Cost-Utility Analysis Comparing Direct Oral Anticoagulant and Low Molecular Weight Heparin Therapies for Secondary Prevention of Cancer-Associated Thrombosis.

BACKGROUND AND OBJECTIVE: Cancer patients are at elevated risk of cancer-associated thrombosis (CAT). Randomized controlled trials have found that direct oral anticoagulants (DOACs) are associated with fewer recurrent venous thromboembolism (VTE) events and an increased risk of bleeding than low molecular weight heparins (LMWHs) in CAT. With new clinical data available, this study aims to assess the comparative cost-effectiveness of DOACs and LMWHs over 6- and 60-month treatment durations from the US healthcare system and societal perspectives. METHODS: A Markov model for cancer patients eligible to receive rivaroxaban, edoxaban, apixaban, enoxaparin, or dalteparin was used to conduct a cost-utility analysis. Clinical scenarios were analyzed based on 6- and 60-month time horizons from the US healthcare system and societal perspectives. The main outcome was the incremental cost-effectiveness ratio (ICER), expressed as cost in US dollars per quality-adjusted life year (QALY). One-way and probabilistic sensitivity analyses were performed to evaluate the robustness of the results. RESULTS: DOACs were cost-saving and clinically superior to LMWHs and were associated with a cost change ranging from - $9134.66 to - $15,281.92 and incremental effectiveness of 0.43-1.25 QALYs among four clinical scenarios. The most influential model inputs for ICER were the utility associated with LMWH use and probabilities of non-VTE and non-bleeding related death. Probabilistic sensitivity analyses were consistent with the results. CONCLUSIONS: DOACs were found to dominate LMWHs, suggesting that DOACs may be a cost-effective alternative to LMWHs for CAT. This study can help inform decision-makers on the cost-effectiveness of anticoagulation strategies and help in the development of future practice recommendations for cancer patients.

Health Literacy Level and Comprehension of Prescription and Nonprescription Drug Information.

The aim of this study was to investigate the level of misunderstanding of medication information in Korean adults after stratifying by level of health literacy and to identify the factors influencing the misunderstanding of medication information and reading amounts of information on OTC drug labels. A cross-sectional survey was performed with 375 adult participants using the survey instrument. Multiple linear regression analyses were performed to identify factors which influence misunderstanding of medication information. Participants misunderstood 20% of words on OTC drug labels, 9% of prescription drug instructions, and 9% of pictograms. Participants on average read 59% of the overall contents of the OTC drug labels. As prescription drugs' dosing regimens became more complicated, the level of misunderstanding instructions increased. The level of misunderstanding words on OTC drug labels significantly decreased as participants had adequate health literacy (ß = −18.11, p < 0.001) and higher education levels (ß = −6.83, p < 0.001), after adjusting for the study variables. The level of misunderstanding instructions for prescription drugs increased as participants became older (ß = 8.81, p < 0.001) and had lower education levels (ß = −5.05, p < 0.001), after adjusting for the study variables. The level of misunderstanding pictograms was similar to that of misunderstanding instructions for prescription drug labels. The amount of reading information on OTC drug labels significantly increased as respondents had adequate health literacy (ß = 9.27, p < 0.001), were older (ß = 12.49, p < 0.001), or had chronic diseases (ß = 7.49, p = 0.007). Individuals' health literacy level, reading behaviors, and complexity of medication instructions are associated with misunderstanding of medication information. Appropriate word choices in drug labels and an improved format of medication instructions could increase understanding of medication information and prevent adverse drug reactions.

Association of visual motor processing and social cognition in schizophrenia.

Patients with schizophrenia have difficulties in social cognitive domains including emotion recognition and mentalization, and in sensorimotor processing and learning. The relationship between social cognitive deficits and sensorimotor function in patients with schizophrenia remains largely unexplored. With the hypothesis that impaired visual motor processing may decelerate information processing and subsequently affects various domains of social cognition, we examined the association of nonverbal emotion recognition, mentalization, and visual motor processing in schizophrenia. The study examined mentalization using the verbal subset of the Chinese version of Theory of Mind (CToM) Task, an equivalent task of the Faux Pas Test; emotion recognition using the Diagnostic Analysis of Nonverbal Accuracy 2-Taiwan version (DANVA-2-TW), and visual motor processing using a joystick tracking task controlled for basic motor function in 34 individuals with chronic schizophrenia in the community and 42 healthy controls. Patients with schizophrenia had significantly worse performance than healthy controls in social cognition, including facial, prosodic emotion recognition, and mentalization. Visual motor processing was also significantly worse in patients with schizophrenia. Only in patients with schizophrenia, both emotion recognition (mainly in prosodic modality, happy, and sad emotions) and mentalization were positively associated with their learning capacity of visual motor processing. These findings suggest a prospective role of sensorimotor function in their social cognitive deficits. Despite that the underlying neural mechanism needs further research, our findings may provide a new direction for restoration of social cognitive function in schizophrenia by enhancing visual motor processing ability.

