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Masho Tigabe,1 Abaynesh Fentahun,1 Solomon Getawa,2 Kassahun Alemu Gelaye,3 Eyob Alemayehu Gebreyohannes1,4 1Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia; 2Department of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia; 3Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia; 4Division of Pharmacy, School of Allied Health, University of Western Australia, Nedlands, AustraliaCorrespondence: Solomon GetawaDepartment of Hematology and Immunohematology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, P.O. Box 196, Gondar, EthiopiaTel +251 914-665-736Email solomon2525geta@gmail.comBackground: Despite the growing burden of heart failure in developing countries, data describing the clinical characteristics and in-hospital outcomes of acute heart failures are limited. Therefore, this study aimed at describing the clinical characteristics and in-hospital outcomes of acute heart failure patients admitted to the medical ward of University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.Methods: A prospective observational hospital-based cross-sectional study was conducted on 226 patients with acute heart failure at the University of Gondar Comprehensive Specialized Hospital from November 2019 to October 2020. Data were collected by using a pretested data abstraction format and analyzed with Statistical Package for Social Sciences version 21. Bivariable and multivariable binary logistic regression model were fitted to identify factors associated with in-hospital outcome and reported with 95% confidence interval (CI). P-value < 0.05 was considered as statistically significant.Results: The mean (± standard deviation) age of the study participant was 51.17± 19.03 years and 59.3% were females. Majority, 60.6% of patients were admitted with new onset heart failure. Dyspnea (88.05%) and peripheral edema (80.5%) were the most frequent clinical findings. The in-hospital mortality was 10.6% (95% CI: 7.1– 14.7). Atrial fibrillation (AOR=9.46; 95% CI: 1.49– 60.29), concurrent ischemic heart disease (AOR=8.23; 95% CI: 1.15– 58.89), being admitted with reduced left ventricular ejection fraction (AOR=5.36; 95% CI: 2.81– 35.52), presence of orthopnea (AOR=6.63; 95% CI: 2.94– 46.76), and using intranasal oxygen therapy (AOR=9.41; 95% CI: 1.35– 65.82) were significantly associated with in-hospital mortality in patients with acute heart failure.Conclusion: The in-hospital mortality of acute heart failure patients was relatively higher in the study area. Therefore, specific preventative and therapeutic strategies focusing on heart failure patients with reduced left ventricular ejection fraction, atrial fibrillation, ischemic heart disease, orthopnea, and intranasal oxygen therapy are required to reduce the mortality rate.Keywords: heart failure, clinical characteristics, in-hospital mortality, Ethiopia

Eyob Alemayehu Gebreyohannes,1 Akshaya Srikanth Bhagavathula,1,2 Tadesse Melaku Abegaz,1 Tamrat Befekadu Abebe,1 Sewunet Admasu Belachew,1 Henok Getachew Tegegn,1 Sarab M Mansoor3 1Department of Clinical Pharmacy, School of Pharmacy, University of Gondar-College of Medicine and Health Sciences, Gondar, Ethiopia; 2Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates; 3School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, NSW, Australia Purpose: In health communication, pictogram has a comprehensive place to aid attention, memory recall, and promote adherence. This study was conducted to assess whether pictorial intervention would help to identify and improve adverse drug reactions (ADRs) reporting in an antiretroviral therapy (ART) clinic in Northwest Ethiopia.Patients and methods: A cross-sectional study on ART-naïve HIV-positive patients was conducted from July 2015 to January 2016. The patients were randomly categorized into two groups. Group A was subjected to receive pictorial medication information and a pictogram-enhanced tool to identify and report ADRs, while group B did not receive any pictogram-enhanced tool.Results: A total of 207 ART-naïve HIV-positive patients who were registered for the ART treatment attending Gondar University Hospital ART clinic were included. Bivariate analysis showed that sociodemographic characteristics, such as age, sex, education, employment, and marital status were the main predictors of identifying and reporting ADRs. Males were twice more likely to identify ADRs than females. Univariate analysis revealed that patients assigned to group A showed a significant association with the ability to identify ART medications using pictograms. Patients assigned to group A were more likely to identify lamivudine (OR [95% CI] =7.536 [4.042–14.021], P≤0.001), tenofovir (OR [95% CI] =6.250 [2.855–13.682], P≤0.001), nevirapine (OR [95% CI] =5.320 [1.954–14.484], P=0.001), efavirenz (OR [95% CI] =3.929 [1.876–8.228], P≤0.001), and zidovudine (OR [95% CI] =3.570 [1.602–7.960], P=0.002) using pictograms. Patients in group A were 4.3 times more likely to identify diarrhea as an ADR using pictogram compared with group B.Conclusion: The use of pictorial representation resulted in only slight improvement in identification and reporting of ADRs among naïve HIV-positive patients with limited literacy in Northwest Ethiopia. This representation of ADRs merits further investigation with regard to ADR identification and promoting patients’ safety, particularly for HIV-positive patients with limited educational levels. Keywords: HIV, AIDS, ADR, pictogram, Gondar, Ethiopia, HAART

Ousman Abubeker Abdela, Akshaya Srikanth Bhagavathula, Eyob Alemayehu Gebreyohannes, Henok Getachew Tegegn Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia Background: Pharmacogenomics is a field of science which studies the impact of inheritance on individual variation in medication therapy response.Aim: We assessed healthcare professionals’ knowledge, attitude, and interest toward pharmacogenomics.Methods: A cross-sectional survey was conducted using a 32-item questionnaire among physicians, nurses, and pharmacists who were working at the University of Gondar Referral and Teaching Hospital in northwest Ethiopia. Descriptive statistics was applied, and the categorical variables were summarized as frequency and percentages. An analysis of variance (ANOVA) test was performed to compare mean scores among health professionals. A p-value of

