatment of Acute Bacterial Skin and Skin Structure Infections., Method: A systematic search with no start date restrictions was conducted. The Cochrane Risk of Bias tool was used to assess the quality of included RCTs., Results: Of the 577 studies initially identified, nine RCTs were included in the review. The network meta-analysis showed that ceftaroline, ceftobiprole, delafloxacin and tigecycline had similar efficacy in the indirect comparisons [Ceftaroline Odds Ratio (OR) = 1.2, 95% Crl = 0.46-3.6), ceftobiprole (OR = 1.3, 95% Crl = 0.34-3.0) and tigecycline (OR = 0.96, 95% Crl = 0.30-2.9)]. However, the ranking plot for the intention to treat (ITT) population showed that delafloxacin had a probability of 80.8% to be ranked first followed by ceftobiprole (13.1%). The analysis of the overall adverse events showed that ceftaroline (OR = 0.88, 95% Crl = 0.65-1.2), ceftobiprole (OR = 1.1, 95% Crl = 0.69-2.0), delafloxacin (OR = 0.88, 95% Crl = 0.57-1.3) and tigecycline (OR = 1.4, 95% Crl = 0.88-2.2) had similar safety profiles., Conclusion: Delafloxacin did not show any statistically significant differences when compared to ceftaroline, ceftobiprole, and tigecycline in terms of efficacy and safety. However, the surface under the cumulative ranking curve (SUCRA) probability ranked delafloxacin as the first option for the ITT population., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Background Since 2015, NHS England has facilitated the recruitment of pharmacists in general practice (GP) to reduce workload of general practitioners. The role of pharmacists is therefore expected to become more clinical and patient oriented. However, little is known about the current roles performed and the integration of GP pharmacists. Objective To assess the role performed by GP pharmacists and their integration into practice exploring facilitators and barriers to integration. Setting A cross-sectional survey of GP pharmacists in England. Method This study used both online and paper-based questionnaires for a period of six months. Survey items included demographics, roles performed, integration including available support and practice environment. Quantitative data were analysed using descriptive statistics and 95% confidence intervals. Open comments were analysed thematically to identify pharmacists' perceptions of barriers and facilitators to their integration into practice. Main outcome measure Current role and integration of pharmacists into GP. Results 195 participants completed the questionnaire. Three quarters of pharmacists (76%) had only been in GP since 2015. Most pharmacists (81%) were independent prescribers (PIPs). The most reported pharmacists' roles were medicine reconciliation (95%), telephone support for patients (95%) and face-to-face medication review (91%). 82% (95% CI: 76% to 86.8%) were satisfied with their overall integration into practice. Half of pharmacists (45%) were working in a shared office or at a hot desk and 9% had no designated workspace. PIPs had more access to a convenient workplace (p = 0.016) compared to non-IPs. Conclusion Practice pharmacists are fulfilling a wide range of clinical and non-clinical roles in England. Findings highlight relatively a satisfactory level of pharmacists' integration into practice and shed the light on their integration issues. These findings could be significant for the development of future roles of pharmacists in GP., (© 2021. The Author(s).)

Introduction: Given the widespread use of clinical reasoning (CR) in the healthcare practice, it is essential to inculcate the CR practice in undergraduate pharmacy education which can not only facilitate their clinical education and clinical rotations but can also help them become better clinical pharmacists. There is very limited CR employed in the pharmacy curriculum and practice in the Middle East countries. This study aimed to develop and evaluate CR practice in pharmacy undergraduates in one college of pharmacy in Saudi Arabia., Methods: We employed a mixed-methods methodology that included two phases. In Phase I, students were introduced to CR practice ('think aloud' method) and given geriatric clinical cases which they used in two sessions together with a tutor. This was followed by the writing of SOAP notes using the tutor feedback and completion of a survey that included a self-reflection about their experience of using the CR method. Phase II included face-to-face semi-structured interviews involving selected students that were recruited via convenience sampling to further explore the issues identified in Phase I of the study., Results: Of the 155 students who completed the survey (response rate 94%), the majority of them agreed that CR using the 'think aloud' method was useful in gathering (92%) and interpreting (95%) relevant patient information, identifying medication-related problems (95%), exploring therapeutic options for the problem(s) (93%) and formulating a treatment plan for the patient (90%). Qualitative data analysis of the 12 interviews was consistent with these findings. Furthermore, it provided an insight into the challenges faced by the students in applying this CR method., Conclusions: Students found the practice of CR using the 'think aloud' method helpful in working through given cases and taking clinical decisions. This method can be widely employed in pharmacy education and practice., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors.)

