Incremental net monetary benefit of using varenicline for smoking cessation: A systematic review and meta-analysis of economic evaluation studies.

AIMS: To conduct a systematic review and meta-analysis and pool the incremental net benefits (INBs) of varenicline compared with behaviour support with bupropion or nicotine replacement therapy (NRT), behaviour support alone and unaided cessation in adult smokers making a first-time attempt to quit. METHODS: A search for economic evaluation studies was conducted from inception to 30 September 2022, on PubMed, Embase, Cost-Effectiveness Analysis (CEA) Registry by Tufts Medical Centre, EconLit and the NHS Economic Evaluation Database (NHS EED). Eligible studies were included if they were (1) conducted among adults ages 18 years old and older who were smokers attempting to quit for the first time; (2) compared varenicline to behaviour support with bupropion or NRT, behaviour support alone and unaided cessation; and (3) performed a CEA or cost-utility analysis. The INBs were calculated and pooled across studies stratified by country income level and study perspective using the random-effects model. Statistical heterogeneity between studies was assessed using the I2 statistic and Cochrane Q statistic. RESULTS: Of the 1433 identified studies, 18 studies were included in our review. Our findings from healthcare system/payer perspective suggested that the use of varenicline is statistically significantly cost-effective compared with bupropion (pooled INB, $830.75 [95% confidence interval, $208.23, $1453.28]), NRTs ($636.16 [$192.48, $1079.84]) and unaided cessation ($4212.35 [$1755.79, $6668.92]) in high-income countries. Similarly, varenicline is also found to be cost-effective compared to bupropion ($2706.27 [$1284.44, $4128.11]), NRTs ($3310.01 [$1781.53, $4838.50]) and behavioural support alone ($5438.22 [$4105.99, $6770.46]) in low- and middle-income countries. CONCLUSION: Varenicline is cost-effective as a smoking cessation aid when compared with behavioural support with bupropion or nicotine replacement therapies and behavioural support alone in both high-income countries and low- and middle-income countries, from the healthcare system/payer perspective in adult smokers who attempt to quit for the first time.

Impact of pharmacist-delivered interventions on pain-related outcomes: An umbrella review of systematic reviews and meta-analyses.

INTRODUCTION: Pain is a significant healthcare challenge, impacting millions worldwide. Pharmacists have increasingly taken on expanded roles in managing pain, particularly in primary and ambulatory care contexts. This umbrella review aims to systematically evaluate evidence from published systematic reviews that explore the impact of pharmacist-delivered interventions on clinical, humanistic, and economic outcomes related to pain. METHODS: A systematic search was conducted across six electronic databases, including Ovid Embase, MEDLINE, CINAHL, Scopus, CENTRAL, APA PsycINFO, and DARE, from inception until June 2023. Prior to inclusion, two independent reviewers assessed study titles and abstracts. Following inclusion, an assessment of the methodological quality of the included studies was conducted. AMSTAR 2 was used to evaluate the methodological quality of the included SRs. RESULTS: From 2055 retrieved titles, 11 systematic reviews were included, with 5 out of 11 being meta-analyses. These SRs encompassed diverse pharmacist-led interventions such as education, medication reviews, and multi-component strategies targeting various facets of pain management. These findings showed favorable clinical outcomes, including reduced pain intensity, improved medication management, enhanced overall physical and mental well-being, and reduced hospitalization durations. Significant pain intensity reductions were found due to pharmacists' interventions, with standardized mean differences (SMDs) ranging from -0.76 to -0.22 across different studies and subgroups. Physical functioning improvements were observed, with SMDs ranging from -0.38 to 1.03. Positive humanistic outcomes were also reported, such as increased healthcare provider confidence, patient satisfaction, and quality of life (QoL). QoL improvements were reported, with SMDs ranging from 0.29 to 1.03. Three systematic reviews examined pharmacist interventions' impact on pain-related economic outcomes, highlighting varying cost implications and the need for robust research methodologies to capture costs and benefits. CONCLUSION: This umbrella review highlights the effectiveness of pharmacist-delivered interventions in improving clinical, humanistic, and economic outcomes related to pain management. Existing evidence emphasises on the need to integrate pharamacists into multi-disciplinary pain management teams. Further research is needed to investigate innovative care models, such as pharmacist-independent prescribing initiatives within collaborative pain management clinics.