Background: Reporting of adverse drug events (ADEs) to regulatory authorities remains low, particularly among consumers., Objectives: To explore stakeholders' views on the development and use of a digital platform to improve ADE reporting by consumers to the regulatory authority in Australia, i.e., the Therapeutic Goods Administration., Methods: A qualitative study was conducted using semi-structured interviews, focus group discussions (FGDs), and co-design workshops with consumers, healthcare professionals (HCPs), and regulators. The interview recordings were transcribed verbatim, coded, and analysed thematically according to the Capability, Opportunity, Motivation, Behaviour model. Findings of the FGDs and co-design workshops were incorporated to enhance and complement the insights gathered from the interviews., Results: A total of 39 participants took part in the study (54 % consumers, 41 % HCPs, and 5 % regulators). Uncovered themes related to ADE reporting in general were: difficulty recognizing ADEs and health literacy, awareness about reporting ADEs (Capability); visibility of ADE reporting, professionals' views on consumer ADE reporting, consumer education (Opportunity); the common good, benefit to the reporter, identifying ADEs worth reporting, and concern about reporting (Motivation). Additional identified themes specific to a new digital platform were: physical abilities (Capability); features that facilitate intuitive use, convenience and accessibility, user experience, integration with existing systems, trust, sharing experiences with others (Opportunity); and concern about using a reporting platform, and feedback loop (Motivation)., Conclusions: A cross-section of attitudes and values were obtained regarding ADE reporting in general and a new ADE reporting digital platform for consumers in Australia, which will inform its development, implementation and evaluation., (© 2024. The Author(s).)

Background: Anticholinergic medications are now widely acknowledged for their unfavorable risk-to-benefit profile owing to their adverse effects. Health-related quality of life (HRQoL) is commonly regarded as a crucial person-centered outcome., Aim: This study aimed to investigate the association between anticholinergic burden and HRQoL in hospitalized and ambulatory patients seen in Ethiopia., Method: This cross-sectional study utilized a questionnaire and medical records to collect data from a convenience sample of adult patients attending both inpatient wards and ambulatory clinic of University of Gondar Comprehensive Specialized Hospital between April and September 2022. Anticholinergic burden was measured by anticholinergic cognitive burdens scale (ACBS), while HRQoL was measured using EQ5D-index (Euroqol-5 dimensions-5-Levels index) and EQ5D-VAS (visual analogue scale). Linear regression was used to assess the influence of high anticholinergic burden (ACBS score ≥ 3) on EQ5D-index and EQ5D-VAS, with adjustments made for sociodemographic and clinical confounders., Results: A total of 828 patients participated in this study (median (IQR) age was 45.0 (30, 60) and 55.9% were female). On multiple linear regression analysis, high anticholinergic burden was associated with a statistically significant decline in HRQoL, as evidenced by reductions in both EQ5D index (- 0.174 (- 0.250, - 0.098)) and EQ5D-VAS scores (- 9.4 (- 13.3, - 5.2))., Conclusion: A significant association between high anticholinergic burden and diminished HRQoL was found among a relatively younger cohort in a resource-limited setting, even after adjustment for important confounding variables. Clinicians should be cognizant of the cumulative impact of anticholinergic burden on HRQoL outcomes and strive to minimize anticholinergic burden., Competing Interests: Conflicts of interest There are no conflicts of interest declared by the authors., (© 2024. The Author(s).)

Introduction: Contact investigations with drug-susceptible tuberculosis (DS-TB) patients have demonstrated a high prevalence of tuberculosis infection (TBI). However, the prevalence of TBI among individuals in close contact with drug-resistant tuberculosis (DR-TB) patients is poorly understood. This systematic review and meta-analysis aimed to determine the prevalence of TBI among household and non-household contacts of DR-TB patients., Method and Analysis: We searched five databases (Medline, Embase, Scopus, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) from inception to 2 June 2023. All studies that reported the prevalence of TBI among DR-TB contacts were included in the study. A random-effects meta-analysis was conducted to estimate the pooled prevalence of TBI with a 95% confidence interval (CI). Sub-group analyses were conducted using study characteristics as covariates., Results: Thirty studies involving 7659 study participants from 19 countries were included. The pooled prevalence of TBI among DR-TB contacts was 36.52% (95% CI: 30.27-42.77). The sub-group analysis showed considerable heterogeneity in the estimates, with the highest prevalence reported in Southeast Asia (80.74%; 95% CI: 74.09-87.39), household contacts (38.60%; 95% CI: 30.07-47.14), lower-middle-income countries (LMICs) (54.72; 95% CI: 35.90, 73.55), children (43.27%; 95% CI: 25.50, 61.04), and studies conducted between 2004 and 2012 (45.10; 95% CI: 32.44, 57.76)., Conclusion: The prevalence of TBI among DR-TB contacts was high, with substantial regional variations. Further research is needed to determine the drug susceptibility status of TBI in DR-TB contacts., Protocol Registration: The protocol is registered in PROSPERO (CRD42023390339)., Competing Interests: Declaration of Competing Interest 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., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Numerous studies report that anticholinergic burden (ACB) has been linked with several health consequences, including increased hospital admissions, prolonged hospitalization, and physical and cognitive impairment. However, low- and middle-income settings, as well as younger individuals, are underrepresented., Objectives: To assess the prevalence and determinants of ACB, and to assess the impact of ACB on in-hospital mortality among adult in-patients at University of Gondar Comprehensive Specialized Hospital (UOGCSH)., Design: A cross-sectional study was conducted from June to August 2022 at UOGCSH among adult in-patients., Methods: A pre-tested questionnaire was utilized to collect data from patients and their corresponding medical charts. A consecutive sampling technique was used to select the participants. Descriptive statistics were used to summarize socio-demographic and clinical characteristics. Chi-squared, Fisher's exact, and Wilcoxon rank sum tests, as appropriate, were used to determine associations between independent variables and ACB. Kaplan-Meier survival curve and Cox proportional hazards regression test were used to assess the impact of ACB on in-hospital mortality., Results: A total of 420 adult in-patients, median (interquartile range) age of 38 (26, 55) years, participated in this study. Over half (58.3%) were exposed to anticholinergic medicines, with a high ACB (⩾3) seen in 11.2% of participants. High ACB was associated with higher median number of medicines per patient ( p  = 0.003) higher median hospital length of stay ( p  = 0.033), and having mental and behavioral disorders ( p  < 0.001). No significant association was found between ACB and in-hospital mortality (log-rank test p  = 0.26, Cox regression adjusted hazard ratio: 1.47, 95% CI: 0.335-6.453, p  = 0.61)., Conclusion: Among adult in-patients, a significant majority (58.3%) were subjected to medications possessing anticholinergic properties, with a noteworthy 11.2% of the study subjects exhibiting a high ACB. Participants with higher median length of hospital stay were more likely to have high ACB even in this relatively younger adult patient population., (© The Author(s), 2024.)

