Tuberculosis (TB) treatment challenges in TB-diabetes comorbid patients: a systematic review and meta-analysis

BACKGROUND

The Directly Observed Treatment-Short Course (DOTS) Programme was implemented by WHO and includes a combination of four anti-tuberculosis (TB) drugs (isoniazid, pyrazinamide, ethambutol and rifampicin) for a period of six months to eradicate the TB infection completely. Diabetes mellitus (DM) is recognized as one of a strong contributor of TB according to World Health Organization (WHO). The presence of diabetes mellitus type 2 (DM type 2) makes TB treatment complicated. Thus, the objective of the current meta-analysis was to identify and quantify the impact of type 2 DM on treatment outcomes of TB patients treated under the DOTS Programme.

METHODS

This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Through a systematic review of relevant literature, we focused on studies investigating treatment outcomes including extended treatment duration and recurrence for individuals with both TB and DM undergoing DOTS therapy. The extracted information included study designs, sample sizes, patient characteristics and reported treatment results.

RESULTS

In 44 studies from different parts of the world, the pooled HR for the impact of DM on extended treatment duration and reoccurrence were HR 0.72, 95% CI 0.56-0.83, p < .01 and HR 0.93, 95% CI 0.70-1.04, p = .08, respectively. The pooled HR for impact of DM on composite TB treatment outcomes was calculated as 0.76 (95% CI 0.60-0.87), p < .01 with an effect size of 41.18. The heterogeneity observed among the included studies was moderate (I2 = 55.79%).

CONCLUSIONS

A negative impact of DM was found on recurrence and extended treatment duration in TB patients treated with DOTS therapy. DM type 2 is responsible for the TB treatment prolongation and TB recurrence rates. By implementing effective management strategies and advancing research, the challenges can be mitigated, arising due to the complex interaction between DM and TB.

Management, risk factors and treatment outcomes of rhegmatogenous retinal detachment associated with giant retinal tears: scoping review

BACKGROUND

Rhegmatogenous retinal detachment (RRD) is a serious condition that occurs when the retina detaches from its underlying retinal pigment epithelium. RRDs associated with giant retinal tears (GRTs) are caused by retinal tears at least 90° or one-quarter of the circumferential extent. This scoping review systematically identifies and summarizes clinical studies evaluating surgical techniques for the management of GRT-related RRDs, discusses functional and visual outcomes and the risk factors affecting treatment outcomes.

METHODS

This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Scopus, Google Scholar, and Springer Link databases were searched for relevant papers (from January 2001 to March 2023). Studies that were published in the English language and reported the risk factors, management, and treatment outcomes of GRT-related RRDs were included in the review. The outcome measures included anatomic success rates, changes in BCVA (logMAR) from baseline to the final follow-up, and adverse events.

RESULTS

A total of 11,982 articles were identified. After the title and abstract review, 71 studies were deemed eligible for full-text review. Thirty-six studies that met the eligibility criteria were included in the final review. Four surgical techniques were identified: pars plana vitrectomy (PPV), combined PPV and scleral buckling, scleral buckling alone, and pneumatic retinopexy. Various types of tamponades, including gas, silicone oil, and air, have been used. PPV was the most commonly used surgical technique in 33.1-100% of patients. Among the 20 studies that used PPV alone, 17 were associated with preoperative PVR. In addition, scleral buckling alone or in combination with PPV was reported as a treatment option in 10 studies, with 2-100% of patients experiencing scleral buckling alone and 13.6-100% experiencing combined PPV and complementary scleral buckling. Primary anatomic success (PAS) was achieved with retinal reattachment via a single operation with no residual tamponade, whereas final anatomic success (FAS) was achieved via more than one operation with no residual tamponade. Reported single surgery anatomic success (SSAS) rates range from 65.51 to 100%. The preoperative best-corrected visual acuity (BCVA) ranged from 0.067 to 2.47 logMAR, whereas the postoperative BCVA ranged from 0.08 to 2.3 logMAR. An improvement in visual acuity was observed in 29 studies. Cataracts (3.9-28.3%) were the most common postoperative complication, followed by high IOP (0.01-51.2%) and PVR (0.8-31.57%).

CONCLUSION

PPV is the most common surgical technique, and currently microincision vitrectomy surgery (MIVS) systems are commonly employed. Silicone oil is the most frequently used tamponade in RRD repair. Risk factors for GRT-related RRD include age, sex, lens status, high myopia status, proliferative vitreoretinopathy (PVR), presenting visual acuity, the extent of the GRT and retinal detachment, and macular involvement. Future research areas include guidelines to reduce variability in the reporting of surgical methodology, choice of tamponades, and reporting of functional and visual outcomes to inform the best therapeutic interventions in GRT-related RRD.

Oxidized alginate-gelatin (ADA-GEL)/silk fibroin/Cu-Ag doped mesoporous bioactive glass nanoparticle-based hydrogels for potential wound care treatments

The present work focuses on developing 5% w/v oxidized alginate (alginate di aldehyde, ADA)-7.5% w/v gelatin (GEL) hydrogels incorporating 0.25% w/v silk fibroin (SF) and loaded with 0.3% w/v Cu-Ag doped mesoporous bioactive glass nanoparticles (Cu-Ag MBGNs). The microstructural, mechanical, and biological properties of the composite hydrogels were characterized in detail. The porous microstructure of the developed ADA-GEL based hydrogels was confirmed by scanning electron microscopy, while the presence of Cu-Ag MBGNs in the synthesized hydrogels was determined using energy dispersive x-ray spectroscopy. The incorporation of 0.3% w/v Cu-Ag MBGNs reduced the mechanical properties of the synthesized hydrogels, as investigated using micro-tensile testing. The synthesized ADA-GEL loaded with 0.25% w/v SF and 0.3% w/v Cu-Ag MBGNs showed a potent antibacterial effect againstEscherichia coliandStaphylococcus aureus. Cellular studies using the NIH3T3-E1 fibroblast cell line confirmed that ADA-GEL films incorporated with 0.3% w/v Cu-Ag MBGNs exhibited promising cellular viability as compared to pure ADA-GEL (determined by WST-8 assay). The addition of SF improved the biocompatibility, degradation rate, moisturizing effects, and stretchability of the developed hydrogels, as determinedin vitro. Such multimaterial hydrogels can stimulate angiogenesis and exhibit desirable antibacterial properties. Therefore further (in vivo) tests are justified to assess the hydrogels' potential for wound dressing and skin tissue healing applications.

Analytical corrections for B1 -inhomogeneity and signal decay in multi-slice 2D spiral hyperpolarized 129 Xe MRI using keyhole reconstruction

PURPOSE

Hyperpolarized xenon MRI suffers from heterogeneous coil bias and magnetization decay that obscure pulmonary abnormalities. Non-physiological signal variability can be mitigated by measuring and mapping the nominal flip angle, and by rescaling the images to correct for signal bias and decay. While flip angle maps can be calculated from sequentially acquired images, scan time and breath-hold duration are doubled. Here, we exploit the low-frequency oversampling of 2D-spiral and keyhole reconstruction to measure flip angle maps from a single acquisition.

METHODS

Flip angle maps were calculated from two images generated from a single dataset using keyhole reconstructions and a Bloch-equation-based model suitable for hyperpolarized substances. Artifacts resulting from acquisition and reconstruction schemes (e.g., keyhole reconstruction radius, slice-selection profile, spiral-ordering, and oversampling) were assessed using point-spread functions. Simulated flip angle maps generated using keyhole reconstruction were compared against the paired-image approach using RMS error (RMSE). Finally, feasibility was demonstrated for in vivo xenon ventilation imaging.

RESULTS

Simulations demonstrated accurate flip angle maps and B1 -inhomogeneity correction can be generated with only 1.25-fold central-oversampling and keyhole reconstruction radius = 5% (RMSE = 0.460°). These settings also generated accurate flip angle maps in a healthy control (RSME = 0.337°) and a person with cystic fibrosis (RMSE = 0.404°) in as little as 3.3 s.

CONCLUSION

Regional lung ventilation images with reduced impact of B1 -inhomogeneity can be acquired rapidly by combining 2D-spiral acquisition, Bloch-equation-based modeling, and keyhole reconstruction. This approach will be especially useful for breath-hold studies where short scan durations are necessary, such as dynamic imaging and applications in children or people with severely compromised respiratory function.

A qualitative study exploring community pharmacists' awareness, attitudes and perceptions about drive-thru community pharmacy service in Malaysia during COVID-19

Introduction

Drive-thru services are not given sufficient focus in the community pharmacy setting which was highlighted during COVID-19, particularly in Malaysia. This study aimed to explore the community pharmacists' perspectives regarding drive-thru community pharmacy service during COVID-19 in Malaysia.

Methods

In-depth online semi-structured individual interviews were conducted among 25 community pharmacists working in Malaysia. All interviews were conducted between March 2022 and May 2022 and were audio-recorded and transcribed verbatim, and then analysed by thematic analysis.

Results

Thematic analysis yielded seven major themes, 1-familiarity with drive-thru community pharmacy service during COVID-19, 2-willingness toward this service during COVID-19, 3-perceived benefits toward drive-thru community pharmacy service during COVID-19, 4-perceived disadvantages toward this service, 5-barriers toward drive-thru community pharmacy service, 6-factors affecting the preference toward this service, and 7-facilitators to drive-thru community pharmacy service. Enhancing social distancing and preventing the spread of COVID-19 were the major perceived benefits of this service during COVID-19 as reported by participants.

Conclusion

Overall, community pharmacists reported positive attitudes toward drive-thru community pharmacy service during COVID-19. However, concerns about poor communication between the pharmacist and the patient, limited counselling, and dispensing errors were acknowledged. These concerns would need to be addressed to improve the provision of drive-thru community pharmacy service.