Cost-effectiveness analysis of olaparib maintenance therapy for BRCA mutation ovarian cancer in the public sector in Malaysia.

INTRODUCTION: Ovarian cancer is one of the most common cancer among women in Malaysia. Patients with ovarian cancer are often diagnosed at an advanced stage. Despite initial response to surgery and chemotherapy, most patients will experience a relapse. Olaparib has been reported have promising effects among BRCA mutated ovarian cancer patients. This study aimed to evaluate the cost-effectiveness of olaparib as a maintenance therapy for BRCA ovarian cancer in Malaysia. METHODS: We developed a four-state partitioned survival model which compared treatment with olaparib versus routine surveillance (RS) from a Malaysian healthcare perspective. Mature overall survival (OS) data from the SOLO-1 study were used and extrapolated using parametric models. Medication costs and healthcare resource usage costs were derived from local inputs and publications. Deterministic and probabilistic sensitivity analyses (PSA) were performed to explore uncertainties. RESULTS: In Malaysia, treating patients with olaparib was found to be more costly compared to RS, with an incremental cost of RM149,858 (USD 33,213). Patients treated with olaparib increased life years by 3.05 years and increased quality adjusted life years (QALY) by 2.76 (9.45 years vs 6.40 years; 7.62 vs 4.86 QALY). This translated to an incremental cost-effectiveness ratio (ICER) of RM 49,159 (USD10,895) per life year gained and RM54,357 (USD 12,047) per QALY gained, respectively. ICERs were most sensitive to time horizon of treatment, discount rate for outcomes, cost of treatment and health state costs, but was above the RM53,770/QALY threshold. CONCLUSION: The use of olaparib is currently not a cost-effective strategy compared to routine surveillance based upon the current price in Malaysia for people with ovarian cancer with BRCA mutation, despite the improvement in overall survival.

Development of a Malaysian potentially inappropriate prescribing screening tool in older adults (MALPIP): a Delphi study.

INTRODUCTION: Polypharmacy and potentially inappropriate medications (PIM) are common among older adults. To guide appropriate prescribing, healthcare professionals often rely on explicit criteria to identify and deprescribe inappropriate medications, or to start medications due to prescribing omission. However, most explicit PIM criteria were developed with inadequate guidance from quality metrics or integrating real-world data, which are rich and valuable data source. AIM: To develop a list of medications to facilitate appropriate prescribing among older adults. METHODS: A preliminary list of PIM and potential prescribing omission (PPO) were generated from systematic review, supplemented with local pharmacovigilance data of adverse reaction incidents among older people. Twenty-one experts from nine specialties participated in two Delphi to determine the list of PIM and PPO in February and March 2023. Items that did not reach consensus after the second Delphi round were adjudicated by six geriatricians. RESULTS: The preliminary list included 406 potential candidates, categorised into three sections: PIM independent of diseases, disease dependent PIM and omitted drugs that could be restarted. At the end of Delphi, 92 items were decided as PIM, including medication classes, such as antacids, laxatives, antithrombotics, antihypertensives, hormones, analgesics, antipsychotics, antidepressants, and antihistamines. Forty-two disease-specific PIM criteria were included, covering circulatory system, nervous system, gastrointestinal system, genitourinary system, and respiratory system. Consensus to start potentially omitted treatment was achieved in 35 statements across nine domains. CONCLUSIONS: The newly developed PIM criteria can serve as a useful tool to guide clinicians and pharmacists in identifying PIMs and PPOs during medication review and facilitating informed decision-making for appropriate prescribing.

Impact of deprescribing intervention on potentially inappropriate medications and clinical outcomes among hospitalized older adults in Malaysia: a randomized controlled trial (REVMED RCT) protocol.

