Implementation factor mapping of a pilot study of point-of-care C-reactive protein testing for respiratory tract infections in community pharmacy.

Background: Explicit consideration of implementation factors in community pharmacy service development may facilitate widespread implementation and sustainability. Objectives: This study involved mapping the methodology for the pilot study of point-of-care C-reactive protein (CRP) testing to support pharmacists' management of respiratory tract infections in Western Australian pharmacies against an implementation factor framework, focussing on the resources and training program provided to participating pharmacy staff. Methods: Phase 1 involved post hoc mapping of the pilot study methodology against the framework previously described by Garcia-Cardenas et al.; phase 2 was an a priori evaluation of the resources and training program, involving pre-training, post-training, and post-pilot questionnaires administered to pharmacists and pharmacy assistants/interns. A mixed model analysis compared pharmacists' responses at the three time points. Results: Employment of comprehensive strategies to optimise service feasibility and sustainability was demonstrated across the five domains of 'professional service', 'pharmacy staff', 'pharmacy', 'local environment' and 'system'; further consideration of 'consumer' or 'patient' factors is needed to address issues such as patient refusal. Study pharmacists (n = 10) and pharmacy assistants/interns (n = 5) reported high levels of satisfaction with the training (100% 'good'/'excellent'). Pharmacists reported significantly improved attitudes towards, confidence in, and knowledge about CRP testing and service provision from pre- to post-training (p < 0.05). Positive perceptions were maintained at the post-pilot time point. Conclusions: Post hoc mapping of implementation factors highlighted potential strengths and deficiencies of the current service model. Systematic, prospective mapping, coupled with strategies to explicitly emphasise the patient perspective, may have value in optimising service implementation or modifying future service delivery models.

Point-of-care C-reactive protein testing service for respiratory tract infections in community pharmacy: a qualitative study of service uptake and experience of pharmacists.

Background Targeted interventions in community pharmacies, such as point-of-care C-reactive protein testing, could reduce inappropriate antimicrobial consumption in patients presenting with symptoms of respiratory tract infections, although data regarding Australian pharmacists' perspectives on its provision are limited. Aim To explore pharmacists' experiences and perspectives of point-of-care C-reactive protein testing, including barriers and facilitators, influencing service provision and uptake. Method A point-of-care C-reactive protein testing service for patients presenting with respiratory tract infection symptoms was trialled in five purposively selected community pharmacies in metropolitan Western Australia. Two pharmacists from each pharmacy participated in one-to-one semi-structured telephone interviews, regarding pharmacist demographics, pharmacy characteristics, experience with the point-of-care C-reactive protein service and training/resources. Interviews were audio-recorded and transcribed. Data were imported into NVivo for thematic analysis. Results Interview durations ranged from 28.2 to 60.2 min (mean: 50.7 ± 10.2 min). Of the five themes which emerged, participants reported the point-of-care C-reactive protein testing was simple, fast, reliable and accurate, assisted their clinical decision-making and contributed to antimicrobial stewardship. A major factor facilitating service provision and uptake by consumers was the accessibility and credibility of pharmacists. Barriers included time constraints and heavy documentation. Participants believed there was a public demand for the service. Conclusion Given the global antimicrobial resistance crisis, pharmacists have an important role in minimising the inappropriate use of antimicrobials. The point-of-care C-reactive protein service was readily accepted by the public when offered. However, ensuring efficient service delivery and adequate remuneration are essential for its successful implementation.

Correlation between plasma ZAG and adiponectin in older adults: gender modification and frailty specificity.