Association of Posterior Reversible Encephalopathy Syndrome (PRES) with Preeclampsia with Severe Symptoms and Eclampsia in South East Part of Bangladesh

Posterior reversible encephalopathy syndrome (PRES) is a pathology seen not only in precelampsia with severe symptoms and eclampsia but in a varicty of diseases/ conditions. With the availability of neuroimaging, it is possible to know the exact underlying Central nervous system (CNS) pathology in preeclampsia with severe symptoms and eclampsia and thus therapy can be targeted. Preeclampsia with severe symptoms and eclampsia remains to be an important cause of maternal morbidity and mortality in both the developing and developed world. The objective of this study was to evaluate the association of Posterior reversible encephalopathy syndrome (PRES) by MRI (Magnetic resonance imaging) with preeclampsia with severe symptoms and eclampsia in south east part of Bangladesh. This cross-sectional observational study was performed among women suffering from preeclampsia with severe symptoms and eclampsia who attended at Obstetrics & Gynaecology department of Chittagong Medical College Hospital (CMCH), Bangladesh from January 2021 to June 2021. According to inclusion/exclusion criteria 50 samples were taken by convenient sampling for this study. A detail history was taken and complete general physical and gynecological examination was performed. Required data was collected through preset questionnaire. Neuroimaging reports were reviewed by both neurologist and radiologist. Data was analyzed by using windows based computer software device, SPSS 25.0. Results obtained from this study will be used to make a statement regarding aggressive management for cerebral vasospasm in severe preeclampsia and eclamptia related PRES. PRES has been reported to be reversible but late recognition or incorrect treatment can cause irreversible brain damage. Institution of early treatment leads to resolution of symptoms without any neurologic deficit and thus reduces maternal morbidity and mortality. PRES is a cliniconeuroradiologic entity. This study can aware doctors regarding prompt diagnosis of PRES in peripartum period among patient suffering from preeclampsia with severe symptoms and eclampsia by imaging aside clinical findings. A conclusive decision can be made to improve the outcome in this potentially life threatening but reversible condition.

Humoral and T cell responses to SARS-CoV-2 reveal insights into immunity during the early pandemic period in Pakistan

BACKGROUND

Protection against SARS-CoV-2 is mediated by humoral and T cell responses. Pakistan faced relatively low morbidity and mortality from COVID-19 through the pandemic. To examine the role of prior immunity in the population, we studied IgG antibody response levels, virus neutralizing activity and T cell reactivity to Spike protein in a healthy control group (HG) as compared with COVID-19 cases and individuals from the pre-pandemic period (PP).

METHODS

HG and COVID-19 participants were recruited between October 2020 and May 2021. Pre-pandemic sera was collected before 2018. IgG antibodies against Spike and its Receptor Binding Domain (RBD) were determined by ELISA. Virus neutralization activity was determined using a PCR-based micro-neutralization assay. T cell - IFN-γ activation was assessed by ELISpot.

RESULTS

Overall, the magnitude of anti-Spike IgG antibody levels as well as seropositivity was greatest in COVID-19 cases (90%) as compared with HG (39.8%) and PP (12.2%). During the study period, Pakistan experienced three COVID-19 waves. We observed that IgG seropositivity to Spike in HG increased from 10.3 to 83.5% during the study, whilst seropositivity to RBD increased from 7.5 to 33.3%. IgG antibodies to Spike and RBD were correlated positively in all three study groups. Virus neutralizing activity was identified in sera of COVID-19, HG and PP. Spike reactive T cells were present in COVID-19, HG and PP groups. Individuals with reactive T cells included those with and without IgG antibodies to Spike.

CONCLUSIONS

Antibody and T cell responses to Spike protein in individuals from the pre-pandemic period suggest prior immunity against SARS-CoV-2, most likely from cross-reactive responses. The rising seroprevalence observed in healthy individuals through the pandemic without known COVID-19 may be due to the activation of adaptive immunity from cross-reactive memory B and T cells. This may explain the more favourable COVID-19 outcomes observed in this population.

Reliability and validity of the Malay version of the drive-thru community pharmacy service questionnaire and the Malaysian public's awareness, attitudes, and perceptions of drive-thru community pharmacy during COVID-19

INTRODUCTION

Understanding general public's experiences of using drive-thru pharmacies during COVID-19 in different countries is imperative for establishing these services by standardizing global guidelines for drive-thru pharmacies. The objectives of this study were to validate a Malay version of the drive-thru community pharmacy service questionnaire for use among Malaysians and to obtain a better understanding of the public's awareness, attitudes, and perceptions of drive-thru community pharmacy service during COVID-19.

METHODS

This study was a cross-sectional study, conducted online using a Google form survey using a convenient sampling method among the Malaysian public. The English version of the drive-thru community pharmacy service questionnaire was translated into the Malay language according to international guidelines. The content and face validity of the questionnaire were examined by experts. Then, the questionnaire was pilot tested on 15 native speakers. Reliability was assessed using Cronbach's alpha coefficients. The test-retest reliability was measured with Cohen's κ coefficient.

RESULTS

A total of 519 participants completed the questionnaire. Face and content validity were satisfactory, as noticed by both the experts and pilot study participants. For test-retest reliability (32 participants), most perception statements had very good coefficient agreement values. Cronbach's alpha of the perception part was 0.833, indicating strong internal consistency. The median age of study participants was 50.0 (IQR = 31.0) and about half of them were females (50.3%, n = 261). Despite 20.4% (n = 106) of the participants reported that the drive-thru community pharmacy service was available in their cities, only 10.4% (n = 54) reported using it. Most participants were in favor of introducing drive-thru services in community pharmacies throughout the country. Drive-thru community pharmacies, according to more than half of the participants (n = 394), would be beneficial to the public. Participants acknowledged that community pharmacies with drive-thru services were useful during the COVID-19 and quarantine periods due to the enhanced social distance 43.5% (n = 226), reduced the spread of the COVID-19 virus 47.0% (n = 244), and relieved pressure on other healthcare settings 38.2% (n = 198).

CONCLUSIONS

The translated questionnaire was valid and reliable in assessing the perceptions toward drive-thru community pharmacy service during COVID-19 in Malaysia. The participants expressed good awareness and favorable attitudes and perceptions toward drive-thru community pharmacy service during COVID-19. Furthermore, they perceived those services helped to increase social isolation and stop the COVID-19 virus from spreading.

3D Printing Assisted Fabrication of Copper-Silver Mesoporous Bioactive Glass Nanoparticles Reinforced Sodium Alginate/Poly(vinyl alcohol) Based Composite Scaffolds: Designed for Skin Tissue Engineering

Additive manufacturing (also known as 3D printing) is a promising method for producing patient-specific implants. In the present study, sodium alginate (Na-ALG)/poly(vinyl alcohol) (PVA) polymer blends of varying ratios (1:0, 3:1, 1:1, and 1:3) were used to produce tailored-designed skin scaffolds using a 3D bioprinter. Samples of skin scaffolds were printed at 20 layers with a layer height of 0.15 mm using a needle with an inner diameter of 330 μm while maintaining the extrusion speed, extrusion width, and fill density at 10 mm/s, 0.2 mm, and 85%, respectively. The Na-ALG/PVA blend with a 3:1 ratio showed the best printability due to its good viscosity and minimal nozzle leakage, allowing for the fabrication of skin scaffolds with high fidelity and the desired morphological characteristics. Then, copper-silver doped mesoporous bioactive glass nanoparticles (Cu-Ag MBGNs) were incorporated into the Na-ALG/PVA blend (which had already been prepared by using a Na-ALG:PVA ratio of 3:1) in order to obtain therapeutic (angiogenic and antibacterial) effects. The fabricated Na-ALG/PVA/Cu-Ag MBGNs biocomposite scaffolds with dimensions of 20 mm× 20 × 3 mm3 and pore size of 400 ± 60 μm exhibited a promising fidelity. The presence of chemical bonds attributed to Na-ALG, PVA, and Cu-Ag MBGNs and the uniform distribution of Na, C, and O elements within the microstructure of the scaffolds were confirmed by EDX, SEM, and FTIR analyses. The scaffolds were hydrophilic and exhibited proper swelling and degradation behavior for skin tissue engineering. According to the inhibition halo test, the scaffolds exhibited strong antibacterial activity against Staphylococcus aureus and Escherichia coli. The cytocompatibility to human-derived fibroblast cells was confirmed by the WST-8 assay and in vivo Chorioallantoic Membrane Assay. In addition, Na-ALG/PVA/Cu-Ag MBGNs showed angiogenic potential, exhibiting favorable wound healing properties.

The impact of diabetes mellitus on the emergence of multi-drug resistant tuberculosis and treatment failure in TB-diabetes comorbid patients: a systematic review and meta-analysis

Background

The existence of Type 2 Diabetes Mellitus (DM) in tuberculosis (TB) patients is very dangerous for the health of patients. One of the major concerns is the emergence of MDR-TB in such patients. It is suspected that the development of MDR-TB further worsens the treatment outcomes of TB such as treatment failure and thus, causes disease progression.

Aim

To investigate the impact of DM on the Emergence of MDR-TB and Treatment Failure in TB-DM comorbid patients.

Methodology

The PubMed database was systematically searched until April 03, 2022 (date last searched). Thirty studies met the inclusion criteria and were included in this study after a proper selection process.

Results

Tuberculosis-Diabetes Mellitus patients were at higher risk to develop MDR-TB as compared to TB-non-DM patients (HR 0.81, 95% CI: 0.60-0.96, p < 0.001). Heterogeneity observed among included studies was moderate (I2 = 38%). No significant change was observed in the results after sub-group analysis by study design (HR 0.81, 95% CI: 0.61-0.96, p < 0.000). In the case of treatment failure, TB-DM patients were at higher risk to experience treatment failure rates as compared to TB-non-DM patients (HR 0.46, 95% CI: 0.27-0.67, p < 0.001).

Conclusion

The results showed that DM had a significant impact on the emergence of MDR-TB in TB-diabetes comorbid patients as compared to TB-non-DM patients. DM enhanced the risk of TB treatment failure rates in TB-diabetes patients as compared to TB-non-DM patients. Our study highlights the need for earlier screening of MDR-TB, thorough MDR-TB monitoring, and designing proper and effective treatment strategies to prevent disease progression.

