Direct oral anticoagulants and the risk of adverse clinical outcomes among patients with different body weight categories: a large hospital-based study.

OBJECTIVE: Through predictable pharmacokinetics-including a convenient fixed-dose regimen, direct oral anticoagulants (DOACs) are preferred over previous treatments in anticoagulation for various indications. However, the association between higher body weight and the risk of adverse consequences is not well studied among DOAC users. We aim to explore the association of body weight and adverse clinical outcomes in DOAC users. METHODS: A total of 97,413 anonymised DOAC users in a tertiary care setting were identified following structured queries on the electronic health records (EHRs) to extract the feature-rich anonymised dataset. The prepared dataset was analysed, and the features identified with machine learning (ML) informed the adjustments of covariates in the multivariate regression analysis to examine the association. Kaplan-Meier analysis was performed to evaluate the mortality benefits of DOACs. RESULTS: Among DOAC users, the odds of adverse clinical outcomes, such as clinically relevant non-major bleeding (CRNMB), ischaemic stroke, all-cause mortality, and prolonged hospital stay, were lower in patients with overweight, obesity, or morbid obesity than in patients with normal body weight. The odds of ischaemic stroke (OR 0.42, 95% CI: 0.36-0.88, p = 0.001) and all-cause mortality (OR 0.87, 95% CI: 0.81-0.95, p = 0.001) were lower in patients with morbid obesity than in patients with normal body weight. In the Kaplan-Meier analysis, apixaban was associated with a significantly lower rate of mortality overall and in obesity and overweight subgroups than other DOACs (p < 0.001). However, rivaroxaban performed better than apixaban in the morbid obesity subgroup (p < 0.001). CONCLUSION: This study shows the positive effects of DOAC therapy on clinical outcomes, particularly in patients with high body weight. However, this still needs validation by further studies particularly among patients with morbid obesity.

Embracing Imatinib: a novel approach to safeguarding the endothelial barrier in patients with COVID-19.

Imatinib, an ABL tyrosine-kinase inhibitor, shows promise in restoring endothelial barrier function in patients with COVID-19, thus, preventing cytokine leakage from the alveolar compartment to the systemic compartment. COVID-19 is characterized by an alveolar cytokine storm, and imatinib has been shown to strengthen the endothelial barrier and mitigate alveolar inflammatory responses by modulating NF-κB signaling. Incorporating imatinib into COVID-19 treatment strategies offers a novel approach to safeguard the endothelial barrier and address the complex pathophysiology of the disease, including its potential implications in long COVID. Given that endothelial dysfunction plays a central role in COVID-19 progression and long COVID development, protecting the endothelial barrier during acute infection is crucial in preventing the persistent endothelial dysfunction associated with long COVID.

Intermediate- to high-dose dexamethasone versus low-dose dexamethasone in patients with COVID-19 requiring respiratory support: a systematic review and meta-analysis of randomized trials.

The present review critically appraised the randomized clinical trials that compared mortality outcomes between intermediate- to high-dose dexamethasone and low-dose dexamethasonein patients with COVID-19 and reported pooled mortality risk estimates associated with these two dosing regimens of dexamethasone. The systematic searching of electronic databases was limited to randomized clinical trials that compared mortality outcomes between intermediate- to high-dose dexamethasone with low-dose dexamethasone in patients with COVID-19 requiring respiratory support. The primary outcome of interest in this review was all-cause mortality. A total of eight trials with 1800 patients randomized to receive intermediate to high-dose dexamethasone and 1715 patients randomized to low-dose dexamethasone were included. The meta-analysis of six trials revealed no significant difference in the risk of 28-day all-cause mortality between intermediate- to high-dose dexamethasone and low-dose dexamethasone (odds ratio 1.16, 95% confidence interval, 0.77-1.74). Similarly, the meta-analysis of five trials revealed no significant difference between the two doses regarding 60-day all-cause mortality (odds ratio 0.96, 95% confidence interval 0.74-1.26). The results suggest intermediate- to high-dose dexamethasone to be as effective as low-dose dexamethasone in reducing the risk of mortality among patients with COVID-19 requiring respiratory support. However, higher dexamethasone doses could expose patients with COVID-19 to an increased risk of adverse events, such as hyperglycemia.