Objectives: This study aimed to explore the adverse effects of chemotherapeutic agents used in the treatment of ovarian and cervical cancer by analysing patients' views posted in online discussion forums., Method: UK-centred online discussion forums were used to identify discussion threads on ovarian and cervical cancer between 2008 and 2017. The study was approved by the University of Bournemouth ethics committee. 272 discussion threads with 644 participants from four online discussion forums (Cancer Research UK, Macmillan, Ovacome and Jo's Cervical Cancer Trust) were identified. The threads were exported into NVivo and a thematic content analysis was conducted to identify study themes., Results: Of the 644 participants, 19.4% had a diagnosis of cervical cancer and 80.6% had a diagnosis of ovarian cancer. Four main themes related to: (1) treatment plan, (2) adverse effects, (3) perception of treatment and (4) hospitalisation were identified. Patients' perceptions about their treatment were reported to be positive across all chemotherapeutic agents. 312 adverse effects were reported by patients with cervical cancer taking cisplatin, with fatigue (52.1%) and nausea (30.6%) being the two most frequently reported adverse effects. With regard to the treatment of ovarian cancer, 402 adverse effects were reported by patients on carboplatin and paclitaxel, with neuropathy (29.3%) and fatigue (28.0%) being the two most commonly reported adverse effects., Conclusion: The online discussion forums allowed patients to express their concerns in a blame-free environment that provided novel insight into the impact of chemotherapy-associated adverse effects on patients with cervical and ovarian cancers. Real-life experiences shared by patients can help the healthcare professionals to find the right balance between prolonged survival and quality of life., Competing Interests: Competing interests: None declared., (© European Association of Hospital Pharmacists 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

The perspectives of hypertensive patients on the state of hypertension control during the ongoing pandemic restrictions have not been extensively studied in Malaysia. Therefore, this study aimed to assess the impact of socio-demographic factors, health literacy, and adherence on the overall hypertension management in a group of Malaysian hypertensive patients during the COVID-19 pandemic. An anonymous, online cross-sectional study was conducted over three months that involved a group of Malaysian adults with hypertension. A validated, self-administered 30-item questionnaire was prepared in Malay and English languages on Google Forms. The link was then distributed to participants on social media (Facebook and WhatsApp). Following survey validation, a pilot study with 30 participants who met the inclusion criteria was carried out. The total scores for health literacy, adherence, and pandemic impact on hypertension control were calculated and compared across all independent variables. In a total of 144 study participants, controlled blood pressure was reported in 77% (N = 111). There were good levels of adherence and health literacy scores but moderate levels of pandemic impact scores. The total adherence scores showed a statistically significant difference between age groups (χ 2 = 6.48, p = 0.039) and those who reported having controlled and uncontrolled blood pressure (U = 1116, p = 0.001). Moreover, the analysis revealed statistically significant differences in total pandemic impact scores based on the age group (χ 2 = 15.008, p = 0.001), household income (χ 2 = 6.887, p = 0.032), employment (U = 1712, p = 0.006), and marital status (U = 520.5, p < 0.001). The youngest age group (18-39) years, the lowest income group, unemployed and unmarried individuals, had significantly higher pandemic impact scores. This denotes that those individuals were more prone to be negatively affected by the pandemic regarding their hypertension management. Most participants reported relatively controlled blood pressure and good levels of health literacy as well as adherence amidst the pandemic. To a moderate extent, study participants perceived that the pandemic had a negative effect on hypertension management. The perceived negative impact of the pandemic was attributed to several socio-demographic factors, such as age, household income, employment, and marital status.

Background: Pain after laparoscopic cholecystectomy remains a major challenge. Ondansetron blocks sodium channels and may have local anesthetic properties., Aims: To investigate the effect of intraperitoneal administration of ondansetron for postoperative pain management as an adjuvant to intravenous acetaminophen in patients undergoing laparoscopic cholecystectomy., Methods: Patients scheduled for elective laparoscopic cholecystectomy were randomized into two groups (n = 25 each) to receive either intraperitoneal ondansetron or saline injected in the gall bladder bed at the end of the procedure. The primary outcome was the difference in pain from baseline to 24-h post-operative assessed by comparing the area under the curve of visual analog score between the two groups., Results: The derived area under response curve of visual analog scores in the ondansetron group (735.8 ± 418.3) was 33.97% lower than (p = 0.005) that calculated for the control group (1114.4 ± 423.9). The need for rescue analgesia was significantly lower in the ondansetron (16%) versus in the control group (54.17%) (p = 0.005), indicating better pain control. The correlation between the time for unassisted mobilization and the area under response curve of visual analog scores signified the positive analgesic influence of ondansetron (r s =0.315, p = 0.028). The frequency of nausea and vomiting was significantly lower in patients who received ondansetron than that reported in the control group (p = 0.023 (8 h), and 0.016 (24 h) respectively)., Conclusions: The added positive impact of ondansetron on postoperative pain control alongside its anti-emetic effect made it a unique novel option for patients undergoing laparoscopic cholecystectomy., (Copyright © 2021 The Authors. Published by Elsevier Masson SAS.. All rights reserved.)