Objectives: This systematic review aimed to summarise existing literature on the impacts of armed conflicts on tuberculosis burden and treatment outcomes., Design: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines., Data Sources: PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature Plus, Scopus, ScienceDirect, Embase and medRxiv., Data Extraction and Synthesis: Three reviewers independently screened, selected eligible studies and extracted data. A narrative review was undertaken to summarise the findings qualitatively., Results: Eleven studies were included in this review, reporting on tuberculosis incidence rates, prevalence and treatment outcomes, including mortality. Overall, the impact of armed conflicts on case notifications was variable. Six studies reported overall increases in tuberculosis case notifications following the onset of conflicts, while three studies reported overall decreases in tuberculosis case notifications. Factors, including limited access to healthcare services, challenges in surveillance and laboratory confirmation, the destruction of health systems and incapacitating the healthcare workforce, contributed to a decrease in the number of notified cases. The higher tuberculosis notification in some of the studies could be attributed to the disruption of tuberculosis prevention and control programmes as well as increased socioeconomic deprivation, including malnutrition, mass migration, poor living conditions and overcrowding that are worsened during conflicts. Armed conflicts without effective interventions were associated with worse tuberculosis treatment outcomes, including lower proportions of people with treatment success and higher proportions of people with loss to follow-up, mortality and treatment failure. However, implementing various interventions in conflict settings (such as establishing a National Tuberculosis Control Programme) led to higher tuberculosis notification rates and treatment success., Conclusion: The impact of armed conflicts on tuberculosis notification is complex and is influenced by multiple factors. The findings of this review underscore the importance of concerted efforts to control tuberculosis in conflict settings using available resources., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: This feasibility study aims to develop and test a new model of practice in Australia using digital technologies to enable pharmacists to monitor early signs and symptoms of medicine-induced harms in residential aged care., Methods and Analysis: Thirty residents will be recruited from an aged care facility in South Australia. The study will be conducted in two phases. In phase I, the study team will work with aged care software providers and developers of digital technologies (a wearable activity tracker and a sleep tracking sensor) to gather physical activity and sleep data, as well as medication and clinical data from the electronic medication management system and aged care clinical software. Data will be centralised into a cloud-based monitoring platform (TeleClinical Care (TCC)). The TCC will be used to create dashboards that will include longitudinal visualisations of changes in residents' health, function and medicine use over time. In phase II, the on-site pharmacist will use the centralised TCC platform to monitor each resident's medicine, clinical, physical activity and sleep data to identify signs of medicine-induced harms over a 12-week period.A mixed methods process evaluation applying the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework will be used to assess the feasibility of the service. Outcome measures include service reach, changes in resident symptom scores (measured using the Edmonton Symptom Assessment System), number of medication adverse events detected, changes in physical activity and sleep, number of pharmacist recommendations provided, cost analysis and proportion of all pharmacists' recommendations implemented at 4-week, 8-week and 12-week postbaseline period., Ethics and Dissemination: Ethical approval has been obtained from the University of South Australia's Human Research Ethics Committee (205098). Findings will be disseminated through published manuscripts, conference presentations and reporting to the study funder., Trial Registration Number: ACTRN12623000506695., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: Soil transmitted helminth (STH) infections are estimated to impact 24% of the world's population and are responsible for chronic and debilitating morbidity. Disadvantaged communities are among the worst affected and are further marginalized as infection prevalence fuels the poverty cycle. Ambitious targets have been set to eliminate STH infections, but accurate epidemiological data will be required to inform appropriate interventions. This paper details the protocol for an analysis that aims to produce spatial prediction mapping of STH prevalence in the Western Pacific Region (WPR)., Methods: The protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) guidelines. The study design will combine the principles of systematic review, meta-analysis, and geospatial analysis. Systematic searches will be undertaken in PubMed, Scopus, ProQuest, Embase, and Web of Science for studies undertaken post 2000, to identify surveys that enable the prevalence of human STH infection within the WPR to be calculated. Covariate data for multivariable analysis will be obtained from publicly accessible sources. Survey data will be geolocated, and STH prevalence and covariates will be linked to produce a spatially referenced dataset for analysis. Bayesian model-based geostatistics will be used to generate spatially continuous estimates of STH prevalence mapped to a resolution of 1 km 2 . A separate geospatial model will be constructed for each STH species. Predictions of prevalence will be made for unsampled locations and maps will be overlaid for each STH species to obtain co-endemicity maps., Discussion: This protocol facilitates study replication and may be applied to other infectious diseases or alternate geographies. Results of the subsequent analysis will identify geographies with high STH prevalence's and can be used to inform resource allocation in combating this neglected tropical disease., Trial Registration: Open Science Framework: osf.io/qmxcj., (© 2024. The Author(s).)

