Impact of clinical pharmacist-based parenteral nutrition service for bone marrow transplantation patients: a randomized clinical trial

A study of pharmacists-joint total parenteral nutrition in haematopoietic cell transplantation in accord with diagnosis related groups: A retrospective clinical research

Background

Within Diagnosis Related Groups, based on service capability, efficiency, and quality safety assessment, clinical pharmacists contribute to promoting rational drug utilisation in healthcare institutions. However, a deficiency of pharmacist involvement has been observed in the total parenteral nutrition support to patients following haematopoietic cell transplantation (HCT) within DRGs.

Methods

This study involved 146 patients who underwent HCT at the Department of Haematology, the Second Affiliated Hospital of Dalian Medical University, spanning from January 2020 to December 2022.

Results

Patients were allocated equally, with 73 in the control group and 73 in the pharmacist-involved group: baseline characteristics showed no statistics significance, including age, body mass index, nutrition risk screening-2002 score, liver and kidney function, etc. Albumin levels, prealbumin levels were significantly improved after a 7-day TPN support (34.92 ± 4.24 vs 36.25 ± 3.65, P = 0.044; 251.30 ± 95.72 vs 284.73 ± 83.15, P = 0.026). The body weight was increased after a 7-day support and before discharge (58.77 ± 12.47 vs 63.82 ± 11.70, P = 0.013; 57.61 ± 11.85 vs 64.92 ± 11.71, P < 0.001). The length of hospital stay, costs and the rate of re-admissions were significantly shortened (51.10 ± 1.42 vs 46.41 ± 1.86, P = 0.048; 360,162.67 ± 91,831.34 vs 324,070.16 ± 112,315.51, P = 0.035; 61.64% vs 43.84%, P = 0.046).

Conclusions

Pharmacist-joint TPN support enhances the service efficiency score of medical units, ensuring the fulfilment of orders and rational medication.

The Prevalence of Drug-Drug Interactions and Reported Therapy Related Side Effects in Oncology Out-Patients

Objective: The use of multiple medications in cancer patients is unavoidable; thus, adverse drug-drug interactions are frequent. This study aims to assess the prevalence of potential drug interactions in oncology patients visiting the outpatient chemotherapy unit. Method: Demographic and health-related information of patients visiting an outpatient chemotherapy unit was recorded using a pre-prepared form. A comprehensive list of all concurrently used medications was compiled and checked for interactions with the Micromedex online drug interaction tool. Results: A total of 179 adult patients were included. We recorded an average of 9.3 drugs per patient with 79 patients using more than 10 drugs. A total of 1671 drugs including 303 chemotherapeutic agents were assessed for drug-drug interactions. A total of 374 interactions, of which 203 were significant, were recorded in 118 (65.9%) patients with an average of 3.2 interactions per patient. Only 46 major interactions were recorded for anticancer agents. Cyclophosphamide (n=13) and cisplatin (n=12) were involved in most interactions. The number of interactions correlated with the number of drugs used (p=.001) and the presence of comorbidities (p=.002). The presence of comorbidities increased the risk of interaction by 1.21 (p=.04). Recorded side effects were not correlated to drug interactions. Conclusion: Medication review in cancer patients is essential in establishing all medications used by patients. Routine assessment in terms of potential drug interactions and evaluation of these interactions by a qualified pharmacist may help in optimizing patient outcomes.

Examination of a nutritional treatment pathway according to pretreatment health status and stress levels of patients undergoing hematopoietic stem cell transplantation

Introduction

This study aimed to validate hematopoietic stem cell transplantation (HSCT) treatment via a tailored nutritional pathway in myeloablative conditioning (MAC), determine its efficacy in terms of remission, and explore associations between clinical outcomes and nutritional indicators.

Methods

We included patients who underwent MAC for HSCT at the Shizuoka Cancer Center Stem Cell Transplantation between 2015 and 2019. We evaluated outcomes from the day before treatment initiation (transplant date: day 0) to day 42.