BACKGROUND: Adiponectin and zinc alpha2-glycoprotein (ZAG) are associated with frailty. This study aims to further examine the association of adiponectin with ZAG. METHODS: Outpatients aged 65 years or older with chronic disease followed up in a hospital-based program were recruited for a comprehensive geriatric assessment. We excluded outpatients who were bedridden, residing in a nursing home, with expected life expectancy less than 6 months, or with severe hearing or communication impairment. Plasma ZAG and adiponectin levels were measured. Association between plasma ZAG and adiponectin levels was analyzed by univariate and multivariable linear regression analyses. RESULTS: A total of 189 older adults were enrolled (91 men and 98 women, mean age: 77.2 ± 6.1 years). Log-transformed plasma ZAG level was 1.82 ± 0.11 µg/mL, and it was significantly higher in men than that in women (1.85 ± 0.12 vs 1.79 ± 0.10 µg/mL, P = .0006). Log-transformed plasma adiponectin level was 1.00 ± 0.26 µg/mL, and there was no significant gender difference (P = .195). Overall, plasma ZAG level positively correlated with plasma adiponectin level in the multivariable linear regression analysis (P = .0085). The gender-specific significance, however, was less clear: this relationship was significant in men (P = .0049) but not in women (P = .2072). To be more specific by frailty phenotype components, plasma adiponectin was positively correlated with weight loss (P = .0454) and weakness (P = .0451). CONCLUSIONS: Both of ZAG and adiponectin may be potential frailty biomarkers. Plasma ZAG is an independent factor of plasma adiponectin, especially in older male adults.

Point-of-care C-reactive protein testing to support the management of respiratory tract infections in community pharmacy: A feasibility study.

BACKGROUND: Point-of-care (POC) C-reactive protein (CRP) testing is employed in European primary care settings to differentiate viral from bacterial respiratory tract infections (RTIs) the latter, requiring referral for antibiotics. This service has yet to be trialled in Australian community pharmacy to support over-the-counter RTI management. OBJECTIVES: To evaluate the feasibility, based on clinical and operational outcomes, of POC CRP testing to support Western Australian community pharmacists' management of RTIs. METHODS: Patients with RTI signs and symptoms were recruited from June-August 2019 at 5 community pharmacies. Trained pharmacists made recommendations based on participants' POC CRP levels and routine clinical assessment. Participants completed questionnaires and telephone follow-ups on Days 3 (by pharmacists) and 5 (by researchers) post-testing. Service provision and uptake were assessed in 3 separate weekly tally sheets. RESULTS: Clinical outcomes: CRP levels among the 131 participants recruited were: < 5 mg/L (bacterial infection unlikely; n = 60; 45.8%); 5-19 mg/L (bacterial infection possible if suggestive routine assessment; n = 52; 39.7%) and 20-100 mg/L (bacterial infection likely if suggestive routine assessment; n = 19; 14.5%). Pharmacists' management included over-the-counter medicines (131, 100%), self-care advice (125, 95.4%) and immediate general practitioner (GP) referral (15, 11.5%). Sixty-five percent (76/117) of participants had recovered by Day 5. Operational outcomes: The services was provided in 21.2% of eligible RTI presentations, representing a service uptake rate of 28.1%. Post-CRP testing, 50.9% (58/114) of participants had changed perceptions regarding their need for antibiotics, with 14.3% (16/112) subsequently intending to seek a GP prescription. Consumer satisfaction was high (100%) and most participants (93.4%, 123/131) would utilise the service again. CONCLUSIONS: POC CRP testing was a feasible and well-accepted strategy to facilitate community pharmacy as a triage point for RTI. Consumer confidence in the pharmacists' advice, supported by CRP testing, potentially reduced unnecessary GP visits and antibiotic prescribing.

The Association between Proton Pump Inhibitors and Myocardial Infarction: What Do Food and Drug Administration Data Tell Us?

OBJECTIVE: There is limited and conflicting evidence on the association between proton pump inhibitors (PPIs) and myocardial infarction (MI). This study aims to examine the occurrence of MI associated with PPI use from the Food and Drug Administration (FDA) Adverse Event Reporting System database. METHODS: This is a cross-sectional study using data from the FDA dated from December 2013 to April 2018. Standard descriptive statistics were used to describe demographic information. Logistic regression analyses were performed to investigate the association between the independent variables and MI. FINDINGS: Among the 52,443 individuals who were taking a PPI and experienced an adverse event which was registered on the FDA database, 726 (1.38%) experienced MI. Of all the PPIs, esomeprazole had the largest proportion of users experiencing MI (1.81%). Compared to other PPIs, esomeprazole was associated with a significantly higher rate of MI (odds ratio [OR] =1.53, P < 0.001), whereas lansoprazole was associated with a lower rate of MI (OR = 0.74, P = 0.03). CONCLUSION: Among the PPIs, esomeprazole appeared to have the highest risk of MI. Although the observed associations do not infer causality, this study highlighted a need for further studies to determine if a PPI, especially esomeprazole, can indeed cause MI.