Background: Multidrug-resistant tuberculosis (MDR-TB) is a global health threat associated with high morbidity and mortality rates. Diagnosis and treatment delays are associated with poor treatment outcomes in patients with MDR-TB. However, the risk factors associated with these delays are not robustly investigated, particularly in high TB burden countries such as China. Therefore, this study aimed to measure the length of diagnosis and treatment delays and identify their risk factors among patients with MDR-TB in Hunan province., Methods: A retrospective cohort study was conducted using MDR-TB data from Hunan province between 2013 and 2018. The main outcomes of the study were diagnosis and treatment delay, defined as more than 14 days from the date of symptom to diagnosis confirmation (i.e., diagnosis delay) and from diagnosis to treatment commencement (i.e., treatment delay). A multivariable logistic regression model was fitted, and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to identify factors associated with diagnosis and treatment delay., Results: In total, 1,248 MDR-TB patients were included in this study. The median length of diagnosis delays was 27 days, and treatment delays were one day. The proportion of MDR-TB patients who experienced diagnosis and treatment delay was 62.82% (95% CI: 60.09-65.46) and 30.77% (95% CI: 28.27-33.39), respectively. The odds of experiencing MDR-TB diagnosis delay among patients coming through referral and tracing was reduced by 41% (AOR = 0.59, 95% CI: 0.45-0.76) relative to patients identified through consultations due to symptoms. The odds of experiencing diagnosis delay among ≥ 65 years were 65% (AOR = 0.35, 0.14-0.91) lower than under-15 children. The odds of developing treatment delay among foreign nationalities and people from other provinces were double (AOR = 2.00, 95% CI: 1.31-3.06) compared to the local populations. Similarly, the odds of experiencing treatment delay among severely ill patients were nearly 2.5 times higher (AOR = 2.49, 95% CI: 1.41-4.42) compared to patients who were not severely ill. On the other hand, previously treated TB cases had nearly 40% (AOR = 0.59, 95% CI: 0.42-0.85) lower odds of developing treatment delay compared with new MDR-TB cases. Similarly, other ethnic minority groups had nearly 40% (AOR = 0.57, 95% CI: 0.34-0.96) lower odds of experiencing treatment delay than the Han majority., Conclusions: Many MDR-TB patients experience long diagnosis and treatment delays in Hunan province. Strengthening active case detection can significantly reduce diagnosis delays among MDR-TB patients. Moreover, giving attention to patients who are new to MDR-TB treatment, are severely ill, or are from areas outside Hunan province will potentially reduce the burden of treatment delay among MDR-TB patients., (© 2024. The Author(s).)

Introduction: People having close contact with drug-resistant tuberculosis (DR-TB) patients are at increased risk of contracting and developing the disease. However, no comprehensive review has been undertaken to estimate the burden of DR-TB among contacts of DR-TB patients. Therefore, the current systematic review will quantify the prevalence and incidence of DR-TB among contacts of DR-TB patients., Method and Analysis: Systematic searches will be conducted in Medline, Embase, Web of Science, Scopus, Cochrane Central Register of Controlled trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINHAL) databases. The search will be conducted without restrictions on time, language and geography. A random-effects meta-analysis will be conducted for effect estimates. The pooled prevalence and incidence of DR-TB will be compared between people with and without contact with DR-TB patients. The presence of heterogeneity between studies will be assessed by Higgins I 2 statistics. Subgroup analysis will be conducted to determine the source of heterogeneity. The risk of bias will be assessed using a visual inspection of the funnel plot and Egger's regression test statistics. Trim and fill analysis will be done in the presence of publication bias. A sensitivity analysis will be conducted by trimming low-quality studies. The systematic review will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines., Ethics and Dissemination: Ethical approval will not be required for this study as it will be a systematic review and meta-analysis based on previously published evidence. The findings of the systematic review will be presented at scientific conferences and published in scientific journals., Protocol Registration: The protocol is published in PROSPERO with registration number CRD42023390339., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Purpose: The aim of this study was to investigate treatment burden and its relationship with health-related quality of life (HRQoL) among patients with multimorbidity (two or more chronic diseases) who were taking prescription medications and attending the outpatient department of the University of Gondar Comprehensive Specialized Teaching Hospital., Methods: A cross-sectional study was conducted between March 2019 and July 2019. Treatment burden was measured using the Multimorbidity Treatment Burden Questionnaire (MTBQ), while HRQoL was captured using the Euroqol-5-dimensions-5-Levels (EQ-5D-5L)., Results: A total of 423 patients participated in the study. The mean global MTBQ, EQ-5D index, and EQ-VAS scores were 39.35 (± 22.16), 0.83 (± 0.20), and 67.32 (± 18.51), respectively. Significant differences were observed in the mean EQ-5D-Index (F [2, 81.88] 33.1) and EQ-VAS (visual analogue scale) scores (F [2, 75.48] = 72.87) among the treatment burden groups. Follow up post-hoc analyses demonstrated significant mean differences in EQ-VAS scores across the treatment burden groups and in EQ-5D index between the no/low treatment burden and high treatment burden, as well as between the medium treatment burden and high treatment burden. In the multivariate linear regression model, every one SD increase in the global MTBQ score (i.e., 22.16) was associated with a decline of 0.08 in the EQ-5D index (β - 0.38, 95%CI - 0.48,  - 0.28), as well as a reduction of 9.4 in the EQ-VAS score (β - 0.51, 95%CI -0.60, - 0.42)., Conclusion: Treatment burden was inversely associated with HRQoL. Health care providers should be conscious in balancing treatment exposure with patients' HRQoL., (© 2023. The Author(s).)

