Enhancing Patient Adherence to Newly-Prescribed Medicine for Chronic Diseases: A Comprehensive Review and Cost-Effective Approach to Implementing the New Medicine Service in Community Pharmacies in Poland.

New Medicine Service (NMS) components are an important element to improve patient compliance with medical recommendations. NMS provides support to patients prescribed new medicines, helping them to manage long-term conditions. The purpose of this service is to provide patients with advice, guidelines, and educational materials regarding the use of new medicines to increase patient compliance and therapy safety. The NMS has already been introduced in many European countries. This review aims to identify the benefits and potential barriers to implementing the NMS in community pharmacies and to suggest solutions that would increase its effectiveness. Previous studies have primarily shown that the NMS improves patient compliance with therapy, accelerating the expected effects of the therapy. Pharmacist support during implementation of a new drug therapy substantially increases patient safety. As the experience of numerous countries shows, both pharmacists and patients express positive opinions on this service. Therefore, it seems that NMS should be an indispensable part of pharmaceutical patient care in any healthcare system. This article aims to review the implementation of the New Medicine Service (NMS) for community pharmacists in Poland and the provision of a cost-effective approach to improve patient adherence to newly-prescribed medicine for chronic diseases.

Removing barriers to accessing medical cannabis for paediatric patients.

Medical cannabis (MC) may offer therapeutic benefits for children with complex neurological conditions and chronic diseases. In Canada, parents, and caregivers frequently report encountering barriers when accessing MC for their children. These include negative preconceived notions about risks and benefits, challenges connecting with a knowledgeable healthcare provider (HCP), the high cost of MC products, and navigating MC product shortages. In this manuscript, we explore several of these barriers and provide recommendations to decision-makers to enable a family-centered and evidence-based approach to MC medicine and research for children.

Exploring the Role of Pictograms in the Comprehension of Pain.

Introduction: Pain is both difficult to see and to articulate and this is challenging for both patients and clinicians. The aim of this study was to develop and test pictograms to describe different pain qualities. Methods: 22 pictograms were developed for evaluation based on pain qualities of the short form McGill Pain Questionnaire, version 2 (SF-MPQ-2). An online matching survey was conducted and disseminated via social media in 2021. Results: An overall matching of 66% or higher between pictogram and pain qualities descriptors was considered a proper matching. This study was carried out internationally (males = 57, age=41y.o. ±16; females = 155, age=41y.o.±17) and in Poland (males=49, age =35y.o.±17; females = 164, age=35y.o.±16). There were 14 pictograms that did not achieve 66% matching in any country. 8 pictograms mutually in all subgroups achieved a matching score of ≥66% regardless of geographic location, sex, income, or education level. Discussion and Conclusions: These 8 pictograms can be used clinically once they have been redrawn to improve consistency, and future research in the design of pictograms representing pain qualities of the SF-MPQ-2 should focus on design improvements for the remaining 14 pain qualities with poor comprehensibility.

Patient satisfaction survey of the "Healthy Heart" pharmaceutical care service - evaluation of pharmacy labelling with pharmaceutical pictograms.

INTRODUCTION: Low adherence is a major challenge in healthcare worldwide, being particularly dangerous for patients with chronic diseases, such as cardiovascular diseases and heart failure, where strict adherence is essential. Non-adherence is observed in almost half of patients, and the consequences encompass a lack of therapeutic effects, health deterioration, decreased quality of life, and even death. For cardiovascular patients, the great importance of health education and pharmaceutical education can be provided within pharmaceutical care in community pharmacies. Therefore, our study aimed at evaluating the level of satisfaction with the "Healthy Heart" pharmaceutical service, in which patients received pictograms with dosage information affixed to their medication. MATERIAL AND METHODS: The study was designed for patients who had been prescribed an antiplatelet medication for the first time. The patients were recruited by 577 pharmacies that took part in the study after completing a special course. Ultimately, 1590 patients were enrolled in the study. The project ran from November 2019 to January 2022. RESULTS: Most of patients had a positive attitude to the "Healthy Heart" pharmaceutical service. More than 85% of the respondents were of the opinion that the pictograms facilitated the use of the medication, and 81.7% of the respondents stated that the system of labels helped in adherence. Over 66% of the respondents thought that such labels should be included in pharmacy services, and 77.92% of the participants reported that this system of labelling medications should be offered through all pharmacies. CONCLUSIONS: Pharmaceutical labels in the pharmacists' everyday practice can largely improve patient adherence. These efforts, provided as part of their pharmaceutical services, can have a huge influence on optimisation of patient health outcomes.

