Simplifying Medication Regimens for People Receiving Community-Based Home Care Services: Outcomes of a Non-Randomized Pilot and Feasibility Study

Purpose

Being able to manage a complex medication regimen is key to older people continuing to live at home. This study determined the feasibility of a multi-component intervention to simplify medication regimens for people receiving community-based home care services.

Patients and Methods

Research nurses recruited people receiving community-based home care services to participate in this non-randomized pilot and feasibility study (Australian New Zealand Clinical Trials Registry ACTRN12618001130257). Participants received a one-off clinical pharmacist intervention comprising medication reconciliation, assessment of capacity to self-manage medications, and application of a structured 5-step tool to identify medication simplification opportunities. A mixed-methods feasibility assessment with an explanatory design was undertaken to assess recruitment, protocol adherence and stakeholder acceptability. Data from interviews with 12 stakeholders were thematically analyzed. Secondary outcome measures, including medication discrepancies, and changes in number of medication administration times per day, quality of life, medication adherence and health service utilization, were determined over a 4-month follow-up.

Results

Twenty-five out of the target 50 participants were recruited. Initial recruitment was impacted by apparent uncertain role responsibilities in medication management, with some clients who declined to participate perceiving they would be unlikely to benefit or being reluctant to change regimens. However, with few exceptions, participants who received intervention did so with a high degree of protocol adherence and acceptability. Stakeholders valued the intervention and supported wider implementation. Discrepancies between the baseline medication history from the general medical practitioner and the pharmacist-compiled “best possible medication history” were identified for all participants’ regimens (median of 6 per participant), with one-third resolved at follow-up. Simplification was possible for 14 participants (56%) and implemented for 7 (50%) at follow-up. No significant changes in other secondary outcomes were observed.

Conclusion

The intervention was delivered as planned, and valued by stakeholders. Recruitment barriers should be addressed before wider implementation.

Hospital admissions caused by adverse drug events: an Australian prospective study

OBJECTIVE

To assess the frequency of adverse drug event (ADE)-related admissions (ADE-RAs) during a prospective medical record review of patients admitted to a metropolitan tertiary referral hospital.

METHODS

Potential ADE-RA cases were identified by examination of case records of randomly selected patients. Cases were assessed by an expert panel to measure study outcomes, which were the frequency (ADEs and ADE-RAs) as well as type, likelihood of causality, severity, avoidability and detection of ADEs.

RESULTS

Of the 370 subjects, 59 (16.0%) had a confirmed ADE-RA, with 15 (4.1%) of these serious and preventable. The 59 ADE-RAs were a result of 72 discreet ADEs. Adverse drug reactions were the most common type of ADE, followed by non-compliance. Of the 72 discreet ADEs, 31.9% were classified as 'probable' or 'highly probable'. Most ADEs (54.2%) were classified as 'definitely avoidable', 34.7% were classified as 'severe' and 21.8% were classified as both 'definitely avoidable' and 'severe'. Half the ADEs were detected after the patient had been admitted and most were detected by medical practitioners. Antineoplastics followed by antidiabetic agents were most frequently implicated.

CONCLUSIONS

Implementing a systems approach that involves multiple strategies, such as improving tertiary-to-primary care information transfer and promoting medication adherence through education programs, is necessary to tackle the problem of avoidable ADE-RAs and the associated cost burden. WHAT IS KNOWN ABOUT THE TOPIC? It is estimated that 2-3% of Australian hospital admissions are due to adverse drug events (ADEs), but recent data are lacking. According to the Australian Statistics on Medicines, over 250 million prescriptions were dispensed in 2007, compared with just under 180 million in 1997. This 40% increase in drug utilisation over the 10 years surpasses the Australian population growth of 14% in the same period. An increase in drug use per person indicates that the rate of ADEs and possible ADE-related admissions (ADE-RAs) is likely to have increased. WHAT DOES THIS PAPER ADD? This prospective study was conducted at a large Australian metropolitan teaching hospital and we report that 59 of 370 participants (16.0%) presenting to the Emergency Department had a confirmed ADE-RA, with 15 (4.1%) presenting with a serious and preventable ADE-RA. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? The findings of this study support implementing a systems approach involving multiple strategies to tackle the problem of avoidable ADE-RAs and the associated cost burden. This study reveals that half the ADEs were not detected until after the admission process, which reinforces the importance of focusing efforts towards preventing ADE-RAs and detecting ADE-RAs through measures such as those recommended in the Australian Pharmaceutical Advisory Council guiding principles.