Background: Oral anticoagulants (OACs) are prescribed to patients with atrial fibrillation (AF) in order to lower stroke risk. However, patient refusal to commence OACs hinders effective anticoagulation. This study aimed to explore barriers and facilitators to patient agreement to commence OACs from the perspectives of patients with AF attending Australian general practices., Methods: A qualitative descriptive study utilising semi-structured individual interviews was conducted from March to July 2022., Results: Ten patients (60% male, median age = 78.5 years) completed interviews. Patients' passive roles in decision-making were identified as a facilitator. Other prominent facilitators included doctors explaining adequately and aligning their recommendations with patients' overall health goals, including the prevention of stroke and associated disabilities, and a clear understanding of the pros and cons of taking OACs. Reportedly insufficient explanation from doctors and the inconvenience associated with taking warfarin were identified as potential barriers., Conclusion: Addressing factors that influence patient agreement to commence OACs should be an essential aspect of quality improvement interventions. Subsequent studies should also delve into the perspectives of eligible patients with AF who choose not to commence OACs as well as the perspectives of both patients and doctors regarding the decision to continue OAC treatment.

Objectives: This study aimed to map the national, regional and local prevalence of hypertension and diabetes in Ethiopia., Design and Setting: Nationwide cross-sectional survey in Ethiopia combined with georeferenced ecological level data from publicly available sources., Participants: 9801 participants aged between 15 and 69 years., Primary Outcome Measures: Prevalence of hypertension and diabetes were collected using the WHO's STEPS survey approach. Bayesian model-based geostatistical techniques were used to estimate hypertension and diabetes prevalence at national, regional and pixel levels (1×1 km 2 ) with corresponding 95% credible intervals (95% CrIs)., Results: The national prevalence was 19.2% (95% CI: 18.4 to 20.0) for hypertension and 2.8% (95% CI: 2.4 to 3.1) for diabetes. Substantial variation was observed in the prevalence of these diseases at subnational levels, with the highest prevalence of hypertension observed in Addis Ababa (30.6%) and diabetes in Somali region (8.7%). Spatial overlap of high hypertension and diabetes prevalence was observed in some regions such as the Southern Nations, Nationalities and People's region and Addis Ababa. Population density (number of people/km 2 ) was positively associated with the prevalence of hypertension (β: 0.015; 95% CrI: 0.003-0.027) and diabetes (β: 0.046; 95% CrI: 0.020-0.069); whereas altitude in kilometres was negatively associated with the prevalence of diabetes (β: -0.374; 95% CrI: -0.711 to -0.044)., Conclusions: Spatial clustering of hypertension and diabetes was observed at subnational and local levels in Ethiopia, which was significantly associated with population density and altitude. The variation at the subnational level illustrates the need to include environmental drivers in future NCDs burden estimation. Thus, targeted and integrated interventions in high-risk areas might reduce the burden of hypertension and diabetes in Ethiopia., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aimed to comprehensively evaluate the risk of gastrointestinal bleeding (GIB) with statin monotherapy or with concomitant warfarin use., Data Sources: PubMed, Web of Science, and EMBASE (via Scopus) were searched for observational studies that reported the risk of GIB in adults on statin therapy or with concomitant warfarin use until August 28, 2021., Study Selection and Data Extraction: Observational studies evaluating the risk of GIB in adults (age >18 years) on statin medication or concomitant use with warfarin were included., Data Synthesis: In all, 14 studies with a total of 5 235 123 participants, reporting 48 677 GIB events (43 734 from statin users and 4943 from users of statin combined with warfarin), were included in the analyses. The pooled analysis revealed no difference in the risk of GIB with statin monotherapy (relative risk [RR]: 0.65; 95% CI: 0.42-1.02) or concomitant statin + warfarin use (RR: 0.97; 95% CI: 0.91-1.02). Prior use of statin was not associated with GIB risk (RR: 0.88; 95% CI: 0.63-1.22), whereas a shorter duration of statin use (<5 years) was associated with a lower risk of GIB (RR: 0.42; 95% CI: 0.18-0.97)., Relevance to Patient Care and Clinical Practice: This analysis provides strong evidence on the association between statin use (with/without warfarin) and risk of GIB., Conclusion: Statin alone or combined with warfarin was not significantly associated with either an increased or decreased risk of GIB. The GIB risk was significantly lower when statins were used for a short duration (<5 years). The putative relationship between statins and GIB in warfarin users warrant further investigation.

