Prevalence of Medication Associated with QTc Prolongation Used Among Critically Ill Patients

Background

Acquired prolonged corrected QT (QTc) interval can lead to life-threatening Torsade de Pointes (TdP) arrhythmia. Multiple risk factors including medications, comorbidities, and electrolyte imbalances contribute significantly to acquired manifestations of the QTc prolongation. Critically ill patients are particularly more vulnerable to TdP due to complex medical conditions, aging, and polypharmacy.

Objective

This study aimed to assess the prevalence of TdP-associated medication prescribing, identify risk factors for QTc prolongation and TdP, and determine primary predictors of high TdP medication usage in critically ill patients in Jordan.

Methods

We conducted a retrospective cross-sectional analysis of electronic medical records for patients from King Abdullah University Hospital who were admitted to Intensive Care Unit (ICU) between (July 2012-July 2022). We collected data on patients' demographics, clinical characteristics, comorbidities, laboratory results, and prescribed medications. Medications were categorized into three TdP risk levels according to CredibleMeds® assessment tool. Data were analyzed using descriptive statistics and a binary logistic regression model.

Results

Of the 13,300 patients (58.2% male, median age 62 years). Prescribing prevalence for medications with known TdP risk was 19%, possible risk (24.7%), conditional risk (21.6%), and confirmed conditional risk (8.3%). Common comorbidities included hypertension (40.9%), diabetes (33.3%), and cancer (15.4%). Drugs with known TdP risk included citalopram, amiodarone, clarithromycin, and ciprofloxacin. A binary regression model revealed that as age increased, the odds of TdP associated medication prescribing decreased (OR = 0.989, p < 0.001), while patients on more than five medications had higher odds (OR = 4.281, p < 0.001).

Conclusion

The study identified a notable prevalence of prescribing for medications with QTc prolongation/TdP risk in critically ill patients. Healthcare providers in the ICU should exercise caution to minimize the inadvertent prescription of TdP associated medications especially among older patients and those with polypharmacy.

Medication Adherence and Its Associated Determinants in Older Adults with Type 2 Diabetes and Cardiovascular Comorbidities

Aims of the Study

To evaluate medication adherence level and identify predictors of poor medication adherence in elderly patients with Cardiovascular (CVS) diseases and type 2 diabetes in Jordan.

Methods

This cross-sectional study was conducted on elderly patients who attended King Abdullah University Hospital (KAUH) outpatient diabetes and cardiology clinics from March 6, 2023, to July 6, 2023. Data on age, sex, socio-demographics, biological variables, medication characteristics, and chronic comorbidities were obtained from electronic patients' medical records and a validated questionnaire. Medication adherence levels (low, moderate, and high) were assessed using the Arabic version of the 4-item Morisky, Green, and Levine Medication Adherence Scale-Medication Assessment Questionnaire.

Results

Data from 506 elderly patients were analyzed. The average age of the participants was 67.93 years (SD = 6.22). 7.9% of patients showed low adherence levels, 33.6% showed moderate adherence level, and 58.5% of patients showed a high level of adherence toward their prescribed medications. Multivariable ordinal logistic regression analysis revealed that single/currently unmarried patients and patients who were living with others were more likely to have a higher adherence level; Odd Ratios (ORs) were 4.75 and 4.10, respectively. Patients who took their medications ≥ 3 and 2 times a day showed higher adherence to their medications than those who only took them once a day.; ORs were 2.15 and 2.36, respectively.

Conclusion

This study indicated an inadequate level of adherence among patients with type 2 diabetes and cardiovascular comorbidities. This study revealed the necessity of implementing programs to help in raising the awareness among elderly patients with type 2 diabetes and CVDs of the importance of adherence to prescribed long-term medication regimens.

Assessment of Drug-Related Problems and Health-Related Quality of Life Domains in Elderly Patients with Type 2 Diabetes Mellitus

Aims of the Study

This study aimed to investigate the prevalence and predictors of Drug-related problems (DRPs), as well as to evaluate the impact of DRPs on the health-related quality of life in geriatric patients with type 2 diabetes mellitus.

