West Nile Virus Infection in Liver Transplant Recipient With Neither De Novo Infection nor Donor-Derived Infection: A Case Report.

West Nile virus was first described in 1937 and has sinceperiodically appearedin variousparts oftheworld by infecting people and horses. Reported infection symptoms and signs may be highly variable, ranging from fever and myalgias to meningoencephalitis. A 59-year-old patient was admitted to the University Clinical Centre of Serbia, Belgrade, in September 2018, where livertransplantwasperformedtotreat cirrhosisof ethyl etiology. Immunosuppressive therapy was started immediately after successful transplant, with the patientreceiving methylprednisolone, tacrolimus, and mycophenolate mofetil. Mycophenolate mofetil was excluded from therapy on postoperative day 3 because of progressively worse white blood cell count. The patient became febrile on postoperative day 11 (39.6 °C), and arm tremor, nausea, vomiting, and frequent fluid stools occurred. He complained of pain in the muscles and joints of the lower extremities. The next day he experienced occasional disorientation. Neurological findings revealed no signs of acute focal neurological deficit. We performed culture tests to isolate pathological microorganisms, and results were negative in cultures of the blood, urine, feces, ascites, and a smear of the wound and tip of the central venous catheter. Lumbar puncture resulted in a clear cerebrospinal fluid that was sent for analysis that showed significant increases in white blood cell count (94 × 106 cells/L), total proteins (1.61 g/L), and microalbumin (504.5 mg/L), with a reduction of immunoglobulin G. On postoperative day 15, positive serology of West Nile virus immunoglobulin M in cerebrospinal fluid was verified. Intensive monitoring and symptomatic and supportive therapy resulted in clinical and laboratory improvement, and the patient was discharged in good general condition on postoperative day 22. Considering the high risk of posttransplant complications, there remains the question of whether all donors and recipients should be tested forWest Nile virus atthe onset oftransplant.

Potentially inappropriate prescribing among older patients and associated factors: comparison of two versions of STOPP/START criteria

Abstract The study aimed to estimate and compare the prevalence and type of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) between the STOPP/START original (v1) and updated version (v2) among older patients in various settings, as well as associated factors. The study included 440 patients attending a community pharmacy, 200 outpatients and 140 nursing home users. An increase in the prevalence of STOPP v2 (57.9%) compared to v1 (56.2%) was not statistically significant in the total sample and within each setting (p>0.05). A decrease in the prevalence of START v1 (55.8%) to v2 (41.2%) was statistically significant (p<0.001) in the total sample and within each setting (p<0.05). Drug indication (32.9%) and fall-risk medications (32.2%) were most commonly identified for STOPP v2, while cardiovascular system criteria (30.5%) were the most frequently detected for START v2. The number of medications was the strongest predictor for both STOPP v1 and v2, with odds ratio values of 1.35 and 1.34, respectively. Patients' characteristics associated with the occurrence of STOPP and START criteria were identified. According to both STOPP/START versions, the results indicate a substantial rate of potentially inappropriate prescribing among elderly patients. The prevalence of PIMs was slightly higher with the updated version, while the prevalence of PPOs was significantly lower

Evaluating ground glass opacities (GGO) in the COVID-19 era. Do autoantibodies help?

INTRODUCTION: COVID-19 is an infectious disease, caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and there have been outbreaks worldwide. The presentation may include unspecific and mild symptoms, myalgia, headaches, high fever, dry cough, severe dyspnea and acute respiratory distress syndrome (ARDS). CASE STUDY: We present a rare case of microscopic polyangiitis (MPA) with interstitial lung disease and without renal involvement misdiagnosed as COVID-19. CONCLUSIONS: Differential diagnosis of COVID-19 is extremely important, and must be correctly identified in order to proceed with correct treatment.

Telepharmacy service experience during the COVID-19 pandemic in the Republic of Srpska, Bosnia and Herzegovina.