BACKGROUND: Polypharmacy and the use of potentially inappropriate medications (PIMs) are prevalent among older patients admitted to hospitals, posing a heightened risk of adverse drug events. This trial aims to evaluate the effectiveness of a pharmacist-led deprescribing intervention in reducing medications, PIM and improving clinical outcomes, using the locally developed Malaysian Potentially Inappropriate Prescribing Screening tool in Older Adults (MALPIP). METHODS: This is an 18-month cluster-randomized, open-label, parallel-arm controlled trial conducted at 14 public hospitals in the Perak state of Malaysia. Patients aged 60 and above, who have at least one medication and one comorbidity are eligible. A stratified-cluster randomization design is employed, with 7 hospitals assigned to the control arm and 7 hospitals assigned to the intervention arm. The MALPIP screening tool will be used in the intervention group to review the medications. If PIM is detected, the pharmacists will discuss with doctors and decide whether to stop or reduce the dose. The primary outcomes of this trial are the total number of medications and number of PIM. The secondary outcomes include fall, emergency department visits, readmissions, quality of life and mortality. Outcomes will be measured during enrolment, discharge, 6, 12, and 18 months. DISCUSSION: This REVMED trial aims to test the hypothesis that a pharmacist-led deprescribing intervention initiated in the hospital will reduce the total number of medications and PIM 18 months after hospital discharge, reducing fall, emergency department visits, readmissions, mortality and lead to improvement in quality of life. Trial findings will quantify the clinical outcomes associated with reducing medications and PIM for hospitalized older adults with polypharmacy. TRIAL REGISTRATION NUMBER: This trial was prospectively registered at clinicaltrials.gov (NCT05875623) on the 25th of May 2023. NCT05875623 Clinicaltrials.gov URL: NCT05875623 registered on 25th July 2023.

Polypharmacy and potentially inappropriate medications among hospitalized older adults with COVID-19 in Malaysian tertiary hospitals.

INTRODUCTION: Older adults are among the most vulnerable groups during the COVID-19 epidemic, contributing to a large proportion of COVID-19-related death. Medication review and reconciliation by pharmacist can help reduce the number of potentially inappropriate medications but these services were halted during COVID-19. AIM: To assess the prevalence and factors associated with inappropriate medicine use among older populations with COVID-19. METHODS: This was a cross-sectional, retrospective analysis of medications among hospitalized older adults with COVID-19. Potentially inappropriate medication use was categorized using the Beer's and STOPP criteria. RESULTS: Combining both criteria, 181 (32.7%) of the 553 patients were identified to have used at least one or more potentially inappropriate medication. A marginally higher number of inappropriate medications was documented using the Beers 2019 criteria (151 PIM in 124 patients) compared to STOPP criteria (133 PIMS in 104 patients). The long-term use of proton pump inhibitors (n = 68; 12.3%) and drugs which increases the risk of postural hypotension were the most commonly reported PIM (n = 41; 7.4%). Potentially inappropriate medication use was associated with previous history of hospital admission in the past 12 months (Odds ratio [OR]: 2.27; 95% CI 1.29-3.99) and higher number of discharge medications. CONCLUSIONS: Nearly, one in three older adults with COVID-19 had been prescribed a PIM, and the proportion of older adults with polypharmacy increased after discharge. This highlights the importance of having clinical pharmacist conducting medication reviews to identify PIMs and ensure medication appropriateness.

Community pharmacists-led interventions in tuberculosis care: A systematic review.