An evaluation of the role of practice pharmacists in Australia: a mixed methods study.

Background The need for greater collaboration between pharmacists and general practitioners in Australia facilitated the development of the practice pharmacist role. Practice pharmacists work from within general practices to provide services to patients and health professionals to improve the quality use of medications. Objective To explore the perceptions of Australian accredited pharmacists and pharmacists already working in general practices about current roles, facilitators and barriers, and remuneration expectations of practice pharmacists. Setting This study was conducted Australia wide. Method This was a two-stage study. The first stage involved a quantitative online questionnaire of accredited pharmacists whilst the second stage involved semistructured interviews with pharmacists working in general practice. Main outcome measure Pharmacists' opinions on expected and current roles, barriers and facilitators, remuneration expectations and training requirements for practice pharmacist. Results A total of 65 accredited pharmacists completed the online survey and 20 practice pharmacists participated in interviews. The primary practice pharmacist roles identified included medication reviews, verifying the appropriateness of prescriptions, counselling and promoting adherence and providing education to other allied health professionals in the practice. The major facilitator identified was enhanced communication. Remuneration expectations and current working relationships were identified as main barriers. Conclusion The implementation of an appropriate funding model and a defined scope of role are critical to the successful implementation of the role of practice pharmacists.

Simulated medication errors: A means of evaluating healthcare professionals' knowledge and understanding of medication safety.

OBJECTIVE: To determine multi-disciplinary perceptions of the clinical significance of medication errors (MEs), the responsible health professional(s), the contributing factors and potential preventive strategies. METHODS: The five simulated ME cases represented errors from five wards at a children's hospital in Australia. Pre-determined answers for each case were developed through consensus among the researchers. The root cause analysis (RCA) was undertaken via a questionnaire disseminated to physicians, nurses and pharmacists at the study hospital to seek their opinions on the ME cases. Agreement model between the participants and pre-determined responses regarding the contributing factors was conducted using general estimating equation (GEE) analysis. RESULTS: Of the 111 RCA questionnaires distributed, 25 were returned. The majority (93%) of respondents rated the significance of the MEs as either 'moderate' or 'life-threatening'. Furthermore, they correctly identified two contributing factors relevant to all cases: dismissal of policies/procedures or guidelines (90%) and human resources issues (87%). GEE analysis revealed varied agreement patterns across the contributing factors. Suggested prevention strategies focused on policy and procedures, staffing and supervision, and communication. CONCLUSION: Simulated case studies had potential use to seek front-line healthcare professionals' understanding of the clinical significance and contributing factors to MEs, along with preventive measures.

Plasma zinc alpha2-glycoprotein levels correlate positively with frailty severity in female elders.

Frailty is a geriatric syndrome associated with adiposity. Zinc alpha2-glycoprotein (ZAG), a novel adipokine, is a modulator of body fat mass and positively correlates with age. This observational study aims to investigate the relationship between plasma ZAG levels and frailty in the elderly.We enrolled 189 elder participants from a hospital-based comprehensive geriatric assessment program in Taiwan from January 2007 to June 2008. The demographic data, body weight, body mass index, appendicular skeletal muscle mass index (ASMI), body fat mass percentage, metabolic and inflammatory parameters including plasma tumor-necrosis factor alpha, C-reactive protein and ZAG levels, were assessed. The frailty score was assessed by Fried Frailty Index.The mean age of all participants (91 [48.1%] men and 98 [51.9%] women) was 77.19 ±â€Š6.12 years. Judged by the FFI score, 46 (24.34%) elders were robust, 106 (56.08%) were pre-frail, and 37 (19.58%) were frail. Older men showed greater ASMI and lower fat mass percentage in comparison to older women (P < 0.0001). The log-transformed mean plasma ZAG (µg/mL) level of overall was 1.82 ±â€Š0.11, and it was higher in men than in women (1.85 ±â€Š0.12 vs 1.79 ±â€Š0.1, P = 0.0006). Plasma ZAG levels were different among the robust, pre-frail and frail subgroups (1.78 ±â€Š0.09, 1.83 ±â€Š0.12, 1.83 ±â€Š1.10, respectively, P = 0.028), and the differences were more significant in woman elders (P = 0.005). Further multiple linear regression analysis showed plasma ZAG levels positively correlated with frailty severity in women (P for trend = 0.0435).Plasma ZAG levels positively correlated with frailty severity in woman elders. The difference between sexes suggests certain sex-specific mechanisms may exist to affect the association between plasma ZAG levels and frailty.

