Evaluating the internalisation of the intrinsic role of health advocacy of student pharmacists in a new integrated Bachelor of Pharmacy curriculum: a mixed-methods study.

To keep up with the contemporary health landscape, there is an imperative need for healthcare professionals to practise health advocacy through health promotion on the individual, population, and systems levels. In the Academic Year of 2020/2021, the National University of Singapore (NUS) Department of Pharmacy implemented a new spiral curriculum integrating basic, clinical, and systems sciences with one of its aims to deepen students' health advocacy internalisation and prepare them as future health advocates. A mixed-methods approach was adopted. Questionnaires were disseminated across three time-points to elicit students' levels of internalisation of health advocacy, which were then categorised into levels, and a Mann-Whitney U test was conducted. In comparison with prematriculation, no significant difference was found after students underwent the first year of the curriculum, while a significant difference was found after students underwent two years of the curriculum. Semi-structured interviews were also conducted after each Academic Year to gain deeper insights into the questionnaire results. Thematic analysis of the interviews revealed that curricular integration in the first year was perceived to be lacking. However, with learnt knowledge constantly reinforced and more experiential learning opportunities incorporated throughout the second year, students found the integrated curriculum beneficial in instilling confidence to practise health advocacy. This study offers insights into the prospects of a spiral integrated curriculum in imparting health advocacy, and may even suggest its potential to be applied to other educational settings. Future follow-up studies can also be conducted on the same study population to evaluate long-term impacts and areas for improvement of the curriculum.

Evaluating treatment options for cardiovascular autonomic neuropathy in patients with diabetes mellitus: a systematic review.

Background: Cardiovascular autonomic neuropathy (CAN) is a debilitating complication of diabetes mellitus. To date, there is no systematic review on all the available drug treatments for CAN in diabetic patients, except for one review focusing on aldose reductase inhibitors. Objective: To evaluate available drug treatment options for CAN in diabetic patients. Methods: A systematic review was conducted with a search of CENTRAL, Embase, PubMed and Scopus from database inception till 14th May 2022. Randomised controlled trials (RCTs) of diabetic patients with CAN that investigated the effect of treatment on blood pressure, heart rate variability, heart rate or QT interval were included. Results: Thirteen RCTs with a total of 724 diabetic patients with CAN were selected. There was a significant improvement in the autonomic indices of diabetic patients with CAN given angiotensin-converting enzyme inhibitor (ACEI) for 24 weeks (p<0.05) to two years (p<0.001), angiotensin-receptor blocker (ARB) for one year (p<0.05), single dose of beta blocker (BB) (p<0.05), omega-3 polyunsaturated fatty acids (PUFAs) for three months (p<0.05), alpha-lipoic acid (ALA) for four months (p < 0.05) to six months (p=0.048), vitamin B12 in combination with ALA, acetyl L­carnitine (ALC), superoxide dismutase (SOD) for one year (p=0.001)  and near significant improvement in the autonomic indices of diabetic patients with CAN given vitamin E for four months (p = 0.05) compared to the control group. However, there was no significant improvement in the autonomic indices of patients given vitamin B12 monotherapy (p ≥ 0.05). Conclusion: ACEI, ARB, BB, ALA, omega-3 PUFAs, vitamin E, vitamin B12 in combination with ALA, ALC and SOD could be effective treatment options for CAN, while vitamin B12 monotherapy might be unlikely to be recommended for the treatment of CAN due to its lack of efficacy. Supplementary Information: The online version contains supplementary material available at 10.1007/s13340-023-00629-x.

Patient Case Report Daptomycin Holiday-A Daptomycin Dosing Strategy for Asymptomatic Increases in Creatine Phosphokinase Levels.

Daptomycin possesses excellent activity against many multidrug-resistant gram positive organisms. However, a side effect of concern with daptomycin is skeletal muscle injury, which is manifested in the form of elevated creatine phosphokinase (CPK). Management of such CPK elevations has traditionally been discontinuation of the offending agent, with many studies showing a resolution of a normal CPK level within 1 week of discontinuation and no long term adverse effects. Nevertheless, the question remains if daptomycin can be successfully restarted in such patients. Here, we present a case of a "daptomycin holiday" in which daptomycin was withheld upon CPK elevation and successfully reintroduced to the patient's regimen again after several days without further elevation of the CPK. The patient had a peak CPK of 2,557 U/L, and had no associated symptoms. A hypothesis for this holiday could be the adaptability of the skeletal muscle myocytes, in which the extra period between doses may allow for additional recovery of the membrane structure to further daptomycin exposure. Giving an asymptomatic patient with elevated CPK level, a short daptomycin holiday to allow for the CPK level to trend downward before resuming daptomycin therapy could be a potential strategy in patients for whom continuing daptomycin is still preferred.