Biodegradable Packaging Based on Poly(vinyl Alcohol) and Carboxymethyl Cellulose Films Incorporated with Ascorbic Acid for Food Packaging Applications

Petroleum-based plastics are used as packaging materials because of their low cost and high availability; however, continuous use of these nondegradable materials especially in the food industry has led to environmental pollution. The present study aimed to synthesize antibacterial and biodegradable films based on natural biopolymers carboxymethyl cellulose (CMC), poly(vinyl alcohol) (PVA), and ascorbic acid (AA) cross-linked in the presence of glutaraldehyde (GA). The films were synthesized in two different concentrations, 60PVA:40CMC:AA and 70PVA:30CMC:AA with a fixed amount of AA. Films with smooth texture and overall uniform thickness were obtained. Fourier transform infrared spectroscopy (FTIR) confirmed the cross-linking between the aldehyde group of GA and hydroxyl of PVA through detection of acetal and ether bridges. The synthesized films were thermally stable in the temperature range of 180-300 °C; however, 70PVA:30CMC:AA showed higher weight loss in this range as compared to the 60PVA:40CMC:AA film. Soil burial test demonstrated that the 60PVA:40CMC:AA film was more degradable (71% at day 15) as compared to the 70PVA:30CMC:AA film (65% at day 15). The films exhibited excellent antimicrobial activity against Gram-positive staphylococcus aureus(inhibition zone of 21 mm) and Gram-negative Escherichia coli (inhibition zone of 15 mm). In comparison, the 60PVA:40CMC:AA film showed better results in terms of high mechanical strength, uniform morphology, higher soil burial degradation, and lower water vapor transmission rate. Therefore, the prepared film could be used as a promising candidate in the food packaging industry.

Synthesis and characterization of mesoporous bioactive glass nanoparticles loaded with peganum harmala for bone tissue engineering

Globally, there is an increase in a number of bone disorders including osteoarthritis (OA), osteomyelitis, bone cancer, and etc., which has led to a demand for bone tissue regeneration. In order to take use of the osteogenic potential of natural herbs, mesoporous bioactive glass nanoparticles (MBGNs) have the ability to deliver therapeutically active chemicals locally. MBGNs influence bioactivity and osteointegration of materials making them suitable for bone tissue engineering (BTE). In the present study, we developed Peganum Harmala (P. harmala) loaded MBGNs (PH-MBGNs) synthesized via modified Stöber process. The MBGNs were analyzed in terms of surface morphology, chemical make-up, amorphous nature, chemical interaction, pore size, and surface area before and after loading with P. harmala. A burst release of drug from PH-MBGNs was observed within 8 h immersion in phosphate buffer saline (PBS). PH-MBGNs effectively prevented Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) from spreading. Furthermore, PH-MBGNs developed a hydroxyapatite (HA) layer in the presence of simulated body fluid (SBF) after 21 days, which confirmed the in-vitro bioactivity of MBGNs. In conclusion, PH-MBGNs synthesized in this work are potential candidate for scaffolding or a constituent in the coatings for BTE applications.

Understanding the facilitators and barriers to barcode medication administration by nursing staff using behavioural science frameworks. A mixed methods study

INTRODUCTION

Barcode medication administration (BCMA) technology helps ensure correct medications are administered by nursing staff through scanning of patient and medication barcodes. In many hospitals scanning rates are low, limiting the potential safety benefits. We aimed to explore the barriers and facilitators to BCMA use in a London hospital.

METHODS

In this mixed methods study we used local quantitative data on BCMA scanning rates to identify clinically similar wards (in terms of patient acuity and workload) with different scanning rates for qualitative exploration. Interviews designed to elicit barriers to using BCMA technology were conducted with nursing staff, supported by observations of medication administration. Qualitative data were analysed inductively and a thematic framework constructed housing key themes, subsequently categorised into barriers and facilitators. To explore patient perspectives of BCMA scanning, a purposive sample of patients were also interviewed. These patient data were analysed deductively according to the thematic framework. Themes were mapped to behavioural science frameworks to further understand the behaviours involved.

RESULTS

BCMA was operational on 15 wards, with only six having medication scan rates of more than 10% of scannable doses. Of three wards selected for qualitative investigation, the lowest scan rate was 6.7%. Twenty-seven nurses and 15 patients were interviewed. Eleven key themes were identified, encompassing both barriers and facilitators to BCMA use. Barriers included poor trolley ergonomics and perceived time inefficiency. Facilitators included a streamlined process and thorough training. All nurses described BCMA as positive for patient safety. Patients described BCMA as making them "feel safer". Behavioural science frameworks highlighted the importance of professional role and an individual's belief in their capability.

CONCLUSION

We present a novel exploration of facilitators and barriers to BCMA use from the viewpoint of both patients and nursing staff, highlighting a strong perception that BCMA enhances safety. Barriers were reported on both high and low usage wards, demonstrating the importance of behaviours and motivations. These findings provide a detailed understanding from which to design interventions to support behaviour change and increase BCMA use.

Global landscape of community pharmacy services remuneration: a narrative synthesis of the literature

Community pharmacists form a vital part of the health system all around the globe. Pharmacy remuneration models are aimed to ensure that pharmacies are sustained, and pharmacists could provide cost-effective services to the patients. This review summarizes the pharmacy services remuneration systems from different parts of the globe. Some countries have well-established reimbursement systems that recognize and compensate community pharmacies for their services, others are in the process of expanding the scope of reimbursable services. It further concludes by highlighting the ongoing efforts to incorporate pharmacist-provided services into reimbursement schemes and the need for standardized and consistent approaches to pharmacy remuneration globally.

Over-the-counter use of short-acting beta-2 agonists: a systematic review

BACKGROUND

The widespread use of short-acting beta-2 agonists (SABA) as an as-needed treatment for asthma is well-established. However, excessive use of SABA has been linked to undesirable outcomes such as increased risk of asthma attacks, exacerbations, and even death. The availability of SABA as an over-the-counter (OTC) medication has contributed to their overuse, leading to undertreated asthma and reduced access to asthma education.

OBJECTIVE

This systematic review aimed to summarize the prevalence, characteristic features of, and factors contributing to over-the-counter SABA purchase or overuse.

METHODS

The databases searched included PubMed, Scopus, Springer Link, Google Scholar, CINAHL, and APA PsycArticles. Original research articles reporting the prevalence, characteristics features, and factors regarding over-the-counter SABA use, available as full text, published in English language between the year 2000 and April 2023 were included in this review. Commentaries, letters to editor, review articles, qualitative studies, clinical trials, and conference proceedings were excluded. Data extraction was followed by a review of the quality of studies included and data were then synthesized for meaningful findings. This systematic review had been registered in the PROSPERO with registration number CRD42023421007.

RESULTS

A total of 18 articles were included. The prevalence range of OTC SABA users in populations were 1.4% to 39.6% and SABA over-users among OTC users were 14% to 66.4%. Factors mostly associated with this behavior were moderate-severe asthma, and less use of preventers. On top of that, not understanding the risk of SABA overuse was clear in many studies that explored this factor.

CONCLUSION

Over-the-counter purchase and overuse of SABA medication is a common problem, leading to adverse consequences such as uncontrolled asthma and increased healthcare utilization. Addressing these issues requires improved patient education about their conditions and adequate information regarding the potential long-term effects of SABA use by the healthcare providers. Management and education of asthma patients, including regular monitoring and follow-up, can help reduce overuse of SABA medication and prevent negative consequences.

Investigating the impact of prior COVID-19 on IgG antibody and interferon γ responses after BBIBP-CorV vaccination in a disease endemic population: A prospective observational study

Background and Aims

COVID-19 vaccinations have reduced morbidity and mortality from the disease. Antibodies against severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) have been associated with immune protection. Seroprevalence studies revealed high immunoglobulin G (IgG) antibody levels to SARS-CoV-2 in the Pakistani population before vaccinations. We investigated the effect of BBIBP-CorV vaccination on circulating IgG antibodies and interferon (IFN)-γ from T cells measured in a cohort of healthy individuals, with respect to age, gender, and history of COVID-19.

Methods

The study was conducted between April and October 2021. BBIBP-CorV vaccinated participants were followed up to 24 weeks. Antibodies to SARS-CoV-2 Spike protein and its receptor-binding domain (RBD) were measured. IFNγ secreted by whole blood stimulation of Spike protein and extended genome antigens was determined.

Results

Study participants with a history of prior COVID-19 displayed a higher magnitude of IgG antibodies to Spike and RBD. IgG seropositivity was greater in those with prior COVID-19, aged 50 years or younger and in females. At 24 weeks after vaccination, 37.4% of participants showed IFN-γ responses to SARS-CoV-2 antigens. T cell IFN-γ release was higher in those with prior COVID-19 and those aged 50 years or less. Highest IFN-γ release was observed to extended genome antigens in individuals both with and without prior COVID-19.

Conclusion

We found that IgG seropositivity to both Spike and RBD was affected by prior COVID-19, age and gender. Importantly, seropositive responses persisted up to 24 weeks after vaccination. Persistence of vaccine induced IgG antibodies may be linked to the high seroprevalence observed earlier in unvaccinated individuals. Increased T cell reactivity to Spike and extended genome antigens reflects cellular activation induced by BBIBP-CorV. COVID-19 vaccination may have longer lasting immune responses in populations with a higher seroprevalence. These data inform on vaccination booster policies for high-risk groups.

Development and validation of an assessment tool for public perceptions toward drive-thru community pharmacy services in Malaysia during COVID-19

Introduction

Community pharmacists' roles have expanded and undergone a significant transition over the last few years. Consequently, new and different pharmacy services, such as drive-thru pharmacy services, have emerged. Drive-thru pharmacy services began three decades ago and continued even during outbreaks such as the COVID-19 pandemic. Patients' perceptions are essential to the successful implementation and satisfaction with any new service. This study examines the reliability and validity of the assessment tool of public perceptions toward drive-thru community pharmacy services in Malaysia during COVID-19.

Methods

A cross-sectional study was conducted. The developed tool consists of 28 items to evaluate believed advantages toward drive-thru community pharmacy services, believed disadvantages toward drive-thru community pharmacy services, differences between drive-thru community pharmacy services and instore drug refill services, perceptions toward drive-thru community pharmacy services and feelings regarding how the introduction of drive-thru pharmacy services may affect the image of community pharmacists. Exploratory factor analysis (EFA) was performed to identify the factors of the developed tool, and confirmatory factor analysis (CFA) evaluated the model fitness.