Results

Among the 40 MAC cases (participant characteristics: 20/40 males, mean age of 52 years, and mean body mass index of 21.9 kg/m²), we found that the percent loss of body weight and loss of skeletal muscle mass were correlated with the basal energy expenditure rate (BEE rate; r = 0.70, p<0.001 and r = 0.49, p<0.01, respectively). Based on the receiver operating characteristics curves, the cutoff value for the BEE rate in terms of weight loss was 1.1. Salivary amylase levels did not significantly change during the treatment course. Continuous variables, including oral caloric intake and performance status, showed statistically significant correlations with nutrition-related adverse events during treatment (r = −0.93, p<0.01 and r = 0.91, p<0.01, respectively). Skeletal muscle mass before treatment initiation was an independent predictive variable for reduced 2-year survival (p = 0.04).

Conclusion

Our results support the validity of a safe nutritional pathway with a BEE rate of 1.1 for HSCT patients pretreated with MAC. Specifically, we found that this pathway could prevent weight loss in response to nutrition-related adverse events. Skeletal muscle mass before treatment was identified as an independent risk factor for reduced 2-year survival.

The impact of a hematopoietic cellular therapy pharmacist on clinical and humanistic outcomes: A RE-AIM framework analysis

BACKGROUND

The hematopoietic cellular therapy (HCT) pharmacist is an essential member of the multidisciplinary care team. Yet, standardized incorporation of a pharmacist at transplant centers remains challenging. Implementation science uses theory-driven and systematic approaches to integrate interventions into clinical practice. We describe our experience implementing an HCT pharmacist at our center and conducted a program evaluation using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework.

OBJECTIVE

To evaluate the impact of HCT pharmacist medication management services on allogeneic stem cell transplant patients utilizing the RE-AIM framework.

STUDY DESIGN

We implemented one full-time equivalent pharmacist to provide medication management services through a collaborative practice agreement (CPA) to the allogeneic transplant population at a medium-sized center in rural Pennsylvania over a two-year period. The HCT pharmacist documented all in-person and telephonic care encounters in the electronic medical record. A pharmacist intervention tool was developed to document identified medication related problems (MRPs) with corresponding interventions and magnitude of intervention. The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework was utilized to evaluate the impact of the HCT pharmacist. Summary statistics including frequency and percentages were presented for categorical variables in RE-AIM domain.

RESULTS

Over the 2-year period, the HCT pharmacist followed 40 allogeneic patients at our institution accounting for 1531 patient encounters. The average duration of follow-up was 299 days. The HCT pharmacist medication therapy services were able to reach all allogeneic transplants at our institute. The HCT pharmacist managed 388 medications and identified 2156 medication related problems for which the pharmacist provided 2959 interventions. Time in therapeutic range of immunosuppression was 74% when managed by the HCT pharmacist through a CPA. Of the 24 patients and 9 caregivers who completed the patient satisfaction survey, 25 (76%) were strongly satisfied with their care. Pharmacy services were gradually adopted and expanded to incorporate additional populations, including 121 autologous transplant and 272 hematology patient encounters. The role of the HCT pharmacist was justified with hospital administration and sustained as a designated pharmacist role at our center.

CONCLUSION

The implementation of an HCT pharmacist service can positively impact patient care. The RE-AIM framework provides a methodological approach for programmatic evaluation and generalizability.

The experience and outcomes of multidisciplinary clinical pharmacist-led parenteral nutrition service for individuals with intestinal failure in a center without home parenteral nutrition

BACKGROUND/OBJECTIVES

Intestinal Failure (IF) is a rare but serious form of organ failure, and patients with IF are dependent on Total Parenteral Nutrition (TPN) to maintain growth and development. This study aimed to describe the experiences of a multidisciplinary clinical pharmacist-led TPN service in the Intestinal Rehabilitation Unit of Shiraz Organ Transplant Center.

SUBJECTS/METHODS

This prospective study was conducted in Shiraz Organ Transplant Center, Iran from February 2018 to October 2020, including seven months with and 24 months without the clinical pharmacist involvement. Clinical and nutritional outcomes as well as the potential complications of TPN were compared in these two periods.