The effect of vitamin C on the risk of mortality in patients with COVID-19: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Vitamin C appears to be a viable treatment option for patients with COVID-19. METHODS: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) of vitamin C versus comparative interventions in patients with COVID-19. The outcome of interest was all-cause mortality. RESULTS: The meta-analysis of eleven trials using a random-effects model revealed significant reduction in the risk of all-cause mortality with the administration of vitamin C among patients with COVID-19 relative to no vitamin C (pooled odds ratio = 0.53; 95% confidence interval 0.30-0.92). Subgroup analysis of studies that included patients with severe COVID-19 also produced findings of significant mortality reduction with the administration of vitamin C relative to no vitamin C (pooled odds ratio = 0.47; 95% confidence interval 0.26-0.84). CONCLUSION: Overall, evidence from RCTs suggests a survival benefit for vitamin C in patients with severe COVID-19. However, we should await data from large-scale randomized trials to affirm its mortality benefits.

Systematic review and meta-analysis of anti-CD20 treatments in patients with COVID-19: an assessment of severe illness and mortality outcomes.

BACKGROUND: The use of anti-CD20 monoclonal antibodies, such as rituximab and ocrelizumab, has emerged as a matter of concern, in patients with coronavirus disease 2019 (COVID-19). OBJECTIVE: We aimed to summarize the overall evidence on the pre-admission/pre-diagnosis use of anti-CD20 among patients with COVID-19 with regards to mortality and severe illness outcomes. METHODS: A systematic literature search with no language restriction was performed in electronic databases, including PubMed, Google Scholar, Scopus, and preprint servers (medRxiv, Research Square, SSRN), to identify eligible studies published up to June 13, 2023. The outcomes of interest were the development of severe illness and all-cause mortality. A random-effects model was used to estimate the pooled odds ratio for outcomes of interest using anti-CD20 monoclonal antibodies relative to non-use of anti-CD20 monoclonal antibodies, at 95% confidence intervals. RESULTS: Our systematic review and meta-analysis revealed significantly increased odds for development of severe illness (pooled odds ratio 2.95; 95% confidence interval 2.30, 3.78; n = 534,349) and significantly increased odds for mortality (pooled odds ratio 2.14; 95% confidence interval 1.37, 3.35; n = 333,462) with the use of anti-CD20 monoclonal antibodies, relative to non-use of anti-CD20 monoclonal antibodies, in patients with COVID-19. CONCLUSION: Healthcare practitioners should exercise caution when prescribing these anti-CD20 monoclonal antibodies during the COVID-19 pandemic to patients who are indicated for these agents, particularly those with underlying conditions like multiple sclerosis or rheumatoid arthritis.

The effect of probiotics on the risk of mortality in patients with COVID-19: systematic review and meta-analysis of randomized trials.

Probiotics have been hypothesized to play a beneficial role in modulating immune responses and gut microbiota in various clinical settings. This systematic review and meta-analysis aimed to assess the effectiveness of probiotics in reducing all-cause mortality among patients diagnosed with COVID-19. We conducted a comprehensive search of the following databases: PubMed, Scopus, and Web of Science for published studies, and medRxiv, Research Square, and SSRN for preprints. The search spanned from the inception of these databases to April 4, 2023. We included studies that investigated the use of probiotics as an intervention and their impact on all-cause mortality in patients with COVID-19. A random-effects model meta-analysis was employed to estimate the pooled odds ratio, along with 95% confidence interval, to quantify the outcomes associated with probiotic use compared to other interventions. Our systematic review comprised six studies, encompassing a total of 642 patients. The meta-analysis, employing a random-effects model, demonstrated a statistically significant reduction in the risk of all-cause mortality when probiotics were administered to patients with COVID-19, compared to those not receiving probiotics (pooled odds ratio = 0.44; 95% confidence interval 0.24-0.82). In conclusion, evidence derived from randomized controlled trials (RCTs) indicates a survival benefit associated with the use of probiotics among COVID-19 patients. However, it is essential to exercise caution and await data from large-scale randomized trials to definitively confirm the mortality benefits of probiotics in this patient population.