BACKGROUND: A multidisciplinary approach is required to tackle the tuberculosis (TB) epidemic, which is one of the most pressing public health concerns worldwide. However, community pharmacists are underutilized in TB programs. OBJECTIVE: To identify community pharmacists-led interventions in TB management with their corresponding impacts in TB case detection and treatment outcomes. METHODS: A systematic search was performed in six electronic databases and health organization websites, from database inception to August 2, 2022. Studies which described TB screening, referral and/or treatment monitoring by community pharmacists with their corresponding outcomes were screened and reviewed independently by two reviewers. The studies were checked for the risk of bias using Cochrane risk of bias tools. All data of included studies were analysed qualitatively and presented narratively. RESULTS: The search yielded 8,121 studies and five reports for initial screening. Sixteen studies and two case study reports were included in this review. Community pharmacists were involved throughout the TB care cascade, contributing their services in TB screening, referrals and in directly observed treatment-short course (DOTS) program. These interventions showed improvements in the effective control and prevention of further spread of TB, which improves individual, community and population level outcomes. CONCLUSIONS: The inclusion of community pharmacists into TB program can improve the continuity of care, bridging the gaps in TB case detection and treatment monitoring. Adequate training and support are essential, to further empower the role of community pharmacists in TB control and prevention, in building a TB-free world.

Assessment of the real-world impact of the Thai smoking cessation programme on clinical outcomes: protocol for a multicentre prospective observational study.

BACKGROUND: Tobacco smoking is the most common preventable cause of morbidity and mortality in the world. In an effort to counteract the harmful consequences of smoking, various tobacco control measures have been implemented, including the use of smoking cessation programmes to reduce the number of new smokers as well as helping current smokers to quit smoking. In Thailand, the SMART Quit Clinic Program (FAH-SAI Clinics) was launched in 2010 to provide smoking cessation services by a multidisciplinary team. There are currently 552 FAH-SAI Clinics established across all 77 provinces of Thailand. AIM: This protocol describes a study aiming to evaluate the SMART Quit Clinic Program (FAH-SAI Clinics) in terms of programme performance and clinical outcomes. We hope that the results of the study could be used to improve the current service model and the programme's success. METHOD: A multicentre prospective observational study will be conducted. The study will focus on 24 FAH-SAI Clinics across 21 provinces of Thailand. The primary outcomes are seven-day point prevalence abstinence rate and continuous abstinence rate at three and six months. The outcomes will be measured using a self-reported questionnaire and biochemical validated by exhaled carbon monoxide. DISCUSSION: This study will be the first real-world study that reports the effectiveness of the well-established smoking cessation programme in Thailand. Findings from this study can help improve the quality of smoking cessation services provided by multidisciplinary teams and other smoking cessation services, especially those implemented in low- and middle-income countries.

The impact of Thai multidisciplinary smoking cessation program on clinical outcomes: A multicentre prospective observational study.

Introduction: Tobacco use is the leading preventable cause of morbidity and mortality worldwide. Since 2010, Thailand has implemented a multidisciplinary smoking cessation clinic, which provides smoking cessation services, but the effectiveness of the clinics was not formally evaluated. This study was conducted to assess the real-world effectiveness of this multidisciplinary smoking cessation program. Methods: We conducted a prospective, multicentre, observational study on Thai participants aged 13 years and older in 24 smoking cessation clinics across Thailand's 13 health regions. Each clinic offered smoking cessation interventions according to the well-established 5As model for smoking cessation (Ask, Advise, Assess, Assist, and Arrange). Outcomes of interest were continuous abstinence rates (CAR) at 3 and 6 months. Biochemical confirmation and self-reporting were used to assess the outcomes. Descriptive statistics (mean, SD, median, IQR, and percentage) were used to analyze the smoking cessation outcomes in both intention-to-treat and per-protocol analysis approaches. Results: Smokers receiving services from the Thai multidisciplinary smoking cessation clinics had CAR of 17.49 and 8.33% at 3 and 6 months, respectively. For those with cardiovascular disease (CVD) or cerebrovascular disease, CAR was found to be 26.36% at 3 months and 13.81% at 6 months. While participants with chronic obstructive pulmonary disease (COPD) had CAR ranging from 32.69% at 3 months to 17.31% at 6 months. Conclusion: The multidisciplinary team smoking cessation clinic was effective in assisting smokers in quitting smoking. The effectiveness of the clinic was more pronounced for smokers with CVD, cerebrovascular disease, or COPD. Findings from this study support a decision to include multidisciplinary smoking cessation clinics in the universal health care benefits package.

