Parents' priorities for decision-making of pediatric epilepsy treatments and perceived needs for decision support in multi-ethnic Asian clinical setting: A qualitative analysis.

OBJECTIVE: To identify parents' priorities when making a decision on genetic testing and antiseizure drug (ASD) options for pediatric epilepsy and their support needs for informed decision-making in multi-ethnic Asian clinical settings. METHODS: Qualitative in-depth interviews, using a semi-structured interview guide, were conducted with purposively selected parents of pediatric patients with newly diagnosed epilepsy or known diagnosis of epilepsy (n = 26). Interviews were audio recorded and transcribed verbatim. Thematic analysis was undertaken to generate themes. RESULTS: Parents' narratives showed difficulty assimilating information, while knowledge deficit and emotional vulnerability led parents' desire to defer a decision for testing and ASDs to mitigate decisional burden. Priorities for decisions were primarily based on intuitive ideas of the treatment's risks and benefits, yet very few could elaborate on tradeoffs between risks and efficacy. Priorities outside the purview of the healthcare team, such as children's emotional wellbeing and family burden of ASD administration, were also considered important. Authority-of-medical-professional heuristic facilitated the ASD decision for parents who preferred shared rather than sole responsibility for a decision. Importantly, parents' support needs for informed decision-making were very much related to the availability of support mechanisms in post-treatment decisions owing to perceived uncertainty of the chosen ASD. CONCLUSIONS: Findings suggest that multiple priorities influenced ASD decision process. To address support needs of parents for informed decision-making, more consideration should be given to post-treatment decision support through the provision of educational opportunities, building peer support networks, and developing a novel communication channel between healthcare providers and parents.

Impact of pharmacists' counseling on caregiver's knowledge in the management of pediatric atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a common skin condition in childhood. AD management can be complex, and caregivers may have inadequate information on the disease, aggravating factors, and management. Comprehensive therapeutic education has been closely associated with increased compliance and is recommended for all patients. There are, as yet, no studies on the impact of a pharmacist-led eczema counseling service. OBJECTIVES: The primary objective was to assess the impact of a pharmacist-led eczema counseling service on improving caregivers' knowledge. The secondary objective was to evaluate caregivers' satisfaction of the service and their confidence in handling the patient's condition after counseling. METHODS: This was a prospective, questionnaire-based observational study. After obtaining informed consent, caregivers were required to complete questionnaire A, containing items on demographics and knowledge assessment. Caregivers then underwent a counseling session by a dermatology-trained pharmacist. After counseling, caregivers were required to complete questionnaire B containing items on satisfaction and confidence level. A follow-up phone call was conducted after initial counseling session, during which knowledge-based questionnaire C would be completed. RESULTS: Data from 32 participants were included in the analysis. There was a significant improvement in caregivers' knowledge score after receiving counseling, with mean precounseling score of 8.38 ± 3.92 and mean postcounseling score of 13.88 ± 3.65 (P < 0.001). Majority was satisfied with the service and was confident in handling their child's condition. CONCLUSION: Pharmacist-led eczema counseling has a positive impact on caregiver's knowledge and can lead to improved compliance. The service was well received, although more time could be spent during the counseling.

Complementary and alternative medicines use among pediatric patients with epilepsy in a multiethnic community.

OBJECTIVE: Prior studies highlighted that patients on chronic medications who used complementary and alternative medicines (CAMs) did not share this information with their healthcare providers. Furthermore, there might be potential adverse interactions between CAMs and antiepileptic drug (AED) therapy. However, there are no studies that investigate the effect of religion or race on CAM use in a multiethnic community. Therefore, we aimed to investigate CAM usage among pediatric patients with epilepsy (PPE) and identify predictors of CAM usage in our multiethnic setting. METHODS: This was a cross-sectional study where caregivers of recruited at an outpatient epilepsy clinic between September 2013 and July 2014 completed a self-administered survey. Those who declined participation, lacked understanding of English or Mandarin, or missed the clinic appointments were excluded. Those caring for more than one patient participated only once. RESULTS: Of the 195 surveys collected, 178 were used for analysis. The PPE used an average of 1.50 AEDs (range: 0-4). Forty-nine (27.5%) caregivers reported giving CAMs to their PPE. Commonly used CAMs were multivitamins (44.4%), traditional herbs (42.2%), and acupuncture (17.4%). Multivitamins were mostly given by Christian/Catholic caregivers while Buddhist caregivers mostly gave traditional herbs or acupuncture. The majority of the CAM users were Chinese. Univariate analysis showed that caregivers with secondary school (high school) education were 3.52 times more likely to use CAMs compared to those with primary school (elementary school) education. CONCLUSIONS: While some caregivers gave CAMs to their PPE, they had various misconceptions and did not discuss the usage with their healthcare providers. We propose that the predictors identified in this study can help to identify potential CAM users. Healthcare providers should routinely probe about the usage of CAMs by PPE, and thereafter, the suitability of CAM use could be evaluated. The caregivers will benefit from open discussion with healthcare professionals on the safe use of AEDs with or without CAMs.

Maintaining Updated Patient's Medication Records: Introduction of an Order-on-Behalf Service by Pharmacists.