Community pharmacist's preparedness to provide patient-centred care in Saudi Arabia.

Background: Community pharmacy practice in Saudi Arabia is evolving and needs to be at par with the developed world. Community pharmacists can play a vital role in bridging gaps in the delivery of healthcare services by providing patient-centred care to patients and contributing toward the healthcare transformation plan of vision 2030 of Saudi Arabia. The present study is aimed at evaluating the knowledge, attitude, and practices of community pharmacists in delivering patient-centred care services. Method: A nationwide cross-sectional survey using a validated and pre-tested 27-item self-reported questionnaire was conducted amongst 301 (86.4% male, 13/6% female) community pharmacists from all regions of Saudi Arabia. Both descriptive and inferential analysis was employed using the SPSS version, with 0.05 as the level of significance. Results: Community pharmacists from chain pharmacy groups, female gender and staff community pharmacists had statistically better overall practice standards, knowledge, and attitude to conduct patient-centred care services (p less than 0.01). The majority of community pharmacists would expect extra remuneration and participation in structured professional skills development programs to provide patient-centred care efficiently. Inaccessibility of patient data from healthcare facilities, the unavailability of informative literature, and administrative workload were among the barriers cited in delivering patient-centred care. Conclusion: The study findings show that community pharmacists could play a significant role in providing patient-centred care and contribute to the achievement of the healthcare reform agenda of Saudi Arabia. However, some obstacles must be overcome before this practice can be shifted, including the introduction of a formalized continuing professional development program, financial incentives, and a decrease in the administrative burden on pharmacists. The results of this study may help policymakers in Saudi Arabia better comprehend the country's existing approach to community pharmacy practice.

Use of Calcium Channel Blockers and the Risk of All-cause Mortality and Severe Illness in Patients With COVID-19: A Systematic Review and Meta-analysis.

ABSTRACT: Owing to the reported safety concerns, we aimed to perform a systematic review and meta-analysis to determine the effect of preadmission/prediagnosis use of calcium channel blockers (CCBs) on the clinical outcomes in patients with COVID-19. A systematic literature search with no language restriction was conducted in electronic databases in July 2021 to identify eligible studies. The outcomes of interest were all-cause mortality and severe illness. A random-effects model was used to estimate the pooled summary measure for outcomes of interest with the preadmission/prediagnosis use of CCBs relative to nonuse CCBs, at 95% confidence intervals (CIs). The meta-analyses revealed no significant difference in the odds of all-cause mortality [pooled odds ratio (OR) = 0.82; 95% CI 0.68-1.00; n = 58,355] and in the odds of severe illness (pooled OR = 0.83; 95% CI 0.61-1.15; n = 46,091) respectively, with preadmission/prediagnosis use of CCBs relative to nonuse of CCBs. Nevertheless, subgroup analysis of studies originated from East Asia reported a significant reduction in the odds of all-cause mortality (pooled OR = 0.50; 95% CI 0.37-0.68) and the odds of severe illness (pooled OR = 0.51; 95% CI 0.33-0.78). There may not be safety concerns with the use of CCBs in patients with COVID-19, but their potential protective effects in the East Asian patients merit further investigations.

Preadmission use of inhaled corticosteroids and risk of fatal or severe COVID-19: a meta-analysis.