Rationale and Objectives: Clinical guidelines produced by cardiology societies (henceforth referred to simply as 'clinical guidelines') recommend thromboprophylaxis with oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who have moderate-to-high stroke risk. However, deviations from these recommendations are observed, especially in the primary healthcare setting. The primary aims of this study were to evaluate the self-reported use of AF clinical guidelines and risk stratification tools among Australian general practitioners (GPs), and their perceptions regarding the available resources., Method: We conducted an online survey of Australian GPs. Descriptive statistics were used to summarise the findings., Results: Responses from 115 GPs were included for analysis. Respondents reported various ways of accessing thromboprophylaxis-related information (n = 113), including clinical guidelines (13.3%), 'Therapeutic Guidelines © ' (37.2%) and Royal Australian College of General Practitioners websites (16.8%). Of those who reported reasons against accessing information from clinical guidelines (n = 97), the most frequent issues were: too many AF guidelines to choose from (34.0%; 33/97), different guidelines for different diseases (32.0%; 31/97), time-consuming to read guidelines (21.6%; 21/97), disagreements between different guideline recommendations (20.0%; 19/97), conflict with criteria for government subsidy (17.5%; 17/97) and GPs' busy schedules (15.5%; 15/97). When assessing patients' risk of stroke (n = 112) and bleeding (n = 111), the majority of the respondents reported primarily relying on a formal stroke risk (67.0%) and bleeding risk (55.0%) assessment tools, respectively. Respondents reported using formal stroke and bleeding risk assessment tools mainly when newly initiating patients on therapy (72.4%; 76/105 and 65.3%; 65/101, respectively)., Conclusion: Among our small sample of Australian GPs, most did not access thromboprophylaxis-related information directly from AF-specific clinical guidelines developed by cardiology societies. Although the majority reported using formal stroke and bleeding assessment tools, these were typically used on OAC initiation only. More focus is needed on formal risk reassessment as clinically indicated and at regular review., (© 2022 The Authors. Journal of Evaluation in Clinical Practice published by John Wiley & Sons Ltd.)

Background: There was limited data on treatment outcomes among patients with diabetic ketoacidosis (DKA) in Ethiopia., Objective: The aim of the study was to determine the treatment outcomes of DKA patients attending Debre Tabor General Hospital., Method: A retrospective study was conducted at Debre Tabor General Hospital and data were collected from June 1 to June 30 of 2018. Participants included in the study were all diabetic patients with DKA admitted from August 2010 to May 31, 2018. The primary outcomes were the treatment outcomes of DKA including (in-hospital glycemic control, the length of hospital stay and in-hospital mortality). The statistical analysis was carried out using Statistical Package for Social Sciences (SPSS) version 22. Descriptive statistics was presented in the form of means with standard deviation and binary regression was conducted to determine factors that affect length of hospital stay among DKA patients., Result: 387 patients were included in the study. The mean age of patients was 33.30± 14.96 years. The most common precipitating factor of DKA was new onset diabetes mellitus 150(38.8%). The mean length of hospital stay was 4.64(±2.802) days. The mean plasma glucose at admission and discharge was 443.63(±103.33) and 172.94 (±80.60) mg/dL, respectively. The majority 370 (95.60%) of patients improved and discharged whereas 17 (4.40%) patients died in the hospital. Patients with mild and moderate DKA showed short hospital stay; AOR: 0.16 [0.03-0.78] and AOR:0.17[0.03-0.96] compared with severe DKA. Diabetic ketoacidosis precipitated by infection were nearly five times more likely to have long hospital stay than DKA precipitated by other causes; AOR: 4.59 [1.08-19.42]. In addition, serum glucose fluctuation during hospitalization increased the likelihood of long hospital stay, AOR: 2.15[1.76-2.63]., Conclusions: New onset type 1 diabetes was the major precipitating factor for DKA. Admitted DKA patients remained in hospital for a duration of approximately five days. About five out of hundred DKA patients ended up with death in the hospital. Infection, serum glucose fluctuations and severity of DKA were determinants of long hospital stay. Early prevention of precipitating factors and adequate management of DAK are warranted to reduce length of hospital stay and mortality., Competing Interests: The authors have declared that no competing interests exist.