The COVID-19 pandemic exerted a profound impact on health systems worldwide. Moreover, significant concerns were raised in terms of middle- and long-term consequences of postponing care in non-COVID patients. The primary aim of the study was to describe the remote pharmaceutical care service (telepharmacy) during the COVID-19 pandemic in the Republic of Srpska (RS), Bosnia and Herzegovina. The secondary aim was to identify service users' needs and concerns and to describe community pharmacists' interventions. Ten community pharmacists were appointed by the Pharmaceutical Society of the RS to deliver telepharmacy services. After obtaining users' verbal permission, pharmacists documented issues discussed with them. The prospective data collection included the period from April 13 to May 21, 2020. Descriptive and statistical analysis was performed using IBM SPSS Statistics software (ver. 22). A total of 71 service users' charts were analyzed. Telepharmacy users were on average 61.31 ± 13.27 years of age, with almost equal gender distribution. Patients with chronic or acute/subacute conditions were predominant with a share of 84.5%. Chronic diseases were the main reason for searching pharmacists' consultation (74.6%), 7% had a complaint about worsening of a chronic condition, 9.9% reported only acute/subacute conditions as ambulatory conditions, whereas 15.5% asked information about coronavirus or COVID-19. The vast majority of patients' and users' needs were addressed by a pharmacist during counseling and only 15.5% of the patients required immediate referral to a doctor for refill/prescribing purposes. Remote pharmaceutical care service (telepharmacy) is deemed a convenient model in the RS during the COVID-19 pandemic. Patients and users presented with explicit and specific needs and concerns, both COVID- and non-COVID-related, which should not be neglected. Community pharmacists showed a high level of resilience and ability in addressing patients' needs.

Pentoxifylline with metformin treatment improves biochemical parameters in patients with nonalcoholic steatohepatitis.

BACKGROUND: The progression of the nonalcoholic fatty liver disease to nonalcoholic steatohepatitis (NASH) is multifactorial, and there is still a lack of approved medications for its treatment. The study aimed to evaluate the impact of combined treatment with Pentoxifylline and Metformin on biochemical parameters in patients with Nash. Setting: Outpatient hepatology clinic. METHODS: A prospective trial was conducted. The first cohort included patients with biopsy-proven Nash, while the second cohort consisted of patients with biopsy-confirmed NAFLD. Blood tests were checked at baseline and every three months. Pentoxifylline at a dosage of 400 mg t.i.d. and Metformin at the dosage of 500 mg t.i.d. were introduced for six months in Nash group. The impact of the treatment was assessed based on biochemical results after combined treatment with low-cost medications. RESULTS: All 33 Nash patients completed 24 weeks of treatment. We observed significant improvement (p<0.05) of median values after treatment for the following parameters: serum uric acid levels decreased by 51.0 mmol/L, calcium decreased for 0.27 mmoL/L, magnesium showed an increase of 0.11 mmoL/L. Insulin resistance improved as a reduction of HOMA - IR by 1.3 was detected. A significant decrease of median in liver enzymes, alanine aminotransferase, aspartate aminotransferase and gamma-glutamyltransferase by 24.0 U/L, 9.1 U/L, 10.8 U/L respectively, was noted. CONCLUSIONS: Pentoxifylline and Metformin may provide possible treatment option in Nash. Some new potential benefit of the therapy in improving liver function whilst decreasing cardiovascular risk was perceived.

Attitudes of Nurses Toward Organ Donation in Serbia.

OBJECTIVE: Nurses represent the key persons in the process of organ donation, acting as intermediaries between the patient and the family of a potential donor. The aim of this study was to analyze the factors influencing the attitudes of nurses toward bequeathing and organ and tissue donation. METHODS: The research was designed as a cross-sectional study from November 2013 to November 2014 and included a sample of 264 nurses employed in the health system of Serbia. Data were collected using a specific questionnaire of 18 questions referring to the information on sociodemographic characteristics and the knowledge of organ donation. RESULTS: The investigation enrolled 264 participants, of which 78% were women. The majority of study subjects had secondary medical education (64.4%), lived in an urban area (82.6%), were married (56.4%), and were predominantly Orthodox (87.1%) with their work experience between 5 and 10 years (29.9%) and 10 to 20 years (29.5%). The average knowledge score concerning organ donation was 29.03 (SD, 2.33; range, 23-34). There was a statistically significant difference in the scores between 2 groups formed according the length of service (P < .001) and the level of education (P = .019), which showed the strongest influence on nurses' attitudes toward donation. CONCLUSION: This investigation showed that nurses did not express strong positive attitude toward this issue. Further education of nurses in the Serbian health care system focusing on transplantation and bequeathing of organs and tissues are warranted.