Objective: With emerging of observational evidence, we aimed to perform a meta-analysis to summarize the overall effect of the chronic use of inhaled corticosteroids on the clinical outcomes in patients with coronavirus disease 2019 (COVID-19). Methods:Systematic literature search in electronic databases was performed to identify observational studies that investigated the preadmission use of inhaled corticosteroids on the risk of a fatal or severe course of illness in patients with COVID-19 and reported adjusted measures of association. Adjusted odds ratios or relative risks and the corresponding 95% confidence intervals from each study were pooled to produce pooled odds ratio and 95% confidence interval. Results: The meta-analysis revealed no significant difference in the risk for the development of a fatal course of COVID-19 with preadmission use of inhaled corticosteroids in patients with COVID-19 relative to non-use of inhaled corticosteroids (pooled odds ratio=1.28; 95% confidence interval 0.73-2.26). Similarly, the meta-analysis observed no significant difference in the risk for the development of a severe course of COVID-19 with preadmission use of inhaled corticosteroids in patients with COVID-19 relative to non-use of inhaled corticosteroids (pooled odds ratio=1.45; 95% confidence interval 0.96-2.20).Conclusions: Our findings assured the safety of continued use of inhaled corticosteroids during the COVID-19 pandemic.

The effect of higher-intensity dosing of anticoagulation on the clinical outcomes in hospitalized patients with COVID-19: A meta-analysis of randomized controlled trials.

OBJECTIVE: We aimed to perform a meta-analysis to summarize the overall evidence from randomized controlled trials related to higher-intensity anticoagulation in hospitalized patients with COVID-19. METHODS: A systematic literature search was performed in electronic databases to identify randomized controlled trials comparing the clinical outcomes between intermediate/ therapeutic anticoagulation and prophylactic anticoagulation. Meta-analyses with random-effects models were used to estimate the pooled odds ratio (OR) for outcomes of interest at a 95% confidence interval (CI). RESULTS: Eight randomized controlled trials were included, with a total of 5405 hospitalized patients with COVID-19. The meta-analysis revealed no statistically significant difference in the odds of mortality (pooled OR = 0.92; 95% CI 0.71-1.19) but a statistically significant reduction in the odds of development of thrombotic events (pooled OR = 0.55; 95% CI 0.42-0.72), and significantly increased odds of development of major bleeding (pooled OR = 1.81; 95% CI 1.20-2.72) with the use of intermediate/therapeutic anticoagulation, relative to prophylactic anticoagulation. Subgroup analysis in patients with a severe course of COVID-19 observed a statistically significant reduction in the odds of development of thrombotic events (pooled OR = 0.66; 95% CI 0.45-0.98) but no significant difference in the odds of development of major bleeding events (pooled OR = 1.37; 95% CI 0.74-2.56), with the use of intermediate/therapeutic anticoagulation, relative to prophylactic anticoagulation. CONCLUSION: There could be net clinical benefits with higher-intensity dosing of anticoagulation relative to prophylactic-dosing of anticoagulation among hospitalized patients with severe COVID-19.

Risk Factors Associated with Mortality in COVID-19 Hospitalized Patients: Data from the Middle East.

This study aimed to assess the risk factors for COVID-19 mortality among hospitalized patients in Jordan. All COVID-19 patients admitted to a tertiary hospital in Jordan from September 20, 2020, to August 8, 2021, were included in this study. Demographics, clinical characteristics, comorbidities, and laboratory results were extracted from the patients' electronic records. Multivariable logistic and machine learning (ML) methods were used to study variable importance. Out of 1,613 COVID-19 patients, 1,004 (62.2%) were discharged from the hospital (survived), while 609 (37.8%) died. Patients who were of elderly age (>65 years) (OR, 2.01; 95% CI, 1.28-3.16), current smokers (OR, 1.61; 95%CI, 1.17-2.23), and had severe or critical illness at admission ((OR, 1.56; 95%CI, 1.05-2.32) (OR, 2.94; 95%CI, 2.02-4.27); respectively), were at higher risk of mortality. Comorbidities including chronic kidney disease (OR, 2.90; 95% CI, 1.90-4.43), deep venous thrombosis (OR, 2.62; 95% CI, 1.08-6.35), malignancy (OR, 2.22; 95% CI, 1.46-3.38), diabetes (OR, 1.31; 95% CI, 1.04-1.65), and heart failure (OR, 1.51; 95% CI, 1.02-2.23) were significantly associated with increased risk of mortality. Laboratory abnormalities associated with mortality included hypernatremia (OR, 11.37; 95% CI, 4.33-29.81), elevated aspartate aminotransferase (OR, 1.81; 95% CI, 1.42-2.31), hypoalbuminemia (OR, 1.75; 95% CI, 1.37-2.25), and low platelets level (OR, 1.43; 95% CI, 1.05-1.95). Several demographic, clinical, and laboratory risk factors for COVID-19 mortality were identified. This study is the first to examine the risk factors associated with mortality using ML methods in the Middle East. This will contribute to a better understanding of the impact of the disease and improve the outcome of the pandemic worldwide.

