Pharmaceutical care program for onco-hematologic outpatients: safety, efficiency and patient satisfaction.

BACKGROUND: Self-administration of oral chemotherapy regimens in the home setting leading to new challenges in the health system. OBJECTIVE: To develop and evaluate a comprehensive pharmaceutical care program for cancer outpatients treated with oral antineoplastic agents. SETTING: A Spanish tertiary hospital. METHODS: During 2012, a comprehensive pharmaceutical care program was elaborated following the standards recommended by ASCO. It comprised a standard procedure focusing on: drug indication, dosing regimen, required laboratory tests, route of administration, interactions with other current medications and adverse events; a checklist and informational brochures. A pharmaceutical follow up was defined and structured into three clinical interviews over 6 months which focused on safety and efficiency outcomes. Patients starting treatment with oral antineoplastic agents during 2011 (control group) without pharmacist monitoring were compared to patients beginning treatment at some point in 2013 who were prospectively monitored by a pharmacist (intervention group). Statistical analysis was performed by the statistical program SPSS, 21.0 and p < 0.05 was considered significant. MAIN OUTCOME MEASURES: Patient demographics and clinical data were recorded. The primary endpoint was safety outcomes: detection of drug related problems, drug interactions, and adverse events. Adherence, permanence and patient satisfaction were also collected. RESULTS: A total of 249 patients were enrolled in the study. Two hundred and seventy-five medication errors were recorded [106 in the control group and 169 in the intervention group (p = 0.008)]. The pharmacist intervened in 362 occasions being accepted 88.8 % of the time, mainly to reinforce patient education and literacy and giving information on co-administration with other drugs and herbal medicines. Adherent patients increased at the 6th month of treatment in the intervention group by 20 % (p < 0.001). High satisfaction was reported. CONCLUSION: The program has been implemented and evaluated successfully. It ensures a high quality and standard of pharmaceutical care with high patient satisfaction rate and the key points to prioritize for improvement in terms of safety (interactions and administration errors) and efficiency (adherence and permanence) of oral antineoplastic agents.

[Atrial thrombus entrapped in a patent foramen oval. Report of one case]. / Trombo auricular atrapado en el foramen oval: Complicación infrecuente en el tromboembolismo pulmonar.

We report a 63 year-old female with a pulmonary embolism in whom echocardiography revealed the presence of right heart thrombus. A section of this thrombus was entrapped in a patent foramen oval and floating in both atria. This rare situation, named impending paradoxical embolism, prompted us to perform a surgical intervention, removing the thrombus and repairing the foramen ovale.

Trombo auricular atrapado en el foramen oval: Complicación infrecuente en el tromboembolismo pulmonar / Atrial thrombus entrapped in a patent foramen oval: Report of one case

We report a 63 year-old female with a pulmonary embolism in whom echocardiography revealed the presence ofríght heart thrombus. A section ofthis thrombus was entrapped in a patent foramen oval and floating in both atria. This rare situation, named impending paradoxical embolism, prompted us to perform a surgical intervention, removing the thrombus andrepairing the foramen ovale.

[The application of new technologies to hospital pharmacy in Spain]. / Aplicación de las nuevas tecnologías a la farmacia hospitalaria en España.