Using the Theory of Planned Behavior to Understand Factors Influencing South Asian Consumers' Intention to Seek Pharmacist-Provided Medication Therapy Management Services.

The study purpose was to use the theory of planned behavior to understand factors influencing South Asian consumers' intention to seek pharmacist-provided medication therapy management services (MTMS). Specific objectives were to assess effects of attitude, subjective norm (SN), perceived behavioral control (PBC), and socio-demographics on South Asian consumers' intention to seek MTMS. Participants who were ≥18 years of age, of South Asian origin, with a previous visit to a pharmacy in the US for a health-related reason, and with ability to read and comprehend English were recruited from independent pharmacies in New York City. Responses were obtained through a self-administered survey. Descriptive statistics were performed, and multiple linear regression analysis was conducted to assess the study objective. SPSS was used for data analyses. Out of 140 responses, 133 were usable. Mean scores (standard deviation) were 4.04 (0.97) for attitude, 3.77 (0.91) for SN, 3.75 (0.93) for PBC, and 3.96 (0.94) for intention. The model explains 80.8% of variance and is a significant predictor of intention, F (14,118) = 35.488, p < 0.05. While attitude (ß = 0.723, p < 0.05) and PBC (ß = 0.148, p < 0.05) were significant predictors of intention, SN (ß = 0.064, p = 0.395) was not. None of the socio-demographics were significant predictors of intention. Strategies to make South Asians seek MTMS should focus on creating positive attitudes and removing barriers in seeking MTMS.

Fondaparinux Sodium Compared With Low-Molecular-Weight Heparins for Perioperative Surgical Thromboprophylaxis: A Systematic Review and Meta-analysis.

Background Fondaparinux sodium has been compared with low-molecular-weight heparins ( LMWH ) in randomized controlled trials for perioperative surgical thromboprophylaxis. However, the results from these studies are inconsistent in terms of efficacy and safety to reach a clinical decision. The objective of this study was to systematically review the randomized controlled trials comparing the efficacy and safety of fondaparinux and LMWH for perioperative surgical thromboprophylaxis. Methods and Results Systematic search in various databases was done to identify randomized controlled trials comparing fondaparinux and LMWH published during the years 2000 to 2017. Outcomes of interest in this study included venous thromboembolism up to day 15, all-cause mortality up to day 90, major bleeding, and minor bleeding during the treatment period. Analyses were performed with the relative odds based on a random-effects model using Mantel-Haenszel statistics. Results were presented as odds ratios with their 95% CIs. The assessment of study quality was performed as per Cochrane collaboration. After screening 10 644 articles, 12 randomized controlled trials including 14 906 patients were included in the final analyses. Pooled analyses showed the odds of venous thromboembolism in the fondaparinux group were 0.49 times the odds in LMWH group ( OR =0.49 [0.38-0.64]). However, the odds of major bleeding in the fondaparinux group were 1.48 times the odds in the LMWH group ( OR =1.48 [1.15-1.90]). Conclusions Fondaparinux was associated with a superior efficacy in terms of reduction of venous thromboembolism in this meta-analysis. However, it was also associated with increased odds of major bleeding.

Exploring the Community Pharmacist's Knowledge of Celiac Disease.

Objective. To evaluate pharmacists' knowledge of celiac disease, and identify potential areas where additional continuing education may be needed. Methods. A survey was sent to community pharmacists practicing in a national chain pharmacy in one region of New Jersey and New York. Results. There were 418 pharmacists who responded to the survey with a response rate of 38%. Only 27% of all respondents who reported their understanding of celiac disease to be basic or advanced correctly defined celiac disease as both an autoimmune and a chronic lifelong disease. The majority (60%) of respondents correctly stated there are no federal regulations requiring manufacturers to designate medications as gluten-free. Twenty percent of respondents said they often recommended a change in diet to people suspected to have celiac disease before a confirmed diagnosis. Conclusion. Community pharmacists possess some knowledge of the disease and would benefit from and desire additional education about this disorder.