The use of neutralizing monoclonal antibodies and risk of hospital admission and mortality in patients with COVID-19: a systematic review and meta-analysis of randomized trials.

AIM: Several randomized trials have evaluated the effect of neutralizing monoclonal antibodies on the risk of hospital admission and risk of mortality in patients with COVID-19. We aimed to summarize the overall evidence in the form of a systematic review and meta-analysis. METHODS: A systematic literature search with no language restriction was performed in electronic databases and preprint repositories to identify eligible studies published up to 29 June 2021. The outcomes of interest were hospital admission and all-cause mortality. A random-effects model was used to estimate the pooled odds ratio (OR) for outcomes of interest with the use of neutralizing monoclonal antibodies relative to nonuse of neutralizing monoclonal antibodies, at 95% confidence intervals (CI). RESULTS: Our systematic literature search identified nine randomized controlled trials. Three trials had an overall low risk of bias, while four trials had some concerns in the overall risk of bias. The meta-analysis revealed no statistically significant difference in the odds of mortality (pooled OR = 0.69; 95% CI 0.33-1.47), but a statistically significant reduction in the odds of hospital admission (pooled OR = 0.29; 95% CI 0.21-0.42), with the administration of a neutralizing monoclonal antibody among patients with COVID-19, relative to non-administration of a neutralizing monoclonal antibody, at the current sample size. CONCLUSION: The reduced risk of hospital admission with neutralizing monoclonal antibodies use suggests that the timing of neutralizing antibodies administration is key in preventing hospital admission and, ultimately, death. Future randomized trials should aim to determine if the clinical outcomes with neutralizing monoclonal antibodies differ based on serostatus.

The effectiveness of BNT162b2 mRNA vaccine against COVID-19 caused by Delta variant of SARS-CoV-2: a systematic review and meta-analysis.

Meta-analyses were utilized to determine the overall effectiveness of BNT162b2 mRNA vaccine (Pfizer vaccine) against COVID-19 caused by Delta variant from large real-world studies. A systematic literature search with no language restriction was performed in electronic databases to identify eligible observational studies that reported the effectiveness of the BNT162b2 mRNA vaccine to prevent reverse transcription-polymerase chain reaction (RT-PCR) confirmed COVID-19 caused by Delta variant of SARS-CoV-2 (B.1.617.2). Random-effects meta-analysis model was used to estimate the pooled odds ratio (OR) at a 95% confidence interval, and the vaccine effectiveness was indicated as (pooled OR - 1)/OR. Seven studies were included for this meta-analysis. The meta-analysis revealed that the administration of BNT162b2 mRNA vaccine protected against RT-PCR confirmed COVID-19 caused by Delta variant ≥ 21 days after the first dose, with vaccine effectiveness of 55% (95% confidence interval 46-63%), as well as ≥ 14 days after the second dose, with vaccine effectiveness of 81% (95% confidence interval 69-88%). In conclusion, the BNT162b2 mRNA vaccine offers a substantial protection rate against RT-PCR confirmed COVID-19 caused by the Delta variant upon full vaccination, albeit with slightly reduced effectiveness relative to other strains of SARS-CoV-2.

The effect of tocilizumab on mortality in hospitalized patients with COVID-19: a meta-analysis of randomized controlled trials.