OBJECTIVE: To describe the degree of introduction of new technologies in the medication use process in pharmacy services in Spain. METHOD: A descriptive study via a survey into the degree of introduction of computer systems for: management, computerized physician order entry (CPOE), automated unit dose drug dispensing, preparation of parenteral nutrition solutions, recording drug administration, pharmaceutical care and foreseen improvements. The survey was sent by electronic mail to the heads of the pharmacy services of 207 hospitals throughout Spain. RESULTS: Response index: 82 hospitals (38.6%). 29 hospitals (36.7%) have a modular management system, 24 (30.4%) an integrated one and 34 (44.9%) a modular-integrated one. CPOE is utilised in 17 (22.4%). According to the size of the hospital, between 17.9 and 26.7% of unit dose dispensing is done online with a management software; between 5.1 and 33.3% of unit dose dispensing is automated. Automation of unit dose dispensing centred in the pharmacy service varies between 10 and 33.3%. Between 13.2 and 35.7% of automated in-ward dispensing systems are utilised. Administration records are kept manually on a computerised sheet at 23 (31.5%) of the hospitals; at 4 (5.4%) on CPOE and 7 (9.5%) online on the integral management programme and 4 (5.4%) on specific nursing softwares. Sixty-three per cent foresee the implementation of improvements in the short to medium term. CONCLUSIONS: The introduction of new technologies is being developed in Spain aiming to improve the safety and management of drugs, and there is a trend towards increasing their deployment in the near future. It is hoped that their fomentation could help to bring about process reengineering within pharmacy services in order to increase the time available for devotion to pharmaceutical care.

[Recommendations from GESIDA/SEFH/PNS to improve adherence to antiviral treatment (2004)]. / Recomendaciones GESIDA/SEFH/PNS para mejorar la adherencia al tratamiento antirretroviral en el año 2004.

Since the early days of antiretroviral therapy, adherence has emerged as the milestone of success; in fact, it is the most potent predictor of effectiveness. The main factors related to adherence include the complexity of the therapeutic regimen, adverse effects, psychological problems, alcoholism and active addiction to drugs, lack of social and family support and the patient's beliefs and attitudes about the treatment. Adherence monitoring should be part of the HIV patient's regular care, and should be done with feasible, easily applied methods adapted to the different clinical settings. The minimally acceptable measures should include use of a validated questionnaire, together with data from the Pharmacy Department's drug dispensation registry. All patients that begin HAART or undergo a change of treatment should participate in a treatment education program imparted by health professionals with knowledge and experience in the management of patients with HIV infection. The health team (doctors, pharmacists and nursing professionals) should offer maximum availability to solve the doubts and problems that may occur during treatment. When sub-optimal adherence is detected, intervention strategies based on psychological therapy, educational efforts and personal advice should be attempted, in order to adapt the treatment scheme to the patient's habits and provide solutions to the problem of non-compliance. In certain situations, co-morbid conditions will also require attention. Treatment adherence, being a multidimensional problem, needs a multidisciplinary team approach. The choice of therapy, only one aspect of the multidimensional problem of adherence, must be a careful and individualized decision; however, simpler regimens with regard to the number of pills and daily dose are desirable.

Recomendaciones GESIDA/SEFH/PNS para mejorar la adherencia al tratamiento antirretroviral en el año 2004 / Recommendations from GESIDA/SEFH/PNS to improve adherence to antiviral treatment (2004)

El cumplimiento incorrecto del tratamiento antirretroviral(TAR) constituye el factor principal de fracaso terapéutico. Los factores que han demostrado estar relacionados con la adherencia de forma más relevante incluyen la complejidad del tratamiento, los efectos secundarios, los problemas psicológicos, la adicción activa a drogas y/o alcohol, la falta de soporte socio familiar y las actitudes y creencias del paciente acerca del tratamiento. La monitorización del cumplimiento debe formar parte de la atención habitual del paciente con infección por el virus de la inmunodeficiencia humana (VIH), deben utilizarse métodos factibles, adaptados a la realidad del hospital y lo más universalmente aplicables. Puede considerarse un mínimo aceptable la asociación de un cuestionario validado y el registro de dispensación del servicio de farmacia. Todo paciente que inicie o cambie el tipo de TAR debe realizar un programa de educación sanitaria sobre el tratamiento, a cargo de profesionales sanitarios con experiencia y conocimiento del manejo de pacientes con infección por VIH. Debe procurarse la máxima disponibilidad del equipo asistencial (médicos, farmacéuticos y profesionales de enfermería) para resolverlas dudas y problemas que se presenten a lo largo del tratamiento. En los pacientes en los que no se alcancen niveles de cumplimiento adecuados, se deben intentar estrategias de intervención, basadas en aspectos psico-educativos y de asesoramiento personal, con capacidad para adaptar el esquema del TAR a los hábitos de vida del paciente y proporcionando estrategias de resolución de problemas. En determinadas situaciones será necesario resolverla comorbilidad, por lo tanto el enfoque debe ser pluridisciplinar. Son aconsejables pautas más sencillas en cuanto a número de comprimidos y a dosis diarias (AU)