Pharmaceutical pictograms: User-centred redesign, selection and validation.

Objective: In an earlier study, several tested International Pharmaceutical Federation (FIP) pictograms did not achieve validity among older adults in Singapore. In this study, for 27 unvalidated FIP pictograms, we (1) developed variants of each pictogram, (2) elicited the most-preferred variant, and (3) assessed the validity of the most-preferred variant among older Singaporeans. Methods: In phase 1, up to three variants of the 27 pictograms were developed, based on older adults' feedback from a previous study. In phase 2, the most-preferred variant of 26 pictograms, which had two or three variants, was selected by 100 older participants. In phase 3, the 27 most-preferred variants (including the pictogram with only one variant) were assessed for validity - transparency and translucency - among 278 older participants (10 pictograms per participant). To evaluate transparency, participants were first asked: "If you see this picture on a medicine label, what do you think it means?" for each assigned pictogram. If they responded, they were asked, "How do you know?", and if not, they were told, "Tell me everything you see in this picture". Then, participants were shown their assigned pictograms again, one by one, and the pictogram's intended meaning was revealed to evaluate translucency. Pictograms were classified as valid (≥66% participants interpreted its intended meaning correctly [transparency criterion] and ≥85% participants rated its representativeness as ≥ 5 [translucency criterion]), partially valid (only transparency criterion fulfilled) or not valid. Results: In phase 1, 77 variants of the 27 pictograms were developed. In phase 2, a majority of the most-preferred variants were selected by >50% participants. In phase 3, 10 (37.0%) of the 27 pictograms tested were considered valid, and five (18.5%) were partially valid. A higher proportion of pictograms portraying dose and route of administration and precautions were valid or partially valid, versus those depicting indications or side effects. Conclusion: Contextual redesigning and selection of pharmaceutical pictograms, which initially failed to achieve validity in a population, contributed to their validation. Innovation: The redesigned validated pictograms from this study can be incorporated into relevant patient information materials in clinical practice.

An examination of cannabis-related information typically asked by consumers at retail cannabis locations: A Canadian survey of budtenders and managers.

Background: Since cannabis has been legalized in Canada for medicinal and recreational use, there has been an increased demand on pharmacists for cannabis counselling. The aim of the study was to examine typical questions posed by consumers to managers and budtenders working at licensed recreational cannabis stores in Canada and to assess how often consumers seek unlicensed medical advice to treat various conditions using cannabis. Methods: An online survey was synthesized, consisting of 22 questions capturing demographics and Likert scale responses to survey questions, and was distributed online across Canada from January to June 2021. Results: There were 211 survey respondents: 91 budtenders and 120 managers. A total of 87.7% (n = 185) of respondents indicated that they receive questions related to cannabis use for medical purposes and/or perceived medical benefit, with the same number indicating that they have been told by a customer that their physician sent them to obtain a cannabis-containing product for medical purposes. The most common cannabis component asked about in an average day was THC (42% of responses). Conclusion: An alarming proportion of budtenders and managers in Canada report that they are fielding medical cannabis questions. This situation has the potential to put individuals at risk for drug-drug interactions and drug-disease interactions and to increase unnecessary hospitalizations due to adverse effects.

Clinical Course of 53 Previously Vaccinated Patients Admitted to the National Hospital in Warsaw, Poland with COVID-19 Between November 2021 and March 2022.