Intrahepatic Cholestasis of Pregnancy: A Case Study of the Rare Onset in the First Trimester.

Intrahepatic cholestasis of pregnancy (ICP) is a gestation-specific liver disorder, defined most often as the onset of pruritus, usually from the third trimester of pregnancy, associated with abnormal liver test results and/or increased total serum bile acids and spontaneous relief after delivery. The 21-year-old patient was admitted to our ward in the 11th week of pregnancy due to raised liver enzymes. The first onset of pruritus and jaundice appeared a month before hospitalization. Immunology tests and Toxoplasma gondii were negative. We excluded viral etiology, while alpha-1-antitrypsin, serum and urine copper levels, and thyroid hormones were within the reference values. The patient denied she had taken any medicines and herbal preparations before and during pregnancy. Total bile acids in the serum were significantly elevated (242 µmol/L). The abdominal ultrasound revealed a regular finding. Liver biopsy suggested a cholestatic liver disorder. After a presentation of all risks, the patient decided to stop the pregnancy. After a month, the hepatogram was within the reference values. Very rarely an ICP can occur in early pregnancy (first trimester), which calls for close monitoring. The risk of serious adverse fetal outcomes and spontaneous preterm delivery is proportional with increased levels of maternal serum bile acid.

A Simple Index for Nonalcoholic Steatohepatitis-HUFA-Based on Routinely Performed Blood Tests.

Background and objectives: Data suggests that nearly 30% of the general population have steatosis and up to 5% of this population develops nonalcoholic steatohepatitis (NASH). Liver biopsy is still considered to be the gold standard for the diagnosis of NASH. Great effort is being made toward the identification of sensitive diagnostic tests that do not involve invasive procedures to address a common concern in patients with the nonalcoholic fatty liver disease-whether they have NASH or simple steatosis. We aimed to investigate the independent predictors and develop a non-invasive, easy-to-perform, low-cost set of parameters that may be used in clinical practice to differentiate simple steatosis from NASH. Methods: А cross-sectional study of nonalcoholic fatty liver disease (NAFLD) patients divided into two groups: group I-simple steatosis (SS) and group II-biopsy-proven NASH. Strict inclusion criteria and stepwise analysis allowed the evaluation of a vast number of measured/estimated parameters. Results: One hundred and eleven patients were included-82 with simple steatosis and 29 with biopsy-proven NASH. The probability of NASH was the highest when homeostatic model assessment of insulin resistance (HOMA-IR) was above 2.5, uric acid above 380 µmol/L, ferritin above 100 µg/L and ALT above 45 U/L. An acronym of using first letters was created and named the HUFA index. This combined model resulted in an area under the receiver operator characteristic curve (AUROC) of 0.94, provided sensitivity, specificity, positive predictive value and a negative predictive value for NASH of 70.3%, 95.1%, 83.1% and 90.0%, respectively. Conclusion: We suggest a simple non-invasive predictive index HUFA that encompasses four easily available parameters (HOMA-IR, uric acid, ferritin and ALT) to identify patients with NASH, which may reduce the need for a liver biopsy on a routine basis in patients with NAFLD.

The Clinical Importance of Cystatin C and Hepatic Artery Resistive Index in Liver Cirrhosis.

BACKGROUND: Data suggest cystatin C (CysC) levels and hepatic artery resistive index (HARI) correspond to the progression of chronic liver disease. We aimed to evaluate the clinical significance of these parameters in assessment of fibrosis in patients with liver cirrhosis. METHODS: The cross-sectional study included 63 patients with liver cirrhosis. A control group consisted of 30 age- and gender-matched healthy persons. RESULTS: We confirmed significantly higher values of CysC in patients with cirrhosis compared to control group (p = 0.036). Average value of HARI in the examined group was increased (0.72 ± 0.06) and there was the statistically significant difference compared to controls (0.66 ± 0.03) (p < 0.001). We found statistically significant correlation between HARI and CysC in the study group. Analyzing the possibility of distinguishing healthy subjects from patients with fibrosis, we have found that the area under the curve is far greater in the HARI index than CysC. Comparison of CysC among Child⁻Pugh stages and correlation with a model for end-stage liver disease (MELD) score showed statistically significant results. CONCLUSION: We confirmed HARI is a more accurate parameter than CysC in discriminating healthy subjects from patients with fibrosis, while CysC could be a better indicator of the stage of liver cirrhosis.

