A survey on the implementation of clinical medication reviews in community pharmacies within a multidisciplinary setting.

BACKGROUND: Polypharmacy is common in chronic medication users, which increases the risk of drug related problems. A suitable intervention is the clinical medication review (CMR) that was introduced in the Netherlands in 2012, but the effectiveness might be hindered by limited implementation in community pharmacies. Therefore our aim was to describe the current implementation of CMRs in Dutch community pharmacies and to identify barriers to the implementation. METHODS: An online questionnaire was developed based on the Consolidated Framework for Implementation Research (CFIR) and consisted of 58 questions with open ended, multiple choice or Likert-scale answering options. It was sent out to all Dutch community pharmacies (n = 1,953) in January 2021. Descriptive statistics were used. RESULTS: A total of 289 (14.8%) community pharmacies filled out the questionnaire. Most of the pharmacists agreed that a CMR has a positive effect on the quality of pharmacotherapy (91.3%) and on medication adherence (64.3%). Pharmacists structured CMRs according to available selection criteria or guidelines (92%). Pharmacists (90%) believed that jointly conducting a CMR with a general practitioner (GP) improved their mutual relationship, whereas 21% believed it improved the relationship with a medical specialist. Lack of time was reported by 43% of pharmacists and 80% (fully) agreed conducting CMRs with a medical specialist was complicated. Most pharmacists indicated that pharmacy technicians can assist in performing CMRs, but they rarely do in practice. CONCLUSIONS: Lack of time and suboptimal collaboration with medical specialists are the most important barriers to the implementation of CMRs.

Prescription patterns of direct oral anticoagulants and concomitant use of interacting medications in the Netherlands.

OBJECTIVES: To describe the prevalence, temporal and regional trends in prescribing direct oral anticoagulants (DOACs) in conjunction with interacting medications. METHODS: We performed a cross-sectional study of pharmacy dispensing data in the Foundation for Pharmaceutical Statistics (SFK) registry on patients who have had a prescription for a DOAC filled at one of 831 randomly selected pharmacies in the Netherlands between Jan 2014-Jan 2019. RESULTS: We identified 99,211 patients who had a first DOAC prescription filled. Mean age was 71.6 ± 10.9 years, 58% were male. In 2014, 8,293 patients were treated with DOACs, in 2018, 35,415 were newly started on a DOAC. In 2018, the use of apixaban was most common (52%) in the Eastern region, whereas rivaroxaban was most frequently prescribed (32-48%) in the other regions. At time of first prescription, the vast majority (99.3%) used ≥ 1 concomitant interacting drug, and 3.2% used ≥ 3 interacting medications. Most common were digoxin (37.8%), atorvastatin (31.5%), verapamil (13.7%) and amiodarone (9.7%). While the number of interacting medications remained unchanged over time (median 1, interquartile range 1-1), there was a notable decrease in antiarrhythmic medications and an increase in non-cardiovascular interacting medications (e.g. dexamethasone from 0.9% to 7.1%, antiepileptic drugs from 2.5% to 3.8%, and haloperidol from 0.5% to 2.2% in 2014 and 2018, respectively). CONCLUSION: DOAC use has quadrupled in Dutch clinical practice over the 5­year period from 2014 to 2018. While the number of patients who take interacting medications remained stable, the profile of interacting medications has changed over time from cardiovascular to medications affecting other organ systems.

Sex differences associated with adverse drug reactions resulting in hospital admissions.

BACKGROUND: Adverse drug events, including adverse drug reactions (ADRs), are responsible for approximately 5% of unplanned hospital admissions: a major health concern. Women are 1.5-1.7 times more likely to develop ADRs. The main objective was to identify sex differences in the types and number of ADRs leading to hospital admission. METHODS: ADR-related hospital admissions between 2005 and 2017 were identified from the PHARMO Database Network using hospital discharge diagnoses. Patients aged ≥ 16 years with a drug possibly responsible for the ADR and dispensed within 3 months before admission were included. Age-adjusted odds ratios (OR) with 95% CIs for drug-ADR combinations for women versus men were calculated. RESULTS: A total of 18,469 ADR-related hospital admissions involving women (0.35% of all women admitted) and 14,678 admissions involving men (0.35% of all men admitted) were included. Most substantial differences were seen in ADRs due to anticoagulants and diuretics. Anticoagulants showed a lower risk of admission with persistent haematuria (ORadj 0.31; 95%CI 0.21, 0.45) haemoptysis (ORadj 0.47, 95%CI 0.30,0.74) and subdural haemorrhage (ORadj 0.61; 95%CI 0.42,0.88) in women than in men and a higher risk of rectal bleeding in women (ORadj 1.48; 95%CI 1.04,2.11). Also, there was a higher risk of admission in women using thiazide diuretics causing hypokalaemia (ORadj 3.03; 95%CI 1.58, 5.79) and hyponatraemia (ORadj 3.33, 95%CI 2.31, 4.81) than in men. CONCLUSIONS: There are sex-related differences in the risk of hospital admission in specific drug-ADR combinations. The most substantial differences were due to anticoagulants and diuretics.