BACKGROUND Current vaccines against SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) and vaccine booster programs aim to reduce hospitalizations due to severe COVID-19 (coronavirus disease 2019). It is now accepted that vaccination does not completely prevent infection and that breakthrough COVID-19 does occur. This study included 53 vaccinated patients who were hospitalized at a single center in Poland with breakthrough COVID-19 and aimed to evaluate the factors associated with their clinical course. MATERIAL AND METHODS This study covered the period 26 November 2021 to 11 March 2022. All patients had been vaccinated against COVID-19 with one of the following 4 vaccines: the mRNA-1273 (Moderna) mRNA vaccine (Spikevax); the BNT162b2 (Pfizer-BioNTech) mRNA vaccine (nucleoside-modified) (Comirnaty); the Ad26.COV2.S (Janssen/J0ohnson & Johnson) recombinant vaccine (Jcovden); and the AZD1222 (ChAdOx1) (Oxford/AstraZeneca) recombinant vaccine (Vaxzevria). RESULTS The course of COVID-19 in vaccinated patients was relatively similar. The patients vaccinated more than 24 weeks earlier rarely needed a stay in the Intensive Care Unit (ICU) (P=0.021), and the occurrence of deaths was significantly lower in this group (P=0.046). Women remained in hospital considerably longer than men (P=0.011). Age and comorbidities did not affect the course of this infection. CONCLUSIONS Despite the many advantages of the COVID-19 vaccination, our observations indicate a potential risk of infection after vaccination. The assessment of the course of COVID-19 in vaccinated patients gives the possibility to compare different vaccines and indicate factors that can reduce immunity.

The Course of COVID-19 among Unvaccinated Patients-Data from the National Hospital in Warsaw, Poland.

INTRODUCTION: Studies to date indicate the relatively high effectiveness of vaccinations in preventing severe COVID-19 symptoms. However, in Poland, 40% of the population remains unvaccinated. OBJECTIVE: The objective of this study was to describe the natural history of COVID-19 in unvaccinated hospital patients in Warsaw, Poland. MATERIAL AND METHODS: This study evaluated data from 50 adult patients from the National Hospital in Warsaw, Poland, in the period 26 November 2021 to 11 March 2022. None of these patients had been vaccinated against COVID-19. RESULTS: Analysis showed that the average hospitalisation time for these unvaccinated COVID-19 patients was 13 days. Clinical deterioration was observed in 70% of these patients, 40% required the intensive care unit, and 34% subsequently died prior to the end of the study. CONCLUSIONS: There was a significant deterioration and high mortality rate in the unvaccinated patients. For this reason, it seems prudent to take measures to increase the vaccination coverage level of the population against COVID-19.

Patient satisfaction with pharmacist-administered COVID-19 vaccines in Poland: a survey study in the vaccination centres context.

BACKGROUND: Since 2021, pharmacists in Poland have been authorised to administer vaccinations against COVID-19, which is of particular significance in the efforts towards preventing the spread of the pandemic. The primary objective of this study was to evaluate the patients' satisfaction with delivering vaccinations through national vaccination centres. METHODS: This study was conducted in 2021. The research tool was an anonymous questionnaire distributed to patients after vaccination. The questionnaire was developed specifically for the purpose of the study. Ultimately, 628 patients participated in this study. RESULTS: Nearly 97% of the respondents agreed that the administration of vaccinations by pharmacists had been convenient, and pharmacists possessed the relevant skills to provide this service. Almost 90% of the respondents expressed their readiness to be vaccinated by pharmacists again. Nearly all the respondents indicated that pharmacists should also provide other vaccinations. CONCLUSIONS: Patients in Poland have a positive attitude toward vaccinations administered by pharmacists in national vaccination centres.

Implementation of the Patient Counselling Service at the Cancer Hospital in Radom, Poland.