OBJECTIVE: We aimed to perform a meta-analysis of randomized controlled trials (RCTs) to summarize the overall effect of tocilizumab on the risk of mortality among patients with coronavirus disease 2019 (COVID-19). METHODS: We systematically searched PubMed, Cochrane Central Register of Controlled Trials, Google Scholar, and medRxiv (preprint repository) databases (up to 7 January 2021). Pooled effect sizes with 95% confidence interval (CI) were generated using random-effects and inverse variance heterogeneity models. The risk of bias of the included RCTs was appraised using version 2 of the Cochrane risk-of-bias tool for randomized trials. RESULTS: Six RCTs were included: two trials with an overall low risk of bias and four trials had some concerns regarding the overall risk of bias. Our meta-analysis did not find significant mortality benefits with the use of tocilizumab among patients with COVID-19 relative to non-use of tocilizumab (pooled hazard ratio = 0.83; 95% CI 0.66-1.05, n = 2,057). Interestingly, the estimated effect of tocilizumab on the composite endpoint of requirement for mechanical ventilation and/or all-cause mortality indicated clinical benefits, with some evidence against our model hypothesis of no significant effect at the current sample size (pooled hazard ratio = 0.62; 95% CI 0.42-0.91, n = 749). CONCLUSION: Despite no clear mortality benefits in hospitalized patients with COVID-19, tocilizumab appears to reduce the likelihood of progression to mechanical ventilation.

Concordance of recommendations across clinical practice guidelines for the management of hypertension in Southeast Asia with internationally reputable sources.

OBJECTIVES: This study aimed to assess the rate of concordance, and to investigate sources of non-concordance of recommendations in the management of hypertension across CPGs in Southeast Asia, with internationally reputable clinical practice guidelines (CPGs). METHODS: CPGs for the management of hypertension in Southeast Asia were retrieved from the websites of the Ministry of Health or cardiovascular specialty societies of the individual countries of Southeast Asia during November to December 2020. The recommendations for the management of hypertension specified in the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline and the 2018 European Society of Cardiology (ESC)/European Society of Hypertension (ESH) guideline were selected to be the reference standards; the recommendations concerning the management of hypertension in the included CPGs in Southeast Asia were assessed if they were concordant with the reference recommendations generated from both the 2017 ACC/AHA guideline and the 2018 ESC/ESH guideline, using the population (P)-intervention (I)-comparison (C) combinations approach. RESULTS: A total of 59 reference recommendations with unique and unambiguous P-I-C specifications was generated from the 2017 ACC/AHA guideline. In addition, a total of 51 reference recommendations with unique and unambiguous P-I-C specifications was generated from the 2018 ESC/ESH guideline. Considering the six included CPGs from Southeast Asia, concordance was observed for 30 reference recommendations (50.8%) out of 59 reference recommendations generated from the 2017 ACC/AHA guideline and for 31 reference recommendations (69.8%) out of 51 reference recommendations derived from the 2018 ESC/ESH guideline. CONCLUSIONS: Hypertension represents a significant issue that places health and economic strains in Southeast Asia and demands guideline-based care, yet CPGs in Southeast Asia have a high rate of non-concordance with internationally reputable CPGs. Concordant recommendations could perhaps be considered a standard of care for hypertension management in the Southeast Asia region.

Prescribing trends of oral anticoagulants in England over the last decade: a focus on new and old drugs and adverse events reporting.

Direct-acting oral anticoagulants (DOACs) are replacing conventional VKA (vitamin K antagonist, i.e., warfarin) for various indications where a therapeutic anticoagulant effect is desired. We evaluated the prescribing patterns of the DOACs and warfarin, cost implications of the increasing DOACs prescribing, and deduce the reporting of serious and fatal events, during 2009-2019 in primary care England. Prescriptions and fatal or serious adverse events reporting data, between 2009 and 2019 were analysed, using linear regression to examine the trends in prescriptions, costs, and serious and fatal events reporting. We also compared the prescribing trends of four direct-acting oral anticoagulants and warfarin, normalised to per 1000 clinical commissioning group (CCG) patient population for the year 2019 to better understand the regional differences in DOACs prescribing. The overall use of any DOACs (as a proportion of total anticoagulants) increased from 16% in 2015 to 62% in 2019 with an average increase of 87% (95% CI 83.1, 90.5) per year. The reporting of serious and fatal events associated with DOACs decreased by 6% (95% CI 12.5, - 0.1) per year. Apixaban is by far the most prescribed with an average drug cost increasing to 156% (95% CI 140, 172) per year. In England, the lowest anticoagulant prescribing region was Greater London whereas the highest prescribing regions were Yorkshire and Humber for DOACs and the East Midlands for warfarin. Interestingly, Lancashire, Merseyside, and Cheshire showed a higher usage for warfarin over DOACs. The differing prescription patterns could be a result of changes in national guidelines and increasing population. Nevertheless, DOACs appear to make an increasing contribution to total anticoagulant prescription items and costs.