Filled prescriptions of age-related contraindicated drugs in children: a one-year nationwide cohort study in the Netherlands.

Background Children are still prescribed age contraindicated drugs, but information about the number and type of these drugs dispensed for children in the Netherlands is limited. Objective To determine the incidence and prevalence of contraindicated drugs that were dispensed for the use by children. Setting The study was conducted in the Netherlands with routinely collected data from 95% of all community pharmacies. Method We performed a one-year nationwide observational study where all patients aged 17 years or younger who have received at least one prescription in 2016 were included. Contraindicated drugs were selected, according to the 5th level of ATC code, using different information sources. Main outcome measure The proportion of (newly) contraindicated drugs that were dispensed to children. Results In total, 3.9% of all children received at least one drug that was contraindicated for their age. The highest percentage of contraindicated drugs that was dispensed, was observed in patients aged 1-2 years and 13-17 years (7.0 and 5.7%, respectively) and the percentage of contraindicated drugs that were dispensed was higher in female than in male patients (4.3 and 3.6%, respectively; p value < 0.001). Conclusion The results of this study show that a substantial percentage of children received a drug that was conta-indicated for their age, and it happes more in female than in male patients. Furthermore, the information about this type of contraindications is limited and inconsistent.

Impact of the CYP4F2 p.V433M polymorphism on coumarin dose requirement: systematic review and meta-analysis.

A systematic review and a meta-analysis were performed to quantify the accumulated information from genetic association studies investigating the impact of the CYP4F2 rs2108622 (p.V433M) polymorphism on coumarin dose requirement. An additional aim was to explore the contribution of the CYP4F2 variant in comparison with, as well as after stratification for, the VKORC1 and CYP2C9 variants. Thirty studies involving 9,470 participants met prespecified inclusion criteria. As compared with CC-homozygotes, T-allele carriers required an 8.3% (95% confidence interval (CI): 5.6-11.1%; P < 0.0001) higher mean daily coumarin dose than CC homozygotes to reach a stable international normalized ratio (INR). There was no evidence of publication bias. Heterogeneity among studies was present (I(2) = 43%). Our results show that the CYP4F2 p.V433M polymorphism is associated with interindividual variability in response to coumarin drugs, but with a low effect size that is confirmed to be lower than those contributed by VKORC1 and CYP2C9 polymorphisms.

Spatial distribution correspondence of a juvenile Atlantic salmon Salmo salar cohort from age 0+ to 1+ years.

The spatial distribution of Atlantic salmon Salmo salar young-of-the-year (0+) and 1 year old parr (1+) from the 2006 spawning cohort in a 5125 m reach of the River Skauga in central Norway was documented. A high degree of similarity was found between the distribution of 0+ and 1+ parr based on catches at 205 transects sampled in both years. Cross-correlations and partial cross-correlations (correcting for habitat variables) confirmed significant positive association between the two distributions on a small spatial scale (within 100 m) and a clear pattern of decreasing correlation with distance.

Long-term anticoagulant effects of the CYP2C9 and VKORC1 genotypes in acenocoumarol users.

BACKGROUND: The required acenocoumarol dose and the risk of underanticoagulation and overanticoagulation are associated with the CYP2C9 and VKORC1 genotypes. However, the duration of the effects of these genes on anticoagulation is not yet known. OBJECTIVES: In the present study, the effects of these polymorphisms on the risk of underanticoagulation and overanticoagulation over time after the start of acenocoumarol were investigated. PATIENTS/METHODS: In three cohorts, we analyzed the relationship between the CYP2C9 and VKORC1 genotypes and the incidence of subtherapeutic or supratherapeutic International Normalized Ratio (INR) values (< 2 and > 3.5) or severe overanticoagulation (INR > 6) for different time periods after treatment initiation. RESULTS: Patients with polymorphisms in CYP2C9 and VKORC1 had a higher risk of overanticoagulation (up to 74%) and a lower risk of underanticoagulation (down to 45%) in the first month of treatment with acenocoumarol, but this effect diminished after 1-6 months. CONCLUSIONS: Knowledge of the patient's genotype therefore might assist physicians to adjust doses in the first month(s) of therapy.