Background: Non-adherence occurs in various groups of patients, including those with chronic diseases. One strategy to increase adherence among oncological patients is to individualise treatment and expand pharmaceutical care. Pharmaceutical labels that remind patients how they should take their medications are of great importance in this respect. Objective: The main objective of this study was to evaluate medication adherence in oncological patients, and to gather their opinions on the individual medication labelling system as an element of effective treatment. Methods: The study was conducted in 2021 among 82 patients of the oncological department of the Centre of Oncology in Radom. The research tool was a questionnaire consisting of personal data and two parts relating to the patient's disease and the medication labelling system. Results: Nearly half of the respondents reported that they forget to take medications and how they should take them. These problems increased with the age of the patient and the number of administered medications. Of the respondents, 89% stated that the labels with dosing information are helpful. Over 67% agreed that these labels should be affixed to all medications. Nearly 90% of the respondents believed the labels should be available in all pharmacies. Conclusions: Non-adherence is a common phenomenon among oncological patients. Pharmacists providing a labelling service for medicinal products can play a significant role in reducing this phenomenon.

Evaluation of a pharmacist-led intervention to improve medication adherence in patients initiating dabigatran treatment: a comparison with standard pharmacy practice in Poland.

BACKROUND: Dabigatran is a direct thrombin inhibitor used to treat cardiac arrhythmias, and rates of non-adherence to dabigatran in Polish populations are high. The current study examined how a pharmacist-led intervention of counselling with pictogram-enhanced medication instructions, and smartphone medication reminders, can improve adherence to dabigatran. METHODS: A 3-month pharmacist-led intervention was conducted in community pharmacies in Poland on 325 men and women filling a dabigatran prescription for the first time. Participating pharmacies were assigned into the Control Group (n = 172 patients) or the Intervention Group (n = 153 patients). The primary outcome of this prospective study was self-reported medication adherence assessed at 3 time points (day 7, day 21, and day 90) after initiation of dabigatran. RESULTS: Patients in the Intervention Group were significantly more adherent (mean days on Dabigatan/week) than the Control Group at 7 days (6.0 ± 0.9 vs 5.4 ± 1.1, p < 0.0001), 21 days (5.6 ± 1.0 vs 4.9 ± 1.3, p < 0.0001), and 90 days (5.5 ± 1.3 vs 4.4 ± 2.0, p < 0.0001), respectively. The percentage of patients in the Intervention Group who reported taking dabigatran twice/day as prescribed was significantly higher than the Control Group at 7 days (82.7% vs 71.4%, p = 0.0311), at 21 days (84.4% vs 58%, p < 0.0001), and at 90 days (78.4% vs 39.7%, p < 0.0001), respectively. The proportion of patients fully adherent (every day, twice/day) at 90 days was significantly higher in the Intervention Group than in the Control Group (26.1% vs 13.2%, p = 0.0145). CONCLUSIONS: Our findings support the role for interventions in community pharmacies in Poland to improve medication adherence, thus providing evidence for the efficacy of a pharmacist-led pictogram and smartphone-based program to support optimal dabigatran treatment.

Concerns, beliefs and attitudes of pharmacists and pharmacy students on cannabis use in Canada.

Background: Since cannabis has been legalized in Canada for medical and recreational use, there has been an increased demand on pharmacists for cannabis counselling. The objective of this study was to determine the concerns, beliefs and attitudes of Canadian pharmacists and pharmacy students towards using cannabis. Methods: An online survey was synthesized under 3 broad themes: concerns, beliefs and attitudes about cannabis, consisting of 27 questions capturing demographics and Likert scale responding to survey questions. We examined whether there were differences in responses by geographic location (i.e., Ontario, Quebec, Canada), sex or practice setting (i.e., community, hospital). Results: Across Canada, there were 654 survey respondents, with 399 in Ontario and 95 in Quebec. Approximately 24% indicated they had used cannabis since legalization, 69% indicated they believed cannabis should be available for medical and recreational use and 34% indicated their perceptions towards cannabis had become more positive since legalization. Relative to Quebec or the rest of Canada, respondents from Ontario were significantly more likely to be comfortable providing counselling to and answering questions of patients on the safety and efficacy of medical cannabis use. Examining sex differences across Canada, male respondents were more comfortable than female counselling patients on the safety and efficacy of medical cannabis. Conclusion: The current results reinforce the perceived need by pharmacists and pharmacy students for targeted education, and future research in cannabis education should consider potential gender differences in attitudes and beliefs surrounding cannabis therapy.