Since the early days of antiretroviral therapy, adherence has emerged as the milestone of success; in fact, it is the most potent predictor of effectiveness. The main factors related to adherence include the complexity of the therapeutic regimen, adverse effects, psychological problems, alcoholism and active addiction to drugs, lack of social and family support and the patient’s beliefs and attitudes about the treatment. Adherence monitoring should be part of the HIV patient’s regular care, and should be done with feasible, easily applied methods adapted to the different clinical settings. The minimally acceptable measures should include use of a validated questionnaire, together with data from the Pharmacy Department’s drug dispensation registry. All patients that begin HAART or under go a change of treatment should participate in a treatment education program imparted by health professionals with knowledge and experience in the management of patients with HIV infection. The health team (doctors, pharmacists and nursing professionals) should offer maximum availability to solve the doubts and problems that may occur during treatment. When sub-optimal adherence is detected, intervention strategies based on psychological therapy, educational efforts and personal advice should be attempted, in order to adapt the treatment scheme to the patient’s habits and provide solutions to the problem of non-compliance. In certain situations, co-morbid conditions will also require attention. Treatment adherence, being a multidimensional problem, needs a multidisciplinary team approach. The choice of therapy, only one aspect of the multidimensional problem of adherence, must be a careful and individualized decision; however, simpler regimens with regard to the number of pills and daily dose are desirable (AU)

Programa multidisciplinario de prevención de errores de medicación en un hospital / Developing a multidisciplinary medication safety program in a hospital

Los errores de medicación (EM) son una de las principales causas de acontecimientos adversos prevenibles en el ámbito hospitalario, y se estima que afectan a un 1,8% (rango, 1,3-7,8%) de los pacientes ingresados. Por ello, se promueve el desarrollo e implantación de prácticas efectivas para mejorar la seguridad del sistema de utilización de medicamentos. El objetivo de este artículo es describir las principales fases de un programa interno de notificación y prevención de incidentes por medicamentos en un hospital, y comentar algunos aspectos que pueden facilitar su abordaje. Se destaca la importancia de contar con el compromiso explícito del equipo directivo para transformar la cultura de la institución y disponer de los recursos necesarios, así como constituir un comité multidisciplinario integrado por farmacéuticos, médicos, enfermeras y representantes del equipo directivo. Este comité debe fomentar la creación de una cultura de seguridad y paralelamente desarrollar los procedimientos necesarios para conocer, evaluar y mejorar continuamente la seguridad del sistema de utilización de los medicamentos. Esto supone una secuencia de actuaciones que incluyen, en primer lugar, el establecimiento de métodos para detectar los EM que ocurren, entre los cuales se comentan la notificación voluntaria, por ser el método básico, y los sistemas automatizados de alerta. A continuación se debe realizar el análisis y evaluación de los EM detectados, para identificar los fallos existentes en el sistema. Finalmente, el paso fundamental del programa es la implantación de medidas de mejora en función de los fallos detectados y el seguimiento de los resultados en términos de prevención de errores