RESULTS

This study was conducted on 107 patients. The most important complication occurred among the patients receiving TPN were catheter infection (42.05%), sepsis, and catheter thrombosis (18.69%). Portal vein thrombosis (OR = 26.56) and length of Intensive Care Unit (ICU) stay (OR = 1.12) were significantly associated with the rate of parenteral nutrition-associated liver disease. The results also revealed an association between the rate of sepsis and history of malignancy, catheter thrombosis, length of the small bowel, length of PN, length of hospital stay, and length of ICU stay. Moreover, the results showed a significant difference regarding the patients' outcomes and TPN complications before and after the clinical pharmacist interventions (P < 0.05).

CONCLUSION

Working as a multidisciplinary team in Intestinal Rehabilitation Unit (IRU) has been suggested to improve patients' outcomes and reduce mortality and morbidity. Presence of a clinical pharmacist in this team can help improve the TPN service provided for individuals with IF.

Nutritional support in stem cell transplantation programs: Results from a multicenter survey of nurses on behalf of the Nurses Group and Transplant Complications Working Party of the European Society for Blood and Marrow Transplantation and the Gruppo Italiano Trapianto di Midollo Osseo

OBJECTIVES

Malnutrition in patients undergoing hematopoietic stem cell transplant (HSCT) can develop rapidly without appropriate nutritional support and affect morbidity and mortality. Guidance to monitor and manage nutrition status is described within the literature; however, whether this is applied in clinical practice is unclear.

METHODS

This paper describes a cross-sectional survey to explore current practice approaches in nutrition support management and adherence to international guidelines.

RESULTS

A total of 108 nurses from 108 centers across 16 countries replied to the questionnaire. A significant variation was observed regarding the availability of documents supporting the monitoring and management of nutrition status, application of recommendations, and nutritional practices.

DISCUSSION

The findings revealed that country was the most important factor influencing the differences in practice; however, significant differences were also observed based on patient age group (pediatrics vs. adults), department composition (hematology + HSCT unit vs. HSCT unit alone), and availability of nutrition health care professionals. Behavioral differences regarding nutritional practice approaches could be indicative of differences in knowledge or subject awareness, as well as a reflection of diversity across health care system policies.

CONCLUSIONS

Guideline dissemination and raising awareness through educational campaigns are suggested approaches to improve health care professionals' knowledge and sensitivity to this important topic.

Effect of malnutrition-driven nutritional support protocol on clinical outcomes in autologous stem cell transplantation patients

PURPOSE

Poor nutrition status in patients receiving high-dose chemotherapy and autologous stem cell transplant (ASCT) has been associated with inferior clinical outcomes. We aim to determine whether a malnutrition-driven nutritional support protocol can improve these outcomes.

METHODS

In this prospective cohort study, we assessed adults for malnutrition who were consecutively admitted for ASCT between October 2017 and March 2019 (n = 251), and provided enteral or parenteral nutrition (EN/PN) to patients who were malnourished early in the transplantation admission. We compared their clinical outcomes with those of a historical cohort admitted between May 2016 and October 2017 (n = 257) for whom nutrition assessment and initiation of EN/PN were not protocol-driven.

RESULTS

Patients receiving ASCT during the intervention period experienced decreased odds of prolonged hospital stay (p = 0.023), central line-associated bloodstream infection (p = 0.015), mucosal barrier injury (p = 0.037), and high weight loss (p = 0.002), in a multivariate analysis as compared with those receiving ASCT during the control period. Outcomes for ICU transfer, deconditioning on discharge, time to platelet engraftment, and unplanned 30-day hospital readmission did not differ significantly between groups.

CONCLUSION

A malnutrition-driven nutritional support protocol may improve outcomes for ASCT patients.