Serum 25-hydroxyvitamin D is associated with reduced verbal episodic memory in healthy, middle-aged and older adults.

BACKGROUND: There is increasing evidence supporting an association of higher serum vitamin D concentration with better cognitive performance in older individuals. However, to date, consideration of the putative association between vitamin D and cognition has been based principally on studies investigating clinical participant samples manifesting vitamin D deficiency, particularly in older people. Moreover, relationships between vitamin D and cognition are typically not considered in the context of counter-regulatory calcium-modulating hormones or calcium homeostasis. OBJECTIVE: Serum vitamin D/bioactive (ionised) calcium/parathyroid hormone homeostasis was considered in the context of cognitive performance in healthy, middle-aged and older individuals. DESIGN: A cross-sectional sample of 179 participants between the ages of 47-84 years was recruited for this study (114 females, 65 males). Participants provided fasting blood samples for analysis of serum 25-hydroxyvitamin D levels, ionised calcium (iCa) and parathyroid hormone (PTH) and completed cognitive measures of verbal episodic learning and memory. RESULTS: Serum 25-hydroxyvitamin D concentrations were negatively associated (with and without covariates of age, gender, depression and NART scores, iCa, and PTH) with measures of verbal episodic learning and memory, in particular with trial 5 of the Rey Auditory Verbal Learning Test (RAVLT) and long-delay free recall on the RAVLT. CONCLUSION: Overall, the findings from this study suggest an association between higher vitamin D status and poorer performance on verbal episodic memory in middle-aged and older individuals with normal vitamin D-calcium-PTH homeostasis. Despite requiring replication in other participant samples, this is a potentially important finding as it indicates that it may not be beneficial from a cognitive perspective to provide vitamin D supplements in individuals with already adequate vitamin D status.

The relationship between pain management and psychospiritual distress in patients with advanced cancer following admission to a palliative care unit.

BACKGROUND: Although many cross-sectional studies have demonstrated the association between cancer pain and psychospiritual distress, the time-dependent relationship has not been fully explored. For that reason, this study aims to investigate the time-dependent relationship between psychospiritual distress and cancer pain management in advanced cancer patients. METHODS: This is a prospective observational study. Two hundred thirty-seven advanced cancer patients were recruited from a palliative care unit in Taiwan. Demographic and clinical data were retrieved at admission. Pain and psychospiritual distress (i.e.: anxiety, depression, anger, level of family and social support, fear of death) were assessed upon admission and one week later, by using a "Symptom Reporting Form". Patients were divided into two groups according to the pain status one week post-admission (improved versus not improved groups). RESULTS: One hundred sixty-three (68.8 %) patients were assigned to the improved group, and 74 (31.2 %) patients were assigned to the not improved group. There were no differences in the psychospiritual variables between groups upon admission. In overall patients, all psychospiritual variables improved one week post-admission, but the improvement of depression and family/social support in the not improved group was not significant. Consistent with this, for depression scores, there was a statistically significant pain group x time interaction effect detected, meaning that the pain group effect on depression scores was dependent on time. CONCLUSIONS: We demonstrated a time-dependent relationship between depression and pain management in advanced cancer patients. Our results suggest that poor pain management may be associated with intractable depression. The inclusion of interventions that effectively improve psychospiritual distress may contribute to pain management strategies for advanced cancer patients.

Consciousness levels one week after admission to a palliative care unit improve survival prediction in advanced cancer patients.