Adsorption and desorption of Cu2+ on paddy soil aggregates pretreated with different levels of phosphate.

Interactions between anions and cations are important for understanding the behaviors of chemical pollutants and their potential risks in the environment. Here we prepared soil aggregates of a yellow paddy soil from the Taihu Lake region, and investigated the effects of phosphate (P) pretreatment on adsorption-desorption of Cu2+ of soil aggregates, free iron oxyhydrates-removed soil aggregates, goethite, and kaolinite with batch adsorption method. The results showed that Cu2+ adsorption was reduced on the aggregates pretreated with low concentrations of P, and promoted with high concentrations of P, showing a V-shaped change. Compared with the untreated aggregates, the adsorption capacity of Cu2+ was reduced when P application rates were lower than 260, 220, 130 and 110mg/kg for coarse, clay, silt and fine sand fractions, respectively. On the contrary, the adsorption capacity of Cu2+ was higher on P-pretreated soil aggregates than on the control ones when P application rates were greater than those values. However, the desorption of Cu2+ was enhanced at low levels of P, but suppressed at high levels of P, displaying an inverted V-shaped change over P adsorption. The Cu2+ adsorption by the aggregate particles with and without P pretreatments was well described by the Freundlich equation. Similar results were obtained on P-pretreated goethite. However, such P effects on Cu2+ adsorption-desorption were not observed on kaolinite and free iron oxyhydrates-removed soil aggregates. The present results indicate that goethite is one of the main soil substances responsible for the P-induced promotion and inhibition of Cu2+ adsorption.

A facile "turn-on" fluorescent method with high sensitivity for Hg(2+) detection using magnetic Fe3O4 nanoparticles and hybridization chain reactions.

In this manuscript, the authors molecularly engineered a hybridization chain reactions (HCRs) based probe on magnetic Fe3O4 nanoparticles for the sensitive detection of Hg(2+). The sensing system comprised three probes: capture probe H1, report probe H2, and report probe H3. The capture probe was modified on the surface of magnetic Fe3O4 nanoparticles. The report probes were labeled with fluorescein isothiocyanate (FITC). Without Hg(2+), the report probes were stable as molecular beacons in solution. In the presence of Hg(2+), the T-rich capture probes and report probes will hybridize into double-helical DNA domains with the aid of T-Hg(2+)-T coordination chemistry. Trigged by this reaction, more molecular beacons open and form a super tandem structure. Herein, the fluorescence signal was magnified by capturing more report probes. Separating the target and captured report probes from reaction solution was benefit to decrease the background signal and interference from other metal ions. The detection limit of this method was about 0.36nM, which is much lower than the regulations of World Health Organization and U.S. Environmental Protection Agency on Hg(2+) in drink water. This proposed sensing strategy also showed favorable selectivity over other common metal ions. In addition, it has good practicability in real water samples.

Incidence of Sepsis and Mortality With Prior Exposure of HMG-COA Reductase Inhibitors in a Surgical Intensive Care Population.

The anti-inflammatory properties of hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) may reduce the risk of developing sepsis in surgical intensive care patients and improve outcomes in those who do become septic. The objective of this study was to assess whether surgical intensive care unit (SICU) patients with prior exposure to HMG-CoA reductase inhibitors had a lower incidence of developing sepsis and improved outcomes. A retrospective cohort study was conducted. Patient demographic data, statin use, sequential organ failure assessment (SOFA) scores, vasopressor requirements, ventilator days, length of SICU stay, and mortality in septic patients were collected. Incidence of development of sepsis was determined using systemic inflammatory response syndrome criteria. Patients were grouped into cohorts based on whether they met the sepsis criteria and if they had previously received statins. Cohorts of patients who did and did not become septic with prior statin exposure were compared and an odds ratio was calculated to determine a protective effect. The setting was a SICU. The study comprised of 455 SICU patients and had no interventions. Among the 455 SICU patients, 427 patients were included for the final results. Patients receiving statins verses not receiving statins were similar in demographics. Previous statin exposure had a protective effect in the development of sepsis (9.77% on statins vs. 33.6% without statins; odds ratio 0.203, confidence interval 0.118-0.351). Of those patients who developed sepsis, there was a statistically significant decrease in 28-day mortality in patients with prior statin exposure (P = 0.0341). No statistical difference was noted in length of stay, vasopressor requirements, or days on mechanical ventilation. Prior exposure to statins may have a protective effect on the development of sepsis and decrease mortality in critically ill surgical patients.