Purpose: Cancer patients have faced intersecting crises during the COVID-19 pandemic. This review aimed to examine patients' and caregivers' experiences of accessing cancer services during the pandemic and its perceived impact on their psychological wellbeing., Patients and Methods: A protocol-led (CRD42020214906) systematic review was conducted by searching six databases including EMBASE, MEDLINE and CINAHL for articles published in English-language between 1/2020 and 12/2020. Data were extracted using a pilot-tested, structured data extraction form. Thematic synthesis of data was undertaken and reported as per the PRISMA guideline., Results: A total of 1110 articles were screened, of which 19 studies met the inclusion criteria. Studies originated from 10 different countries including the US, UK, India and China. Extracted data were categorised into seven themes. Postponement and delays in cancer screening and treatment, drug shortages and inadequate nursing care were commonly experienced by patients. Hospital closures, resource constraints, national lockdowns and patient reluctance to use health services due to infection worries contributed to the delay. Financial and social distress, isolation, and spiritual distress were also commonly reported. Caregivers in addition felt anxious about infecting cancer patients with COVID-19., Conclusion: Patients and caregivers experienced delays in cancer screening, treatment and care during the COVID-19 pandemic and negatively affected their psychological wellbeing. Their views and preferences should be accounted to minimise the impact of the current and any future pandemics and ensure resilient cancer services., Protocol Registration: Published protocol registered with Centre for Review and Dissemination CRD42020214906 (https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=214906)., Competing Interests: The authors declare that they have no conflicts of interest in this work., (© 2021 Dhada et al.)

Objectives: The main objectives are: to evaluate the feasibility and effectiveness of a community-pharmacy based medication therapy management programme; to explore patients' experiences and views towards medication therapy management service delivered by community pharmacists., Research Design and Methods: A mixed-methods research design consisting of a pilot randomized controlled trial embedded with qualitative study will be used in this study. The study consists of two phases: a 6-month follow-up pilot randomized control trial (quantitative approach) to assess the feasibility and effectiveness of a community pharmacy-based medication therapy management programme. The primary outcome is HbA1C and secondary outcomes include: clinical and health services utilization and process measures, medication adherence, diabetes distress as well as satisfaction with care. Phase two consists of an embedded qualitative study using semi-structured interviews to explore patients' experiences and views with the medication therapy management programme. Study data collection will be collected between April 2021 and December 2021., Ethics Consideration: The study has been approved by institutional review boards from Princess Nourah bent Abdulrahman University (Approval # 20-0240), King Fahad Medical City (Approval # 20-388E) and Birmingham University (Approval # ERN&#95;20-0768)., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Author(s).)

Background: The COVID-19 pandemic has further strengthened the need for pharmacists to uptake non-traditional roles. Pharmacy practice in Saudi Arabia is emerging in recent years with greater policy emphasis on pharmacists taking new clinical roles. This study aimed to explore the experiences, perceptions and barriers of Saudi pharmacists about their uptake of non-traditional roles using Theoretical Domains Framework (TDF)., Methods: A qualitative semi-structured study using face-to-face or telephone interviews were conducted. Eligible participants included qualified pharmacists from Saudi Arabia. Interviews focused on pharmacist's perceptions, current opportunities and key challenges towards the uptake of non-traditional roles. Interviews were audiotaped and transcribed verbatim. Results were analysed through the framework analysis method and were later mapped with respective domains of TDF., Results: A total of 14 pharmacists completed the interview (9 females and 5 males). Participants showed an overall positive attitude towards the uptake of non-traditional roles. Participants felt that there was wider support available for pharmacists at the policy level to uptake non-traditional roles. However, a need for greater recognition of roles by other healthcare professionals and patients were identified. Participants alluded to reluctance of some physicians to take on board the suggestions from a pharmacist. Key barriers to uptake of non-traditional roles were related to environmental context and resources domain of TDF. For example, participants discussed the need for even further practical experiences during their undergraduate degree to become ready to adopt non-traditional roles in clinical practice., Conclusions: Participants of this theoretically informed qualitative study showed an overall positive attitude towards the way pharmacy practice is progressing in Saudi Arabia and their uptake of non-traditional roles. However, there is a need to improve interdisciplinary working, patient awareness of pharmacist competencies and their educational preparedness in furthering their uptake of non-traditional roles. Addressing such barriers and promoting uptake of novel roles by pharmacists is imperative in the context of emerging COVID-19 and future pandemics.

Background: Breast cancer is the most common type of cancer in women worldwide. The benefits of chemotherapy vary depending on the treatment regimen used and the characteristic of the tumour. However, adverse drug reactions associated with chemotherapeutic agents can cause dose delays or reductions; thereby, affecting the treatment outcomes., Objective: To explore adverse drug reactions of chemotherapeutic agents used to treat breast cancer from the patients' perspective., Methods: A total of 110 threads from nine online discussion forums were evaluated. They were exported into NVivo for Mac where content analysis was applied. Threads were read carefully to observe emerging patterns which were then coded into sub-themes and grouped into main themes., Results: The participants' characteristics on online discussion forums were often missing. Four hundred and eleven participants experienced 473 adverse drug reactions that were mainly associated with the nervous and immune systems. The forums' analysis yielded three main themes: patient-patient advice, self-medication and lifestyle changes., Conclusion: Online discussion forums proposed valued source of data on adverse drug reactions associated with chemotherapeutic agents and overall patients' experience with cancer. The adverse drug reactions experienced by patients changed their priorities and the way they dealt with the disease. Therefore, healthcare professionals must consider the patients' experience and attitudes towards cancer when designing a treatment plan. This can be established by increasing communication between healthcare professionals and patients.