Significance of a clinical pharmacist-led comprehensive medication management program for hospitalized oncology patients

Background The use of highly toxic drugs in cancer treatment and supportive care medications exposes patients to an increased number of drug-related problems (DRPs). Clinical pharmacists contribute to the optimal use of medications by intervening in identified drug-related problems. Objective To evaluate the relevance of a comprehensive medication management service in oncology patients. Setting Marmara University Teaching and Research Hospital Medical Oncology Ward, Istanbul, Turkey. Methods This prospective study was carried out between December 2015 and April 2016 with adult patients with confirmed malignancy. Comprehensive medication management was performed by the clinical pharmacist throughout the patient's hospital stay. The medication-related data as well as data regarding demographic and general health status of the patients were reviewed for the presence of drug-related problems. The identified problems, interventions and acceptance rate by physicians were recorded with the help of the Pharmaceutical Care Network Europe V6.0 (PCNE) classification. Main outcome measures Number and causes of drug-related problems, nature and acceptance rate of clinical pharmacist interventions and rate of problems solved. Results The study included 137 patients. The mean (SD) age of the patients was 58 (14.6) years. A total of 481 drug-related problems were recorded. The most frequent drug-related problems were 'adverse drug events [including drug interactions]' (n = 376), 'untreated indications' (n = 59) and 'unnecessary drug treatment' (n = 25). Inappropriate combination of drugs was the cause of 73.2% of the total problems. Interventions were made to stop administration of a suitable drug if the combination with another drug was contraindicated while prescribers were mostly informed about major drug interactions. The prescribers approved 93% of the total intervention proposals. The majority (90.9%) of the identified problems were totally solved. Conclusion Integration of clinical pharmacy services through a comprehensive medication management program in oncology will help to reduce the number of drug-related problems.

Benefit of Reducing Body Weight Loss with A Nutritional Support Pathway in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

BACKGROUND

This retrospective, historically controlled investigative study examined the benefit of a nutritional support pathway that included nutritional education before the start of conditioning and emphasized oral nutrition in response to nutrition-related adverse events in patients undergoing hematopoietic stem cell transplantation (HSCT).

MATERIAL AND METHODS

Participants were patients undergoing allogeneic HSCT; 46 were in the control group (i.e., did not follow our nutritional pathway) and 36 were in the group that underwent nutritional intervention (enhanced nutrition group). We compared the following parameters between groups from the day before the start of conditioning to the day after completion of parenteral nutrition (PN): percent loss of body weight (%LBW), percent loss of skeletal muscle mass (%LSMM), and estimated basal energy expenditure (EBEE) sufficiency rate. The relationship between each parameter and %LBW was also examined. We also compared nutritional indices, gastrointestinal graft versus host disease (GvHD) grade, oral energy intake, and %LBW between groups.

RESULTS

There was a relationship between %LBW, %LSMM, and EBEE sufficiency rate in both groups. Compared with the control group, the enhanced nutrition group had significantly improved energy intake amount, EBEE sufficiency rate, PN duration, and oral energy intake over time. The enhanced nutrition group also had increased oral energy intake, no difference in gastrointestinal GvHD grade, and improved %LBW compared with the control group.

CONCLUSIONS

Use of our nutritional support pathway in patients undergoing HSCT may be beneficial for %LBW and gastrointestinal GvHD grade, enabling early enhanced nutritional intervention after HSCT.

Body weight, body composition and survival after 1 year: follow-up of a nutritional intervention trial in allo-HSCT recipients