BACKGROUND: Consciousness is an important factor of survival prediction in advanced cancer patients. However, effects on survival of changes over time in consciousness in advanced cancer patients have not been fully explored. OBJECTIVE: This study evaluated changes in consciousness after admission to a palliative care unit and their correlation with prognosis in terminal cancer patients. METHODS: This is a prospective observational study. From a palliative care unit in Taiwan, 531 cancer patients (51.8% male) were recruited. Consciousness status was assessed at admission and one week afterwards and recorded as normal or impaired. RESULTS: The mean age was 65.28±13.59 years, and the average survival time was 23.41±37.69 days. Patients with normal consciousness at admission (n=317) had better survival than those with impaired consciousness at admission (n=214): (17.0 days versus 6.0 days, p<0.001). In the analysis on survival within one week after admission, those with normal consciousness at admission had a higher percentage of survival than the impaired (78.9% versus 44.3%, p<0.001). Patients were further classified into four groups according to consciousness levels: (1) normal at admission and one week afterwards, (2) impaired at admission but normal one week afterwards, (3) normal at admission but impaired one week afterwards, and (4) impaired both at admission and one week afterwards. The former two groups had significantly better survival than the latter two groups: (median survival counted from day 7 after admission), 25.5, 27.0, 7.0, and 7.0 days, respectively. CONCLUSION: Consciousness levels one week after admission should be integrated into survival prediction in advanced cancer patients.

Indonesian students' participation in an interprofessional learning workshop.

Interprofessional learning activities, such as workshops allow students to learn from, with and about each other. This study assessed the impact on Indonesian health students' attitudes towards interprofessional education (IPE) from participating in a workshop on medication safety. The students attended a two-day IPE workshop on medication safety. Thirty-five (48.6%) students completed pre-/post-workshop surveys using a modified Readiness for Interprofessional Learning Scale (RIPLS) survey. The post-workshop survey also had a series of open-ended questions. Students' responses to each RIPLS statement pre-/post-workshop were compared, whilst their responses to open-ended questions in post-workshop survey were thematically analysed. Students reported positive attitudinal changes on statements of shared learning and teamwork sub-scale (Wilcoxon p value <0.05). Analysis of the open-ended questions indicated that students perceived the workshop as having improved their understanding on the importance of teamwork and communication skills. This study found that learning with other health students through an IPE workshop improved medical, nursing and pharmacy students' attitudes towards the importance of shared learning, teamwork and communication in healthcare service.

The difference in pharmacists' interventions across the diverse settings in a children's hospital.

AIMS: This study aimed to document and compare the nature of clinical pharmacists' interventions made in different practice settings within a children's hospital. METHODS: The primary investigator observed and documented all clinical interventions performed by clinical pharmacists for between 35-37 days on each of the five study wards from the three practice settings, namely general medical, general surgical and hematology-oncology. The rates, types and significance of the pharmacists' interventions in the different settings were compared. RESULTS: A total of 982 interventions were documented, related to the 16,700 medication orders reviewed on the five wards in the three practice settings over the duration of the study. Taking medication histories and/or patient counselling were the most common pharmacists' interventions in the general settings; constituting more than half of all interventions. On the Hematology-Oncology Ward the pattern was different with drug therapy changes being the most common interventions (n = 73/195, 37.4% of all interventions). Active interventions (pharmacists' activities leading to a change in drug therapy) constituted less than a quarter of all interventions on the general medical and surgical wards compared to nearly half on the specialty Hematology-Oncology Ward. The majority (n = 37/42, 88.1%) of a random sample of the active interventions reviewed were rated as clinically significant. Dose adjustment was the most frequent active interventions in the general settings, whilst drug addition constituted the most common active interventions on the Hematology-Oncology Ward. The degree of acceptance of pharmacists' active interventions by prescribers was high (n = 223/244, 91.4%). CONCLUSIONS: The rate of pharmacists' active interventions differed across different practice settings, being most frequent in the specialty hematology-oncology setting. The nature and type of the interventions documented in the hematology-oncology were also different compared to those in the general medical and surgical settings.