Background: The COVID-19 pandemic has overwhelmed health systems in both developed and developing nations alike. Africa has one of the weakest health systems globally, but there is limited evidence on how the region is prepared for, impacted by and responded to the pandemic., Methods: We conducted a scoping review of PubMed, Scopus, CINAHL to search peer-reviewed articles and Google, Google Scholar and preprint sites for grey literature. The scoping review captured studies on either preparedness or impacts or responses associated with COVID-19 or covering one or more of the three topics and guided by Arksey and O'Malley's methodological framework. The extracted information was documented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension checklist for scoping reviews. Finally, the resulting data were thematically analysed., Results: Twenty-two eligible studies, of which 6 reported on health system preparedness, 19 described the impacts of COVID-19 on access to general and essential health services and 7 focused on responses taken by the healthcare systems were included. The main setbacks in health system preparation included lack of available health services needed for the pandemic, inadequate resources and equipment, and limited testing ability and surge capacity for COVID-19. Reduced flow of patients and missing scheduled appointments were among the most common impacts of the COVID-19 pandemic. Health system responses identified in this review included the availability of telephone consultations, re-purposing of available services and establishment of isolation centres, and provisions of COVID-19 guidelines in some settings., Conclusions: The health systems in Africa were inadequately prepared for the pandemic, and its impact was substantial. Responses were slow and did not match the magnitude of the problem. Interventions that will improve and strengthen health system resilience and financing through local, national and global engagement should be prioritised., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: A significant proportion of the atrial fibrillation (AF) population attending Australian primary care is not receiving guideline-adherent oral anticoagulant (OAC) treatment. This study aimed to explore reasons for non-adherence to thromboprophylaxis guidelines in AF from the perspectives of general practitioners (GPs) and to map these reasons to the Capability, Opportunity, Motivation-Behaviour (COM-B) model to identify potential opportunities to support practice change., Methods: An exploratory qualitative descriptive study among GPs practising in Western Australia was conducted using semi-structured interviews, from November 2020 to February 2021. The Framework Method was employed to facilitate thematic analysis, using NVivo software. Interview responses were also mapped to the COM-B model., Results: Nine of the 10 GPs initially consented participated in the semi-structured interview (Male = 56%, median age = 52 years, data saturation reached with 6 participants). Two themes emerged from analysis of the interview transcripts: (1) GPs' decision-making process and (2) Patient refusal to take OACs. The COM-B model mapping identified behavioural factors that could impact adherence: capability (GPs' knowledge and understanding of AF guideline recommendations), opportunity (access to a cardiologist, and patients' refusal to take OACs), and motivation (using formal bleeding risk assessment tools)., Conclusion: GPs identified various reasons contributing to non-adherence to thromboprophylaxis guidelines in patients with AF. Multifaceted interventions should consider behavioural opportunities to improve adherence, including education and training, electronic decision support, clinical audits by allied health professionals, partnership between general practices and local hospitals, and cardiologist-led interventions to support GPs. Further studies are needed to capture patients' reasons for refusing OACs., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Clinical guidelines on atrial fibrillation management help optimize the use of oral anticoagulants. However, guideline non-adherence is common, particularly in the primary care setting. The primary aim of this systematic review was to identify effective strategies for improving adherence to guideline-directed thromboprophylaxis to patients with atrial fibrillation in the primary care setting., Methods: A search was conducted on 6 electronic databases (Medline, Embase, ScienceDirect, Scopus, the Cumulative Indexing of Nursing and Allied Health Literature, and Web of Science) supplemented by a Google advanced search. Studies aimed at improving oral thromboprophylaxis guideline adherence in patients with atrial fibrillation, in the primary care setting, were included in the study., Results: A total of 33 studies were included in this review. Nine studies employed electronic decision support (EDS), of which 4 reported modest improvements in guideline adherence. Five of 6 studies that utilized local guidelines as quality improvement measures reported improvement in guideline adherence. All 5 studies that employed coordinated care and the use of specialist support and 4 of the 5 studies that involved pharmacist-led interventions reported improvements in guideline adherence. Interventions based mainly on feedback from audits were less effective., Conclusions: Multifaceted interventions, especially those incorporating coordinated care and specialist support, pharmacists, or local adaptations to and implementation of national and/or international guidelines appear to be more consistently effective in improving guideline adherence in the primary care setting than interventions based mainly on EDS and feedback from audits., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Few studies have been conducted on multimorbidity (two or more chronic diseases) and rational geriatric prescribing in Africa. This study examined the prevalence and determinants of multimorbidity, polypharmacy (five or more long-term medications), and potentially inappropriate medication (PIM) use according to the 2019 Beers criteria among the older adults attending chronic care clinics from a single institution in Ethiopia. A hospital-based cross-sectional study was conducted among 320 randomly selected older adults from 12 March 2020 to 30 August 2020. A multivariable logistic regression analysis was performed to identify the predictor variables. The prevalence of multimorbidity, polypharmacy, and PIM exposure was 59.1%, 24.1%, and 47.2%, respectively. Diuretics (10%), insulin sliding scale (8.8%), amitriptyline (7.8%), and aspirin (6.9%) were among the most frequently prescribed PIMs. Older patients experiencing pain flare-ups were more likely to have multimorbidity (adjusted odds ratio (AOR): 1.64, 95% confidence intervals: 1.13-2.39). Persistent anger (AOR: 3.33; 1.71-6.47) and use of mobility aids (AOR: 2.41, 1.35-4.28) were associated with polypharmacy. Moreover, cognitive impairment (AOR: 1.65, 1.15-2.34) and health deterioration (AOR: 1.61, 1.11-2.32) increased the likelihood of PIM exposure. High prevalence of multimorbidity and PIM use was observed in Ethiopia. Several important determinants that can be modified by applying PIM criteria in routine practice were also identified.

Atrial fibrillation is the most common arrhythmia. It increases the risk of thromboembolism by up to fivefold. Guidelines provide evidence-based recommendations to effectively mitigate thromboembolic events using oral anticoagulants while minimizing the risk of bleeding. This review focuses on non-adherence to contemporary guidelines and the factors associated with guideline non-adherence. The extent of guideline non-adherence differs according to geographic region, healthcare setting, and risk stratification tools used. Guideline adherence has gradually improved over recent years, but a significant proportion of patients are still not receiving guideline-recommended therapy. Physician-related and patient-related factors (such as patient refusals, bleeding risk, older age, and recurrent falls) also contribute to guideline non-adherence, especially to undertreatment. Quality improvement initiatives that focus on undertreatment, especially in the primary healthcare setting, may help to improve guideline adherence.

Background: Insulin is an effective therapeutic agent in the management of diabetes, but also sensitive to the external environment. Consequently, diabetic patients' adherence to insulin delivery recommendations is critical for better effectiveness. Patients' lack of knowledge, skill and irrational practices towards appropriate insulin delivery techniques may end up in therapeutic failure and increase costs of therapy. The aim of this study was to evaluate patients' knowledge, skills and practices of insulin storage and injection techniques., Methods: An interview-based cross-sectional study was conducted through purposive selection of participants in Northwest Ethiopian primary hospitals from March 1 to May 30, 2019. Levels of knowledge were assessed with right or wrong responses, while practice was measured by using a 4-point Likert scale structured questionnaire collected via face-to-face interviews. Likewise, a five-point observational (demonstration) techniques checklist employed to assess patients' skills., Results: Among 194 patients approached, 166 participants completed the survey giving a response rate of 85.6%. More than half of the respondents (54.8%) were males and the mean age (±SD) was 38.5 ± 13.8 years. The overall patients' median knowledge and practice levels on insulin storage and handling techniques were moderately adequate (64.3%) and fair (55.4%), respectively. In patients' skill assessments, 94.6% correctly showed injection sites, 70% indicated injection site rotations, and 60.75% practiced injection site rotations. Education (P < 0.001), duration of insulin therapy (P = 0.008), and duration of diabetes (P = 0.014) had significant impact on knowledge level. Education (P < 0.001), occupation (P < 0.001), duration of insulin therapy (P = 0.001), duration of diabetes (P = 0.036) and patients' knowledge level (P < 0.001) were found to have a significant effects on the patients' practice levels. A Mann-Whitney U test also disclosed that residency, ways to get insulin and mocked injection technique during the first training had significant effects on patients' knowledge levels., Conclusion: The current study revealed that patients had moderately adequate knowledge and fair practice levels on insulin storage and handling techniques. However, patients missed important insulin administration skills. This study highlights the need of regular public health education so as to enhance the patients' knowledge, skill and practice levels on insulin handling techniques.