The role of body weight change in survival among recipients of hematopoietic stem-cell transplantation is controversial. We assessed the effect of optimizing energy and protein intake on 1-year survival, body weight and body composition, and the effect of body weight and body composition on 1-year survival in 117 patients (57 intervention, 60 control) in a randomized controlled trial. Cox regression was used to study effects of the intervention, weight and body composition on death, relapse, and nonrelapse mortality (NRM). We found no significant effect of intervention versus control on death hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.54-2.04, p = 0.88), relapse (HR 1.15, 95% CI 0.48-2.27, p = 0.75), and NRM (HR 0.95, 95% CI 0.39-2.28, p = 0.90). Body weight, fat-free mass index, body fat mass index and total body water changed over time (p < 0.001), similarly in both groups (0.17 ≤ p ≤ 0.98). In multivariable analyses adjusted for group, gender and age, HRs and 95% CIs per one kilo increase in weight were 1.03 (1.01-1.06) and 1.04 (1.01-1.08) for death and NRM after 1 year (p ≤ 0.02), respectively, and 1.08 (1.01-1.15) for relapse after 3 months (p = 0.02). In conclusion, weight gain is possibly due to fluid retention and is an indicator of a complication in HSCT, rather than a marker of improved nutritional status.

Clinical and economic impacts of clinical pharmacists' interventions in Iran: a systematic review

OBJECTIVES

There are many studies about Iranian clinical pharmacists' interventions and their impacts on medication safety and cost. The aim of this study is to collect data and critically evaluate the clinical and economic effects of Iranian clinical pharmacist interventions and activities. To our best of knowledge, this research is the first review of publications about Iranian clinical pharmacists' interventions and activities.

EVIDENCE ACQUISITION

Six online databases, including PubMed, Scopus, Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systemic Reviews, and Google Scholar were searched using the terms '"Iranian", "clinical pharmacist", 'adverse drug reactions", "medication errors", "drug interaction", "drug utilization evaluation", "cost", and "interventions" for English studies conducted in Iran and described clinical pharmacist-initiated interventions, published before December 2018. The search and extraction process followed PRISMA guidelines. Observational or retrospective studies, clinical trials, congress abstracts, and case reports or case series were excluded. The search strategy after full-text review identified 39 articles matching the eligibility criteria.

RESULTS

Thirty-nine articles were recruited. They included establishing pharmaceutical care in out-patient clinics and drug information centers (n = 4); prevention, detection, and management of adverse drug reactions(n = 4), designing protocols and improving drug utilization pattern(n = 16), prevention, detection, and management of medication errors (n = 11), and all clinical pharmacist services(n = 4). Most clinical pharmacist interventions and activities were regarding designing protocols, improving drug utilization pattern, as well as detection, prevention, and management of medication errors. About three-fourth (74.35%) of included studies were from either ambulatory care or in-patient settings in Tehran. The median (interquartile range) duration of intervention as well as follow-up phases was 9 (5) months.

CONCLUSION

Data of our review support the beneficial role of clinical pharmacists in the improvement of quality, safety, and efficiency of patients' pharmaceutical care in Iran. Graphical abstract Clinical pharmacists' interventions in Iran.

Role of pharmacists in providing parenteral nutrition support: current insights and future directions

BACKGROUND

Parenteral nutrition (PN) therapy is a complex and critical therapy that requires special clinical knowledge, skills, and practice experience to avoid errors in prescribing, compounding, and clinical management of patients. Pharmacists with adequate clinical training and expertise in PN therapy can have pivotal role in the care of patients receiving PN therapy.

OBJECTIVE

The aim of this systematic review was to describe and evaluate the different roles of pharmacists and their provided services related to PN therapy.

MATERIALS AND METHODS

A comprehensive systematic literature review on the topic was conducted via PubMed database using several keywords related to the topic (from 1975 to 2017). Additional resources included the standards of practice and clinical guidelines from recognized organizations such as the American Society for Parenteral and Enteral Nutrition (ASPEN) and the American Society of Health-System Pharmacists (ASHP).

RESULTS

Pharmacists have diverse roles in relation to PN therapy including the following: the assessment of patients' nutritional needs; the design, compounding, dispensing, and quality management of PN formulations; monitoring patients' response to PN therapy; supervision of home parenteral nutrition (HPN) programs; education of patients, caregivers, and other health care professionals on nutrition support and conducting PN-related research and quality improvement activities. These services seem to be variable across clinical settings and among different countries depending on the practice environment and pharmacists' clinical practice in these settings. However, each of these practice domains helps to support the delivery of safe and effective PN therapy to patients.