Nature and frequency of medication errors in a geriatric ward: an Indonesian experience.

PURPOSE: To determine the nature and frequency of medication errors during medication delivery processes in a public teaching hospital geriatric ward in Bali, Indonesia. METHODS: A 20-week prospective study on medication errors occurring during the medication delivery process was conducted in a geriatric ward in a public teaching hospital in Bali, Indonesia. Participants selected were inpatients aged more than 60 years. Patients were excluded if they had a malignancy, were undergoing surgery, or receiving chemotherapy treatment. The occurrence of medication errors in prescribing, transcribing, dispensing, and administration were detected by the investigator providing in-hospital clinical pharmacy services. RESULTS: Seven hundred and seventy drug orders and 7,662 drug doses were reviewed as part of the study. There were 1,563 medication errors detected among the 7,662 drug doses reviewed, representing an error rate of 20.4%. Administration errors were the most frequent medication errors identified (59%), followed by transcription errors (15%), dispensing errors (14%), and prescribing errors (7%). Errors in documentation were the most common form of administration errors. Of these errors, 2.4% were classified as potentially serious and 10.3% as potentially significant. CONCLUSION: Medication errors occurred in every stage of the medication delivery process, with administration errors being the most frequent. The majority of errors identified in the administration stage were related to documentation. Provision of in-hospital clinical pharmacy services could potentially play a significant role in detecting and preventing medication errors.

Proton pump inhibitor-associated hypomagnesemia: what do FDA data tell us?

BACKGROUND: Proton pump inhibitors (PPIs) are a class of medications indicated for the treatment of gastric acid-related diseases. Hypomagnesemia is a rare but serious adverse effect of PPIs. OBJECTIVE: To address the association between the use of different PPIs and hypomagnesemia by examining the frequency of occurrence of hypo magnesemia among the reported adverse drug reactions from the Food and Drug Administration (FDA) Adverse Event Reporting System database. METHODS: We conducted a cross-sectional study of PPI-associated adverse effect cases reported to the FDA between November 1, 1997, and April 1, 2012. Logistic regression was used to examine the association of sex, age, and different PPIs with hypomagnesemia. χ² analysis was conducted to investigate the association of PPI-associated hypomagnesemia with hypocalcemia and hypokalemia. RESULTS: Among 66,102 subjects identified as experiencing 1 or more adverse effects while taking a PPI, 1.0% (n = 693) were reported to have hypomagnesemia. The mean (SD) age of PPI users presenting with hypomagnesemia was 64.4 (12.9) years. Results from logistic regression indicated that, compared with esomeprazole, all other PPIs had a higher rate of hypomagnesemia, with pantoprazole having the highest rate (OR 4.3; 95% CI 3.3-5.7; p < 0.001). The risk of female subjects having hypo magnesemia (OR 0.83; 95% CI 0.71-0.97; p = 0.016) was significantly lower than that of males. Elderly subjects (age >65 years) were at increased risk of PPI-associated hypomagnesemia (OR 1.5; 95% CI 1.2-1.7; p < 0.001). χ² analysis showed strong association between hypomagnesemia and both hypocalcemia (p < 0.001) and hypokalemia (p < 0.001). CONCLUSIONS: All PPIs were associated with hypomagnesemia, with esomeprazole having the lowest risk and pantoprazole having the highest risk. The risk of PPI-associated hypomagnesemia was higher in males and the elderly population. Hypocalcemia and hypokalemia commonly coexisted with PPI-associated hypomagnesemia.

The prevalence of co-administration of clopidogrel and proton pump inhibitors.