The current pandemic of the COVID-19 infection, coupled with the increased global burden of diabetes, has imposed significant challenges to the healthcare providers in providing effective and sustained care to patients with diabetes during the ongoing pandemic. It is, therefore, important for healthcare providers to understand and follow the recommended changes in the delivery of care, lifestyle modifications, and pharmacotherapy to ensure optimal care to the patients during and post-pandemic era. This commentary aims to discuss the impact of COVID-19 on diabetes care and the important considerations for pharmacists during this pandemic., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Olanzapine, neurokinin-1-receptor-antagonists (NK-1-RA), and thalidomide added to palonosetron + dexamethasone (PALO-DEX) have been evaluated in separate studies as prophylaxis for chemotherapy-induced nausea and vomiting (CINV) due to highly emetogenic chemotherapy (HEC). We conducted a Bayesian network meta-analysis to compare the prophylactic efficacy of these agents in combination with PALO-DEX., Methods: PubMed, Medline/Ovid, Embase, and Clinicaltrials.gov were searched from inception through 22 Mar 2018. Study quality was assessed using the Cochrane methodology. A Bayesian network meta-analysis using random-effects models was used to asses complete response (CR) and rate of no nausea (RNN) in acute, delayed, and overall phases and were expressed as odds ratios (OR) and 95% credible interval (95% CrI). Ranking probabilities of treatments were calculated using the surface under the cumulative ranking curve (SUCRA) to identify the probability of a given treatment as the best option against the worst option., Results: Nine RCTs involving two thousand nine hundred fifty-nine patients were included. The olanzapine-based regimen showed greater CR in the acute, delayed, and overall-phases versus the PALO-DEX regimen (OR = 3.97, 95% CrI = 1.02-19.13; OR = 5.62, 95% CrI = 1.66-28.58; OR = 4.79, 95% CrI = 1.40-24.02, respectively). Additionally, it showed greater RNN than the NK-1-RA-based and the PALO-DEX regimens in the delayed phase only (OR = 2.90, 95% CrI = 1.34-5.15; OR = 4.53, 95% CrI = 1.89-10.55, respectively). Olanzapine-, NK-1-RA-, and thalidomide-based regimens did not differ in CR in the three phases. SUCRA probabilities ranked the olanzapine-based regimen as the best option in terms of CR and RNN, while ranking the NK-1-RA-based regimens as the second best option in terms of CR throughout the three phases., Conclusion: Based on the data included in the analyses, there is insufficient evidence to support adding thalidomide or NK-1-RA to PALO-DEX in preventing CINV induced by HEC. However, adding olanzapine to PALO-DEX achieves better CR and RNN. Olanzapine side-effects and the absence of direct comparisons explain why some guidelines are cautious in suggesting the use of olanzapine.

Aims: To conduct a systematic review and meta-analysis of the effectiveness of general practice-based pharmacist interventions in reducing the medical risk factors for the primary prevention of cardiovascular events., Methods: A systemic search was undertaken in 8 databases: PubMed, MEDLINE, EMBAS, PsycINFO, Cochrane Library, CINAHL Plus, SCOPUS and Science Citation Index, with no start date up to 27 March 2019. Randomised controlled trials assessing the effectiveness of pharmacist-led interventions delivered in the general practice in reducing the medical risk factors of cardiovascular events were included in the review. The risk of bias in the studies was assessed using the Cochrane risk of bias tool., Results: A total of 1604 studies were identified, with 21 randomised controlled trials (8933 patients) meeting the inclusion criteria. Fourteen studies were conducted in patients with diabetes, 7 in hypertension, 2 involving dyslipidaemia, and 2 with hypertension and diabetes together. The most frequently used interventions were medication review and medication management. The quality of the included studies was variable. Patients receiving pharmacist-led interventions were associated with a statistically significant reduction in their systolic blood pressure (-9.33 mmHg [95% Confidence Interval (CI) -13.36 to -5.30]), haemoglobin A1C (-0.76% [95% CI -1.15 to -0.37]) and low-density lipoprotein-cholesterol (-15.19 mg/dL [95% CI -24.05 to -6.33]). Moreover, practice-based pharmacists' interventions were also reported to have a positive impact on patient adherence to medications., Conclusion: The findings of this review suggest that pharmacist-led interventions in general practice can significantly reduce the medical risk factors of cardiovascular disease events. These findings support the involvement of pharmacists as healthcare providers in managing patients with hypertension, diabetes and dyslipidaemia., (© 2019 The British Pharmacological Society.)