CONCLUSION

Pharmacists have been actively participating in providing PN-related services to patients. To fulfill the requirements of their essential role in this area of practice, pharmacists need adequate educational preparation and clinical training on nutrition support. Empowerment of pharmacists to assume a stronger leadership role in this dimension of pharmacy practice will enhance the quality of care provided to patients receiving PN therapy and improve PN services.

Effects of individualized nutrition after allogeneic hematopoietic stem cell transplantation following myeloablative conditioning; a randomized controlled trial

BACKGROUND & AIMS

Reduced quality of life (QoL) is prevalent after allogeneic hematopoietic stem cell transplantation (allo-HSCT). In this randomized trial we examined the effect of individualized nutritional support during hospitalization for allo-HSCT. Primary outcome was change in global QoL three months post-HSCT with oral mucositis (OM) and acute graft-versus-host disease (aGVHD) as main secondary outcomes.

METHODS

Whereas the intervention group received recommended minimum daily intakes of 126 kJ/kg and 1.5-2.0 g protein/kg as food, supplements, enteral or parenteral nutrition, the controls received routine feeding. QoL was self-reported using the EORTC QLQ-C30 questionnaire.

RESULTS

Between August, 2010 and February, 2016, we randomized 59 and 60 patients to intervention and control, respectively; 40 and 48 being eligible for analysis of QoL. There was no difference between the two groups in mean global QoL after three months (-3.10, 95% CI -11.90-5.69; P = 0.49). Nor were there any differences in OM grades 3 or 4 (RR (vs grades 0-2), 1.11, 95% CI 0.59-2.11 and 0.95, 95% CI 0.72-1.25, respectively; P = 0.78), or aGVHD grades 3 or 4 (RR (vs grades 0-2) 0.44, 95% CI 0.12-1.60; and 0.65, 95% CI 0.20-2.20, respectively; P = 0.37).

CONCLUSION

Individualized nutritional support with recommended energy and protein intakes during hospitalization had no effect on QoL, OM or aGVHD three months after allo-HSCT compared to routine nutrition.

Clinical pharmacists’ contributions to hematopoietic stem cell transplantation: A systematic review

Aims

The goal of the present review was to identify studies that assess how pharmaceutical services contribute to hematopoietic stem cell transplantation (HSCT).

Methods

We conducted a systematic literature review of published studies describing results from clinical services provided by pharmacists working with HSCT, conducted according to PRISMA guidelines ( PROSPERO registration number CRD42017062391). A search strategy was applied within PubMed, CENTRAL, EMBASE, SCOPUS, and LILACS databases in April 2017. Inclusion criteria were observational or experimental studies that addressed the following research question: “What are a clinical pharmacist’s main contributions to HSCT?” The quality of selected studies was evaluated using the Downs and Black checklist.

Results

We identified 1838 studies, and seven were included in the systematic review. The results indicated that clinical pharmacy is useful during HSCT treatment within both inpatient and outpatient settings. Pharmaceutical contributions identified included management of pharmacotherapy-related problems, participation in discussions with clinical teams, drug reconciliation, patient and team education regarding pharmacotherapy, preparation of guidelines and educational materials, and evaluation of medication adherence. These activities favored the control and prevention of pharmacotherapy-related problems, the maintenance of immunosuppressive serum levels, improvement in patients’ clinical and nutritional status, facilitated medication adherence, and provided economic and humanistic gains.

Conclusions

Despite the small number of articles discussing the topic under analysis, the results were unanimous in confirming the positive impact of pharmacists’ contributions to clinical practice for HSCT.