Medication errors (ME) constitute one of the main causes of preventable adverse events in hospital settings, affecting an estimated 1.8% (range, 1.3-7.8%) of hospitalized patients. Concerns over this problem are leading to the development and implantation of effective practices designed to improve the safety of the medication use system. The objective of this article was to describe the principal steps of an internal program for reporting and preventing medication-related incidents in a hospital and to discuss certain aspects that might facilitate putting such a program into practice. The importance of obtaining an explicit commitment from the hospital administration to transform the culture of the institution and to provide the necessary resources, as well as to create a multidisciplinary committee including pharmacists, physicians, nurses, and administrators is emphasized. This committee should be charged with encouraging the creation of a culture of safety and at the same time with developing the procedures required to continually study, evaluate, and improve the safety of the medication use system. All of this presupposes a sequence of actions that includes, first of all, the establishment of methods for detecting MEs when they occur, which may include voluntary reporting, as the basic method, and computer alert systems. Next, analysis and evaluation of the detected MEs should be carried out to identify existing faults in the system. Finally, the fundamental step in the program is the implantation of measures for improvement according to the failures detected, with appropriate follow-up of results in terms of error prevention

Augustamine type alkaloids from Crinum kirkii.

Sixteen more Amaryllidaceae alkaloids have been isolated from bulbs of Crinum kirkii Baker of which noraugustamine and 4a,N-dedihydronoraugustamine are hitherto unknown. Their structures and those of earlier known alkaloids have been established by physical and spectroscopic analysis. Application of 2D NMR techniques was used for complete characterization of the alkaloids as well as of 3-O-acetylsanguinine. 1,2-Diacetyllycorine and 3-O-acetylsanguinine showed activity against Trypanosoma brucci rhodesiense, the parasite associated with sleeping sickness. 3-O-acetylsanguinine also showed some activity against Trypanosoma cruzi.

Probabilidad diagnóstica de endocarditis infecciosa antes de la realización del ecocardiograma.: Sobreutilización del ecocardiograma transesofágico

RESUMEN El ecocardiograma es una herramienta ampliamente utilizada y de elevado valor para el diagnóstico de endocarditis infecciosa (EI). En nuestro centro hospitalario se indica en forma rutinaria el ecocardiograma transesofágico (ETE) para valorar este diagnóstico y sólo en caso de contraindicación se limita la valoración al ecocardiograma transtorácico (ETT). Objetivo: individualizar criterios clínicos y microbiológicos que permitan identificar una población en la que el ETE aporte información diagnóstica útil, racionalizando su uso. Material y método: registro prospectivo de 116 pacientes referidos para diagnóstico de EI por medio de ETE por el médico tratante. Se comparó el resultado ecocardiográfico con el diagnóstico de cierre de la historia clínica y con el que resultó de la aplicación en los criterios de Duke. Se realizó análisis univariado y multivariado para detectar condiciones clínicas asociadas con el diagnóstico de EI. Resultados: se comprobaron 23 casos de EI como diagnóstico de cierre de la historia clínica, de los cuales 14 fueron EI definida (EID), ocho posibles (EIP) en ausencia de hemocultivos (HC) positivos y uno rechazada, que fue excluida del resto del análisis. El ETE fue positivo en 20 casos (17,2%), que coincidieron con 20 de los casos positivos por cierre de la historia (90,9%). Los dos casos no diagnosticados por ETE fueron diagnosticados por ETT, por lo que el ecocardiograma en conjunto fue positivo en 100% de las EID y de las EI por cierre de la historia. El análisis multivariado mostró que la presencia de cardiopatía predisponente pre ETE, dos o más HC positivos y la ausencia de un foco no endovascular, implica una probabilidad de 88% de EID, en tanto que la ausencia de estos tres elementos implica una probabilidad de 0% de EID o 7,8% de EIP. Conclusiones: existe una sobreindicación de ETE para el diagnóstico de EI. La ausencia dos o más HC positivos, la existencia de cardiopatía predisponente y la ausencia de un foco infeccioso no endovascular podrían implicar la no realización de ETE. Si se hubiera limitado la realización de ETE a los pacientes que cumplieran con estos criterios se hubieran realizado 68 (58,6%) estudios menos inicialmente.