Methodology

A cross-sectional study was conducted over a three-month period. Patients aged 60 years and older visited diabetes clinics from October 1, 2022, to December 31, 2022, were included in the study. Data were collected through structured questionnaires, whereas lab results, medication records, comorbidities, and the consequences of DRPs were collected from electronic medical records. DRPs were identified and classified using the PCNE V501 classification system. Health-related quality of life (HRQoL) was evaluated using the validated EuroQol criteria.

Results

A total of 491 patients participated in the study, and the mean age of the patients was 67.51 years (SD = 5.84 years). Female patients represented 52.34% of total subjects. A total of 461 (around 94%) experienced at least one drug-related problem (DRP), ranging from one to nine DRPs per patient, with a total number of DRPs equal to 1625 identified. The most common DRP was the drug choice problem, affecting 52.98% of patients. Factors such as high drug frequency, living conditions, the number of diabetes medications, comorbidities, and smoking were significantly associated with higher numbers of DRPs. Higher numbers of DRPs were found to significantly worsen health-related quality of life (HRQoL) among patients.

Conclusion

Geriatric individuals with type 2 diabetes mellitus encounter a significant prevalence of DRPs, with drug choice problems being the most common followed by dosing problems. Risk factors contributing to these DRPs include high drug frequency, living conditions, high number of diabetes medications, multimorbidity, and smoking. Also, the study concluded that the increased number of DRPs was associated with negative impact on HRQoL domains in geriatric patients with type 2 diabetes.

Lessons Learned from the Pandemic in the UAE: Children COVID-19 Vaccine Hesitancy and Its Impact on the Choice of Distance versus Face-to-Face Learning Modalities: An In-Depth Analysis of a National Study

This study addresses the crucial aspect of childhood COVID-19 vaccination and its impact on parental decisions concerning learning modalities during the pandemic. This study aimed to gauge parental hesitancy towards vaccinating their children and its influence on choosing between distance and face-to-face learning options. Following STROBE guidelines for cross-sectional studies, this study surveyed 1973 parents in the United Arab Emirates using Google Forms during the COVID-19 pandemic. The results revealed that while more than half of the parents (51.6%) were willing to vaccinate their children if the COVID-19 vaccine was accessible and affordable, a significant majority (91.2%) expressed concerns about the rapid vaccine development process, which was the primary reason for vaccine rejection. Interestingly, a sizable portion (55.3%) had experienced online learning in the previous academic term, and, of those, 59.6% believed it negatively influenced their children's academic performance. Consequently, 66.4% expressed intent to shift their children back to face-to-face learning once feasible. Significantly, parents with medical backgrounds were more inclined (91.6%) to opt for face-to-face schooling compared to those without such backgrounds. Logistic regression analysis indicated associations between sociodemographic characteristics, educational level and background, and the decision to return children to face-to-face learning. Interestingly, when it comes to vaccine hesitancy, a noteworthy connection exists between the parents' reluctance to vaccinate their children and their preference for distance learning. In fact, parents who responded negatively to vaccinating their children against COVID-19, if the vaccine was available, showed a clear preference for the distance learning modality (p-value < 0.0001). This study underscores the complex interplay of factors and community perspectives shaping parental acceptance of childhood COVID-19 vaccination. The development pace of vaccines significantly influences parents' attitudes and beliefs about vaccination programs. Parents' medical backgrounds exhibit a clear correlation with their perceptions of sending children back to school safely. This highlights the potential impact of parental medical knowledge on decision making, emphasizing the need to consider parents' professional backgrounds when devising education- and vaccination-related policies.

Prevalence and Associated Predictors of Inappropriate and Omitted Medications Prescribing in Older Patients with Advanced Cancer: A Cross-Sectional Study

Aims of the Study

This study aimed to identify the prevalence and significant predictors of both potentially inappropriate medications (PIMs) and potentially omitted medications (POMs) events among geriatric patients with advanced cancer using the STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria.

Methods

This retrospective cross-sectional study included patients aged ≥65 years who were diagnosed and treated for advanced stage of cancer. Patients' medical charts were evaluated to identify polypharmacy (≥5 medications) prevalence as well as potential PIMs and POMs incidents and their associated predictors. SPSS software was used to perform the analysis. Multivariate logistic regression models were used to identify factors associated with dependent variables including PIMs use and POMs.