Expectations, concerns, and needs of patients who start drugs for chronic conditions. A prospective observational study among community pharmacies in Serbia.

BACKGROUND: During the initiation of treatment of a chronic disease, patients may have varying interests, expectations, concerns, and reasons to stop treatment, influencing compliance with prescribed treatment. Thus, healthcare professionals are expected to integrate these needs into medicines management. OBJECTIVES: To determine what information is important to patients; assess predictors of patients' interests, expectations, concerns, reasons to stop therapy; evaluate drug-related problems following initiation of therapy and summarize how pharmacists resolve them during patient-pharmacist counselling. METHODS: In 2014, a four-month study was performed in Serbian community pharmacies, as part of the Pharmaceutical Care Quality Indicators Project led by the European Directorate for the Quality of Medicines & Healthcare. Seventy community pharmacists were asked to participate in the study. Pharmacists recruited adult patients who consented to participate in the study and who initiated treatment, lasting at least six months. Patients completed an open-ended questions form. After two-to-four weeks, a patient-pharmacist consultation was performed. RESULTS: Forty-four community pharmacists (response rate 62.9%) sent back the completed forms from 391 patients (response rate 67.1%). The total number of dispensed drugs was 403. In terms of drug safety, 29.4% of patients sought information, 32.5% expressed concerns, and 28.1% of patients cited it as a reason to discontinue treatment. During the first weeks of therapy, 18% of patients experienced practical problems, while 27.3% reported adverse drug reactions. CONCLUSION: Safety issues are a major focus of patients' prescribed new medicines for long-term treatment.

Impact of community pharmacists' interventions on asthma self-management care.

BACKGROUND: Asthma self-management is aimed to improve the quality and effectiveness of asthma care by supporting the patients to manage their illness by themselves. OBJECTIVE: The aim of the study was to evaluate the impact of pharmacist-delivered counselling on patients knowledge and beliefs about the medicines, adherence level, and asthma control. METHODS: A prospective intervention study was conducted in community pharmacies. A total of 90 patients completed the study. Four questionnaires were used: (1) Beliefs about medicines questionnaire (BMQ), (2) Knowledge of asthma and asthma medicine (KAM), (3) Asthma control test (ACT), and (4) 8-item Morisky medication adherence scale questionnaire (MMAS-8). Questionnaires were completed at baseline and 3 months later. RESULTS: Low level of adherence and poor asthma control were determined initially. Better asthma control was significantly associated with higher adherence level, lower concerns regarding the medication use, and knowledge of triggers. Statistically significant improvement was found after 3 months in patients knowledge of asthma and its medications, their attitude towards medications (decrease in harm, overuse and concern; increase in necessity score), asthma control score (increased from 19 to 20, p < 0.05) and level of adherence (MMAS-8 score decreased from 3 to 2 p < 0.05). Better asthma control was achieved in 60% of patients. Sixteen patients (18%) were transferred from poor to well-controlled asthma, implying no need for patients' referral to the doctor and no additional cost for the health system. CONCLUSIONS: Improved disease control could be a result of enhanced knowledge and understanding of the disease-medication relationship, improved inhalation technique, and support on patients' adherence. Acquired knowledge and skills, as well as improved attitude, empowered patients to take a more active part in asthma management. Education in further patients' follow-up should consider topics tailored to the patients' characteristics, needs, and prior counselling schedule with issues discussed.

Problems, interventions, and their outcomes during the routine work of hospital pharmacists in Bosnia and Herzegovina.

Background In the last 30 years, activities of hospital pharmacists have gone through significant changes. Pharmacists are increasingly involved in patient care. Objectives To explore drug-related and logistic problems, interventions, and their outcomes during routine everyday work of hospital pharmacists. Setting Institute for physical medicine and rehabilitation, Banja Luka, Bosnia and Herzegovina. Methods In the period of January 2013-October 2015 a prospective observational study was performed. Medical doctors, nurses, therapists, and patients addressed pharmacists, face-to-face or by telephone, with drug-related problems (DRPs) and/or logistic issues. Main outcome measure Type of DRP or logistic issue, intervention, outcome, initiator and time spent for solving the problem were documented for each consultation. Results Out of 1515 interventions, 48.8% were aimed at solving DRPs. The most common DRPs were the recommendation of a drug or dose and need for additional information about drugs. Drug price and supply were the most prevalent logistic issues. DRPs were more frequently initiated by medical doctors and required more time to solve the problem compared to logistic issues (Mann-Whitney U test, p ≤ 0.001, respectively). The acceptance rate of interventions to solve DRPs (83.7%) was lower compared to logistic issues (95.2%; p ≤ 0.001). Conclusions Hospital pharmacists were faced with an approximately equal number of DRPs and logistic issues during their routine everyday work. The overall acceptance rate of pharmacists' interventions was high, and the results of our study indicate that there is a need for more involvement of hospital pharmacists in Bosnia and Herzegovina in clinical activities. Impact on practice.