Results

The EFA identified five elements and 25 items for the tool, and through CFA results, the observed model of the 25 items structure of the tool was verified as an excellent fit for the data [χ2 (265, N = 565) = 819.586, p < 0.001, IFI = 0.931, CFI = 0.93, RMSEA = 0.064]. The results of the CFA indicated a good model fit between the observed model and the proposed model. The internal reliability of the entire tool and each factor was very satisfactory as Cronbach's Alpha for the whole structured tool was 0.843 and for each factor was as follows, first factor (believed advantages) = 0.909, second factor (believed disadvantages) = 0.921, third factor (differences between drive-thru and instore refill) = 0.647, fourth factor (perceptions) = 0.926, and fifth factor (feelings) = 0.681.

Conclusion

The developed and validated tool would be valuable for assessing the public's perceptions of the drive-thru community pharmacy service during COVID-19 and future pandemics.

Observation of high-energy neutrinos from the Galactic plane

The origin of high-energy cosmic rays, atomic nuclei that continuously impact Earth's atmosphere, is unknown. Because of deflection by interstellar magnetic fields, cosmic rays produced within the Milky Way arrive at Earth from random directions. However, cosmic rays interact with matter near their sources and during propagation, which produces high-energy neutrinos. We searched for neutrino emission using machine learning techniques applied to 10 years of data from the IceCube Neutrino Observatory. By comparing diffuse emission models to a background-only hypothesis, we identified neutrino emission from the Galactic plane at the 4.5σ level of significance. The signal is consistent with diffuse emission of neutrinos from the Milky Way but could also arise from a population of unresolved point sources.

Imaging characteristics of idiopathic scleroma: a retrospective case series and review of the literature

BACKGROUND

Idiopathic scleroma (previously coined solitary idiopathic choroiditis or focal scleral nodule) is an innocuous lesion affecting the sclera with intraocular manifestations. It is often the basis of many misdiagnoses such as amelanotic choroidal melanoma, osteoma or metastatic lesions. Patients are often asymptomatic and the course is benign. With increasing use of community based imaging, more of such cases are being identified. This paper is a retrospective case series investigating the multi-modal imaging findings of idiopathic scleroma.

METHODS

A retrospective analysis of prospectively collected data were analysed. Over the course of January 2008-January 2022, 44 patients diagnosed with idiopathic scleroma and imaged with wide-field colour fundus photography, fundus autofluorescence, ocular coherence tomography (OCT) and B-scan ultrasonography. Due to a poor image, only 43 images were included for OCT review. We also reviewed our patient's demographics, symptoms and baseline ophthalmic characteristics upon presentation.

RESULTS

The mean age was 52 years (range 32-79) and there was no predilection towards gender. All lesions were post equatorial with the most common location being inferotemporal (n = 16, 36%); 32 lesions (73%) were yellow on fundus photography. 82% (n = 36/44) of lesions exhibited hyperautoflourescence and 43 lesions (98%) showed hyperechogenicity on B-scan ultrasonography. 100% of lesions originated from the sclera with no lesions showing active inflammation. 20 (47%) lesions had associated blood vessels overlying them on OCT.

DISCUSSION

Idiopathic scleroma is a yellow, hyperautofluorescent, hyperechogeneic scleral lesion that has no signs of active inflammation. These characteristics help define them from other more sinister cause of amelanotic fundal lesions.

Attitudes, awareness, and perceptions of general public and pharmacists toward the extended community pharmacy services and drive-thru pharmacy services: a systematic review

BACKGROUND

Several extended and newly added pharmacy services were evaluated in different countries. This review aims to provide a summary of studies on attitudes, awareness, or perceptions toward various extended and drive-thru pharmacy services at community settings among pharmacists and the general public.

METHODS

To find qualitative and descriptive quantitative studies, that reported on the attitudes, awareness, or perceptions of the general public and pharmacists toward the practice of any extended community pharmacy service and drive-thru pharmacy services in a community setting and conducted from March 2012 to March 2022. Researchers used databases such as Embase, Medline PubMed, Scopus, Web of Science, and Science Direct. The reviewers extracted data independently using the PRISMA checklist.

RESULTS

There were 55 studies found according to the inclusion criteria. Various extended pharmacy services (EPS) and drive-thru pharmacy services were noted in the community setting. Pharmaceutical care services and healthcare promotion services were the noticeable performed extended services. There were positive perceptions and attitudes toward extended and drive-thru pharmacy services among pharmacists and the public. However, some factors, such as lack of time and shortage of staff, affect the practice of those services.

CONCLUSION

Understanding the major concerns toward the provision of extended and drive-thru community pharmacy services and improving pharmacists' skills through more training programs to provide such services efficiently. In the future, more reviews for EPS practice barriers are recommended to faceup all concerns and find standardized guidelines by stakeholders and organizations for efficient EPS practices.

Assessment of risk factors associated with potential drug-drug interactions among patients suffering from chronic disorders

Patients suffering from chronic diseases are more likely to experience pDDIs due to older age, prolonged treatment, severe illness and greater number of prescribed drugs. The objective of the current study was to assess the prevalence of pDDIs and risk factors associated with occurrence of pDDIs in chronic disease patients attending outpatient clinics for regular check-ups. Patients suffering from diabetes, chronic obstructive pulmonary disease (COPD), stroke and osteoporosis were included in the study. This study was a cross sectional, observational, prospective study that included 337 patients from outpatient clinics of respiratory ward, cardiac ward and orthopedic ward of Nishter Hospital Multan, Pakistan. The mean number of interactions per patient was 1.68. A greater risk for occurrence of pDDI was associated with older age ≥ 60 years (OR = 1.95, 95% CI = 1.44-2.37, p<0.001); polypharmacy (≥ 5 drugs) (OR = 3.74, 95% CI 2.32-4.54, p<0.001); overburden (OR = 2.23, 95% CI = 1.64-3.16, p<0.01); CCI score (OR = 1.28, 95% CI = 1.04-1.84, p<0.001); multiple prescribers to one patient (OR = 1.18, 95% CI = 1.06-1.41, p<0.01); and trainee practitioner (OR = 1.09, 95% CI = 1.01-1.28, p<0.01). Old age, polypharmacy, overburden healthcare system, higher comorbidity index, multiple prescribers to one patient and trainee practitioner were associated with increased risk of occurrence of pDDIs in chronic disease patients.

Perceptions, attitudes, and behaviors of asthma patients towards the use of short-acting β2-agonists: A systematic review

BACKGROUND

Short-acting β2-agonists (SABA), the most potent and rapid-acting relievers are commonly used to provide quick relief of asthma symptoms. However, there is an increasing concern regarding the misuse of SABA medicines.

OBJECTIVE

This qualitative systematic review aims to determine, evaluate, and summarize the perceptions, attitudes, and behaviors towards the use of SABA from the patients' perspectives.

METHODS

The databases searched included PubMed, Scopus, PsycINFO, CINAHL, and Cochrane database. Original research articles reporting the perceptions, attitudes, or behaviors of asthma patients towards the use of SABA, which was available as full text, published in the English language between the year 2000 and February 2023 were included in the review. Commentaries, letters to editor, review articles, and conference proceedings were excluded.

RESULTS

A total of five articles were included. Six overarching themes were obtained: (1) perceptions on health status; (2) perceptions and attitudes towards the impact of asthma; (3) perceptions towards asthma control; (4) perceptions towards asthma knowledge; (5) risk perceptions; (6) perceptions, attitudes, and behaviors towards the use of SABA.

CONCLUSION

Despite the fact that SABA could rapidly alleviate asthma symptoms, SABA over-users were less likely to describe their health status and asthma control as 'excellent'. Most SABA over-users did not know that frequent SABA usage would worsen their asthma control, and they exhibited psychological linkage towards the use of SABA. Collaborative efforts between policymakers, healthcare professionals and patients are warranted to reconstruct SABA prescribing practice and usage.

Evidence for neutrino emission from the nearby active galaxy NGC 1068

A supermassive black hole, obscured by cosmic dust, powers the nearby active galaxy NGC 1068. Neutrinos, which rarely interact with matter, could provide information on the galaxy’s active core. We searched for neutrino emission from astrophysical objects using data recorded with the IceCube neutrino detector between 2011 and 2020. The positions of 110 known gamma-ray sources were individually searched for neutrino detections above atmospheric and cosmic backgrounds. We found that NGC 1068 has an excess of 79 − 20 + 22 neutrinos at tera–electron volt energies, with a global significance of 4.2σ, which we interpret as associated with the active galaxy. The flux of high-energy neutrinos that we measured from NGC 1068 is more than an order of magnitude higher than the upper limit on emissions of tera–electron volt gamma rays from this source.

Development and Characterization of Chitosan and Chondroitin Sulfate Based Hydrogels Enriched with Garlic Extract for Potential Wound Healing/Skin Regeneration Applications

Hydrogels can provide instant relief to pain and facilitate the fast recovery of wounds. Currently, the incorporation of medicinal herbs/plants in polymer matrix is being investigated due to their anti-bacterial and wound healing properties. Herein, we investigated the novel combination of chitosan (CS) and chondroitin sulfate (CHI) to synthesize hydrogels through freeze gelation process and enriched it with garlic (Gar) by soaking the hydrogels in garlic juice for faster wound healing and resistance to microbial growth at the wound surface. The synthesized hydrogels were characterized via Fourier-transform infrared spectroscopy (FTIR), which confirmed the presence of relevant functional groups. The scanning electron microscopy (SEM) images exhibited the porous structure of the hydrogels, which is useful for the sustained release of Gar from the hydrogels. The synthesized hydrogels showed significant inhibition zones against Escherichia coli (E. coli) and Staphylococcus aureus (S. aureus). Furthermore, cell culture studies confirmed the cyto-compatibility of the synthesized hydrogels. Thus, the novel hydrogels presented in this study can offer an antibacterial effect during wound healing and promote tissue regeneration.