Results

Electronic medication charts of 510 patients were evaluated. The average age of the patients was 73.25 years, and 264 (51.8%) patients were males. The average number of medications prescribed per patient was 10.3 (range-2-26). Polypharmacy was present in 85.9% of patients, while excessive polypharmacy prevalence was 52.2%. At least one PIM was encountered in 253 patients (49.6%), while at least one POM was encountered in all patients owing to the omission of pneumococcal vaccines. The most common PIMs were opioid analgesics, followed by benzodiazepines, and hypnotics. Additionally, the most omitted medications, excluding vaccinations, were cardiovascular agents and laxatives in patients on regular opioid analgesics. Polypharmacy and diagnosis with solid cancer compared to hematological cancer were associated with increased odds for PIMs occurrence (ORs = 1.293 (p < 0.001) and 3.022 (p = 0.03), respectively), while coexistence of hypertension diagnosis in cancer patients was associated with increased the odds for POMs events (OR = 2.286 (p = 0.007)).

Conclusion

Polypharmacy, PIMs, and POMs were highly prevalent among older cancer patients based on the polypharmacy definition and STOPP/START Criteria.

Patterns of drug-related problems and the services provided to optimize drug therapy in the community pharmacy setting

Introduction

Drug-related problems (DRPs) are events or circumstances involving drug therapy that actually or potentially interferes with desired health outcomes.

Objectives

To assess community pharmacists' knowledge and practice regarding DRP-reduction services, as well as the barriers and factors associated with decreased provision of these services.

Methods

This cross-sectional study utilized a validated questionnaire to assess pharmacists' knowledge, practice, and barriers to the provision of DRP-reduction services in the community pharmacy setting. Binary regression model was used to assess the variables associated with the practice of DRP-reduction services.

Results

A total of 412 pharmacists participated in the study. The pharmacists demonstrated strong knowledge but inadequate practice of DRP-reduction services. The most reported DRPs were inappropriate combination of drugs, or drugs and herbal medications, or drugs and dietary supplements (52.4%), patients' inability to understand instructions properly (46.1%), inappropriate drug according to guidelines (43.7%), and too high dose (40.3%). The most common barriers to these services were increased workload (60.5%), limited time (53.2%), and lack of good communication skills (49.8%). The presence of a counselling area in the pharmacy increased the practice of DRP-reduction services (OR: 3.532, 95%Cl: 2.010-5.590, P < 0.001), while increased weekly working hours (OR: 0.966, 95%Cl: 0.947-0.986), P < 0.01) and serving < 10 patients daily (OR = 0.208, 95%Cl: 0.072-0.601, P < 0.01) decreased it.

Conclusions

Community pharmacists' practice of DRP-reduction services showed a scope for improvement. Future pharmaceutical care initiatives should increase the number of personnel working in the pharmacy and provide them with opportunities for continued education and training in order to improve the provision of DRP services and optimize patients' outcomes.

Anticholinergic burden risk and prevalence of medications carrying anticholinergic properties in elderly cancer patients in Jordan

BACKGROUND

Geriatric cancer patients are susceptible to adverse drug events due to the complexity of their chemotherapy regimens and collateral treatments for their comorbid conditions. Prescribing medications with anticholinergic burden characteristics can complicate their condition, leading to negative impacts on their health outcomes and quality of life, including an increase in adverse drug event frequency, physical and cognitive impairments.

OBJECTIVE

This study aims to examine the prevalence of anticholinergic prescribing and identify the cumulative anticholinergic load risk associated with drugs prescribed to elderly cancer patients. Also, to identify the predictors that might lead to raised anticholinergic burden in these patients.

METHODOLOGY

This retrospective cross-sectional study included elderly patients (age ≥ 65) diagnosed with cancer and admitted to the adult oncology unit at King Abdullah University Hospital (KAUH) in Jordan during the period between (January 1st, 2019, and January 1st, 2022). The medication charts of 420 patients were evaluated for study outcomes.