Elderly polypharmacy patients' needs and concerns regarding medication assessed using the structured patient-pharmacist consultation model.

OBJECTIVE: To evaluate elderly polypharmacy patients' needs and concerns regarding medication through the Structured Patient-Pharmacist Consultation (SPPC). METHODS: Older patients on chronic treatment with ≥5 medications were asked to fill in the SPPC form at home. A consultation with the community pharmacist, structured according to patient's answers, followed within 2-4 weeks. Logistic regression associated patients' individual treatment with care issues and consultation outcomes. RESULTS: Out of 440 patients, 39.5% experienced problems, and 46.1% had concerns about medication use. 122 patients reported reasons for discontinuing treatment. The main outcome of the consultation was a better understanding of medication use (75.5%). Side effects and/or non-adherence were identified in 50% of patients, and 26.6% were referred to the doctor. Atrial fibrillation, COPD, anticoagulants, benzodiazepines, and beta agonists/corticosteroids were associated with problems during medication use. Patients with diabetes improved their understanding of medication use significantly. CONCLUSION: Patients on benzodiazepines, anticoagulants, and beta agonists/corticosteroids, with atrial fibrillation and/or COPD, may have a higher potential for non-adherence. Counseling patients based on the SPPC model may be particularly useful for patients with diabetes. PRACTICE IMPLICATIONS: The SPPC model is a useful tool for counseling based on patient needs.

Dabigatran - Metabolism, Pharmacologic Properties and Drug Interactions.

BACKGROUND: The superiority of dabigatran has been well proven in the standard dosing regimen in prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) and extended venous thromboembolism (VTE) treatment. Dabigatran, an anticoagulant with a good safety profile, reduces intracranial bleeding in patients with atrial fibrillation and decreases major and clinically relevant non-major bleeding in acute VTE treatment. However, several important clinical issues are not fully covered by currently available directions with regard to dabigatran administration. The prominent one is reflected in the fact that dynamic impairment in renal function due to dehydratation may lead to haemorragic complications on the one hand, while on the other hand glomerular hyperfiltration may be a possible cause of dabigatran subdosing, hence reducing the drug's efficacy. Furthermore, limitations of the Cockcroft-Gault formula, considered a standard equation for assessing the renal function, may imply that other calculations are likely to obtain more accurate estimates of the kidney function in specific patient populations. Method and Conclusions: Although not routinely recommended, a possibility of monitoring dabigatran in special clinical settings adds to optimization of its dosage regimens, timely perioperative care and administration of urgently demanded thrombolytic therapy, therefore significantly improving this drug's safety profile. Despite the fact that dabigatran has fewer reported interactions with drugs, food constituents, and dietary supplements, certain interactions still remain, requiring considerable caution, notably in elderly, high bleeding risk patients, patients with decreased renal function and those on complex drug regimens. Additionally, upon approval of idarucizumab, an antidote to dabigatran solution, hitherto being a major safety concern, has been finally reached, which plays a vital role in life-threatening bleeding and emergency interventions and surgery.

Evaluation of drug-related problems in older polypharmacy primary care patients.