Objectives: The risk of recurrent Clostridium difficile infections (RCDIs) is high when treated with standard antibiotics therapy (SAT) alone. It is suggested that the addition of faecal microbiota transplantation (FMT) or bezlotoxumab after SAT reduces the risk of RCDI. In the absence of head-to-head randomised controlled trials (RCTs), this review attempts to compare the efficacy and safety of bezlotoxumab with FMT in reducing the risk of RCDI in hospitalised patients., Design: A systematic review and Bayesian network meta-analysis., Data Source: A comprehensive search from inception to 30 February 2019 was conducted in four databases (Medline/PubMed, Embase, Scopus, ClinicalTrials.gov)., Eligibility Criteria: RCTs reporting the resolution of diarrhoea associated with RCDI without relapse for at least 60 days after the end of treatments as the primary outcome., Data Extraction and Synthesis: We extracted author, year of publication, study design and binomial data that represented the resolution of diarrhoea or adverse events of monoclonal antibodies and FMT infusion. Random-effects models were used for resolution rate of RCDI and adverse events. The Cochrane Risk of Bias tool was used to assess the quality of included RCTs., Results: Out of 1003 articles identified, seven RCTs involving 3043 patients contributed to the review. No difference was reported between single or multiple infusions of FMT and bezlotoxumab in resolving RCDI, (OR 1.53, 95% credible interval (CrI) 0.39 to 5.16) and (OR 2.86, 95% CrI 1.29 to 6.57), respectively. Patients treated with SAT alone or bezlotoxumab with SAT showed significantly lower rates of diarrhoea than FMT (OR 0, 95% CrI 0 to 0.09) and (OR 0, 95% CrI 0 to 0.19), respectively. There was no difference in terms of other adverse events., Conclusions: This is the first network meta-analysis that has compared the recently Food and Drug Administration-approved monoclonal antibody bezlotoxumab with FMT for resolving RCDI. The quality of the included RCTs was variable. The findings of this study suggested no difference between single or multiple infusions of FMT and bezlotoxumab. However, FMT was associated with a higher rate of non-serious diarrhoea as opposed to SAT used alone or in combination with bezlotoxumab., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: This review aimed to determine the prevalence, causes and risk factors of medicine-related problems (MRPs) in patients with liver cirrhosis., Methods: Eight online databases were searched up to 30 September 2018 with no start date. Appropriate Critical Appraisal Skills Programme tools were used to assess the quality of included studies., Results: An overall 16 quantitative and 11 qualitative studies were included in the review. Methodological quality of the included studies was variable. Mean frequency of MRPs reported in the quantitative studies ranged from 14 to 23.4%. The most frequent causes of MRPs included drug interactions, inappropriate dosing and use of contraindicated drugs. The qualitative analysis identified three themes: patient-related factors, healthcare professionals' related factors and stigma associated with liver cirrhosis., Conclusion: MRPs were found to be prevalent in patients with liver cirrhosis. Factors contributing to MRPs in liver cirrhosis were not limited to medicines' effects and interactions but included healthcare systems and patients. Therefore, management of liver cirrhosis should not be limited to providing an effective medicine therapy and should take into account the patients' behaviour towards the condition.

Background: Proton pump inhibitors (PPIs) are used worldwide for the treatment of gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD). Although considered to be widely safe, PPIs have been associated with the potential risk of adverse effects such as infections including pneumonia and Clostridium difficile , malabsorption of vitamins and minerals, dementia and more recently with chronic kidney disease (CKD). Evidence including large cohort studies suggests that there is a greater risk of developing CKD in chronic users of PPIs. However, the association of CKD with PPI use reported in these studies is weak and does not establish a clear causality. This review aims to further investigate the association of CKD with PPI use by including studies with various study designs., Methods: A literature search of published articles with no start date restrictions was undertaken in May 2018 in three electronic databases (PubMed, ScienceDirect, Google Scholar). Search terms included 'Proton Pump Inhibitors', 'chronic kidney disease', and 'association'. Both observational and randomised controlled trials (RCTs) investigating the association of CKD with PPI use were eligible for inclusion., Results: Ten observational studies with 1,005,899 patients contributed to the review. No experimental study was available for inclusion in the review. Of the included studies, six used a retrospective study design, while the rest were prospective (two) or a case-controlled studies (two). A large prospective cohort study with 144,032 patients conducted in the USA reported that PPI use compared to no PPI use was associated with an increased risk of CKD Hazard ratio [HR] 1.28; 95% Confidence Interval [CI] 1.22-1.34. However, the observational study design of this study together with other studies included in the review suggests that the strength of evidence associating PPI use with CKD is weak and does not establish true causality., Conclusions: The current evidence related to the potential association of CKD with PPI use remains inconclusive in establishing true causality. Further prospective studies including randomised controlled trials and cohort studies would be required to confirm the findings reported in this review and to draw any conclusions., Competing Interests: Not applicableNot applicable“The author declare that he has no competing interests”.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This study aimed to identify any drug-related problems (DRPs) in diabetic patients during Ramadan fasting in Saudi Arabia. The study used a mixed-methods approach consisting of two phases and was conducted in Makkah, Saudi Arabia from December 2017 to March 2018. The first phase of the study involved qualitative semi-structured individual interviews with diabetic patients. A 13-item questionnaire was used in the second phase to further identify DRPs in the wider population. The data was mainly presented as frequencies and percentages. Inferential statistics was performed using Statistical Package for Social Sciences (SPSS) version 21 to compare relevant variables/questions using the chi-square test. Twenty patients (10 male, 10 female) attended face-to-face interviews during the first phase of the study while 95 (40 male, 55 female) completed the questionnaire in the second phase of the study. Two possible risk factors for DRPs were identified from the qualitative data: patient-related factors, including changes in their medicine intake during fasting, and healthcare professionals-related factors, including lack of advice from healthcare professionals regarding fasting. The quantitative results indicated that 52 (54%) of the 95 participants who observed fasting reported to have changed the way they were taking their medicines. Furthermore, 41% of the participants experienced general healthcare problems such as hypoglycemia, hyperglycemia, fatigue, excessive sweating, and gastrointestinal disturbances. Healthcare professionals need to educate patients who are at risk of DRPs by providing structured education and counseling.