SUMMARY Transesophage echocardiogram (ETE) is an efficient tool for infective endocarditis (EI). Objective: to individualize clinical criteria to identify populations in which ETE is efficient to diagnosis. Methods: a prospective study of 116 patients suspected of EI who underwent ETE. Echocardiographic results were compared to those obtained by clinical history analysis and Duke criteria. Uni and multivaried analysis were used to determine clinical conditions associated with EI. Results: 23 cases of EI were found as conclusion of clinical history analysis, among them 14 were definitive (EID). ETE was positive in 22 cases (18.96%) included in the 23 cases above-mentioned; ETE was positive for suspected infective endocarditis (EIP) in 8 cases, without positive blood cultures (HC). Multivariate analysis showed that presence of cardiopathy prior to ETE, 2 or more positive HC and lack of non-endovascular focus implies an 88% probability of EID. Lack of these criteria indicates 0% probability of EID and 7.8% probability of EIP. Conclusions: there is an overindicated use of ETE for EI. Lack of 2 or more positive HC, predispositional cardiopathy and lack of infectious non-endovascular focus might imply no use of ETE. If ETE would have been limitated to these criteria, 67.9 (58.5%) could have been saved.

Comparación de tres métodos de cálculo de adherencia en pacientes con tratamiento antirretroviral / Comparison of three methods to calculate adherence in patients receiving antiretroviral treatment

INTRODUCCIÓN. El cálculo de la adherencia al tratamiento antirretroviral constituye un dato de gran utilidad en el seguimiento de los pacientes con infección por virus de la inmunodeficiencia humana (VIH). Se han propuesto varios métodos para calcular la adherencia, pero cada uno de ellos presenta ciertas dificultades de aplicación. PACIENTES Y MÉTODOS. Se han evaluado, de forma prospectiva, tres métodos para el cálculo de la adherencia: el recuento de la medicación sobrante (RMS), la entrevista estructurada (EN) y el registro de dispensación de medicación desde el servicio de farmacia (DM). Se ha considerado el RMS como método patrón y se ha evaluado la sensibilidad y la especificidad de los otros dos métodos con respecto a éste. RESULTADOS. Los tres métodos se han podido aplicar a 69 casos. De éstos, el porcentaje de pacientes que ha tomado el 95 por ciento o más de las dosis prescritas ha sido del 72,5 por ciento (RMS), el 85,5 por ciento (EN) y el 81,2 por ciento (DM). Si se considera el RMS como el método patrón, la concordancia con DM ha sido del 75,1 por ciento y con EN del 73,2 por ciento. La sensibilidad de DM y EN ha sido del 52,6 y 42,1 por ciento, respectivamente. Los pacientes con una adherencia 90 por ciento (RMS) presentaron una probabilidad de alcanzar una buena respuesta virológica 1,29 veces mayor (intervalo de confianza [IC] del 95 por ciento: 1,04-1,62; p 0,0138). CONCLUSIÓN. Aunque la concordancia entre los métodos es aceptable, DM y EN sobrestiman la adherencia respecto a RMS. Debido a que no se dispone de un método ideal para medir la adherencia es importante combinar varios métodos para realizar una medición lo más aproximada posible a los datos reales (AU)

[Comparison of three methods to calculate adherence in patients receiving antiretroviral treatment]. / Comparación de tres métodos de cálculo de adherencia en pacientes con tratamiento antirretroviral.

INTRODUCTION: Knowledge of the patient's adherence to antiretroviral treatment is extremely useful for monitoring HIV infection. Several methods have been proposed to calculate adherence, but they all have certain problems at application. The aim of this study was to compare three of the available methods for assessing medication adherence in order to determine their accuracy for this purpose. PATIENTS AND METHODS: Three methods for evaluating medication adherence were prospectively studied: 1. Remaining pill count (RPC), 2. Structured interview (SI), and 3. Pharmacy registry of drug refills (DR). The RPC was considered the gold standard and sensitivity and specificity of the other methods was calculated according to the RPC. The study included 100 consecutive patients and had a follow-up of one year. RESULTS: We were able to assess all three methods in 69 cases. The percentages of patients taking 95% or more of the prescribed dose according to the three methods were 72.5% (RPC), 85.5% (SI) and 81.2% (DR). Taking the RPC as gold standard, there was 75.1% concordance with the DR and 75.1% with the SI method. The sensitivities of the DM and SI were 52.6 % and 42.1 %, respectively. After one year of follow-up, patients with > 90% adherence (RPC) had a 1.29-times higher probability of achieving good virological response (CI 95% 1.04-1.62, p 5 0.0138). CONCLUSION: Although concordance among the methods was acceptable, the SI and DR overestimated adherence as compared to the RPC. Since there is currently no ideal method for determining treatment adherence, it is important to combine several methods to minimize errors and provide results that are as close to the true situation as possible.