AIMS AND OBJECTIVES: Targeting older patients with predictive factors for drug-related problems (DRPs) could make clinical medication reviews more cost-effective. The aim of this study was to identify the number, type, and potential predictive factors for DRPs in older polypharmacy patients. METHODS: Community pharmacists performed clinical medication reviews and documented DRPs, types of interventions, and their implementation in older patients. RESULTS: Three hundred eighty-eight medication reviews were analyzed, 964 DRPs (average 2.5 ± 1.9), and 1022 interventions (average 2.6 ± 2.0) were identified. The overall implementation rate of interventions was 70.1%, the highest was observed in interventions aiming to resolve the lack of therapy monitoring (86.8%). Patients with ≥12 medications had an increased risk of ≥5 DRPs (P < .001). Asthma was associated with lack of adherence (P = .002), lack of aspirin, statins, and proton pump inhibitors use with additional therapy needed (P = .002-.004). Predictive factors for drug interactions were antihypertensive medications and/or medications with narrow therapeutic index (P < .05). Lack of efficacy was associated with diabetes (P = .006). Nonsteroidal anti-inflammatory drugs were risk factors for inappropriate drug selection (P = .002). Lack of monitoring was associated with hypertension (P = .013), whereas benzodiazepines (P < .001) and aspirin (P = .021) were overused. CONCLUSION: Patients with asthma, hypertension, and diabetes and lack of statin, antithrombotic agent, and/or proton pump inhibitor use were associated with higher risks for DRPs.

Role of cystatin C and renal resistive index in assessment of renal function in patients with liver cirrhosis.

AIM: To evaluate the clinical significance of cystatin C and renal resistive index for the determination of renal function in patients with liver cirrhosis. METHODS: We conducted a study of 63 patients with liver cirrhosis. A control group comprised of 30 age and gender-matched healthy persons. Serum cystatin C was determined in all study subjects and renal Doppler ultrasonography was made. Estimated glomerular filtration rate from serum creatinine (GFRCr) and cystatin C (GFRCys) was calculated. RESULTS: We confirmed significant differences in values of cystatin C between patients with different stages of liver cirrhosis according to Child-Pugh (P = 0.01), and a significant correlation with model of end stage liver disease (MELD) score (r s = 0.527, P < 0.001). More patients with decreased glomerular filtration rate were identified based on GFRCys than on GFRCr (P < 0.001). Significantly higher renal resistive index was noted in Child-Pugh C than in A (P < 0.001) and B stage (P = 0.001). Also, a significant correlation between renal resistive index and MELD score was observed (r s = 0.607, P < 0.001). Renal resistive index correlated significantly with cystatin C (r s = 0.283, P = 0.028) and showed a negative correlation with GFRCys (r s = -0.31, P = 0.016). CONCLUSION: Cystatin C may be a more reliable marker for assessment of liver insufficiency. Additionally, cystatin C and renal resistive index represent sensitive indicators of renal dysfunction in patients with liver cirrhosis.

Potentially inappropriate prescribing in older primary care patients.

OBJECTIVES: The aim of the study was to determine the rate of Potentially Inappropriate Medicines (PIM) and Potential Prescription Omissions (PPO) according to Screening Tool of Older Person's potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment (STOPP/START) criteria. STUDY DESIGN: A cross-sectional survey in community pharmacy. METHOD: A prospective cross-sectional study was performed, during March-May 2012, in five community pharmacies. Patients aged ≥65 years, who collected one or more prescribed medications, were asked to participate in the study, and an interview was scheduled. Patients were asked to provide their complete medical and biochemical record from their general practitioner. RESULTS: 509 patients, mean age 74.8±6.5 years, 57.4% female, participated in the study. 164 PIM were identified in 139 patients (27.3%). The most common were: long-term use of long-acting benzodiazepines (20.7%), use of non-steroidal antiinflammatory drugs (NSAID) in patients with moderate-severe hypertension (20.1%), use of theophylline as monotherapy for chronic obstructive pulmonary disease (COPD, 15.9%) and use of aspirin without appropriate indication (15.2%). Patients with more than four prescpritions had a higher risk for PIM (OR 2.85, 95% CI 1.97-4.14, p<0.001). There were 439 PPO, identified in 257, (50.5%) patients. Predictors for PPO were older age, presence of diabetes, myocardial infarction, osteoporosis, stroke, COPD and/or angina pectoris. CONCLUSION: STOPP/START criteria may be useful in identifying inappropriate prescribing and improving the current prescribing practices. Pharmacists should focus more on patients with more than four medications and/or patients with gout or pain accompanied with arterial hypertension because those patient may be at higher risk of PIM. Additionlly, patients older than 74 years with diabetes, osteoporosis, myocardial infarction, stroke, angina pectoris and/or COPD may have an increased risk of PPO.