Digital health use in latent tuberculosis infection care: A systematic review.

PURPOSE: With one-quarter of the world's population estimated to have latent tuberculosis infection (LTBI), it is important that the drop-outs from the LTBI cascade of care are minimized. Digital health technology could play an important role in case detection and treatment adherence. This study aims to evaluate the use and impact of digital health technology in LTBI care. METHODS: A systematic literature search was conducted on six electronic databases from database inception until May 31st 2021. Studies that reported on the clinical use or economic analysis of digital health technology for LTBI care were included. Two investigators independently evaluated, extracted relevant studies, and assessed the risk of bias of using the Cochrane tools. The studies were synthesized qualitatively. RESULTS: Fifteen articles describing 14 studies were included. Voice and/or textual reminders and synchronous video call to improve LTBI treatment adherence were the most commonly examined digital health interventions. Other interventions examined the use of mobile phones to improve the number of patients who returned for tuberculin skin test follow-up measurement (screening retention) and eLearning videos to enhance health literacy in LTBI care. The economic analysis supported the use of textual reminders in LTBI treatment as a cost-effective option for widescale implantation. CONCLUSIONS: Despite limited evidence on the effects of digital health technologies in LTBI, available studies suggest they are at least equivalent to current practice. This means digital health can potentially supplement current practice, to constantly monitor and engage with people undergoing LTBI screening or treatment, as an initiative to ensure the provision of continuous and optimal care to all LTBI-affected individuals.

The Health Effects of Chocolate and Cocoa: A Systematic Review.

Chocolate has a history of human consumption tracing back to 400 AD and is rich in polyphenols such as catechins, anthocyanidins, and pro anthocyanidins. As chocolate and cocoa product consumption, along with interest in them as functional foods, increases worldwide, there is a need to systematically and critically appraise the available clinical evidence on their health effects. A systematic search was conducted on electronic databases such as MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) using a search strategy and keywords. Among the many health effects assessed on several outcomes (including skin, cardiovascular, anthropometric, cognitive, and quality of life), we found that compared to controls, chocolate or cocoa product consumption significantly improved lipid profiles (triglycerides), while the effects of chocolate on all other outcome parameters were not significantly different. In conclusion, low-to-moderate-quality evidence with short duration of research (majority 4-6 weeks) showed no significant difference between the effects of chocolate and control groups on parameters related to skin, blood pressure, lipid profile, cognitive function, anthropometry, blood glucose, and quality of life regardless of form, dose, and duration among healthy individuals. It was generally well accepted by study subjects, with gastrointestinal disturbances and unpalatability being the most reported concerns.

Cancer risk in Parkinson disease: An updated systematic review and meta-analysis.

BACKGROUND AND PURPOSE: Increasing evidence suggests significant associations between Parkinson disease (PD) and cancer risks. We conducted an updated review of studies that examined the risks of various cancer among PD patients and how this differed when cancer preceded PD diagnosis or PD diagnosis preceded cancer. METHODS: Four databases were searched for studies that examined the association between PD and incidence of cancer from database inception to 4 June 2021. Three independent reviewers screened the articles for eligibility and extracted study data. Pooled relative risk with 95% confidence intervals were calculated using a random effects model. RESULTS: Forty studies involving 11 case-control studies, two nested case-control studies, 22 cohort studies, and five cross-sectional studies were included. Compared to controls, PD patients had lower risks of lung, genitourinary, gastrointestinal, and haematological cancers. Conversely, higher risks of melanoma and brain cancer were noted among PD patients. No association was found between PD and risk of female cancers. Subgroup analysis found negative associations between PD patients and risks of colon cancer, rectal cancer, and non-Hodgkin lymphoma. CONCLUSIONS: Findings from our meta-analysis suggest PD patients had lower risks of lung, genitourinary, gastrointestinal, and haematological cancers and increased risks of melanoma and brain cancer. Future research to investigate the underlying mechanisms between PD and cancers is warranted.