Search for Unstable Sterile Neutrinos with the IceCube Neutrino Observatory

We present a search for an unstable sterile neutrino by looking for a resonant signal in eight years of atmospheric ν_{μ} data collected from 2011 to 2019 at the IceCube Neutrino Observatory. Both the (stable) three-neutrino and the 3+1 sterile neutrino models are disfavored relative to the unstable sterile neutrino model, though with p values of 2.8% and 0.81%, respectively, we do not observe evidence for 3+1 neutrinos with neutrino decay. The best-fit parameters for the sterile neutrino with decay model from this study are Δm_{41}^{2}=6.7_{-2.5}^{+3.9}  eV^{2}, sin^{2}2θ_{24}=0.33_{-0.17}^{+0.20}, and g^{2}=2.5π±1.5π, where g is the decay-mediating coupling. The preferred regions of the 3+1+decay model from short-baseline oscillation searches are excluded at 90% C.L.

Strong Constraints on Neutrino Nonstandard Interactions from TeV-Scale ν_{μ} Disappearance at IceCube

We report a search for nonstandard neutrino interactions (NSI) using eight years of TeV-scale atmospheric muon neutrino data from the IceCube Neutrino Observatory. By reconstructing incident energies and zenith angles for atmospheric neutrino events, this analysis presents unified confidence intervals for the NSI parameter ε_{μτ}. The best-fit value is consistent with no NSI at a p value of 25.2%. With a 90% confidence interval of -0.0041≤ε_{μτ}≤0.0031 along the real axis and similar strength in the complex plane, this result is the strongest constraint on any NSI parameter from any oscillation channel to date.

OP0074 DISTINCT CIRCULATING LYMPHOCYTE SUBSETS DISTINGUISH FLARE FROM DRUG-FREE REMISSION IN RHEUMATOID ARTHRITIS

Background

Rheumatoid arthritis (RA) is characterised by relapsing joint and systemic inflammation, yet the immunopathological basis of these disease flares and their clinical prediction remain uncertain.

Objectives

Using mass cytometry and single cell RNA sequencing, we aimed to identify circulating lymphocyte subsets associated with RA flare, and identify potential cellular biomarkers to predict flare versus drug-free remission (DFR).

Methods

We analysed peripheral blood mononuclear cells (PBMCs) from patients recruited to the BioRRA study (Figure 1), a prospective clinical trial of conventional synthetic disease-modifying anti-rheumatic drug (csDMARD) cessation.[1] Patients with RA in clinical (DAS28-CRP < 2.4) and ultrasound (absence of power Doppler signal in 7 joints) remission stopped csDMARDs, with flare defined as DAS28-CRP ≥ 2.4 during 6 month follow-up. A 44-marker mass cytometry panel was used to profile PBMCs from 36 patients (20 flare, 16 DFR) at two time points each (baseline, and flare onset / month 6 DFR). In a subset of patients (n = 12: 8 flare, 4 DFR), fluorescence-activated cell sorting of T and B cells was followed by single cell sequencing (n = 81,923 cells) incorporating 320 immune genes, 34 oligo-tagged surface protein antibodies, and TCR/BCR CDR3 sequence. Clones were defined as ≥2 cells with identical CDR3 nucleotide sequence, and clonal expansion as a significant increase in proportion from baseline to final study visit. Statistical significance was assessed after Benjamini-Hochberg multiple test correction (adj p < 0.05).

Figure 1.

Results

Mass cytometry revealed 31 distinct cell clusters: notably, greater proportions of memory (CD45RO+/PD1hi) CD4+ and CD8+ T cells, and memory (CD27+/CD21-) B cells, were observed at onset of flare versus baseline (Table 1).

Table 1.Mass cytometry (n = 20 flare + 16 DFR)ContrastClusterMedian %Adj. p (GLMM)Flare onset vs baseline: Flare patientsCD4+/CD45RO+/PD1+ memory T cells2.14 vs 0.24<0.001CD8+/CD45RO+/PD1+ memory T cells6.64 vs 0.07<0.001CD19+/CD27+/CD21- memory B cells2.39 vs 0.03<0.001Single cell RNAseq (n = 8 flare + 4 DFR)ContrastClusterMedian %Adj. p (Wilcoxon)Flare onset vs baseline: Flare patientsIgA+ plasma cells0.37 vs 0.210.020Flare vs DFR patients: BaselineCD4+/CD25+/Foxp3+ Treg cells0.55 vs 1.270.022

To better characterise these flare-associated subsets, single cell sequencing of CD45RO+/PD1hi CD4+ and CD8+ T cells, and CD19+ B cells, was performed and identified 21 distinct clusters. CDR3 sequencing revealed significant clonal expansion (Fisher exact, adj. p < 0.05) at flare onset within five unique CD8+ clones (4 patients), one CD4+ clone (1 patent), and no B clones. Overall, there was a significantly greater proportion of IgA+ plasma cells at flare onset versus baseline. In contrast, a significantly lower proportion of CD25+/FoxP3+ regulatory T cells were present at csDMARD cessation (baseline) in subsequent flare versus DFR patients (Table 1), suggesting biomarker potential.

To further assess the predictive performance of CD4+ Tregs as a biomarker for flare versus DFR, we analysed PBMCs from an independent cohort of 50 patients (25 flare, 25 DFR) stopping csDMARDs in the ongoing BIO-FLARE study.[2] By flow cytometry, we confirmed a lower proportion of CD4+/CD25hi Tregs at baseline in flare vs DFR (median 4.74 versus 6.37%, Wilcoxon p = 0.037; AUC: 0.67). In this cohort, stopping csDMARDs only in patients with elevated (> 6.11% total CD4) baseline Tregs would have prevented drug cessation in 18/25 (72%) of flare patients; 9/25 (36%) of DFR patients would have continued csDMARDs unnecessarily.

Conclusion

We present a detailed longitudinal characterisation of circulating lymphocyte surface phenotype, gene expression, and clonal expansion in RA flare vs DFR. Furthermore our data, across two independent cohorts, suggests a role for CD4+ Tregs in promoting drug-free remission meriting further investigation, with potential for future clinical biomarker development.

References

[1]Baker et al; J Autoimmunity; 105:102298

[2]Rayner et al; BMC Rheumatology; 5:22

Acknowledgements

This work was funded by research grants from Wellcome Trust [102595/Z/13/A to KFB], Newcastle NIHR Biomedical Research Centre [BH136167/PD0045 to KFB], British Society for Rheumatology [KFB], Academy of Medical Sciences [SGL022\1074 to KFB], Newcastle University Wellcome Trust Translational Partnership [KFB], Newcastle Hospitals Charity [8033 to KFB], and a National Institute for Health Research Clinical Lectureship [CL-2017-01-004 to KFB]. Our work is supported by the Research into Inflammatory Arthritis Centre Versus Arthritis (RACE) (grant number 20298), and Rheuma Tolerance for Cure (European Union Innovative Medicines Initiative 2, grant number 777357). AGP and JDI are named as inventors on a patent application by Newcastle University (“Prediction of Drug-Free Remission in Rheumatoid Arthritis”; International Patent Application Number PCT/GB2019/050902). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.

Disclosure of Interests

Kenneth F Baker Consultant of: Modern Biosciences Ltd, Grant/research support from: Pfizer, Genentech, Fiona Rayner: None declared, Henrique Lemos: None declared, David McDonald: None declared, Gillian Hulme: None declared, Rafiqul Hussain: None declared, Jonathan Coxhead Speakers bureau: Tesaro, Arthur Pratt Grant/research support from: Pfizer, Gilead, Amy E. Anderson: None declared, Andrew Filby Grant/research support from: Becton Dickinson, John Isaacs Speakers bureau: Abbvie, Gilead, Roche, UCB, Grant/research support from: GSK, Janssen, Pfizer.

Diabetes mortality and trends before 25 years of age: an analysis of the Global Burden of Disease Study 2019

BACKGROUND

Diabetes, particularly type 1 diabetes, at younger ages can be a largely preventable cause of death with the correct health care and services. We aimed to evaluate diabetes mortality and trends at ages younger than 25 years globally using data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We used estimates of GBD 2019 to calculate international diabetes mortality at ages younger than 25 years in 1990 and 2019. Data sources for causes of death were obtained from vital registration systems, verbal autopsies, and other surveillance systems for 1990-2019. We estimated death rates for each location using the GBD Cause of Death Ensemble model. We analysed the association of age-standardised death rates per 100 000 population with the Socio-demographic Index (SDI) and a measure of universal health coverage (UHC) and described the variability within SDI quintiles. We present estimates with their 95% uncertainty intervals.

FINDINGS

In 2019, 16 300 (95% uncertainty interval 14 200 to 18 900) global deaths due to diabetes (type 1 and 2 combined) occurred in people younger than 25 years and 73·7% (68·3 to 77·4) were classified as due to type 1 diabetes. The age-standardised death rate was 0·50 (0·44 to 0·58) per 100 000 population, and 15 900 (97·5%) of these deaths occurred in low to high-middle SDI countries. The rate was 0·13 (0·12 to 0·14) per 100 000 population in the high SDI quintile, 0·60 (0·51 to 0·70) per 100 000 population in the low-middle SDI quintile, and 0·71 (0·60 to 0·86) per 100 000 population in the low SDI quintile. Within SDI quintiles, we observed large variability in rates across countries, in part explained by the extent of UHC (r2=0·62). From 1990 to 2019, age-standardised death rates decreased globally by 17·0% (-28·4 to -2·9) for all diabetes, and by 21·0% (-33·0 to -5·9) when considering only type 1 diabetes. However, the low SDI quintile had the lowest decline for both all diabetes (-13·6% [-28·4 to 3·4]) and for type 1 diabetes (-13·6% [-29·3 to 8·9]).

INTERPRETATION

Decreasing diabetes mortality at ages younger than 25 years remains an important challenge, especially in low and low-middle SDI countries. Inadequate diagnosis and treatment of diabetes is likely to be major contributor to these early deaths, highlighting the urgent need to provide better access to insulin and basic diabetes education and care. This mortality metric, derived from readily available and frequently updated GBD data, can help to monitor preventable diabetes-related deaths over time globally, aligned with the UN's Sustainable Development Targets, and serve as an indicator of the adequacy of basic diabetes care for type 1 and type 2 diabetes across nations.