The Hematopoietic Cell Transplant Pharmacist: Roles, Responsibilities, and Recommendations from the ASBMT Pharmacy Special Interest Group

Pharmacists are increasingly recognized as an essential member of the multidisciplinary team for hematopoietic cell transplant (HCT) patients. However, until recently, their educational background, required training, and potential roles have not been well described. Therefore, the purpose of this manuscript is to provide supporting evidence for the HCT Clinical Pharmacist Role Description, which has been endorsed by several organizations including the American Society for Blood and Marrow Transplantation. This document provides justification for the various roles pharmacists fulfill with respect to medication management, transitions of care, patient and provider education, policy development, quality improvement, and research. Furthermore, evidence supporting the value, financially and otherwise, HCT pharmacists provide is reviewed. Pharmacists in the HCT setting are encouraged to report on novel practice models and potential impact of their services to increase awareness and utilization of HCT pharmacists.

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

Publications presenting negative impacts of pharmacists

OBJECTIVES

The main objective was to evaluate the rate of publications with at least one indicator of the negative impact of clinical pharmaceutics activity.

METHODS

This is a descriptive and retrospective literature review. A literature search was conducted using Pubmed. Articles published between 2009-2014 that described the role and impacts of pharmacists were included. We calculated the rate of publication containing at least one negative indicator. We collected the indicators with negative results.

RESULTS

A total of 203 articles were included. Nine articles (4%) that had at least one indicator of negative impact were identified. A total of 66% (6/9) were conducted in the United States. The study designs of the articles included were a meta-analysis (n=1), a systematic review (n=1), randomized studies (n=2), pre-post studies (n=3), a cohort study (n=1) and a survey (n=1). Nine indicators of negative impact were identified.

CONCLUSION

There were nine publications with at least one negative indicator of the impact of clinical pharmacy activity. While there are a large number of studies about the positive impact of clinical pharmacy activities; the publication of negative results should be encouraged.

The need for community pharmacists in oncology outpatient care: a systematic review

Background One-third of all deaths in Europe each year are attributable to cancer. Issues relating to cancer care, therefore, will continue to expand. To manage the increased challenges-including doctor shortages, an ageing population, and rural distribution of supplies-community pharmacists will likely be required to assume responsibility within oncology care. Aim of the review To assess the need for further investigation into quantity and utility of community pharmacists' interventions in assisting oncology outpatients. Methods Initial search terms for identifying relevant literature within the PubMed database were informed by four key questions. Study selection for the systematic review was performed based on inclusion and exclusion criteria, which were defined a priori using the PICO tool. Literature searches identified 2470 papers, for which titles and abstracts were reviewed. Of these, 220 papers were retained for detailed analysis. The full texts of these manuscripts were then screened by applying the inclusion criteria. The remaining 68 papers were included in the systematic review. Results Several models of pharmacists' interventions in inpatient, medium, and outpatient care have proven to be successful, have been consistently efficacious, and have positively influenced patient outcomes. Importantly, the quantity of scientific research, and thus of reported beneficial outcomes, in outpatient care is much lower than that conducted for inpatient and medium care. Conclusion Based on our findings, we suggest that further investigation of community pharmacists' interventions into oncology outpatient assistance is necessary, and that further research should be conducted to address this need.

Role of the pharmacist in parenteral nutrition therapy: challenges and opportunities to implement pharmaceutical care in Kuwait

BACKGROUND

Pharmacists can provide beneficial pharmaceutical care services to patients receiving Parenteral Nutrition (PN) therapy by working within Nutrition Support Teams (NSTs).

OBJECTIVE

This study was designed to explore pharmacists' role in PN therapy in hospitals of Kuwait, sources of PN-related information, opinions on NSTs, perceptions about the barriers to pharmaceutical care implementation and views on how to enhance their practices.

METHODS

Data were collected via face-to-face semi-structured interviews with the senior Total Parenteral Nutrition (TPN) pharmacists at all the hospitals which provide TPN preparation services (six governmental hospitals and one private hospital) in Kuwait. Descriptive statistics were used to describe pharmacists' demographic details and practice site characteristics. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

The pharmacists mainly performed technical tasks such as TPN compounding with minimal role in providing direct patient care. They used multiple different sources of TPN-related information to guide their practice. They reported positive and negative experiences with physicians depending on their practice environment. None of the hospitals had a functional NST. However, pharmacists expressed preference to work within NSTs due to the potential benefits of enhanced communication and knowledge exchange among practitioners and to improve service. Pharmacists perceived several barriers to providing pharmaceutical care including lack of reliable sources of TPN-related information, lack of a standard operating procedure for TPN across hospitals, insufficient staff, time constraints and poor communication between TPN pharmacists. To overcome these barriers, they recommended fostering pharmacists' education on TPN, establishing national standards for TPN practices, provision of pharmacy staff, development of NSTs, enhancing TPN pharmacists' communication and conducting TPN-research research.