Use of potentially inappropriate medications among older outpatients and inpatients in a tertiary care hospital in Malaysia.

BACKGROUND: Older individuals are seemingly having more medical conditions, which predispose them to a greater risk of polypharmacy. Potentially inappropriate medications (PIMs), including those having anticholinergic and sedative properties, are common in their prescriptions, often associated with functional decline and negative health outcomes. Thus, this study reports proportions of inappropriate drugs and drug burden exposures and its correlation with patient-reported outcomes (PROs) among cognitively intact older adults admitted to a ward or visiting the outpatient clinic at a tertiary care hospital in Malaysia. METHODS: This cross-sectional study included data from 344 older (173 inpatients and 171 outpatients) patients, aged 60 years and above, through validated questionnaires. Medication appropriateness was assessed via Medication Appropriateness Index (MAI) tool, whereas Beers and Screening Tool of Older Person's Potentially Inappropriate Prescribing (STOPP) criteria were used to evaluate PIMs and potentially inappropriate prescribing (PIP), respectively. The Drug Burden Index (DBI) and polypharmacy, as well as PROs, included Groningen Frailty Indicator (GFI), Katz Index of Independence in Activities of Daily Living (Katz ADL) and Older People's Quality of Life (OPQOL) were also evaluated. RESULTS: Overall, inpatients received significantly higher medications (6.90 ± 2.70 vs 4.49 ± 3.20) than outpatients. A significantly higher proportion of inpatients received at least one PIM (65% vs 57%) or PIP (57.4% vs 17.0%) and higher mean MAI score (1.76 ± 1.08 and 1.10 ± 0.34) and DBI score (2.67 ± 1.28 vs 1.49 ± 1.17) than outpatients. Inpatients had significantly higher total OPQOL (118.53 vs 79.95) and GFI score (5.44 vs 3.78) than outpatients. We only found significant correlations between GFI and DBI and total OPQOL and the number of PIMs. CONCLUSIONS: Proportions of PIMs and DBI exposure were significantly higher in an inpatient setting. No significant correlations between exposures to inappropriate medications or drug burden and PROs were observed.

The impact of clinical pharmacist services on patient health outcomes in Pakistan: a systematic review.

BACKGROUND: The pharmacist's role shifts from dispensing to bedside care, resulting in better patient health outcomes. Pharmacists in developed countries ensure rational drug use, improve clinical outcomes, and promote health status by working as part of a multidisciplinary team of healthcare professionals. However, clinical pharmacist services on healthcare utilization in low-and middle-income countries (LMICs) like Pakistan are unclear. As a result, we aim to systematically review pharmacists' clinical roles in improving Pakistani patients' therapeutic, safety, humanistic, and economic outcomes. METHODS: We searched PubMed, Scopus, EMBASE, CINAHL, and Cochrane Library for relevant articles published from inception to 28th February 2021. All authors were involved in the screening and selection of studies. Original studies investigating the therapeutic, humanistic, safety, and economic impact of clinical pharmacists in Pakistani patients (hospitalised or outpatients) were selected. Two reviewers independently assessed the risk of bias in studies, and discrepancies were resolved through mutual consensus. All of the included studies were descriptively synthesised, and PRISMA reporting guidelines were followed. RESULTS: The literature search found 751 articles from which nine studies were included; seven were randomized controlled trials (RCTs), and two were observational studies. Three RCTs included were having a low risk of bias (ROB), two RCTs were having an unclear ROB, while two RCTs were having a high ROB. The nature of clinical pharmacist interventions included one or more components such as disease-related education, lifestyle changes, medication adherence counselling, medication therapy management, and discussions with physicians about prescription modification if necessary. Clinical pharmacist interventions reduce medication-related errors, improve therapeutic outcomes such as blood pressure, glycemic control, lipid control, CD4 T lymphocytes, and renal functions, and improve humanistic outcomes such as patient knowledge, adherence, and health-related quality of life. However, no study reported the economic outcomes of interventions. CONCLUSIONS: The findings of the studies included in this systematic review suggest that clinical pharmacists play important roles in improving patients' health outcomes in Pakistan; however, it should be noted that the majority of the studies have a high risk of bias, and more research with appropriate study designs is needed.