Biodiversity of mannose-specific lectins within Narcissus species.

Mannose-specific lectins (MSLs) were isolated from the bulbs of 27 species of wild Spanish Narcissi and compared to the commercially available MSL from daffodil (Narcissus pseudonarcissus, NPA). Molecular weight analysis showed the monomers of all the MSLs were at, or around, 12.5 kD. Haemagglutination assays showed that the MSLs exhibited activities at up to four times greater than that displayed by NPA and other MSLs derived from other species such as Galanthus nivalus (snowdrop) and Allium ursinum (ramson). Elution profiles from ion exchange chromatography exhibited similarities for species within the same taxonomic section suggesting that this method could aid in species classification. Further analysis by isoelectric focusing showed many isolectins are present in vivo and that even within a single peak from ion exchange chromatography there are numerous isolectins present. The basis of the isolectin heterogeneity is suggested to reside in the tetraploidy (sometime triploidy) nature of Narcissus genes.

Recomendaciones GESIDA/SEFH/PNS para mejorar la adherencia al tratamiento antirretroviral / The recommendations of GESIDA/SEFH/PNS for improving adherence to antiretroviral treatment

El objetivo del tratamiento antirretroviral es la supresión profunda y duradera de la replicación viral. Las especiales características virológicas del virus de la inmunodeficiencia humana (VIH) determinan que cuando existen concentraciones subterapéuticas de los fármacos el VIH puede multiplicarse y desarrollar resistencias. Esto puede justificar el fracaso terapéutico, la posible transmisión de cepas resistentes y la utilización inadecuada de los recursos económicos. Por tanto, uno de los factores más importantes para conseguir unos niveles terapéuticos adecuados es la correcta adherencia terapéutica. En esta revisión se analizan los factores que influyen en la adherencia, los métodos de evaluación y se recomiendan las posibles estrategias de intervención y de actuación de un equipo multidisciplinario que debe ser integrado por médicos, farmacéuticos, enfermeras, psicólogos y personal de soporte. El inicio del tratamiento antirretroviral no es habitualmente urgente. Dada la importancia que tiene realizar de manera correcta este primer tratamiento conviene, antes de iniciar la terapia, preparar al paciente, tratar de identificar las potenciales situaciones concomitantes que puedan dificultar una correcta adherencia y corregirlas. Si se decide que el paciente inicie el tratamiento es imprescindible que en el momento de la prescripción y la dispensación de los fármacos se ofrezcan una información detallada, soporte y accesibilidad en todos los aspectos relacionados con el tratamiento. Durante éste, la evaluación de la adherencia es imprescindible y deberá tenerse en cuenta en la toma de decisiones terapéuticas. Al no existir un único método fiable, recomendamos utilizar varias técnicas como la entrevista y el cuestionario estructurado, el recuento de la medicación sobrante y la asistencia a las citas de dispensación de fármacos junto con la evolución clínica y analítica del paciente. Para ello es indispensable que exista una buena coordinación entre todos los estamentos implicados. Si se detecta una falta de adherencia debe intervenirse de forma activa para corregirla, y en situaciones extremas puede valorarse la suspensión del tratamiento. Los beneficios que aporta un programa para mejorar la adherencia justifica disponer de suficientes recursos económicos, humanos y de infraestructura que faciliten el desarrollo de estas actividades. (AU)