Effects of discharge and local density on the growth of juvenile Atlantic salmon Salmo salar.

The study explored the combined effects of density, physical habitat and different discharge levels on the growth of juvenile Atlantic salmon Salmo salar in artificial streams, by manipulating flow during both summer and winter conditions. Growth was high during all four summer trials and increased linearly with discharge and mean velocity. Differences in fish densities (fish m(-3)) due to differences in stream volume explained a similar proportion of the variation in mean growth among discharge treatments. Within streams, the fish aggregated in areas of larger sediment size, where shelters were probably abundant, while growth decreased with increasing densities. Fish appeared to favour the availability of shelter over maximization of growth. Mean growth was negative during all winter trials and did not vary among discharge treatments. These results suggest that increased fish densities are a major cause of reduced summer growth at low discharge, and that habitat-mediated density differences explain the majority of the growth variation across habitat conditions both during summer and winter.

Genotypes associated with reduced activity of VKORC1 and CYP2C9 and their modification of acenocoumarol anticoagulation during the initial treatment period.

The objective of this study was to investigate the influence of genotypes associated with reduced activity of vitamin K epoxide reductase complex subunit 1 (VKORC1) and cytochrome P450 2C9 (CYP2C9) on anticoagulation with acenocoumarol during the first 6 weeks of treatment. In 1,525 patients from the Rotterdam Study who were started on anticoagulation therapy with acenocoumarol, the presence of VKORC1 1173C>T and CYP2C9*2 and *3 allele variants was determined. The first international normalized ratio (INR) after initial standard dose, risk of overanticoagulation, and mean dosage at the end of the initiation period were compared between genotypes. The initial standard dosage significantly increased the risk of severe overanticoagulation by 85% for each additional VKORC1 T-allele present. At the end of the initiation period, each VKORC1 T-allele present was shown to decrease the required acenocoumarol dosage by 5.1 mg/week, while each CYP2C9 variant allele present reduced the required dosage by 1.8 mg/week. Our conclusion was that an initial standard dosing regimen with acenocoumarol increases the risk of severe overanticoagulation in patients with variant alleles of the VKORC1 and CYP2C9 genes.

Vitamin K epoxide reductase complex subunit 1 (VKORC1) polymorphism and aortic calcification: the Rotterdam Study.

OBJECTIVE: Besides effects on hemostasis, vitamin K-dependent proteins play a role in bone mineralization and arterial calcification. We investigated the association between the VKORC1 1173C>T polymorphism and calcification of the aortic far wall in a large population-based cohort. METHODS AND RESULTS: Aortic calcification was diagnosed by radiographic detection of calcified deposits in the abdominal aorta. In all cohort members for whom DNA was available, the C1173T SNP of VKORC1 (rs9934438) was determined. With multivariable logistic regression analysis the association between this polymorphism and the risk of aortic calcification was calculated, adjusted for potential confounders. The T allele frequency of the VKORC1 1173C>T polymorphism was 38.8%. 1185 (37.2%) persons were homozygous CC, 1529 (48,0%) were heterozygous CT and 473 (14.8%) were homozygous TT. Persons with at least one T-allele had a statistically significant 19% (95% CI 2 to 40%) risk increase of calcification of the aortic far wall compared to CC homozygous persons, adjusted for age and gender. CONCLUSIONS: The T-allele of the VKORC1 1173C>T polymorphism was associated with a significantly higher risk of aortic calcification in Whites.

Interaction of the photobactericides methylene blue and toluidine blue with a fluorophore in Pseudomonas aeruginosa cells.