RESULTS

Of the total subjects, females represented 49.3%, and the average age was 72.95 (SD = 7.33). A total of 354 (84.3%) patients were prescribed at least one drug carrying anticholinergic burden properties. Median for anticholinergic medications was 3 (IQR = 4). Our study found that 194 (46.2%) patients were at a high risk of adverse events associated with anticholinergic load (cumulative score ≥ 3). Metoclopramide, furosemide, and tramadol were the most frequently prescribed drugs with anticholinergic properties. Alimentary tract drugs with anticholinergic action were the most commonly encountered items in our study population.

CONCLUSION

Our study revealed a significantly high prevalence of anticholinergic prescribing among elderly cancer patients. Nearly half of the patients were at high risk of developing serious effects related to anticholinergic activity from the drugs administered. Polypharmacy was strongly associated with increased anticholinergic burden score. Evidence-based recommendations utilizing prescribing strategies for safer alternatives and deprescribing of inappropriate medications could reduce such inappropriate prescribing.

Artificial intelligence in pharmacy practice: Attitude and willingness of the community pharmacists and the barriers for its implementation

BACKGROUND

Artificial intelligence (AI) is the capacity of machines to perform tasks that ordinarily require human intelligence. AI can be utilized in various pharmaceutical applications with less time and cost.

OBJECTIVES

To evaluate community pharmacists' willingness and attitudes towards the adoption of AI technology at pharmacy settings, and the barriers that hinder AI implementation.

METHODS

This cross-sectional study was conducted among community pharmacists in Jordan using an online-based questionnaire. In addition to socio-demographics, the survey assessed pharmacists' willingness, attitudes, and barriers to AI adoption in pharmacy. Binary logistic regression was conducted to find the variables that are independently associated with willingness and attitude towards AI implementation.

RESULTS

The present study enrolled 401 pharmacist participants. The median age was 30 (29-33) years. Most of the pharmacists were females (66.6%), had bachelor's degree of pharmacy (56.1%), had low-income (54.6%), and had one to five years of experience (35.9%). The pharmacists showed good willingness and attitude towards AI implementation at pharmacy (n = 401). The most common barriers to AI were lack of AI-related software and hardware (79.2%), the need for human supervision (76.4%), and the high running cost of AI (74.6%). Longer weekly working hours (attitude: OR = 1.072, 95% C.I (1.040-1.104), P < 0.001, willingness: OR = 1.069, 95% Cl. 1.039-1.009, P-value = 0.011), and higher knowledge of AI applications (attitude: OR = 1.697, 95%Cl (1.327-2.170), willingness: OR = 1.790, 95%Cl. (1.396-2.297), P-value < 0.001 for both) were significantly associated with better willingness and attitude towards AI, whereas greater years of experience (OR = 20.859, 95% Cl (5.241-83.017), P-value < 0.001) were associated with higher willingness. In contrast, pharmacists with high income (OR = 0.382, 95% Cl. (0.183-0.795), P-value = 0.010), and those with<10 visitors (OR = 0.172, 95% Cl. (0.035-0.838), P-value = 0.029) or 31-50 visitors daily (OR = 0.392, 95% Cl. (0.162-0.944), P-value = 0.037) had less willingness to adopt AI.

CONCLUSIONS

Despite the pharmacists' positive willingness and attitudes toward AI, several barriers were identified, highlighting the importance of providing educational and training programs to improve pharmacists' knowledge of AI, as well as ensuring adequate funding support to overcome the issue of AI high operating costs.

An assessment of the current practice of community pharmacists for the disposal of medication waste in the United Arab Emirates: A deep analysis at a glance

Objective

The study aimed to identify the current practice carried out by community pharmacists to dispose of expired medications in their workplace and assess any practical steps utilized to reduce medication waste.

Method

A cross-sectional study was conducted among community pharmacists in the United Arab Emirates (UAE). The participants were asked about their routine practice in disposing of different expired medications and the current actions taken to reduce the number of disposed medicines.

Results

The study included (n = 418) community pharmacists. More than a third of expired liquid, solid, and semi-solid dosage forms were collected by licensed contractors. In addition, more than a third of the pharmacists disposed of different dosage forms via unauthorized methods (general garbage, sink and toilet). Most expired drugs were skin and hair products, antibiotics and analgesics. The majority of pharmacists (68.4 %, n = 286) agreed that expired pharmaceutical and non-pharmaceutical products, other than those disposed of via contractor, should be done through a specialized centre. This opinion was found to be strongly associated with years of practice as community pharmacists (P < 0.05).