Impact of anticholinergic load of medications on the length of stay of cancer patients in hospice care.

OBJECTIVES: An important goal of hospice care is to relieve pain and suffering of terminal cancer patients. Anticholinergic medications are effective in the symptom palliation among terminal cancer patients. However, use of these medications has been associated with increased risk of side effects, which might lead to premature mortality. Short lengths of stay in hospice care leave patients with a higher level of unmet needs. The study was conducted to examine the effect of increasing anticholinergic load on the length of stay of cancer patients in hospice care in the USA. METHODS: The National Home and Hospice Care Survey 2007 was used as the data source. The Cox proportional hazards model was used to investigate the risk of death among users of moderate and high anticholinergic load compared with users of low anticholinergic load in presence of other prognostic factors. KEY FINDINGS: Cancer patients on a moderate anticholinergic load had a 12.7% lower hazard of death (P = 0.0244), while those on a high anticholinergic load had a 15.6% lower hazard of death (P = 0.0071) as compared with those patients on a low anticholinergic load. Among other prognostic factors, non-elderly age group, male gender, white race, metropolitan hospice agency, non-profit hospice agency, severe activities of daily living dependency and cognitive impairment were significantly associated with a higher probability of death. CONCLUSIONS: These results provide no evidence for increasing anticholinergic load increasing mortality in cancer patients using hospice care. Thus, high anticholinergic load might have conferred a protective effect on the patients because of better symptom control.

Modification of a pharmacokinetics course design to improve student performance.

OBJECTIVE: To determine if the addition of weekly quizzes or reducing the number of faculty members teaching improved third-year (P3) pharmacy students' final grades in a clinical pharmacokinetics course. DESIGN: Four sections of a pharmacokinetics and pharmacodynamics course were divided according to the number of faculty members teaching the course and the administration of weekly quizzes. Two sections were taught by 6 faculty members and 2 were taught by 3 faculty members. Also, 1 section in each group received weekly quizzes, creating a 2-by-2 design. ASSESSMENT: The performance of the 201 P3 students enrolled in the course was assessed by comparing the average of 3 examination grades while excluding quiz grades. The mean final grade of classes in which quizzes were not administered was lower than that for classes in which quizzes were administered (p=0.019). The mean final grade in classes taught by 3 faculty members vs 6 faculty members was higher, but not significantly. A positive significant correlation existed between performance in a prerequisite biopharmaceutics class and this advanced class. CONCLUSION: Making minor modifications to the delivery of a course, such as number of quizzes administered and number of faculty members teaching the course, had a positive impact on student performance. Grades in a prerequisite course may enable earlier identification of students at risk of poor performance in advanced courses.

Factors associated with in vitro interferon-gamma production in tuberculosis.

BACKGROUND/PURPOSE: Macrophage activation assisted by interferon-gamma (IFN-γ) is a primary mechanism by which Mycobacterium tuberculosis is killed, but IFN-γ (production is inhibited in tuberculosis (TB) patients. The production of IFN-γ is influenced by many factors, such as interleukin (IL)-10, IL-12, IL-18, and clinical diseases; but the relative importance of each factor is unclear. METHODS: We evaluated the effects of these factors in 46 healthy individuals, 81 patients with TB, and 88 patients with non-TB pneumonia. The responses of IFN-γ, IL-10, IL-12 and IL-18 were determined from phytohemagglutinin-stimulated peripheral blood mononuclear cells (PBMCs). RESULTS: General linear model analysis showed that disease status and IL-12 response were the independent factors associated with the IFN-γ response. The production of IFN-γ was not affected by IL-10 and IL-18. There was a significant relationship between the IFN-γ response and the IL-12 response among patients with non-TB pneumonia, patients with TB, and healthy participants (Pearson's correlation coefficients of 0.466, 0.483, and 0.464, respectively). CONCLUSION: Production of IFN-γ in PBMCs was associated with active pulmonary TB and IL-12 response.