FUNDING

Bill & Melinda Gates Foundation.

Cancer Incidence, Mortality, Years of Life Lost, Years Lived With Disability, and Disability-Adjusted Life Years for 29 Cancer Groups From 2010 to 2019: A Systematic Analysis for the Global Burden of Disease Study 2019

IMPORTANCE

The Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019) provided systematic estimates of incidence, morbidity, and mortality to inform local and international efforts toward reducing cancer burden.

OBJECTIVE

To estimate cancer burden and trends globally for 204 countries and territories and by Sociodemographic Index (SDI) quintiles from 2010 to 2019.

EVIDENCE REVIEW

The GBD 2019 estimation methods were used to describe cancer incidence, mortality, years lived with disability, years of life lost, and disability-adjusted life years (DALYs) in 2019 and over the past decade. Estimates are also provided by quintiles of the SDI, a composite measure of educational attainment, income per capita, and total fertility rate for those younger than 25 years. Estimates include 95% uncertainty intervals (UIs).

FINDINGS

In 2019, there were an estimated 23.6 million (95% UI, 22.2-24.9 million) new cancer cases (17.2 million when excluding nonmelanoma skin cancer) and 10.0 million (95% UI, 9.36-10.6 million) cancer deaths globally, with an estimated 250 million (235-264 million) DALYs due to cancer. Since 2010, these represented a 26.3% (95% UI, 20.3%-32.3%) increase in new cases, a 20.9% (95% UI, 14.2%-27.6%) increase in deaths, and a 16.0% (95% UI, 9.3%-22.8%) increase in DALYs. Among 22 groups of diseases and injuries in the GBD 2019 study, cancer was second only to cardiovascular diseases for the number of deaths, years of life lost, and DALYs globally in 2019. Cancer burden differed across SDI quintiles. The proportion of years lived with disability that contributed to DALYs increased with SDI, ranging from 1.4% (1.1%-1.8%) in the low SDI quintile to 5.7% (4.2%-7.1%) in the high SDI quintile. While the high SDI quintile had the highest number of new cases in 2019, the middle SDI quintile had the highest number of cancer deaths and DALYs. From 2010 to 2019, the largest percentage increase in the numbers of cases and deaths occurred in the low and low-middle SDI quintiles.

CONCLUSIONS AND RELEVANCE

The results of this systematic analysis suggest that the global burden of cancer is substantial and growing, with burden differing by SDI. These results provide comprehensive and comparable estimates that can potentially inform efforts toward equitable cancer control around the world.

Search for Relativistic Magnetic Monopoles with Eight Years of IceCube Data

We present an all-sky 90% confidence level upper limit on the cosmic flux of relativistic magnetic monopoles using 2886 days of IceCube data. The analysis was optimized for monopole speeds between 0.750c and 0.995c, without any explicit restriction on the monopole mass. We constrain the flux of relativistic cosmic magnetic monopoles to a level below 2.0×10^{-19}  cm^{-2} s^{-1} sr^{-1} over the majority of the targeted speed range. This result constitutes the most strict upper limit to date for magnetic monopoles with β≳0.8 and up to β∼0.995 and fills the gap between existing limits on the cosmic flux of nonrelativistic and ultrarelativistic magnetic monopoles.

Global, regional, and national sex differences in the global burden of tuberculosis by HIV status, 1990-2019: results from the Global Burden of Disease Study 2019

BACKGROUND

Tuberculosis is a major contributor to the global burden of disease, causing more than a million deaths annually. Given an emphasis on equity in access to diagnosis and treatment of tuberculosis in global health targets, evaluations of differences in tuberculosis burden by sex are crucial. We aimed to assess the levels and trends of the global burden of tuberculosis, with an emphasis on investigating differences in sex by HIV status for 204 countries and territories from 1990 to 2019.

METHODS

We used a Bayesian hierarchical Cause of Death Ensemble model (CODEm) platform to analyse 21 505 site-years of vital registration data, 705 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, and 680 site-years of mortality surveillance data to estimate mortality due to tuberculosis among HIV-negative individuals. We used a population attributable fraction approach to estimate mortality related to HIV and tuberculosis coinfection. A compartmental meta-regression tool (DisMod-MR 2.1) was then used to synthesise all available data sources, including prevalence surveys, annual case notifications, population-based tuberculin surveys, and tuberculosis cause-specific mortality, to produce estimates of incidence, prevalence, and mortality that were internally consistent. We further estimated the fraction of tuberculosis mortality that is attributable to independent effects of risk factors, including smoking, alcohol use, and diabetes, for HIV-negative individuals. For individuals with HIV and tuberculosis coinfection, we assessed mortality attributable to HIV risk factors including unsafe sex, intimate partner violence (only estimated among females), and injection drug use. We present 95% uncertainty intervals for all estimates.

FINDINGS

Globally, in 2019, among HIV-negative individuals, there were 1·18 million (95% uncertainty interval 1·08-1·29) deaths due to tuberculosis and 8·50 million (7·45-9·73) incident cases of tuberculosis. Among HIV-positive individuals, there were 217 000 (153 000-279 000) deaths due to tuberculosis and 1·15 million (1·01-1·32) incident cases in 2019. More deaths and incident cases occurred in males than in females among HIV-negative individuals globally in 2019, with 342 000 (234 000-425 000) more deaths and 1·01 million (0·82-1·23) more incident cases in males than in females. Among HIV-positive individuals, 6250 (1820-11 400) more deaths and 81 100 (63 300-100 000) more incident cases occurred among females than among males in 2019. Age-standardised mortality rates among HIV-negative males were more than two times greater in 105 countries and age-standardised incidence rates were more than 1·5 times greater in 74 countries than among HIV-negative females in 2019. The fraction of global tuberculosis deaths among HIV-negative individuals attributable to alcohol use, smoking, and diabetes was 4·27 (3·69-5·02), 6·17 (5·48-7·02), and 1·17 (1·07-1·28) times higher, respectively, among males than among females in 2019. Among individuals with HIV and tuberculosis coinfection, the fraction of mortality attributable to injection drug use was 2·23 (2·03-2·44) times greater among males than females, whereas the fraction due to unsafe sex was 1·06 (1·05-1·08) times greater among females than males.

INTERPRETATION

As countries refine national tuberculosis programmes and strategies to end the tuberculosis epidemic, the excess burden experienced by males is important. Interventions are needed to actively communicate, especially to men, the importance of early diagnosis and treatment. These interventions should occur in parallel with efforts to minimise excess HIV burden among women in the highest HIV burden countries that are contributing to excess HIV and tuberculosis coinfection burden for females. Placing a focus on tuberculosis burden among HIV-negative males and HIV and tuberculosis coinfection among females might help to diminish the overall burden of tuberculosis. This strategy will be crucial in reaching both equity and burden targets outlined by global health milestones.

FUNDING

Bill & Melinda Gates Foundation.

Estimation of the global prevalence of dementia in 2019 and forecasted prevalence in 2050: an analysis for the Global Burden of Disease Study 2019

BACKGROUND

Given the projected trends in population ageing and population growth, the number of people with dementia is expected to increase. In addition, strong evidence has emerged supporting the importance of potentially modifiable risk factors for dementia. Characterising the distribution and magnitude of anticipated growth is crucial for public health planning and resource prioritisation. This study aimed to improve on previous forecasts of dementia prevalence by producing country-level estimates and incorporating information on selected risk factors.

METHODS

We forecasted the prevalence of dementia attributable to the three dementia risk factors included in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 (high body-mass index, high fasting plasma glucose, and smoking) from 2019 to 2050, using relative risks and forecasted risk factor prevalence to predict GBD risk-attributable prevalence in 2050 globally and by world region and country. Using linear regression models with education included as an additional predictor, we then forecasted the prevalence of dementia not attributable to GBD risks. To assess the relative contribution of future trends in GBD risk factors, education, population growth, and population ageing, we did a decomposition analysis.

FINDINGS

We estimated that the number of people with dementia would increase from 57·4 (95% uncertainty interval 50·4-65·1) million cases globally in 2019 to 152·8 (130·8-175·9) million cases in 2050. Despite large increases in the projected number of people living with dementia, age-standardised both-sex prevalence remained stable between 2019 and 2050 (global percentage change of 0·1% [-7·5 to 10·8]). We estimated that there were more women with dementia than men with dementia globally in 2019 (female-to-male ratio of 1·69 [1·64-1·73]), and we expect this pattern to continue to 2050 (female-to-male ratio of 1·67 [1·52-1·85]). There was geographical heterogeneity in the projected increases across countries and regions, with the smallest percentage changes in the number of projected dementia cases in high-income Asia Pacific (53% [41-67]) and western Europe (74% [58-90]), and the largest in north Africa and the Middle East (367% [329-403]) and eastern sub-Saharan Africa (357% [323-395]). Projected increases in cases could largely be attributed to population growth and population ageing, although their relative importance varied by world region, with population growth contributing most to the increases in sub-Saharan Africa and population ageing contributing most to the increases in east Asia.

INTERPRETATION

Growth in the number of individuals living with dementia underscores the need for public health planning efforts and policy to address the needs of this group. Country-level estimates can be used to inform national planning efforts and decisions. Multifaceted approaches, including scaling up interventions to address modifiable risk factors and investing in research on biological mechanisms, will be key in addressing the expected increases in the number of individuals affected by dementia.

FUNDING

Bill & Melinda Gates Foundation and Gates Ventures.