Opioid dose and postoperative respiratory adverse events after adenotonsillectomy in medically complex children.

STUDY OBJECTIVES: Obstructive sleep-disordered breathing is commonly treated with adenotonsillectomy. Our study objective was to describe perioperative opioid dosing in children with a range of medical complexity evaluated for obstructive sleep-disordered breathing undergoing adenotonsillectomy and to investigate its association with postoperative respiratory adverse events (PRAEs). METHODS: A retrospective chart review of children who underwent adenotonsillectomy and had preoperative polysomnography performed was conducted. PRAEs included requiring oxygen, jaw thrust, positive airway pressure, or mechanical ventilation. Multivariable logistic regression was performed to examine for associations between covariates and PRAEs. RESULTS: The cohort included 374 children with obstructive sleep-disordered breathing, median (interquartile range) age 6.1 (3.9, 9.3) years; 344 (92%) had obstructive sleep apnea (apnea-hypopnea index > 1 events/h) while 30 (8%) had a normal polysomnogram (apnea-hypopnea index < 1 events/h). The median (interquartile range) postoperative morphine-equivalent dose administered was 0.17 (0.09, 0.25) mg/kg. Sixty-six (17.6%) experienced at least 1 PRAE. Multivariable modeling identified the following predictors of PRAE: younger age at surgery (odds ratio 0.90, 95% confidence interval 0.83, 0.98), presence of cardiac comorbidity (odds ratio 2.07, 95% confidence interval 1.09, 3.89), and presence of airway anomaly (odds ratio 3.48, 95% confidence interval 1.30, 8.94). Higher total apnea-hypopnea index and morphine-equivalent dose were associated with PRAE risk, and an interaction between these variables was detected (P = .01). CONCLUSIONS: This study identified opioid dose in morphine equivalents to be a strong predictor of PRAE. Additionally, severity of obstructive sleep apnea and postoperative morphine-equivalent dose contributed together and independently to the occurrence of PRAEs. Attention to opioid dosing, particularly among medically complex children with obstructive sleep-disordered breathing, is required to mitigate risk of PRAEs. CITATION: Tsampalieros A, Murto K, Barrowman N, et al. Opioid dose and postoperative respiratory adverse events after adenotonsillectomy in medically complex children. J Clin Sleep Med. 2022;18(10):2405-2413.

Cannabis use in patients with insomnia and sleep disorders: Retrospective chart review.

Background: Medical cannabis has been increasingly used in Canada after being sanctioned by Health Canada in 2001. Insomnia and sleep disorders are among the most common conditions for which patients report using cannabis. Current research shows cannabis may have a beneficial effect in sleep disorders and may improve patient-reported sleep scores. Methods: A retrospective chart review was conducted at Hybrid Pharm community pharmacy in Ottawa, Ontario, and included patients who were interested in, or already using, medical cannabis for sleep disorders. A qualitative, exploratory approach was taken to evaluate the descriptive efficacy and safety of medical cannabis when prescribed for insomnia or comorbid conditions. The comprehensive data collection also involved investigating the impact of cannabis on other medication used for insomnia. Results: A total of 38 patients were identified as having adequate follow-up documentation to assess the impact of medical cannabis. At time of data collection, 15 patients (39%) were able to reduce or completely discontinue a prescription medication indicated for sleep. On follow-up, 27 patients (71%) reported a subjective improvement in their sleep or related condition. Only 8 patients (21%) reported any adverse effects from medical cannabis use, and these were manageable and did not require discontinuation of cannabis. Conclusion: This study highlights the importance of a pharmacist's role in the management of cannabis-based therapy, including ongoing supportive care, follow-up and medication management. Can Pharm J (Ott) 2022;155:xx-xx.

Pictograms for safer medication handling by health care workers: a validation study in nursing students in Poland.