Objective: The study was aimed to explore patient safety culture of community pharmacists working in Dessie and Gondar towns, Northern Ethiopia., Methods: A cross-sectional study was conducted from 1st to 31st March 2018. In this cross-sectional survey, the Pharmacy Survey on Patient Safety Culture (PSOPSC), developed by the Agency for Healthcare Research and Quality (AHRQ), was used to collect data. PSOPSC is a self-administered questionnaire. The questionnaire was distributed among staffs who work in community pharmacies of Dessie and Gondar towns. All staffs available on data collection period in the pharmacy were included. The Statistical Package for Social Science (SPSS) software version 25 was used to enter and analyze the data., Results: A total of 120 participants were approached and completed the questionnaire. Results from the study showed that high positive response rate was demonstrated in the domains of "Teamwork" (90.2%) followed by physical space and environment (83.1%). On the other hand, the result also identified that there is an enormous problem related to mistake communication (44.8%) and work pressure (45%). In addition, significant difference of percent positive responses were obtained across towns and staff working hours., Conclusions: The patient safety culture of community pharmacists is appreciable especially with respect to their teamwork. Besides, urgent attention should be given to areas of weakness, mainly in the domain of "mistake communication" and "staffing and work pressure"., Competing Interests: There is no competing interest of authors on the whole work.

Following publication of the original article [1], the authors flagged that the name provided for the 4th author had been misspelled; the 4th author was (incorrectly) spelled as 'Eyob Alemayehu Gebreyohanns'.

Background: Asthma is one of the chronic diseases which affects the airway, and inhalers are the preferred medications to treat this problem. Improper inhalational technique leads to decreased efficacy of the medication by reducing its deposition in the lungs. The aim of this study was to assess the barriers to and competency with the use of Metered Dose Inhaler (MDI) and its impact on disease control among adult asthmatic patients., Methods: A prospective cross-sectional study was conducted in University of Gondar comprehensive specialized hospital outpatient department (OPD) chronic follow up from 12-March-2018 to 15-May- 2018. Patients were interviewed face to face with questions which determined their competency, asthma control level and barriers for inhaler use., Result: Overall, 307 asthmatic patients were included in the study. More than half of participants were females, 170 (55.4%) and lived in urban area 185 (60.3%). The mean age of the respondents was 51.77 years with a standard deviation of ±15.40. The cost of medication, 282 (91.9%) and the perception that medication should be used in response to symptoms but not on a regular basis 277 (90.2%) were the most identified barriers. Only 56 (18.2%) were competent for Metered Dose Inhaler use (MDIU) and 17 (5.5%) patients had well controlled asthma. Being not competent AOR 0.168[0.41-0.687] was one of the factors decreasing asthma control., Conclusion: Generally from this study, cost of the medication and the perception that medication should be used only for symptoms were the major identified barriers that affect the MDI use among asthmatic patients. Patients show very poor competence to their MDI which in turn led to poor asthma control. So, patients need to be taught the correct inhaler technique in the hospital and pharmacy while they came for follow up every time.

Background: Cervical cancer is causing a huge burden in Sub-Saharan Africa (SSA). It mainly affects women in their young ages making female university students at risk of cervical cancer. Knowledge and awareness about cervical cancer and human papillomavirus (HPV) in SSA including Ethiopia is very poor. We aimed to assess the knowledge and awareness of cervical cancer and HPV in University of Gondar (UOG) medicine and health science female students. A cross-sectional study was done., Methods: This study was conducted from April 1 to May 30, 2016 at UOG, College of Medicine and Health Sciences, Gondar, Northwest Ethiopia. Undergraduate female students were included in the study. A 14-item self-administered questionnaire was then provided to each of the participants to measure their level of knowledge and awareness about cervical cancer and HPV., Results: A total of 267 female students participated in the study (mean age 20.58 ± 1.22). More than half of the participants (59.6%) did not know the main cause of cervical cancer, whereas just about a fifth of them (19.5%) identified HPV as the main cause of cervical cancer. As high as 83.9% of the participants did not know other causes of cervical cancer. Binary logistic analysis revealed that students from midwifery (adjusted odds ratios [AOR] = 14.14, P < 0.05), anesthesiology (AOR = 9.66, P < 0.05) and medicine (AOR = 5.84, P < 0.05) departments were associated with knowledge of the main cause of cervical cancer., Conclusions: Knowledge about cervical cancer and its causes were found to be inadequate among higher education female students. Hence, awareness about cervical cancer, causes and its prevention, importance of screening and vaccination should be promoted through university's campaign, curricular changes, and community and research projects., Competing Interests: There are no conflicts of interest., (Copyright: © 2019 International Journal of Preventive Medicine.)