Background: Excessive and inappropriate antimicrobial use in the community is one risk factor that can result in the spread of antimicrobial resistance. Upper respiratory tract infections are most frequently reported among children and mainly of viral origin and do not require antibiotics. We have conducted Knowledge, Attitude and Perception (KAP) survey of parents to explore the parent's knowledge, attitude & perception of Saudi parents., Methods: A knowledge attitude perception questioner was adopted from a previous study conducted in Greece by Panagakou et al. Raosoft online sample size calculator calculated the sample size by adding the total estimated Makkah population of 5,979,719 with a response rate of 30%, 5% margin of error and 99% confidence interval. Based on the described criteria five hundred & fifty-eight was the required sample size of the study. Incomplete questioners were excluded from the statistical analysis. SPSS version 21 was used to analyse data and to produce descriptive statistics., Results: Most of the mothers (95%) responded among parents. 67% had no health insurance to cover medications costs. Most of them (74%) were related to medium income level. Seventy per cent of the parents believed physicians as a source of information for judicious antibiotics use. Interestingly, only 8% were agreed that most of the upper respiratory tract infections are caused by viral reasons. Majority of Saudi parents (53%) expect pediatricians to prescribe antimicrobials for their children for symptoms like a cough, nose discharge, sore throat and fever. Moreover, most the parents had the poor knowledge to differentiate commonly used OTC medications for URTI and antibiotics like Augmentin (Co-amoxiclav), Ceclor (cefaclor) and Erythrocin (Erythromycin). While comparing males and female's knowledge level, few males have identified Amoxil (Amoxicillin). Similarly, parents of age 20-30 years have good knowledge about the antibiotics., Conclusions: Majority of Saudi parents believe in pediatricians and use antibiotics on physician's advice. Most of them expect antibiotics from their physicians as a primary treatment for upper respiratory tract infections. There is need for more educational activities to parents by the pharmacists to prevent antibiotics overuse among children.

Background: Pharmacists have limited knowledge about adverse drug reactions (ADRs) in Saudi Arabia., Objective: The aim of this study was to assess the impact of educational intervention on the knowledge of hospital pharmacists about ADRs., Methods: This was a 3-month randomized controlled trial conducted in Saudi Arabia between January 2018 and March 2018. Participants in both groups were required to complete an online questionnaire at baseline and at 12-week follow-up. Participants in the intervention group received a structured information sheet about ADRs 2 weeks after the first assessment. The main outcome measure was difference in mean knowledge score about ADRs., Main Outcome Measure: Difference in mean knowledge score about ADRs., Results: A total of 46 participants were included in the study. At the 12-week follow-up, there was a significant improvement in the mean knowledge score (± standard deviation) of intervention participants from 7.67 (± 2.1) at baseline to 11.22 (± 0.4) (95% CI -4.5 to -2.5; p  < 0.0001). The mean knowledge score of control participants remained unchanged at 6.71 (± 2.3) during both baseline and follow-up assessments., Conclusion: ADR-specific education was associated with a significant improvement in the knowledge and understanding of pharmacists about ADRs and their methods of reporting., Competing Interests: Conflict of interestThe authors declare no relevant conflicts of interest, (© Springer Nature Switzerland AG 2019.)

Purpose: This study was aimed to determine whether structured written and verbal education provided to patients by community pharmacists about high blood pressure (BP) and its treatment would be (a) better retained and (b) be associated with improved BP control as compared to patients receiving verbal advice only., Methods: The study was designed as a randomised controlled trial and was conducted in the West Midlands, UK, between January 2014 and June 2014. The primary outcome measures were differences in systolic and diastolic BP from baseline and retention of information about high BP assessed with a questionnaire at 2-, 4- and 26-week follow-up points., Results: A total of 64 adults were included in the study. At the week 26 follow-up, compared to participants in the control group, there was a significant improvement in the knowledge of intervention participants about the risks associated with high BP (p < 0.001) and awareness about potential adverse effects of the new BP medicine (p < 0.001). Similarly, there was a greater and more significant reduction in systolic BP in favour of the intervention group 8 mmHg (95% CI 2.1-13.3 p = 0.009) compared to 6 mmHg (95% CI 0.6-11.7 p = 0.02) in the control group at the week 4 follow-up. However, this greater effect of an intervention on BP was not sustained at the 26-week follow-up. For diastolic BP, there was no added effect of the intervention., Conclusion: This randomised controlled trial suggests that although written advice provided by community pharmacists in comparison to verbal advice was more effective in improving knowledge and understanding of patients about hypertension and its treatment, it did not lead to better blood pressure control.