BACKGROUND AND OBJECTIVE: Medication use often causes errors that are dangerous to the health of patients. Previous studies indicate that the use of pharmaceutical pictograms can effectively reduce medication errors. The purpose of this study was to determine the comprehensibility, representativeness, and recall rate of nine medication safety pictograms in a sample of nursing students in Poland in order to validate these images. METHODS: A pictogram validation study was conducted in two phases among nursing students at the Hipolit Cegielski State University of Applied Sciences, Gniezno, Poland. All experimental protocols were approved by the Children's Hospital of Eastern Ontario Research Ethics Board (REB Protocol No: 19/122X). All methods were carried out in accordance with relevant guidelines and regulations. In phase 1, the participants' first exposure to the pictograms, the students were asked to guess the meaning of the pictograms without any additional information in order to assess the pictograms' comprehensibility. To be considered valid, according to ISO standards, the pictograms had to be correctly understood by at least 66.7% of participants. After testing all pictograms, students were given explanations and meanings of the pictograms and asked to rate the representativeness of pictograms. To do so, participants were asked to select a number on a seven-point Likert-style scale to indicate the perceived strength of the relationship between the pictogram and its intended meaning for each pictogram. To be considered valid, a pictogram had to be rated at least five on this scale by at least 66.7% of participants. Phase 2 took place four weeks later, during which recall of the intended meaning and representativeness were assessed following the same procedure. RESULTS: A total of 66 third-year nursing students participated in both phases. In phase 1, of the nine pictograms, six met ISO requirements for comprehensibility and seven met ISO requirements for representativeness. In phase 2, all nine pictograms were correctly understood and rated at least 5 by at least 66.7% of participants. Therefore, all nine pictograms are considered valid. CONCLUSIONS: The nine medication safety pictograms can be deployed, but must be combined with training and a written hazard statement to improve comprehension.

Patient Perceptions on Receiving Vaccination Services through Community Pharmacies.

(1) Introduction: Pharmacists are medical professionals who play an active role in the protection of public health. Since 2021, pharmacists with an appropriate certification have been authorised to administer vaccines against COVID-19. (2) Objective: The objective of this study was to ascertain the perceptions of patients about receiving vaccinations through community pharmacies. (3) Material and methods: This study was conducted in 2021. The research tool was an anonymous questionnaire published on the websites of patient organisations. Ultimately, 1062 patients participated in this study. (4) Results: This study shows that most of the respondents find community pharmacies more accessible than outpatient clinics (85.3%). Sixty-one percent of the respondents stated that getting vaccinated at pharmacies would be less time consuming than at outpatient clinics. Nearly every third respondent (29.5%) declared that they would get vaccinated if they received such a recommendation from a pharmacist. Fifty-six percent of the respondents were of the opinion that the administration of vaccines by pharmacists would relieve the burden on medical staff and the healthcare system. (5) Conclusions: Polish patients participating in the study have a positive attitude towards the implementation of vaccination services in community pharmacies as an effective way of combating infectious diseases.

Development of Pediatric Hospital Position Statements on Medical and Non-Prescribed Cannabis.

The pediatric demand for medical cannabis has been increasing. This has necessitated the need to develop hospital statements and policies at the Children's Hospital of Eastern Ontario (CHEO) to provide clinicians and administrators with recommendations for working with patients and caregivers seeking the use of prescribed or non-prescribed cannabis. Through a structured working group, two hospital position statements and policies on the pediatric use of medical and non-prescribed cannabis were developed for patients served at CHEO. In highlighting the procedural framework and position statements, these policies provide valuable recommendations and resources to other hospitals seeking to develop similar administrative action. In a changing medical landscape, best practices and policies are needed for hospital administrators on the patient use of medical and non-prescribed cannabis. The authors highlight recent policy work and position statements from CHEO, providing a valuable reference to all pediatric and adult hospitals.

Two-month administration of methylphenidate improves olfactory sensitivity and suppresses appetite in individuals with obesity.