Frailty and potentially inappropriate medications using the 2019 Beers Criteria: findings from the Australian Longitudinal Study on Women's Health (ALSWH).

BACKGROUND: Frailty is an essential consideration with potentially inappropriate medications (PIMs), especially among older women. AIMS: This study determined the use of potentially inappropriate medications according to frailty status using the Beers Criteria 2019, identified medications that should be flagged as potentially inappropriate and harmful depending on individual health factors, and determined the association between frailty and PIMs, adjusted for characteristics associated with PIMs. METHODS: This prospective longitudinal study included 9355 participants aged 77-82 years at baseline (2003). Frailty was measured using the FRAIL (fatigue, resistance, ambulation, illness and loss of weight) scale. Generalised estimating equations using log-binomial regressions determined the association between frailty and risk of using PIMs. RESULTS: Among participants who were frail and non-frail at baseline, the majority used ≥ 3 PIMs (74.2% and 58.5%, respectively). At 2017, the proportion using ≥ 3 PIMs remained constant in the frail group (72.0%) but increased in the non-frail group (66.0%). Commonly prescribed medications that may be potentially inappropriate in both groups included benzodiazepines, proton-pump inhibitors and non-steroidal anti-inflammatory drugs, and risperidone was an additional contributor in the non-frail group. When adjusted for other characteristics, frail women had a 2% higher risk of using PIMs (RR 1.02; 95% CI 1.01, 1.03). CONCLUSION: Given that the majority of frail women were using medications that may have been potentially inappropriate, it is important to consider both frailty and PIMs as indicators of health outcomes, and to review the need for PIMs for women aged 77-96 years who are frail.

Common combinations of medications used among oldest-old women: a population-based study over 15 years.

BACKGROUND: Older people use many medications, but combinations of medications used among the oldest old (≥ 80 years) are not commonly reported. AIMS: This study aimed to determine common combinations of medications used among women aged 77-96 years and to describe characteristics associated with these combinations. METHODS: A cohort study of older women enroled in the Australian Longitudinal Study on Women's Health over a 15-year period was used to determine combinations of medications using latent class analysis. Multinomial logistic regression was used to determine characteristics associated with these combinations. RESULTS: The highest medication users during the study were for the cardiovascular (2003: 80.28%; 2017: 85.63%) and nervous (2003: 66.03%; 2017: 75.41%) systems. A 3-class latent model described medication use combinations: class 1: 'Cardiovascular & neurology anatomical group' (27.25%) included participants using medications of the cardiovascular and nervous systems in their later years; class 2: 'Multiple anatomical group' (16.49%) and class 3: 'Antiinfectives & multiple anatomical group' (56.27%). When compared to the reference class (class 1), the risk of participants being in class 3 was slightly higher than being in class 2 if they had > 4 general practitioner visits (RRR 2.37; 95% CI 2.08, 2.71), Department of Veterans Affairs' coverage (RRR 1.59; 95% CI 1.36, 1.86), ≥ 4 chronic diseases (RRR 3.16; 95% CI 2.56, 3.90) and were frail (RRR 1.47; 95% CI 1.27, 1.69). CONCLUSION: Identification of combinations of medication use may provide opportunities to develop multimorbidity guidelines and target medication reviews, and may help reduce medication load for older individuals.