Pharmacists worldwide, including Saudi Arabia, are now increasingly expected to play a more patient-centred role. The transition of pharmacists from a dispensing role to a more patient-centred clinical role requires the adoption of innovative learning techniques in pharmacy teaching and learning to transform the future pharmacy workforce. One such innovation in pharmacy education is simulation-based pharmacy teaching. The use of simulation in pharmacy education allows pharmacy students to not only improve their clinical knowledge and skills, but also serves as a tool to improve their critical thinking that is a pre-requisite in sound clinical decision-making. Given the importance of patient-oriented teaching in pharmacy education, the majority of institutions offering pharmacy education in the developed countries have successfully integrated simulation-based teaching in their respective curricula to meet both patient and practice needs. However, most of the universities offering undergraduate pharmacy programs in the developing world, including Saudi Arabia, have limited application of patient-focused teaching in their respective programs. This article aims to highlight the importance of introducing simulation-based teaching in pharmacy education in Saudi Arabia., Competing Interests: The authors declare no conflict of interest.

Objective: To assess the association between test-related anxiety and pharmacy students' performance in the Objective Structured Clinical Examination (OSCE)., Methods: A cross-sectional survey was conducted among Year-5 Doctor of Pharmacy (PharmD) students enrolled at a public university in Saudi Arabia. Students completed Test Anxiety Inventory (TAI), a 20-item validated questionnaire used to assess test-related anxiety, prior to the commencement of a summative OSCE. TAI has two subscales: TAI-Emotionality (TAI-E) and TAI-Worry (TAI-W). The overall maximum possible total score (TAI-T) is 80, with a minimum possible score of 20., Key Findings: All 25 students, 10 males and 15 females completed the survey. The overall mean scores for TAI-E, TAI-W and TAI-T were 20.2, 19.6 and 50.2, respectively. There were no statistically significant differences between males and females with respect to the TAI-E score (P = 0.43), TAI-W score (P = 0.25) and TAI-T score (P = 0.34). Females had higher marks in the OSCE compared with males (P = 0.01), however. After adjusting for gender, multiple linear regression analysis showed a statistically significant negative association between TAI-W score and marks obtained in OSCE (P = 0.02; 95% CI = -0.42, -0.03)., Conclusion: Assessment-related worry may negatively affect students' scores in performance-based examination and could lead to overall underperformance., (© 2017 Royal Pharmaceutical Society.)

Background: Adverse drug events (ADEs) impose a major clinical and cost burden on acute hospital services. It has been reported that medicines reconciliation provided by pharmacists is effective in minimizing the chances of hospital admissions related to adverse drug events., Objective: To update the previous assessment of pharmacist-led medication reconciliation by restricting the review to randomized controlled trials (RCTs) only., Methods: Six major online databases were sifted up to 30 December 2016, without inception date (Embase, Medline Ovid, PubMed, BioMed Central, Web of Science and Scopus) to assess the effect of pharmacist-led interventions on medication discrepancies, preventable adverse drug events, potential adverse drug events and healthcare utilization. The Cochrane tool was applied to evaluate the chances of bias. Meta-analysis was carried out using a random effects model., Results: From 720 articles identified on initial searching, 18 RCTs (6,038 patients) were included. The quality of the included studies was variable. Pharmacists-led interventions led to an important decrease in favour of the intervention group, with a pooled risk ratio of 42% RR 0.58 (95% CI 0.49 to 0.67) P<0.00001 in medication discrepancy. Reductions in healthcare utilization by 22% RR 0.78 (95% CI 0.61 to 1.00) P = 0.05, potential ADEs by10% RR 0.90 (95% CI 0.78 to 1.03) P = 0.65 and preventable ADEs by 27% RR 0.73 (0.22 to 2.40) P = 0.60 were not considerable., Conclusion: Pharmacists-led interventions were effective in reducing medication discrepancies. However, these interventions did not lead to a significant reduction in potential and preventable ADEs and healthcare utilization.