Olfaction contributes to feeding behaviour and is modulated by changes in dopamine levels. Methylphenidate (MPH) increases brain dopamine levels and has been shown to reduce appetite and promote weight loss in patients with attention deficit hyperactivity disorder. The objectives of this study were to test the effect of MPH on olfaction, appetite, energy intake, and body weight (BW) on individuals with obesity. In a randomized, double-blind study, 12 participants (age 28.9 ± 6.7 years) with a body mass index (BMI) of 36.1 ± 4.5 kg/m2 were assigned to MPH (0.5 mg/kg) (n = 5) or placebo (n = 7) twice daily for 2 months. Appetite (visual analog scale), odour threshold (Sniffin' Sticks®), energy intake (food menu), and BW (DEXA scan) were measured at day 1 and day 60. MPH intake significantly increased odour threshold scores (6.3 ± 1.4 vs. 9.4 ± 2.1 and 7.9 ± 2.3 vs. 7.8 ± 1.9, respectively; p = 0.029) versus placebo. There was a significantly greater suppression of appetite sensations (desire to eat (p = 0.001), hunger (p = 0.008), prospective food consumption (p = 0.003)) and an increase in fullness (p = 0.028) over time in the MPH versus placebo. MPH suppressed appetite and improved olfactory sensitivity in individuals with obesity. These data provide novel findings on the favourable effects of MPH on appetite and weight regulation in individuals living with obesity.

The plague of unexpected drug recalls and the pandemic of falsified medications in cardiovascular medicine as a threat to patient safety and global public health: A brief review.

Valsartan, losartan, and irbesartan, are widely used in the treatment strategies of cardiovascular medicine diseases, including hypertension and heart failure. Recently, many formulations for the aforementioned diseases contained active pharmaceutical ingredients and had been abruptly recalled from the market due to safety concerns mainly associated with unwanted impurities - nitrosamines, which are highly carcinogenic substances accidentally produced during manufacturing. Along with cardiovascular medications, formulations containing ranitidine were also recalled from the market. This poses a particular threat to public health due to the non-prescription status of these drugs. Regulatory authorities, including the Food and Drug Administration and European Medicines Agency among others, have taken action to minimize patient risk and improve the manufacturing quality as well as re-checking current guidelines and recommendations. While these steps are necessary to avoid further recalls, authorities should remember the growing concerns of patients regarding the safety and efficacy of pharmacotherapy. Apart from the genuine manufacturing mistakes mentioned above, falsified and counterfeit medications should be at the heart of global attention. The lack of a well-accepted definition of falsified/counterfeit medications has impeded political and scientific efforts to mitigate risk of this phenomenon. Falsified Medicines Directive should be considered the most pivotal legislation recently enacted to harmonize international cooperation. In summary, one should remember that only international and direct collaboration between patients, stakeholders, and authorities be considered a remedy for a pandemic of falsified medicines and plague of unexpected recalls due to safety concerns.

Validation of pharmaceutical pictograms among older adults with limited English proficiency.

OBJECTIVE: Pictograms on prescription medication labels enhance medication literacy and medication adherence. However, pictograms need to be contextually validated. We assessed the validity of 52 International Pharmaceutical Federation pictograms among 250 older Singaporeans with limited English proficiency. METHODS: Participants were randomly assigned 11 pictograms each. For each pictogram, participants were first asked its intended meaning. Then, they were told the intended meaning and asked to rate how well the pictogram represented the meaning, on a scale of 1-7. Pictograms were classified as valid (≥66% participants assigned the pictogram interpreted its intended meaning correctly [transparency criterion] and ≥85% participants rated its representativeness as ≥5 [translucency criterion]), partially valid (only transparency criterion was fulfilled) or not valid. Open-ended questions gathered feedback to improve pictograms. RESULTS: 14 pictograms (26.9%) achieved validity and 6 pictograms (11.5%) achieved partial validity. A greater proportion of pictograms for dose and route of administration, and dosage frequency achieved validity or partial validity versus those depicting precautions, indications or side effects. CONCLUSION: Majority (61.5%) of the assessed pictograms did not achieve validity or partial validity, highlighting the importance of contextual validation. PRACTICE IMPLICATIONS: Low pictogram comprehension emphasizes the importance of facilitating pictogram understanding during medication counseling.