Incorporation of rapid diagnostic tests to improve time to antimicrobial therapy for gram-positive bacteremia and candidemia.

PURPOSE: Even with rapid diagnostic technology to swiftly identify infectious organisms, prompt response is needed to translate results into appropriate actions. The purpose of this study was to determine if the introduction of real-time pharmacist response to positive rapid diagnostic test results would decrease time to antimicrobial therapy for gram-positive bacteremia and candidemia in a community hospital setting. METHODS: A quasi-experimental study was conducted in 2 community hospitals. The study comprised 2 cohorts of adult patients who tested positive for gram-positive bacteremia involving Staphylococcus aureus, Enterococcus faecalis, Enterococcus faecium, or Candida species. The preintervention cohort consisted of patients admitted from November 2017 through May 2018. The intervention cohort consisted of patients admitted from July 2018 through January 2019, after the intervention went live. The primary outcomes were time to optimal antimicrobial therapy and time to effective antimicrobial therapy. RESULTS: A total of 140 patients were included in the preintervention group, with 124 patients included in the intervention group. The mean (SD) time to effective therapy decreased from 13.9 (21.6) hours in the preintervention group to 8.6 (12.5) hours in the intervention group (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.89-1.48; P = 0.29). The mean (SD) time to optimal therapy significantly decreased from 53.7 (57.7) hours in the preintervention group to 38.4 (31.5) hours in the intervention group (HR, 1.73; 95% CI, 1.33-2.26; P < 0.001). CONCLUSION: The introduction of real-time pharmacist response to positive rapid diagnostic test results led to a significant decrease in time to optimal antimicrobial therapy but did not significantly affect time to effective therapy. The results showed that the allocation of limited resources of a community hospital to such a stewardship program is justifiable.

Switching from Ticagrelor to Clopidogrel in Asian Patients with ST-Elevated Myocardial Infarction - A Time Dependent Analysis Study.

BACKGROUND: Ticagrelor is initially prescribed after an ST-elevated myocardial infarction (STEMI) and this may be followed by a switch to clopidogrel. However, studies involving antiplatelet switching have been conflicting and only assessed at a specific switch point. The objective of this study was to investigate switching from ticagrelor to clopidogrel in an Asian population, after accounting for various switch points as in a real-world environment. METHODS: A retrospective cohort of 349 STEMI patients started on ticagrelor and aspirin were followed-up for 1 year after a percutaneous coronary intervention that was performed between June 2014 and November 2016. Patients who switched to clopidogrel were compared with those who remained on ticagrelor. Outcomes measured were major adverse cardiac and cerebrovascular events (MACCEs) and clinically significant bleeding (CSB). Cox regression analysis with switch status as a time-dependent covariate was performed. RESULTS: The switched group was not associated with MACCEs or CSB [10.0% vs. 13.8%; hazard ratio (HR) = 0.484; 95% confidence interval (CI): 0.196-1.191; p = 0.114]. There was also no significant difference when MACCEs were analyzed alone (2.3% vs. 7.7%; HR = 0.518; 95% CI: 0.137-1.957; p = 0.332). For CSB, the switched group was less likely to have an event (7.8% vs. 8.5%; HR = 0.298; 95% CI: 0.091-0.982; p = 0.047). CONCLUSIONS: This study showed no significant difference between staying on ticagrelor and switching to clopidogrel. Switching might decrease the incidence of CSB. De-escalation from ticagrelor to clopidogrel could translate to cost savings for Asian patients without compromising safety and efficacy.

The Effect of Zero Copayments on Medication Adherence in a Community Pharmacy Setting.