BACKGROUND: Recent studies have suggested that proton pump inhibitors (PPIs) may inhibit the antiplatelet activity of clopidogrel, increasing the risk of major cardiovascular events in patients taking clopidogrel and PPIs together. AIM: The primary aim of this study was to determine the prevalence of co-prescription of clopidogrel and PPIs amongst residents of aged-care facilities in New South Wales, Australia. METHODS: One-year prescription records of 791 aged-care residents were analysed for prevalence of co-prescribing of clopidogrel and PPIs, and aspirin with clopidogrel and PPIs. Prevalence of co-prescribing of clopidogrel, aspirin and PPI in diabetic patients and clopidogrel with various CYP2C19 inhibitors was also examined. RESULTS: Of the 791 residents studied, 60 were prescribed clopidogrel, 248 were on aspirin and 326 were prescribed a PPI. Among residents who were prescribed PPIs, 155 were prescribed omeprazole, 72 pantoprazole, 15 lansoprazole, 44 esomeprazole and 51 rabeprazole. Eleven of these residents had taken more than one PPI during the study period. Thirty-nine residents took a combination of clopidogrel and a PPI (any PPI) for a mean 203 days (SD 12). Thirteen residents were on the combination of aspirin and clopidogrel for a mean of 202 days (SD 111). Nine residents took the combination of clopidogrel, aspirin and a PPI (any PPI) for a mean of 173 days (SD 81). Only one patient on clopidogrel was receiving a CYP2C19 inhibitor in addition to a PPI. CONCLUSIONS: A significant number of residents in this cohort were taking a combination of clopidogrel and a PPI, mainly omeprazole. Residents who were on the combination of clopidogrel and a PPI, with or without aspirin, were on these combinations for a significantly long duration, which could increase their risk of adverse cardiovascular events.

Comparison of risk of neurovascular and cardiovascular side effects between tiotropium and other anticholinergic agents.

AIM: The aim of this study was to examine the risk of cardiovascular diseases among users of both inhaled (ipratropium bromide or tiotropium bromide) and oral (oxybutynin and propantheline, solifenacin, tolterodine) anticholinergics. METHOD: A retrospective study was undertaken on data obtained from the Food and Drug Administration (FDA) from subjects who had received either an inhaled or oral form of an anticholinergic drug and experienced some side effect during the period from 1988 to 2009. The recorded data included: patient's age, sex, list of drugs and side effects. Side effect rates for the anticholinergic drugs were compared using univariate (Chi-square) and multivariate (logistic regression) methods. RESULTS: The files from the FDA held data for 36 491 different subjects, of whom 2610 (7.15%) experienced a cardiovascular or neurovascular side effect. Subjects were classified as taking the oral (45%) or inhaled (55%) class of the drug, with only 109 subjects (0.3%) taking drugs in both forms. Side effect rates differed between anticholinergic drugs. Stroke and hypertension were significantly more common for subjects taking oral anticholinergic drug compared with tiotropium, while other reported vascular side effects (cardiac ischaemia or arrhythmiascardiac failure, cardiac arrest) tended to be more commonly associated with the use of inhaled anticholingerics. These differences persisted after adjustment for age and gender. CONCLUSION: This observational study of recorded side effects showed that, except for stroke and hypertension, patients who were treated with an inhaled anticholinergic drug appeared to be at higher risk of developing neurovascular or cardiovascular side effects, than those treated with an oral drug. However, physicians should also be aware that oral anticholinergic drugs may have similar adverse impacts on health. Further studies on the association between anticholinergic drugs and cardiovascular and neurovascular side effects are recommended.

Protein, fibre and blood pressure: potential benefit of legumes.

1. Prevention of hypertension and improved blood pressure control can be achieved through dietary modification. In particular, population studies and randomised controlled trials have indicated a beneficial effect of both dietary protein and dietary fibre on level of blood pressure. 2. A large population study indicates that an increase in 37 g/day of protein leads to a decrease in mean systolic and diastolic blood pressure by approximately 3 and 2.5 mmHg, respectively. This protective effect is independent of the source of dietary protein. 3. Meta-analysis suggests that a fibre increase of approximately 17 g/day will decrease systolic blood pressure by 1.15 mmHg and diastolic blood pressure by 1.65 mmHg, with soluble fibre showing a stronger effect than insoluble fibre. 4. Protein and dietary fibre may have additive effects to lower blood pressure. One feasible approach to increasing both protein and fibre in the daily diet could be through the incorporation of legumes, a protein- and fibre-rich food. 5. This review assesses the evidence for effects of protein and fibre to reduce blood pressure and the potential of incorporation of legumes into the daily diet as a feasible approach to achieving such benefits for blood pressure.