The effects of isolated versus multiple lipid disorders on resource utilization among metabolic syndrome patients with lipid abnormalities despite Lipid-modifying treatment.

OBJECTIVE: The aim of this study was to compare resource utilization among metabolic syndrome (MetS) patients with multiple (≥ 2) lipid disorders (MLD) versus isolated (any 1) lipid disorder (ILD). METHODS: Data for MetS patients on lipid-modifying therapy (LMT) were collected from the 2006 Adelphi Metabolic Syndrome Disease Specific Programme(©) cross-sectional study of patients from 5 European countries. The presence of MetS and lipid disorders, including elevated low-density lipoprotein cholesterol (LDL-C) and triglycerides (TG), and low high-density lipoprotein (HDL-C), were based on the National Cholesterol Education Program definitions. Analyses compared primary care physician (PCP) and specialist visits over the past 6 months among ILD versus MLD patients. RESULTS: Among 4,836 MetS patients, 2,843 had ≥ 1 lipid disorders and were on LMT. Controlling for other risk factors, MLD patients had significantly higher physician visits than those with ILD (p = 0.009), but hospitalizations were not significantly different. Patients experiencing all 3 lipid disorders had significantly more endocrinologist visits (p = 0.002) as compared with ILD patients, while patients with elevated LDL-C and abnormal HDL-C and/or TG compared with isolated elevated LDL-C had significantly more PCP (p = 0.001) and cardiologist visits (p < 0.001). CONCLUSION: Among MetS patients on LMT, presence of MLD resulted in significantly higher PCP and specialist visits compared with ILD.

Effects of potentially inappropriate psychoactive medications on falls in US nursing home residents: analysis of the 2004 National Nursing Home Survey database.

BACKGROUND AND OBJECTIVE: Use of potentially inappropriate psychoactive medications (PIPMs) poses a serious threat of falls among elderly nursing home residents. This study was conducted to identify the effects of PIPMs on falls compared with use of other psychoactive medications among elderly US nursing home residents. METHODS: The 2004 National Nursing Home Survey (NNHS) was used as the data source. Logistic regression was performed to ascertain the relationship between elderly residents who fell in the past 30 days and the use of PIPMs as per Beers' criteria in the presence of other risk factors. The data analysis was performed using SAS version 9.1. RESULTS: The 2004 NNHS database includes data concerning 11 940 elderly residents in 1174 facilities. The mean age of the elderly residents was 84.1 +/- 7.97 years. Residents receiving PIPMs were at an increased risk of falling compared with those receiving other psychoactive medications (odds ratio [OR] = 0.830, p = 0.028) as well as compared with residents not receiving psychoactive medications (OR = 0.624, p < 0.001). In addition, residents' fall risk increased with an increase in the number of impaired activities of daily living (OR = 1.160, p < 0.001). Presence of depressed mood indicators was also identified as an important risk factor (OR = 1.256, p < 0.001). Use of bedrails had a protective effect on residents' fall risk (OR = 0.714, p < 0.001). Demographic factors such as male sex and White race were also significant fall-risk factors. CONCLUSION: Prevention of falls in elderly nursing home residents remains a challenge. Despite the recommendations of prescribing guidelines, PIPMs are still prescribed to elderly nursing home residents. Access to appropriate psychoactive medications should be ensured. Residents with the identified risk factors should be closely monitored. Further research should be pursued to evaluate the impact on falls of potentially inappropriate medications in other therapeutic categories.

Prospective study of amphotericin B formulations in immunocompromised patients in 4 European countries.