Aim: To assess the knowledge and attitude of senior medical, dental, nursing and pharmacy students toward Middle East respiratory syndrome-corona virus (MERS-CoV) in Saudi Arabia., Subjects and Methods: A cross-sectional survey using a 21-item questionnaire was conducted for a 3-month period from November 2015-January 2016 in Makkah, Saudi Arabia. The questionnaire was designed to evaluate students' understanding and perception of MERS-CoV. An ANOVA test was used to determine the association of study discipline and academic year with the student knowledge score on MERS., Results: A total of 364 students were assessed during the study. The majority (62%) of the participants were in the 20-22-year age group. More than half (53%) were pharmacy students followed by (22%) medical students. More than two thirds (71%) of the participants were aware that MERS is caused by the coronavirus. More than half (59%) of the participants believed that MERS can be transmitted through direct or indirect contact with infected camels. A statistically significant association was reported between the study discipline and mean knowledge score ( p  < 0.0001) with medical students achieving an overall better knowledge score compared with students from other study disciplines., Conclusion: Overall, students had good knowledge about MERS epidemiology, transmission and the recommended protective measures. However, students expressed their reluctance to work in healthcare facilities with inadequate MERS infection control isolation policies., Competing Interests: Ethical approval was obtained from the ethics committee of the university. All information collected from this study was kept strictly confidential. All procedures performed in the study were in accordance with the ethical standards of the university research and ethics committee. Consent for participation was understood by completion and submission of the survey.All authors declare no conflict of interest.

Introduction: The purpose of this study was to evaluate Saudi undergraduate pharmacy students' knowledge, attitude, and readiness towards pharmacovigilance and reporting of adverse drug reactions (ADRs)., Methods: A cross-sectional survey was conducted between January 15, 2016 and February 18, 2016 using a structured, validated and pilot-tested questionnaire among senior (year 4, 5, and 6) undergraduate pharmacy students enrolled at a governmental or private university/college. Students completed an online 27-item questionnaire developed using Google Forms™. The questionnaire consisted of four sections: demographics; knowledge about pharmacovigilance and ADR reporting; attitudes towards ADR reporting; and pharmacy students' readiness towards ADR reporting., Results: Two hundred and fifty-nine students completed the questionnaire. Most of the participants were females (n=174; 67.2%) and were year 4 (n=128; 49.4%) students. Out of a total possible score of seven, the mean knowledge score (SD) was 4.15 (1.1). Multiple linear regression showed that after adjusting for gender and program of study (BPharm/PharmD), year of the study was found to be an independent predictor (p=0.03) of the total knowledge score. More than half of the respondents (n=166; 64.1%) acknowledged that they do not know how to report ADRs to the relevant authorities in Saudi Arabia. The majority (n=213; 82.2%) of respondents believed that information on how to report ADRs should be taught to senior pharmacy students., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To assess the community pharmacists' knowledge, attitude, perception and current practices towards generic medicines substitution in Saudi Arabia., Methods: A cross-sectional study was conducted between February and March 2016 in the Makkah region, Saudi Arabia. A 25-item, structured, validated, pilot-tested and self-completed questionnaire was used to achieve study objectives. A 4-step systematic sampling technique was used to recruit community pharmacists. Data were analysed using SPSS version 20., Results: Of 128 community pharmacists approached, 121 participated in the study (response rate=95%). Majority of the participants (n=108; 89.3%) had graduated from Egypt, were working as staff pharmacists (n=85; 70%) and had BPharm degree (97; 80.2%). Only 26 (22%) of the participants correctly answered all knowledge questions accurately. No statistically significant difference in total knowledge score was observed across different sociodemographic characteristics of participants (all P>0.05).Two-thirds of the respondents (83; 68.2%) supported the use of generic substitution. Medicines cost and patients' request were the most commonly cited reasons for performing generic substitution. Country of graduation (P=0.01) and number of years of practicing in Saudi Arabia (P=0.02) was associated with the pharmacists' support towards generic substitution., Conclusion: The community pharmacists had clear knowledge deficits about generic medicines and their substitution which may partly explain low consumption of generic medicines in Saudi Arabia. Healthcare policy makers need to improve awareness about the safety and efficacy of generic medicines and promote their use in order to cut down cost of medicines and overall healthcare expenditure., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Aims: To undertake a systematic review and meta-analysis of randomized controlled trials concerned with the impact of community pharmacist-led interventions on blood pressure control in patients with hypertension., Methods: Eight electronic databases were searched up to 30 November 2013, with no start date (Web of Science, Embase, The Cochrane Library, Medline Ovid, Biomed Central, Biosis Citation Index, CINAHL, PsycINFO). All studies included were randomized controlled trials involving patients with hypertension, with or without cardiovascular-related co-morbidities, with difference in blood pressure as an outcome. Data collected included the study design, baseline characteristics of study populations, types of interventions and outcomes. The Cochrane tool was used to assess risk of bias., Results: From 340 articles identified on initial searching, 16 randomized controlled trials (3032 patients) were included. Pharmacist-led interventions were patient education on hypertension, management of prescribing and safety problems associated with medication, and advice on lifestyle. These interventions were associated with significant reductions in systolic [11 studies (2240 patients); -6.1 mmHg (95% confidence interval, -3.8 to -8.4 mmHg); P < 0.00001] and diastolic blood pressure [11 studies (2246 patients); -2.5 mmHg (95% confidence interval, -1.5 to -3.4 mmHg); P < 0.00001]., Conclusions: Community pharmacist-led interventions can significantly reduce systolic and diastolic blood pressure. These interventions could be useful for improving clinical management of hypertension., (© 2014 The British Pharmacological Society.)