How Willing Are Patients or Their Caregivers to Deprescribe: a Systematic Review and Meta-analysis.

BACKGROUND: Polypharmacy is associated with the increased use of potentially inappropriate medications, where the risks of medicine use outweigh its benefits. Stopping medicines (deprescribing) that are no longer needed can be beneficial to reduce the risk of adverse events. We summarized the willingness of patients and their caregivers towards deprescribing. METHODS: A systematic search was conducted in four databases from inception until April 30, 2021 as well as search of citation of included articles. Studies that reported patients' and/or their caregivers' attitude towards deprescribing quantitatively were included. All studies were independently screened, reviewed, and data extracted in duplicates. Patients and caregivers willingness to deprescribe their regular medication was pooled using random effects meta-analysis of proportions. RESULTS: Twenty-nine unique studies involving 11,049 participants were included. All studies focused on the attitude of the patients towards deprescribing, and 7 studies included caregivers' perspective. Overall, 87.6% (95% CI: 83.3 to 91.4%) patients were willing to deprescribe their medication, based upon the doctors' suggestions. This was lower among caregivers, with only 74.8% (49.8% to 93.8%) willing to deprescribe their care recipients' medications. Patients' or caregivers' willingness to deprescribe were not influenced by study location, study population, or the number of medications they took. DISCUSSION: Most patients and their caregivers were willing to deprescribe their medications, whenever possible and thus should be offered a trial of deprescribing. Nevertheless, as these tools have a poor predictive ability, patients and their caregivers should be engaged during the deprescribing process to ensure that the values and opinions are heard, which would ultimately improve patient safety. In terms of limitation, as not all studies may published the methods and results of measurement they used, this may impact the methodological quality and thus our findings. OPEN SCIENCE FRAMEWORK REGISTRATION: https:// osf.io/fhg94.

Association of Deprescribing With Reduction in Mortality and Hospitalization: A Pragmatic Stepped-Wedge Cluster-Randomized Controlled Trial.

OBJECTIVES: Deprescribing has gained awareness recently, but the clinical benefits observed from randomized trials are limited. The aim of this study was to examine the effectiveness of a pharmacist-led 5-step team-care deprescribing intervention in nursing homes to reduce falls (fall risks and fall rates). Secondary aims include reducing mortality, number of hospitalized residents, pill burden, medication cost, and assessing the deprescribing acceptance rate. DESIGN: Pragmatic multicenter stepped-wedge cluster randomized controlled trial. SETTING AND PARTICIPANTS: Residents across 4 nursing homes in Singapore were included if they were aged 65 years and above, and taking 5 or more medications. METHODS: The intervention involved a 5-step deprescribing intervention, which involved a multidisciplinary team-care medication review with pharmacists, physicians, and nurses (in which pharmacists discussed with other team members the feasibility of deprescribing and implementation using the Beers and STOPP criteria) or to an active waitlist control for the first 3 months. RESULTS: Two hundred ninety-five residents from 4 nursing homes participated in the study from February 2017 to March 2018. At 6 months, the deprescribing intervention did not reduce falls. Subgroup analysis showed that intervention reduced fall risk scores within the deprescribing-naïve group by 0.18 (P = .04). Intervention was associated with a reduction in mortality [hazard ratio (HR) 0.16, 95% confidence interval 0.07, 0.41; P < .001] and number of hospitalized residents (HR 0.16, 95% CI 0.10, 0.26; P < .001). Pre-post analysis witnessed a reduction in pill burden at the end of the study, and a conservative daily cost saving estimate of US$11.42 (SG$15.65) for the study population. Approximately three-quarters of deprescribing interventions initiated by the pharmacists were accepted by the physicians. CONCLUSIONS AND IMPLICATIONS: Multidisciplinary medication review-directed deprescribing was associated with reductions in mortality and number of hospitalized residents in nursing homes and should be considered for all nursing home residents.

Warfarin and food, herbal or dietary supplement interactions: A systematic review.