BACKGROUND: Prescription medication copayments can be a financial burden to many patients. When patients cannot afford their medications, they may become nonadherent, and as a result, this can lead to an increase in chronic disease complications and healthcare costs. OBJECTIVE: The objective of this study was to determine if zero copayments have an effect on medication adherence in a community pharmacy. METHODS: This retrospective cohort study examined the prescription refill records of patients who filled specific generic medications for hypertension, hyperlipidemia, and gastroesophageal reflux disease (GERD) in 2016 at the NSU Clinic Pharmacy. The adherence rates of patients with zero copayments were compared to the adherence rates of patients with copayments greater than $0. Adherence was determined by calculating the proportion of days covered (PDC). Patients were considered adherent if their PDC was greater than or equal to 80%. RESULTS: GERD patients with no copayments had average PDC ratios of 87.4% and were statistically significantly more adherent than GERD patients with copayments, who had average PDC ratios of 76.7% (P = 0.042). Hyperlipidemia and hypertension patients with no copayments had average PDC ratios of 89.3% and 90.3%, respectively, and those with copayments had PDC ratios of 85.3% (P = 0.314) and 87.9% (P = 0.534). CONCLUSION: Overall, patients with $0 copayments had higher adherence rates than patients with copayments greater than $0. GERD patients with no copayments were significantly more adherent than GERD patients with copayments. However, no statistically significant difference was found between patients with or without copayments in the hyperlipidemia and hypertension cohorts. Further studies are recommended to analyze additional factors that may influence medication adherence.

Off-Label Prescribing for Children with Migraines in U.S. Ambulatory Care Settings.

BACKGROUND: Migraines, Which Affect About 10% Of School-Age Children In The United States, Can Significantly Impair Quality Of Life. Despite Potential Disability, Many Children Do Not Receive Treatment Or Prophylaxis, Since Medications Specifically Approved For Children Are Significantly Less Than For Adults. There Is Also Controversy Surrounding The Apparent Widespread Practice Of Prescribing Off-Label Medications For Children With Migraines. However, Little Research Has Been Done To Identify Physician-Prescribing Patterns Of Migraine Medication For Children. OBJECTIVE: To Investigate The Prevalence And Pattern Of Off-Label Prescribing For Children With Migraines. METHODS: A Secondary Data Analysis Was Conducted Using The Pooled National Ambulatory Medical Care Survey (Namcs) 2011 And 2012. Patients Aged 17 Years Or Younger With A Migraine Diagnosis Were Included. A Series Of Weighted Descriptive Analyses Were Used To Estimate The Prevalence Of Migraine Drugs Prescribed During Pediatric Office Visits. A Weighted Logistic Regression Was Constructed To Compare The Prescribing Patterns Between Off-Label And Fda-Approved Medications. Analyses Used Sas 9.4 Methodology And Incorporated Sample Weights To Adjust For The Complex Sampling Design Employed By Namcs. RESULTS: Of The 12.9 Million Outpatient Visits With A Migraine Diagnosis That Took Place Between 2010 And 2012, 1.2 Million Were Pediatric Visits. Females Accounted For Nearly Twice The Number Of Migraine Visits Than Males (66% Vs. 34%). Children Aged 12-17 Years Accounted For The Highest Frequency Of Visits (84%), Compared With Those Aged Under 12 Years (16%). 66.7% Of These Pediatric Patients Received At Least 1 Migraine Drug. Of These, Off-Label Medications Were Prescribed 1.5 Times More Than Fda-Approved Medications For Children (60.34% Vs. 39.65%). The Results Of Logistic Regression Showed A Significant Likelihood Of Prescribing Off-Label Medications Based On Physician Specialty, Patient Race, And Reason For Visit. Neurologists (Or = 0.028, P < 0.05) And Pediatricians (Or = 0.095, P < 0.05) Were Less Likely To Prescribe Off-Label Drugs Than General And Family Practitioners. Visits For Preventive Care (Or = 5.8, P < 0.05) And Flare-Ups From Chronic Migraines (Or = 5.0, P < 0.05) Were More Likely To Result In Off-Label Drug Prescriptions Than Visits For New Migraine Incidence. CONCLUSIONS: This Study Provides Significant Real-World Evidence Of The Widespread Practice Of Prescribing Off-Label Drugs To Children With Migraines. Although Medical Literature Shows That Off-Label Prescribing May Not Be Harmful, There Is A Dearth Of Research And Practice Guidelines To Help Practitioners Uphold Safety Standards And Ensure The Prescription Of Age-Appropriate Medications To Children. DISCLOSURES: No outside funding supported this study. The authors report no potential conflicts of interest relevant to this research. Lai and Ting contributed to study concept and design and collected the data, along with the other authors. Data interpretation was performed by Lai, Koh, Obi, Ho, and Ting. The manuscript was written and revised by Lai, Koh, and Ho, with assistance from Ting and Obi.