National pharmacy associations in the commonwealth: current scenario and future needs to maximise effective contributions of the pharmacy profession towards universal health coverage

BACKGROUND

The Commonwealth Pharmacists Association (CPA) is a charity representing pharmacists across the Commonwealth, with the vision of empowering and collaboratively develop the profession and fully utilise the potential of pharmacists to strengthen health systems through supporting better access to, quality and use of medicines and related services. Commonwealth comprises predominantly of low- and middle-income countries, where limited data often exists in pharmacy practice. There is a recognised need across the Commonwealth to focus on developing, implementing and fully utilising pharmacy professional services to progress universal health coverage and achieve the sustainable development goals, particularly in low and middle-income countries; however, currently a knowledge gap exists in understanding the national priorities in Commonwealth nations. CPA is ideally positioned to access to these nations. The aim of this study was thus to explore the priorities and focus areas of NPAs across the Commonwealth and create evidence for a needs-based approach to inform the support that the Commonwealth pharmacists association can collaboratively and strategically provide to its members to progress towards shared goals.

METHODS

Data were collected virtually on Zoom by conducting interviews using a semi-structured interview guide developed for this study with CPA councillors representing NPAs or their equivalents if no official body existed. An inductive, reflexive, thematic analysis was performed for data analysis.

RESULTS

In total, 30 councillors were interviewed from 30 low- and medium-income countries. The three main overarching priority areas identified across respective Commonwealth nations developing extended pharmacy services, improving pharmacy education, and developing and redefining the role of NPAs.

CONCLUSIONS

This novel study highlights the collective priorities for the pharmacy profession across the low and middle-income countries of the Commonwealth and the urgent need for supporting NPAs around the three identified overarching priority areas. The mapped-out priorities will inform an evidence-based approach for the CPA to better support NPAs in their mission through advocacy and practitioner development, to fully harness pharmacists' unique skill set and maximise their contribution to progressing universal health coverage.

Adherence to National Antimicrobial Guidelines in Hospitalized Geriatric Patients with Community-Acquired Pneumonia: A Prospective Observational study in a Malaysian Hospital

The evaluation of disease progression and onsite therapeutic care choices for community-acquired pneumonia (CAP) patients is vital for their well-being and the optimum utilization of healthcare resources. The current study was conducted to assess physicians’ adherence to clinical practice standards and antibiotic prescribing behavior for the treatment of CAP in older people. A prospective study that included 121 consecutive patients admitted for CAP was conducted at Kulim Hospital, Kedah, from March 2020 to August 2020. Medical records including demographic data, comorbidity, physical examination, laboratory or radiologic findings, and drugs used for the treatment of CAP were accessed from bed head tickets (BHT). The mean age for patients was 73.5 ± 6.2 years, 73 (60.3%) and 48 (39.6%) were males and females, respectively. Amoxicillin/clavulanate (19.8%) was the most prescribed antibiotic for non-severe pneumonia followed by ampicillin sodium/sulbactam sodium (6.6%), while in patients with severe CAP beta-lactam + beta lactamase inhibitors (BLIs) with a combination of macrolide were the most common antibiotics prescribed either in patients with (21.4%) or without co-morbidities (8.2%). The average length of stay in the hospital with severe pneumonia was 6–7 days for 23.9% of patients and < 5 days for 21.4% of patients. The duration of intravenous antibiotics in patients with severe pneumonia was 6–7 days for 32.2% of patients. The present findings revealed the adherence of antibiotic prescribing practices to the Malaysian National Antimicrobial Guideline 2019 for CAP therapy among geriatric patients and adherence to the CAP criteria for hospital admissions.

Upregulated type I interferon responses in asymptomatic COVID-19 infection are associated with improved clinical outcome

Understanding key host protective mechanisms against SARS-CoV-2 infection can help improve treatment modalities for COVID-19. We used a blood transcriptome approach to study biomarkers associated with differing severity of COVID-19, comparing severe and mild Symptomatic disease with Asymptomatic COVID-19 and uninfected Controls. There was suppression of antigen presentation but upregulation of inflammatory and viral mRNA translation associated pathways in Symptomatic as compared with Asymptomatic cases. In severe COVID-19, CD177 a neutrophil marker, was upregulated while interferon stimulated genes (ISGs) were downregulated. Asymptomatic COVID-19 cases displayed upregulation of ISGs and humoral response genes with downregulation of ICAM3 and TLR8. Compared across the COVID-19 disease spectrum, we found type I interferon (IFN) responses to be significantly upregulated (IFNAR2, IRF2BP1, IRF4, MAVS, SAMHD1, TRIM1), or downregulated (SOCS3, IRF2BP2, IRF2BPL) in Asymptomatic as compared with mild and severe COVID-19, with the dysregulation of an increasing number of ISGs associated with progressive disease. These data suggest that initial early responses against SARS-CoV-2 may be effectively controlled by ISGs. Therefore, we hypothesize that treatment with type I interferons in the early stage of COVID-19 may limit disease progression by limiting SARS-CoV-2 in the host.

Global, regional, and national mortality among young people aged 10-24 years, 1950-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10-24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10-24 years by age group (10-14 years, 15-19 years, and 20-24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10-24 years with that in children aged 0-9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10-24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017).

FINDINGS

In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39-1·59) worldwide in people aged 10-24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10-14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15-19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1-4 years (2·4%), and around a third less than in females aged 1-4 years (2·5%). The proportion of global deaths in people aged 0-24 years that occurred in people aged 10-24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%.

INTERPRETATION

Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10-24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group.

FUNDING

Bill & Melinda Gates Foundation.

Measuring routine childhood vaccination coverage in 204 countries and territories, 1980-2019: a systematic analysis for the Global Burden of Disease Study 2020, Release 1

BACKGROUND

Measuring routine childhood vaccination is crucial to inform global vaccine policies and programme implementation, and to track progress towards targets set by the Global Vaccine Action Plan (GVAP) and Immunization Agenda 2030. Robust estimates of routine vaccine coverage are needed to identify past successes and persistent vulnerabilities. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2020, Release 1, we did a systematic analysis of global, regional, and national vaccine coverage trends using a statistical framework, by vaccine and over time.

METHODS

For this analysis we collated 55 326 country-specific, cohort-specific, year-specific, vaccine-specific, and dose-specific observations of routine childhood vaccination coverage between 1980 and 2019. Using spatiotemporal Gaussian process regression, we produced location-specific and year-specific estimates of 11 routine childhood vaccine coverage indicators for 204 countries and territories from 1980 to 2019, adjusting for biases in country-reported data and reflecting reported stockouts and supply disruptions. We analysed global and regional trends in coverage and numbers of zero-dose children (defined as those who never received a diphtheria-tetanus-pertussis [DTP] vaccine dose), progress towards GVAP targets, and the relationship between vaccine coverage and sociodemographic development.

FINDINGS

By 2019, global coverage of third-dose DTP (DTP3; 81·6% [95% uncertainty interval 80·4-82·7]) more than doubled from levels estimated in 1980 (39·9% [37·5-42·1]), as did global coverage of the first-dose measles-containing vaccine (MCV1; from 38·5% [35·4-41·3] in 1980 to 83·6% [82·3-84·8] in 2019). Third-dose polio vaccine (Pol3) coverage also increased, from 42·6% (41·4-44·1) in 1980 to 79·8% (78·4-81·1) in 2019, and global coverage of newer vaccines increased rapidly between 2000 and 2019. The global number of zero-dose children fell by nearly 75% between 1980 and 2019, from 56·8 million (52·6-60·9) to 14·5 million (13·4-15·9). However, over the past decade, global vaccine coverage broadly plateaued; 94 countries and territories recorded decreasing DTP3 coverage since 2010. Only 11 countries and territories were estimated to have reached the national GVAP target of at least 90% coverage for all assessed vaccines in 2019.

INTERPRETATION

After achieving large gains in childhood vaccine coverage worldwide, in much of the world this progress was stalled or reversed from 2010 to 2019. These findings underscore the importance of revisiting routine immunisation strategies and programmatic approaches, recentring service delivery around equity and underserved populations. Strengthening vaccine data and monitoring systems is crucial to these pursuits, now and through to 2030, to ensure that all children have access to, and can benefit from, lifesaving vaccines.

FUNDING

Bill & Melinda Gates Foundation.

Assessment of risk factors responsible for rapid deterioration of lung function over a period of one year in patients with chronic obstructive pulmonary disease

Compromised lung function is a common feature of COPD patients, but certain factors increase the rate of lung function decline in COPD patients. The objective of the current study was to investigate the effect of different clinically important factors responsible for rapid deterioration of lung function quantified as ≥ 60 ml decline in FEV1 over a period of one year. COPD patients recruited from the chest clinic of Penang hospital were followed-up for one year from August 2018 to August 2019. Rapid deterioration of lung function was defined as greater than 60 ml/year decline in force expiratory volume in one second. Among 367 included patients 73.84% were male, with mean age 65.26 (9.6) years and % predicted FEV1 51.07 (11.84). 30.27% patients showed mean decline of ≥ 60 ml in FEV1. The regression analysis showed that current smoking relative risk (RR) = 2.38 (1.78-3.07), p < 0.001); GOLD Stage III& IV RR = 1.43 (1.27-1.97), p < 0.001); mMRC score 3 to 4 RR = 2.03 (1.74-2.70), p < 0.01); SGRQ-C score ≥ 10 points difference RR = 2.01 (1.58-2.73), p < 0.01); SGRQ-C symptoms Score ≥ 10 points difference RR = 1.48 (1.23-2.29), p < 0.001); 6MWT < 350 m RR = 2.29 (1.87-3.34), p < 0.01); ≥ 3 exacerbation in study year RR = 2.28 (1.58-2.42, p < 0.001); 8 or more hospital admission days (RR = 3.62 (2.66-4.20), p < 0.001); Charlson comorbidity index ≥ 3 RR = 3.18 (2.23-3.76), p < 0.01) and emphysema RR = 1.31 (1.15-1.79), p < 0.01) were significant risk factors for the rapid deterioration of lung function (FEV1 decline ≥ 60 ml). Among different factors CCI score ≥ 3, abrupt decline in health status, exacerbation frequency ≥ 3, hospital admission days ≥ 8 and emphysema were reported as risk factors for rapid deterioration of lung function.

Mental health of older people with mild and moderate intellectual disability in Australia

BACKGROUND

The progressive increase in life expectancy of people with intellectual disability (ID) has resulted in enhanced survival into old age and has also seen a growth in research on both lifelong and emerging ageing-related health issues. Health issues amongst provider-supported adults have been previously studied, but these studies have not always included older community-dwelling adults with ID.