INTRODUCTION: Accurate medication records are integral to healthcare, especially for obstetrics and gynecology and pediatric patients. When pharmacists perform verbal interventions with prescribers, these were often not updated in the patients' medication records. To address this issue, the order-on-behalf (OOB) service by pharmacists was implemented in late November 2015, with the aim of providing timely updates of patients' medication records. The impact of service will be evaluated in this article. METHODS: The OOB records from December 2015 to April 2017 were collected and reviewed. Details collected include patient type, date performed, date of prescription, and details of interventions. Respective pharmacists who entered the orders were approached for further clarifications, where required. This was a process improvement project exempted from review. RESULTS: A total of 1501 entries (824 for women, 677 for children) were reviewed. Top three medication-related problems identified were inappropriate dosage regimen (845), improper drug selection (185), and therapeutic substitution (226). The most commonly implicated drugs were hormones (28%) and antibiotics (18%) for obstetrics and gynecology-related entries and antibiotics (27%) and antiepileptic drugs (6%) for pediatric-related entries. CONCLUSIONS: The OOB service has updated many patients' medication records. Having updated records enhances patient safety because it provides the most accurate information for the prescribers at the next patient visit. Review of OOB data identified the most common types of medication-related problems, as well as the patient subtypes involved. This provides a platform for future work to be performed on system optimizations to improve patient safety.

Association of carbamazepine-induced severe cutaneous drug reactions and HLA-B*1502 allele status, and dose and treatment duration in paediatric neurology patients in Singapore.

OBJECTIVES: To determine the association between severe cutaneous drug reactions (SCDR), HLA-B*1502 allelism, carbamazepine dose and treatment duration in a Singapore paediatric population. METHOD: Case-control study of SCDR with carbamazepine and HLA-B*1502. We recruited 32 cases, 5 with Steven Johnson Syndrome/Toxic Epidermolytic Necrolysis (SJS/TEN) (2 Chinese, 3 Malay), 6 with hypersensitivity syndrome (HSS) (5 Chinese, 1 Indian), 11 with minor drug reactions (9 Chinese, 2 Malay) and 10 controls (7 Chinese, 2 Malay, 1 Indian). HLA-B*1502 allelism was assayed. HLA-B*1502 status and the type of drug reaction were compared using univariate analysis. The time-span from treatment onset to reaction and the dose-time to reaction association in the 3 groups were analysed. RESULTS: HLA-B*1502 was positive in: 5/5 (SJS/TEN), 0/6 (HSS), 1/11 (minor drug reactions) and 1/10 controls. OR for SJS/TEN in HLA-B*1502-positive patients relative to that in HLA-B*1502-negative patients was estimated by exact logistic regression to be 27.20 (95% CI 2.67 to ∞). Median treatment duration (days) until allergic reactions was 12 (range 11-13), 16 (range 10-37) and 11 (range 0-63) for SJS/TEN, HSS and minor drug reactions, respectively. Median dose at onset of reactions was 6.2 mg/kg/day (range 4.6-7.4), 9.8 mg/kg/day (range 7.7-12.2) and 6.7 mg/kg/day (range 3.6-20.0) for the 3 groups, respectively. CONCLUSIONS: HLA-B*1502 positivity increases the odds of carbamazepine-induced SCDR in Singapore children of Chinese and Malay ethnicity. Adverse drug reactions to carbamazepine occurred within 2 weeks and at low doses.

The impact of pharmacist's counseling on pediatric patients' caregiver's knowledge on epilepsy and its treatment in a tertiary hospital.

BACKGROUND: Epilepsy is a chronic condition requiring compliance to long treatment regimes. Knowledge on epilepsy can affect compliance to treatment. Pediatric epileptic patients need caregivers for their care; however, prior research showed that caregivers had inadequate knowledge in epilepsy. In view of this, outpatient pharmacist epilepsy service was set up in collaboration with neurologists to bridge knowledge gaps. OBJECTIVE: To determine if caregiver education provided by outpatient pharmacists is associated with improved knowledge in epilepsy and its management. SETTING: Pediatric outpatient clinic at a pediatric and women's health hospital. METHODS: A cross-sectional pre- to post-intervention study using scores of caregiver knowledge of epilepsy as the primary outcome was conducted. The intervention was one counseling session by pharmacists. A knowledge questionnaire (A) was administered to the caregiver to obtain baseline information before the session and readministered by telephone (C) 2 weeks post-session. Additionally, a perception questionnaire (B) was administered immediately after the session. MAIN OUTCOME MEASURE: Knowledge scores pre and post pharmacist counseling. RESULTS: Twenty-seven completed questionnaire sets (A, B and C) were collected from 55 caregivers who received the intervention (response rate = 49 %) between September 2010 and May 2011. Average post-counseling knowledge scores was significantly higher than pre-counseling scores (14.7 vs. 10.4, p = 0.000) (score range -21 to 21). Caregivers' confidence to administer antiepileptic drugs to the child increased significantly from 3.60 to 3.94 post-counseling (p = 0.002, score range 0-5). Mean total satisfaction score was 36.00 (score range 5-40). CONCLUSION: A specialized counseling session given by pharmacists increased caregiver's knowledge about epilepsy and medication adherence. The session was well received by caregivers. Pharmacists should continue to be involved in the care of epileptic patients.