CONCLUSION

TPN pharmacists in Kuwait are confined to performing TPN manufacturing processes. There are promising avenues for future development of their role in patient care. This can be achieved by overcoming the barriers to pharmaceutical care practice and providing pharmacists with educational opportunities to equip them with the clinical competencies needed to practise as nutrition support pharmacists with patient-centred roles.

Nutritional assessment as predictor of complications after hematopoietic stem cell transplantation

Introduction

Nutritional support is pivotal in patients submitted to hematopoietic stem cell transplantation. Nutritional status has been associated with time of engraftment and infection rates. In order to evaluate the association between nutritional parameters and clinical outcomes after transplantation a cohort of transplant patients was retrospectively evaluated.

Methods

All 50 patients transplanted between 2011 and 2014 were included. The nutritional status before transplantation, ten days after transplantation and before discharge was assessed including anthropometry, body mass index, albumin, prealbumin and total urinary nitrogen.

Results

The median follow-up time was 41 months and the median age of patients was 41 years. Thirty-two underwent allogeneic and 18 autologous transplants. Diagnoses included acute leukemias (n = 27), lymphoma (n = 7), multiple myeloma (n = 13), and aplastic anemia (n = 3). Thirty-seven patients developed mucositis (three Grade 1, 15 Grade 2, 18 Grade 3 and one Grade 4), and twenty-two allogeneic, and five autologous transplant patients required total parenteral nutrition. Albumin and total urinary nitrogen were associated with length of hospital stay and platelet and neutrophil engraftment. None of the nutritional parameters evaluated were associated with overall survival. Non-relapse mortality was 14% and overall survival was 79% at 41 months of follow-up.

Conclusions

After hematopoietic stem cell transplantation, high catabolism was associated with longer length of hospital stay, the need of total parenteral nutrition and platelet and neutrophil engraftment times. Nutritional parameters were not associated with overall survival.

Challenges and outcomes of a randomized study of early nutrition support during autologous stem-cell transplantation

Patients undergoing myeloablative conditioning regimens and autologous stem-cell transplantation (asct) are at high risk of malnutrition. This randomized study aimed to determine if early nutrition support (commenced when oral intake is less than 80% of estimated requirements) compared with usual care (commenced when oral intake is less than 50% of estimated requirements) reduces weight loss in well-nourished patients undergoing high-nutritional-risk conditioning chemotherapy and asct. In the 50 well-nourished patients who were randomized, the outcomes evaluated included changes in weight and lean body mass (mid-upper arm circumference), length of stay, time to hemopoietic engraftment, and quality of life (Memorial Symptom Assessment Scale - Short Form). On secondary analysis, after exclusion of a single extreme outlier, both groups demonstrated significant weight loss over time (p = 0.0005). Weight loss was less in the early nutrition support group at time of discharge (mean: -0.4% ± 2.9% vs. -3.4% ± 2.6% in the usual care group, p = 0.001). This difference in weight was no longer observed at 6 months after discharge (mean: -1.0% ± 6.8% vs. 1.4% ± 6.1%, p = 0.29). In practice, an early start to nutrition support proved difficult because of patient resistance and physician preference, with 8 patients (33%) in the control group and 4 (15%) in the intervention group not commencing nutrition support when stipulated by the study protocol. No significant differences between the groups were found for other outcomes. In well-nourished patients receiving asct, early nutrition support maintained weight during admission, but did not affect other outcomes. Interpretation of results should take into consideration the difficulties encountered with intervention implementation.