AIMS: To present an updated overview on the safety of concurrent use of food, herbal or dietary supplement and warfarin. METHODS: A systematic literature review was performed on 5 databases from inception up to 31 December 2019. These interactions were classified depending on the likelihood of interaction and supporting evidences. RESULTS: A total of 149 articles describing 78 herbs, food or dietary supplements were reported to interact with warfarin. These reports described potentiation with 45 (57.7%) herbs, food or dietary supplements while 23 (29.5%) reported inhibition and 10 (12.8%) reported limited impact on warfarin pharmacokinetics and pharmacodynamics. Twenty unique herb and dietary supplements also reported to result in minor bleeding events, such as purpura and gum bleeding as well as major events such as intracranial bleeding that led to death. CONCLUSION: While most food, herbs and supplements can be safely taken in moderation, healthcare professionals should be aware of the increased risk of bleeding when taking several food and herbs. These include Chinese wolfberry, chamomile tea, cannabis, cranberry, chitosan, green tea, Ginkgo biloba, ginger, spinach, St. John's Wort, sushi and smoking tobacco. Patients should be counselled to continue to seek advice from their healthcare professionals when starting any new herbs, food or supplement.

Patients' and Caregivers' Attitudes Toward Deprescribing in Singapore.

BACKGROUND: Knowledge of decision-making preference of patients and caregivers is needed to facilitate deprescribing. This study aimed to assess the perspectives of caregivers and older adults towards deprescribing in an Asian population. Secondary objectives were to identify and compare characteristics associated with these attitudes and beliefs. METHOD: A cross-sectional survey of two groups of participants was conducted using the Revised Patients' Attitudes Towards Deprescribing questionnaire. Descriptive results were reported for participants' characteristics and questionnaire responses from four factors (belief in medication inappropriateness, medication burden, concerns about stopping, and involvement) and two global questions. Correlation between participant characteristics and their responses was analyzed. RESULTS: A total of 1,057 (615 older adults; 442 caregivers) participants were recruited from 10 institutions in Singapore. In which 511 (83.0%) older adults and 385 (87.1%) caregivers reported that they would be willing to stop one or more of their medications if their doctor said it was possible, especially among older adults recruited from acute-care hospitals (85.3%) compared with older adults in community pharmacies (73.6%). Individuals who take more than five medications and those with higher education were correlated with greater agreement in inappropriateness and involvement, respectively. CONCLUSIONS: Clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice, especially when polypharmacy is present. Further research is needed into how to engage older adults and caregivers in shared decision making based on their attitudes toward deprescribing.

"Suiting Up" to Enhance Empathy Toward Aging: A Randomized Controlled Study.

Background: Healthcare professionals who have a positive attitude and who are more empathetic toward older adults are in a better position to deliver quality healthcare. This study examines the impact of using an aging simulation suit on undergraduate pharmacy students' empathy levels. Methods: One hundred and twenty first-year students enrolled in the Bachelor of Pharmacy course were randomized to either a medication review polypharmacy workshop (control) or an immersive aging simulation suit and medication review polypharmacy workshop (intervention). Intervention participants donned the aging suit and performed a series of tasks, including walking up a flight of stairs and filling up a form to simulate the physical limitations experienced by an older adult. The workshop was delivered at week 10 of semester. Both groups also completed a medication review polypharmacy workshop at week 12 of semester. The primary outcome was a measurement of change on the Jefferson Empathy Scale-Healthcare Professional Questionnaire among both groups at week 12 of semester. Secondary outcomes include the longitudinal impact of intervention after 3 months of the workshop and perceptions on learning. Results: The use of a simulation suit did not increase participants' self-rated empathy compared to control. However, the suit enhanced the ability of participants to understand the physical limitations and visual issues associated with aging. Participants also felt that it enhanced their health advocacy, as it taught them the importance of listening, patience and respect for older adults. Conclusion: The use of an immersive aging suit can be a useful adjunctive tool to help enhance students' understanding of the physical limitations and visual limitations of aging. Further research is needed to understand how these limitations affect other healthcare students. Trial Registration: ClinicalTrials.gov identifier: NCT04133727.