BACKGROUND: Amphotericin B is a widely used broad-spectrum antifungal agent, despite being associated with significant adverse events, including nephrotoxicity. METHODS: The present prospective study collected data on outcomes for 418 adult patients treated consecutively with polyenes in hematology and oncology wards in 20 hospitals in Europe. RESULTS: Patients initially received amphotericin B deoxycholate (62% of patients), liposomal amphotericin B (27%), or other lipid formulations of amphotericin B (11%). Of the patients initially treated with amphotericin B deoxycholate, 36% had therapy switched to lipid formulations of amphotericin B, primarily because of increased serum creatinine levels (in 45.7% of patients) or other amphotericin B-attributable adverse events (in 41.3% of patients). Nephrotoxicity, which was defined as a > or = 50% increase in the serum creatinine level, developed in 57% of patients with normal kidney function at baseline. Predictors of nephrotoxicity included formulation type and duration of treatment. Compared with patients without nephrotoxicity, patients with nephrotoxicity had a higher mortality rate (24%), and their mean length of stay in the hospital was prolonged by 8.6 days. Slight increases in the serum creatinine level (i.e., > or = 50%) were associated with a significantly longer stay in the hospital. Severe nephrotoxicity (i.e., a > or = 200% increase in the serum creatinine level) was a significant predictor of death, as were severe underlying medical conditions and documented fungal infection. CONCLUSION: This prospective study confirmed that, in European hospitals, amphotericin B formulations have a major influence on the length of stay in the hospital and nephrotoxicity-associated mortality.

Use of health-related quality of life information in managed care formulary decision-making.

BACKGROUND: The extent to which the increased volume of available health-related quality of life (HRQOL) information and heightened education has increased the acceptance and use of HRQOL remains unclear. Likewise, the value of HRQOL information in the formulary decision-making process continues to be undefined. OBJECTIVE: To investigate the perceptions and use of HRQOL by managed care decision-makers in the formulary development process. METHODS: A mail survey was sent to a nationwide sample of 108 Academy of Managed Care Pharmacy (AMCP) members who were involved in formulary management. Survey candidates were identified according to their job titles listed in the 1999-2000 AMCP membership directory. The survey process began in May 2000 and ended in August 2000. The main outcome measures included (a) managed care formulary decision-makers' assessment of HRQOL as a treatment outcome, (b) the existing role and future use of HRQOL information in formulary decisions, and (c) the level of understanding of HRQOL concepts and the benefits attributable to favorable HRQOL results. RESULTS: A response rate of 51.9% was obtained. Most of the respondents (>70%) believed that patients consider HRQOL as an important treatment outcome. Fewer respondents (43%) felt that payers view HRQOL outcomes as an important quality indicator. Most respondents (95%) considered HRQOL data in making formulary decisions, and many (73%) believe that HRQOL outcomes will play a more important role in future formulary decisions. Respondents indicated a better understanding of disease-specific and generic HRQOL measurements than utility measurement and interpretation of results. A minority of respondents (34%) would be willing to pay a higher price for a product with better HRQOL outcomes. When asked which factors would lead to increased use of HRQOL information, respondents indicated that health care cost savings and increased productivity were considered important (77% and 65%, respectively). CONCLUSIONS: A drug product with better HRQOL outcomes alone will not command a favorable listing on managed care formularies. HRQOL information needs to be made more applicable to managed care decision-making. Future studies should focus on the link between positive HRQOL outcomes, health care cost savings, and increased productivity.

Evaluation of outpatient adverse drug reactions leading to hospitalization.

Outpatient adverse drug reaction (ADR)related hospitalization through the emergency department of a nonprofit hospital and the contributing factors are reviewed. Patients who were hospitalized because of suspected ADRs were selected from daily admissions reports and patient medication profiles from 1997 and 1998 by the pharmacy department of a nonprofit community teaching hospital. Hospital charges for individual patients were obtained from the institution's accounting system. Suspected drugs, their therapeutic class, and the organ systems involved in the ADRs were identified. A total of 191 patients who had a complete medical history and cost information were included in the study. Of those patients, 56% were female, and 45% of the patients were 75 years of older. The average hospital charge per ADR patient was $9491. Room and board accounted for more than 50% of total charges. The average length of stay for study patients was 8.0 +/- 10.3 days. Major therapeutic classes implicated in ADRs included antidiabetic agents (27.8%), anticoagulants (15.2%), anticonvulsants (10.0%), beta-blockers (7.9%), and angiotensin-converting-enzyme inhibitors (7.9%). Organ systems most commonly involved in ADR admissions were the endocrine (30.9%) and cardiovascular (24.1%) systems. The implicationed therapeutic groups and organ systems exhibited a different pattern from those of earlier ADR studies. The elderly and the poor are most affected by ADRs. The availability of new drugs and the shift in disease treatment necessitate the continuous monitoring of new ADRs. Patients and family members should be integral components of a multidisciplinary strategy for minimizing the personal and social impact of ADRs.