Increased abundance of Sutterella spp. and Ruminococcus torques in feces of children with autism spectrum disorder

Background

A recent report indicated that numbers of Sutterella spp. are elevated in gastrointestinal biopsies taken from children with autism spectrum disorder (ASD). We have recently reported changes in the numbers of some bacteria within the stool of ASD children, and now examine whether numbers of Sutterella spp. and some other mucosa-associated bacteria linked with gastrointestinal disease (Ruminococcus gnavus and Ruminococcus torques) are also altered in the stool of these children.

Findings

We show that numbers of Sutterella spp. are elevated in feces of ASD children relative to controls, and that numbers of R. torques are higher in the children with ASD with a reported functional gastrointestinal disorder than those without such a disorder.

Conclusions

We show further evidence of changes in the gut microbiota of children with ASD and confirm that the abundance of Sutterella spp. is altered in stool.

The potential role of the antioxidant and detoxification properties of glutathione in autism spectrum disorders: a systematic review and meta-analysis

BACKGROUND

Glutathione has a wide range of functions; it is an endogenous anti-oxidant and plays a key role in the maintenance of intracellular redox balance and detoxification of xenobiotics. Several studies have indicated that children with autism spectrum disorders may have altered glutathione metabolism which could play a key role in the condition.

METHODS

A systematic literature review and meta-analysis was conducted of studies examining metabolites, interventions and/or genes of the glutathione metabolism pathways i.e. the γ-glutamyl cycle and trans-sulphuration pathway in autism spectrum disorders.

RESULTS

Thirty nine studies were included in the review comprising an in vitro study, thirty two metabolite and/or co-factor studies, six intervention studies and six studies with genetic data as well as eight studies examining enzyme activity.

CONCLUSIONS

The review found evidence for the involvement of the γ-glutamyl cycle and trans-sulphuration pathway in autistic disorder is sufficiently consistent, particularly with respect to the glutathione redox ratio, to warrant further investigation to determine the significance in relation to clinical outcomes. Large, well designed intervention studies that link metabolites, cofactors and genes of the γ-glutamyl cycle and trans-sulphuration pathway with objective behavioural outcomes in children with autism spectrum disorders are required. Future risk factor analysis should include consideration of multiple nutritional status and metabolite biomarkers of pathways linked with the γ-glutamyl cycle and the interaction of genotype in relation to these factors.

A review of candidate urinary biomarkers for autism spectrum disorder

CONTEXT

Autism is a complex, heterogeneous neurodevelopmental condition with a strong genetic component potentially impacted by various environmental factors influencing susceptibility. There are no reliable laboratory tests available to confirm an autism diagnosis.

OBJECTIVE

To examine the published literature and identify putative urinary biomarkers of autism.

METHODS

A comprehensive literature search was conducted using electronic bibliographic databases.

RESULTS

Putative autism biomarkers were identified that could be categorized according to the key theories that exist regarding the etiology of autism: gastrointestinal factors, immune dysregulation, heavy metal toxicity, neurotransmitter abnormalities, and oxidative stress.

CONCLUSION

There is scope for specific urinary biomarkers to be useful for identification of autistic metabolic phenotypes.

Low relative abundances of the mucolytic bacterium Akkermansia muciniphila and Bifidobacterium spp. in feces of children with autism

Gastrointestinal disturbance is frequently reported for individuals with autism. We used quantitative real-time PCR analysis to quantify fecal bacteria that could influence gastrointestinal health in children with and without autism. Lower relative abundances of Bifidobacteria species and the mucolytic bacterium Akkermansia muciniphila were found in children with autism, the latter suggesting mucus barrier changes.

Clinical Outcomes of a Collaborative, Home-Based Postdischarge Warfarin Management Service

Background:

Warfarin remains a high-risk drug for adverse events, especially following discharge from the hospital. New approaches are needed to minimize the potential for adverse outcomes during this period.