Pharmacist services in nursing homes: A systematic review and meta-analysis.

AIMS: Pharmacists have been contributing to the care of residents in nursing homes and play a significant role in ensuring quality use of medicine. However, the changing role of pharmacist in nursing homes and their impact on residents is relatively unknown. METHODS: Six electronic databases were searched from inception until November 2018 for articles published in English examining the services offered by pharmacists in nursing homes. Studies were included if it examined the impact of interventions by pharmacists to improve the quality use of medicine in nursing homes. RESULTS: Fifty-two studies (30 376 residents) were included in the current review. Thirteen studies were randomised controlled studies, while the remainder were either pre-post, retrospective or case-control studies where pharmacists provided services such as clinical medication review in collaboration with other healthcare professionals as well as staff education. Pooled analysis found that pharmacist-led services reduced the mean number of falls (-0.50; 95% confidence interval: -0.79 to -0.21) among residents in nursing homes. Mixed results were noted on the impact of pharmacists' services on mortality, hospitalisation and admission rates among residents. The potential financial savings of such services have not been formally evaluated by any studies thus far. The strength of evidence was moderate for the outcomes of mortality and number of fallers. CONCLUSION: Pharmacists contribute substantially to patient care in nursing homes, ensuring quality use of medication, resulting in reduced fall rates. Further studies with rigorous design are needed to measure the impact of pharmacist services on the economic benefits and other patient health outcomes.

Attitudes towards deprescribing among multi-ethnic community-dwelling older patients and caregivers in Malaysia: a cross-sectional questionnaire study. A Comment.

Understanding older adult and caregiver attitudes towards deprescribing will contribute to medication optimization in clinical practice. The objectives of this study were to explore quantitatively the attitudes and beliefs of older adults and caregivers towards deprescribing and identify participant characteristics that were associated with willingness to have a medication deprescribed. This study was conducted in a government-led primary care health clinic and three private community pharmacies in Malaysia with older adults and caregivers of older adults. The revised patients' attitudes towards deprescribing (rPATD) questionnaire was administered. The rPATD questionnaire had four factors in both older adults' and caregivers' versions of the questionnaire (with four to five questions retained in each factor) alongside two global questions that were not included in any of the scoring factors. Our revised statement of main findings now states that most of older adult (n = 340, 67.7%) and caregiver (n = 34, 65.4%) participants agreed or strongly agreed that they would be willing to stop one or more of their or their care recipient's medications if their or their care recipient's doctor said it was possible to do so.

Antineoplastic-related cardiovascular toxicity: A systematic review and meta-analysis in Asia.

BACKGROUND: Cancer and heart diseases are the leading causes of morbidity and mortality in many countries worldwide. Recent advancement in chemotherapy and targeted therapies has led to an improvement in cancer survival rates, but at a cost of higher cardiac side effects. However, report on antineoplastic-related cardiotoxicities incidence in Asia is lacking. METHODS: We systematically searched multiple databases to identify studies reporting incidence of antineoplastic-related cardiovascular toxicity in Asia published from inception to November 2018. Pre-specified subgroups were performed to explore heterogeneity and study quality assessed and reported according to PRISMA guidelines. RESULTS: A total of 61 studies across 11 countries in Asia reported 8 types of cardiovascular toxicities were included. These studies mostly reported on adult populations, and usually examined cardiotoxicities related to anthracycline use. The most frequently reported cardiotoxicities were heart failure, electrocardiogram abnormalities and left ventricular dysfunction. The pooled estimated incidence of cardiotoxicity was 4.27% (95% CI: 3.53-5.07). Subgroup analysis showed higher incidence in middle income countries compared to high income countries. CONCLUSIONS: Although robust incidence studies are sparse, cardiovascular complications affects approximately one in twenty cancer patients in Asia. This highlights a unique opportunity of cancer patients caring that need cardiologists and oncologist to become familiar with this emerging sub-specialty.