METHODS

A study examining the extent of mental health of 391 community-dwelling adults with ID age 60 and older in both metropolitan and rural areas of two East Coast Australian states was undertaken using a cross-sectional survey. Examined were a range of demographic (age, sex, living arrangements, employment and socio-economic status) and life (co-morbidities, adverse life events and social support) factors. Data were parsed by two age groupings (60-65: n = 234 and >65: n = 157).

RESULTS

Findings revealed that older community-dwelling adults with ID have many of the same mental health disorders as do other ageing people, with the exception of significant psychiatric disorders often associated with older age. Over a third (35%: n = 137) reported some one or more mental health disorders. Age, sex, location (rural or urban), financial hardship, social support or type of living arrangement were not statistically significant as risk factors for poor mental health. However, employment status was a clear predictor. Stepwise regression models showed a strong association between mental ill-health and adverse life events and between mental ill-health and multiple physical co-morbidities.

CONCLUSIONS

The cross-sectional nature of the study limits causal inference. The cumulative effect of chronic health conditions and adverse life events cannot be prevented retrospectively. However, greater awareness amongst both health professionals and care staff that older adults with ID have a high likelihood of significant and/or repeated traumas and need better health care to limit physical co-morbidity may assist in providing support that is better tailored to individual needs in older age to reduce the burden of mental ill-health.

Complementary and alternative medicines use in COVID-19: A global perspective on practice, policy and research

The COVID-19 pandemic has met international health systems with a low level of preparedness and emergency response. While the emergence of effective vaccines has offered the Governments, scientific communities, and members of the public a possible way out of the pandemic, effective pharmacotherapy, including immunotherapy for COVID-19 prevention and treatment, are yet to be established. Internationally, this has led to a surge in the demand and supply of many complementary and alternative medicines (CAM) and practices. Recent studies have shown increasing CAM information requests made to pharmacists and other healthcare staff from members of public and patients aimed at prevention, symptoms relief or treatment of COVID-19.

In this context, it is imperative that healthcare professionals, including pharmacists, are acquainted with current practices, policies, and research in relation to CAM use in COVID-19. This narrative commentary will provide an update on global practices, policies and research in regards to CAM use in the context of COVID-19. Healthcare professionals’ understanding of popular CAMs and those tipped for potential benefits in COVID-19, patient and consumer behaviors in relation to CAM use; and healthcare professionals' awareness of cultural, religious, and self-care practices associated with CAM use are imperative to inform effective communication and counselling practices and promote evidence based self-care when patients present for advice. This narrative provides relevant discussions specific to different continents and regions historically linked to diverse CAM practices.

Economic Burden of Chronic Obstructive Pulmonary Disease Patients in Malaysia: A Longitudinal Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) requires long-term pharmacological and non-pharmacological management that encompasses continuous economic burden on patients and society, and also results in productivity losses due to compromised quality of life. Among working-age patients, COPD is the 11th leading cause of work productivity loss.

OBJECTIVE

The aim of this study was to assess the economic burden of COPD in Malaysia, including direct costs for the management of COPD and indirect costs due to productivity losses for COPD patients.

METHODOLOGY

Overall, 150 patients with an established diagnosis of COPD were followed-up for a period of 1 year from August 2018 to August 2019. An activity-based costing, 'bottom-up' approach was used to calculate direct costs, while indirect costs of patients were assessed using the Work Productivity and Activity Impairment Questionnaire.

RESULTS

The mean annual per-patient direct cost for the management of COPD was calculated as US$506.92. The mean annual costs per patient in the management phase, emergency department visits, and hospital admissions were reported as US$395.65, US$86.4, and US$297.79, respectively; 31.66% of COPD patients visited the emergency department and 42.47% of COPD patients were admitted to the hospital due to exacerbation. The annual mean indirect cost per patient was calculated as US$1699.76. Productivity losses at the workplace were reported as 31.87% and activity limitations were reported as 17.42%.

CONCLUSION

Drugs and consumables costs were the main cost-driving factors in the management of COPD. The higher ratio of indirect cost to direct medical costs shows that therapeutic interventions aimed to prevent work productivity losses may reduce the economic burden of COPD.

Universal health coverage and COVID-19: recent developments and implications

Universal health coverage (UHC) is meant to access the key health services including disease prevention, treatment, rehabilitation, and health promotion. UHC varies according to demographics, epidemiology, and technology-based trends, as well as according to people’s expectations. Globally, the transition towards UHC has been associated with the intent of improving accessibility and affordability of healthcare. The COVID-19 pandemic has disrupted the health systems of even the most developed economies of the world in an unprecedented manner. The situation is also very challenging for the countries with the existing health inequities as well as the countries with the developing healthcare systems. This has amplified the need to accelerate efforts to build strong and resilient health systems to achieve progress towards UHC. This commentary discusses a global overview of UHC in the wake of COVID19. It also highlights the initiatives taken by Pakistan to promote the goals of UHC.

Exploring healthcare professionals' knowledge, attitude, and practices towards pharmacovigilance: a cross-sectional survey

Background

Spontaneous reporting of adverse drug reactions (ADRs) is a method of monitoring the safety of drugs and is the basic strategy for the post-marketing surveillance of the suspected drugs. Despite its importance, there is very little reporting of ADRs by healthcare professionals. The present study has evaluated the knowledge, attitude and practices of health care professionals (HCPs) regarding pharmacovigilance activities in Lahore, Pakistan.

Methods

A cross-sectional questionnaire-based survey was employed, and a convenience sampling was opted to collect the data among physicians, pharmacists and nurses working in tertiary care public hospitals of Lahore, Pakistan from September 2018 to January 2019.

Results

Of the 384 questionnaires distributed, 346 health care professionals responded to the questionnaire (90.10% response rate). Most participants had good knowledge about ADR reporting, but pharmacist had comparatively better knowledge than other HCPs regarding ADR (89.18%) pharmacovigilance system (81.08%), its centres (72.97%) and function (91.89%). Most of the participants exhibited positive attitude regarding ADR reporting, such as 49.1% of physicians (P < 0.05), 70.2% pharmacists and 76.1% nurses showed a positive attitude that they are the most important HCPs to report an ADR. About 64.3% of physicians (P < 0.05) emphasized that consulting other colleagues is important before reporting an ADR. Of all, 77.7% physicians, 75.7% pharmacists and 68% of nurses had positive attitude that ADR reporting is a professional obligation and 67.6% of the pharmacists stated that they have reported ADRs in their workplace and 77.2% nurses have verbally reported ADRs to the concerned personnel or department.

Conclusion

Among all HCPs, pharmacists had better knowledge about ADR reporting and pharmacovigilance. All HCPs had positive attitude and inclination towards ADR reporting. The discrepancies were observed in the practices related to ADR reporting, whereas most of the participants including physicians and nurses did not report any ADR. Based on the above, strategies are needed to educate, train, and empower the HCPs in the domain of pharmacovigilance.

Essential Medicines in Universal Health Coverage: A Scoping Review of Public Health Law Interventions and How They Are Measured in Five Middle-Income Countries

Very few studies exist of legal interventions (national laws) for essential medicines as part of universal health coverage in middle-income countries, or how the effect of these laws is measured. This study aims to critically assess whether laws related to universal health coverage use five objectives of public health law to promote medicines affordability and financing, and to understand how access to medicines achieved through these laws is measured. This comparative case study of five middle-income countries (Ecuador, Ghana, Philippines, South Africa, Ukraine) uses a public health law framework to guide the content analysis of national laws and the scoping review of empirical evidence for measuring access to medicines. Sixty laws were included. All countries write into national law: (a) health equity objectives, (b) remedies for users/patients and sanctions for some stakeholders, (c) economic policies and regulatory objectives for financing (except South Africa), pricing, and benefits selection (except South Africa), (d) information dissemination objectives (ex. for medicines prices (except Ghana)), and (e) public health infrastructure. The 17 studies included in the scoping review evaluate laws with economic policy and regulatory objectives (n = 14 articles), health equity (n = 10), information dissemination (n = 3), infrastructure (n = 2), and sanctions (n = 1) (not mutually exclusive). Cross-sectional descriptive designs (n = 8 articles) and time series analyses (n = 5) were the most frequent designs. Change in patients' spending on medicines was the most frequent outcome measure (n = 5). Although legal interventions for pharmaceuticals in middle-income countries commonly use all objectives of public health law, the intended and unintended effects of economic policies and regulation are most frequently investigated.

Vaccine Prices: A Systematic Review of Literature

Vaccines are among the most vital interventions to control and reduce the morbidity and mortality worldwide. In accessing vaccines, pricing is usually the single most important deciding element. However, there is a scarcity of the literature on the vaccines pricing. The current study aims to review vaccine prices from the published literature and to evaluate factors that impact the pricing of vaccines. The literature (from 2015–2020) was reviewed to identify the original research articles. Systematic searches were conducted across the five databases including, Google Scholar, PubMed, Science Direct, Scopus and Springer Link. Literature search yielded 23,626 articles, of which 7351 were screened and 7310 articles were excluded based on title and abstracts relevance. The 41 studies were selected for full text review and 4 studies were found to meet the inclusion criteria. The included studies discussed vaccine prices for childhood vaccines, for Human Papilloma Virus (HPV) in US, China and in Europe. One study detailed the various scenarios of the HPV vaccines pricing. It was found that recently introduced vaccines have higher prices owing to the involvement of technology and research for their manufacture. However, prices tended to decrease over some maturation in price and by the involvement of Global Alliance for Vaccine Initiative (GAVI) and other allies. The prices of vaccines in China were much lower than the other high-income countries and the prices offered through United Nations Children’s Fund (UNICEF), mainly due to the large scale of demand in China. The affordable prices of vaccines were related to delicate procedures involving multiple stakeholders and a shorter duration of contract. This review systematically evaluated the literature and identified key factors that could impact vaccines pricing. The prices were higher for the newly introduced vaccines into the market. However, with the price maturation, there was a decline in the pricing and affordable prices could be achieved through tender pricing and involvement of GAVI and other allies.