Objective:

To evaluate the clinical outcomes of a collaborative, home-based postdischarge warfarin management service adapted from the Australian Home Medicines Review (HMR) program.

Methods:

In a prospective, nonrandomized controlled cohort study, patients discharged from the hospital and newly initiated on or continuing warfarin therapy received either usual care (UC) or a postdischarge service (PDS) of 2 or 3 home visits by a trained, HMR-accredited pharmacist in their first 8 to 10 days postdischarge. The PDS involved point-of-care international normalized ratio (INR) monitoring, warfarin education, and an HMR, in collaboration with the patient's general practitioner and community pharmacist. The primary outcome measure was the combined incidence of major and minor hemorrhagic events in the 90 days postdischarge. Secondary outcome measures included the incidences of thrombotic events, combined hemorrhagic and thombotic events, unplanned and warfarin-related hospital readmissions, death, INR control, and persistence with therapy al 8 and 90 days postdischarge.

Results:

The PDS (n = 129) was associated with statistically significantly decreased rates of combined major and minor hemorrhagic events to day 90 (5.3% vs 14.7%; p = 0.03) and day 8 (0.9% vs 7.2%; p = 0.01) compared with UC (n = 139). The rate of combined hemorrhagic and thrombotic events to day 90 also decreased (6.4% vs 19.0%; p = 0.008) and persistence with warfarin therapy improved (95.4% vs 83.6%; p = 0.004). No significant differences in readmission and death rates or INR control were demonstrated.

Conclusions:

This study demonstrated the ability of appropriately trained accredited pharmacists working within the Australian HMR framework to reduce adverse events and improve persistence In patients taking warfarin following hospital discharge. Widespread implementation of such a service has the potential to enhance medication safety along the continuum of care. KEY WORDS: adverse drug events, community pharmacy services, international normalized ratio, patient discharge, warfarin.

Consumers' views of pharmacogenetics--A qualitative study

BACKGROUND

Adverse drug reactions are recognized as a significant public health issue. Pharmacogenetics (PGx) provides a potential means of preventing some adverse drug reactions by predicting the optimal medication dose for an individual; however, PGx is rarely used in clinical practice. Thus far, there have been few studies investigating consumers' perceptions of the barriers to the implementation of PGx in clinical practice.

OBJECTIVES

This study explored the views of the general public regarding their current use of medications, and their experiences of side effects and opinions on PGx.

METHODS

Members of the general public who suffered a chronic medical condition and/or had an immediate family member with a chronic medical condition were recruited to form 5 separate focus groups (n=35). Three separate age ranges were used in the focus groups. A questioning route was developed and used in focus groups to determine participants' experiences with medication use and opinions on PGx (referred to as "Personalized Medicine"). Focus group discussions were transcribed by 2 separate investigators, and qualitative analysis, based on the framework approach, was applied to the data. Data were independently coded to identify key themes then compared both within and between focus groups.

RESULTS

A common theme was a desire to have a holistic approach to disease diagnosis and medication selection. A wide range of views were expressed by the focus group participants. Concerns were raised regarding the current level of side effects experienced with medications. Storage and privacy of genetic information, and the costs involved, were also seen as potential barriers to implementation of PGx.

CONCLUSIONS

PGx testing was seen as a potential positive contribution, but only if other factors were considered during the prescribing process. As participants desired a high level of information and effective communication from their health-care professionals, PGx education of clinicians and pharmacists will be essential to satisfy consumers' requirements.

Is urinary indolyl-3-acryloylglycine a biomarker for autism with gastrointestinal symptoms?

An autism spectrum disorder (ASD) diagnosis is based on clinical behaviours as there are no validated biological diagnostic tools. Indolyl-3-acryloylglycine (IAG) is a chemical produced by gut microflora and there are conflicting reports as to whether urinary levels are elevated in children with ASD compared with controls. Urinary IAG levels in morning urine samples were statistically significantly higher in children with ASD whose caregivers reported the presence of chronic gastrointestinal (GI) disturbance than children with ASD without chronic GI disturbance. Urinary IAG, however, was not statistically significantly higher in children with ASD, compared with siblings or unrelated controls without ASD.