BACKGROUND AND OBJECTIVES: The difference in photobactericidal efficacy between methylene blue (MB) and toluidine blue (TB) may be explained by their involvement with proteins, lipopolysaccharides (LPS), and siderophores and siderophore-receptor protein complexes on the bacterial outer membrane. This study aims to determine if this is the case by using the fluorescence given off by a pseudomonal siderophore named pyoverdin. STUDY DESIGN/MATERIALS AND METHODS: Confocal laser scanning microscopy was used to observe the fluorescence of Pseudomonas aeruginosa cells excited at 488 nm in the presence of increasing dye concentrations. RESULTS: Cellular fluorescence at 522 nm progressively decreased with increasing dye concentrations. The Stern-Volmer constants for cellular fluorescence quenching with the dyes were compared to the association constants for dyes complexed with LPS. The quenching of cellular fluorescence was associated with the formation of a ground-state complex between the dyes and pyoverdin-FpvA protein system. MB readily complexed with this system, whereas TB complexed more strongly with LPS. CONCLUSION: The different affinities of the dyes for both pyoverdin-protein and LPS will affect the contributions of the dyes' interactions with these biopolymers to the overall bacterial photodamage.

Treatment of oral candidiasis with methylene blue-mediated photodynamic therapy in an immunodeficient murine model.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of using methylene blue (MB)-mediated photodynamic therapy to treat oral candidiasis in an immunosuppressed murine model, mimicking what is found in human patients. STUDY DESIGN: Seventy-five experimental mice with severe combined immunodeficiency disease were inoculated orally with Candida albicans by swab 3 times a week for a 4-week period. On treatment day, mice were cultured for baseline fungal growth and received a topical oral cavity administration of 0.05 mL MB solution at one of the following concentrations: 250, 275, 300, 350, 400, 450, or 500 microgram/mL. After 10 minutes the mice were recultured and underwent light activation with 664 nm of diode laser light with a cylindrical diffuser. After photodynamic therapy the mice were cultured again for colony-forming units per milliliter and then killed, their tissue harvested for histopathology. RESULTS AND CONCLUSIONS: The results indicate an MB dose-dependent effect. Concentrations from 250 to 400 microgram/mL reduced fungal growth but did not eliminate Candida albicans. MB concentrations of 450 and 500 microgram/mL totally eradicated Candida albicans from the oral cavity, resulting in reductions from 2.5 log(10) and 2.74 log(10) to 0, respectively. These results suggest that MB-mediated photodynamic therapy can potentially be used to treat oral candidiasis in immunodeficient patients.

Comparison of the methylene blue and toluidine blue photobactericidal efficacy against gram-positive and gram-negative microorganisms.

BACKGROUND AND OBJECTIVE: Studies on the photobactericidal efficacy of methylene blue (MB) and toluidine blue (TB) have shown inconsistent results in the literature. This study evaluated the bactericidal efficacy of MB and TB against different bacteria under light and dark conditions to determine the most effective bactericidal dye. STUDY DESIGN/MATERIALS AND METHODS: Suspensions of Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus faecalis, Hemophilus influenzae, Escherichia coli, and Pseudomonas aeruginosa in saline were treated in dark and red laser light conditions in the presence of each dye using an argon pumped-dye and a diode laser emitting light at 630 and 664 nm, respectively. The effect of dye concentration, dark incubation time, the fluence and intensity of laser light on the destruction of different bacteria were compared. RESULTS: Both dyes eradicated all examined bacteria under laser light. The complete photodestruction of microorganisms was reached at TB concentrations of 1.5-7-fold less than that of MB. CONCLUSION: TB exhibits a greater bactericidal activity than MB against most bacteria in dark and light conditions. Mostly, these results are consistent with their respective dye partition coefficients.

Experimental and theoretical studies of the d8-d10 interaction between Pd(II) and Au(I): bis(chloro[(phenylthiomethyl)diphenylphosphine]gold(I))- dichloropalladium(II) and related systems.

The reaction between thioether phosphine gold(I) precursors such as [AuCl(Ph2PCH2SPh)], 1, or [Au(Ph2PCH2SPh)2]CF3SO3 and PdCl2(NCPh)2 affords the new compounds [(AuCl(Ph2PCH2SPh)2PdCl2], 2, and [AuPdCl2(Ph2PCH2SPh)2]CF3SO3, 3. The crystal structure of complex 2 has the sterically unhindered Pd(II) and Au(I) at a distance of 314 pm. Quasirelativistic pseudopotential calculations on [AuPdCl3(PH2CH2SH)(SH2)] models give short Au-Pd distances at the second-order Møller-Plesset (MP2) level and long Au-Pd distances at Hartree-Fock (HF) level. A detailed analysis of the Au-Pd interaction shows dominant dispersion, some ionic contributions, and no net charge transfer between the metals.