Sensory processing subtypes in autism: association with adaptive behavior

Children with autism are frequently observed to experience difficulties in sensory processing. This study examined specific patterns of sensory processing in 54 children with autistic disorder and their association with adaptive behavior. Model-based cluster analysis revealed three distinct sensory processing subtypes in autism. These subtypes were differentiated by taste and smell sensitivity and movement-related sensory behavior. Further, sensory processing subtypes predicted communication competence and maladaptive behavior. The findings of this study lay the foundation for the generation of more specific hypotheses regarding the mechanisms of sensory processing dysfunction in autism, and support the continued use of sensory-based interventions in the remediation of communication and behavioral difficulties in autism.

The effects of cyclophosphamide on the pharmacokinetics of triiodothyronine in the male rat

In the present study, the possibility that cyclophosphamide or a cyclophosphamide metabolite may be accelerating the clearance of triiodothyronine has been examined. Following administration of exogenous triiodothyronine to saline- and cyclophosphamide-treated rats, the area under the plasma concentration time curve (AUC), apparent clearance (CLapp) and half-life of triiodothyronine were measured. AUC (34.43 +/- 12.34 compared with 33.32 +/- 9.92 nmol h L-1). CLapp (36.30 +/- 12.89 compared with 37.51 +/- 11.16 mL h-1) and half-life (7.50 +/- 1.39 compared with 6.40 +/- 0.96 h) were not significantly different in the control rats compared with the cyclophosphamide-treated rats. As cyclophosphamide does not appear to alter the elimination of triiodothyronine, it is likely that cyclophosphamide or a cyclophosphamide metabolite is acting at the hypothalamo-pituitary axis, reducing the synthesis or release of thyroid stimulating hormone and consequently decreasing the levels of triiodothyronine and thyroxine.

Cyclophosphamide administered repeatedly to the male rat and as a single dose to the female rat. Its effects on hepatic and pulmonary P450 and associated enzymes

1. Two different aspects of the effects of the cytotoxic agent cyclophosphamide (CP) on rat P450 and associated enzymes have been examined. 2. First, the effects of CP, administered as a single 200 mg/kg dose, on hepatic and pulmonary P450 and some associated enzymes in the female rat have been investigated. Second, the effects of repeat doses of CP (40 mg/kg on days 0-4 with killing on days 5, 8 and 11) to the male rat have been examined. 3. CP decreased the activity of the female rat hepatic enzymes 2A1, 2C6 and/or 2C12 and 2E1, NADPH-P450 oxidoreductase and 17 beta-oxidoreductase and the pulmonary enzyme 2B, 7 days after its administration. The decreases in the activity of the enzymes 2E1 and NADPH-P450 oxidoreductase were accompanied by a corresponding change in the amount of enzyme protein indicating that the alteration in expression of these enzymes occurred via changes in transcription and/or translation or protein degradation. 4. CP also impaired its own activation 7 days after its administration to the female rat. 5. The change in female enzyme profile was accompanied by a reduction in the hormones oestradiol, T4 and T3 7 days after CP administration. 6. Despite an apparent trend for an increase in activity on day 5, a decrease on day 8 and a subsequent increase on day 11, repeat doses of CP to the male rat generally did not alter the P450 isoforms 2A2, 2B1, 2C11, 2E1 and 3A2 or 17 beta-oxidoreductase, NADPH-P450 oxidoreductase and steroid 5 alpha-reductase. 7. Chronic administration of CP to the male rat significantly reduced erythromycin demethylase and NADPH-P450 oxidoreductase 8 days following commencement of dosing and significantly increased 2A2 11 days following commencement of dosing. There was also a statistically significant increase in pulmonary 2B 5 days following commencement of dosing. 8. Plasma testosterone and TSH were unchanged following repeated dosing with CP while T3 was significantly decreased on days 5, 8 and 11 and T4 was significantly decreased on day 8.

[Possibilities of combined diathermo-cryodestruction in the treatment of hyperplastic processes of the cervix uteri]

The authors analyze the results of two-year follow-up of 82 patients operated on for hypertrophy of the cervix uteri. Traditional cone-shaped diathermo-excision and diathermo-cryodestruction in the authors' modification were used. Good results were achieved in all the cases.