Synthesis and structure of organic-soluble binuclear molecular phosphonates of tantalum, molybdenum, and tungsten.

The reaction of (eta 5-C5Me5)TaMe4 with tert-butylphosphonic acid leads to the formation of a mixture of compounds: [[(eta 5-C5Me5)TaMe][t-BuP(O)(OH)][t-BuP(O)(OH)2]]2(t-BuPO3)2 (1) and [[(eta 5-C5Me5)Ta][t-BuP(O)(OH)2]]2(t-BuPO3)2(mu-O)2 (2). Compound 2 was also obtained by recrystallization of 1 from a THF/hexane mixture. Reaction of (eta 5-C5Me5)MCl4 (M = Mo, W) with PhP(O)(OH)2 yields the binuclear phosphonates [[(eta 5-C5Me5)M][PhP(O)(OH)2]]2(PhPO3)2(mu-O)2 (M = Mo (3); M = W (4)). Compounds 2.THF and 3(.)2.5THF were characterized by single-crystal X-ray studies. The tantalum and molybdenum phosphonates 2.THF and 3(.)2.5THF have different structures as compared to those of the previously reported titanophosphonate cages.

Structure and molecular modelling of protected dipeptide fragment (Boc-Phe-Leu-OBzl) of enkephalin.

The conformational characteristics of a flexible totally protected C-terminal dipeptide fragment (Boc-Phe-Leu-OBzl) of enkephalin are studied using X-ray data, molecular modelling and data retrieved from the Cambridge Structural Database. The dipeptide crystallizes with seven conformers in the asymmetric unit. C(27)H(36)N(2)O(5), T = 133 K, monoclinic, P2(1), a = 13.706 (3), b = 22.800 (3), c = 30.674 (5) Å, beta = 97.15 (3) degrees, V = 9511 (3) Å(3), Z = 14, D(c) = 1.145 Mg m(-3). Six of the seven molecules exhibit folded conformations with hydrophobic groups disposed at the opposite side of the peptide backbone. The characteristic Phi(1) and Psi(1) angles of the Phe residue and Phi(2) of the Leu fragment are in the allowed region defined in the Ramachandran diagram. However, they do not belong to the family of the lowest energy conformations. In the crystal, molecules are interconnected via N-H.O hydrogen bonds of peptide groups forming an infinite sheet similar to a parallel beta-sheet. Molecular dynamics simulations performed in vacuo reproduce the conformers and rotamers detected in the solid state.

Multinucleated giant cell formation of swine microglia induced by Mycobacterium bovis.

Multinucleated giant cells (MGC) have been long recognized as a histopathologic feature of tuberculosis, yet little is known about the underlying mechanism of tubercle bacillus-induced formation of these fused macrophages. The main purpose of this study was to characterize cellular mechanisms involved in MGC formation of swine microglia, the resident macrophages of the brain, in cultures containing nonopsonized Mycobacterium bovis. Within 2 h of incubation, MGC were readily detected in these cultures by light and transmission electron microscopy. MGC formation was blocked by anti-CD14 and anti-CD18 antibodies and by thalidomide, a potent inhibitor of tumor necrosis factor-alpha (TNF-alpha) production my microglia. Also, TNF-alpha alone induced MGC formation. These findings suggest that two microglial cell receptors, CD14 and a beta2 integrin, and the cytokine TNF-alpha participate in M. bovis-induced swine microglial MGC formation.

[Psychosocial stresses after hospital admission--a comparison of internal medicine and surgical patients]. / Psychosoziale Belastungen nach der Krankenhausaufnahme--Ein Vergleich internistischer und chirurgischer Patienten.

56 patients have been interviewed about their psychosocial situation at the beginning of their treatment in a medical department, 62 patients in a surgical department of a General Hospital. The "medical" patients were severely disturbed by their illness and by the different diagnostic and therapeutic procedures, even by routine investigations. The "surgical" patients, who just had been operated, concentrated with their feelings on the surgical operation. The clinical atmosphere and the relation and communication to the hospital staff had similar effects on both groups. Further investigations concerning the illness and the treatment should be specified in the different clinical disciplines, while disturbances by the hospital surrounding can be asked at all patients in the same way.