Conclusion

Part of the existing disposal practices for expired pharmaceutical products in the UAE is carried out by contractors licensed by health authorities. However, concern remains regarding some pharmaceutical and non-pharmaceutical products that have not been disposed of correctly. Additionally, there is a need for a specialized center for medication disposal (p < 0.05). A stock limitation is the best practice for managing medication quantities in stock (p < 0.05).

Clinical characteristics and risk factors for mortality among COVID-19 hospitalized patients in UAE: Does ethnic origin have an impact

Background

The relationship between COVID-19 patient’s clinical characteristics and disease manifestation remains incompletely understood. The impact of ethnicity on mortality of patients with COVID-19 infection is poorly addressed in the literature. Emerging evidence suggests that many risk factors are related to symptoms severity and mortality risk, emphasizing the necessity of fulfilling this knowledge gap that may help reducing mortality from COVID-19 infections through tackling the risk factors.

Aims

To explore epidemiological and demographic characteristics of hospitalized COVID-19 patients from different ethnic origins living in the UAE, compare them to findings reported across the globe and determine the impact of these characteristics and ethnicity on mortality during hospitalization.

Methods

A single center, retrospective chart review study of hospitalized COVID-19 patients was conducted in a large COVID-19 referral hospital in UAE. The following outcomes were assessed: patients’ clinical characteristics, disease symptoms and severity, and association of ethnicity and other risk factors on 30-day in hospital mortality.

Results

A total of 3296 patients were recruited in this study with an average age of 44.3±13.4 years old. Preliminary data analysis indicated that 78.3% (n = 2582) of cases were considered mild. Average duration of hospital stay was 6.0±7.3 days and 4.3% (n = 143) were admitted to ICU. The most frequently reported symptoms were cough (32.6%, n = 1075) and fever (22.2%, n = 731). The 30-day mortality rate during hospitalization was 2.7% (n = 90). Many risk factors were associated with mortality during hospitalization including: age, respiratory rate (RR), creatinine, and C-reactive protein, oxygen saturation (SaO₂), hemoglobin, hematocrit, ferritin, creatinine, C-reactive protein, anemia, COPD, Chronic kidney disease, dyslipidemia, Vitamin-D Deficiency, and ethnic origin (p <0.05). Multiple logistic regression analysis showed that higher mortality rates during hospitalization was associated with anemia, chronic obstructive pulmonary disease (COPD), chronic kidney disease, and Middle Eastern origin (p<0.05).

Conclusion

The results indicated that most COVID-19 cases were mild and morality rate was low compared to worldwide reported mortality. Mortality rate during hospitalization was higher in patients from Middle East origin with preexisting comorbidities especially anemia, COPD, and chronic kidney disease. Due to the relatively small number of mortality cases, other identified risk factors from univariate analysis such as age, respiratory rate, and Vitamin-D (VitD) deficiency should also be taken into consideration. It is crucial to stratify patients on admission based on these risk factors to help decide intensity and type of treatment which, possibly, will reduce the risk of death.

Knowledge, Attitudes, and Practices Concerning Breast Cancer and Self Examination Among Females in UAE

Breast cancer (BC) is one of the most prevalent cancers and the leading cause of cancer related deaths among women worldwide with a steadily increasing global annual incidence. This study aims is to evaluate the knowledge, attitude, and practice of females in the UAE toward BC and Breast Self-Examination practice in the seven Emirates. This was a face-to-face questionnaire-based study using CAM (Breast Cancer Awareness Measure) conducted over 3 months (from March to June 2019) on a random sample of females across the UAE. Of the 400 females who filled the questionnaire, 112 (28%) did the CBE at least once, and 184 (46%) practice BSE. Only 33% of participants were aware of the incidence of the BC in the UAE and those females were more likely to practice BSE (P < 0.05). In contrast, the majority showed a high awareness level in identifying cancer as a curable (91.5%) and non-transmittable (87%) disease that can be diagnosed at its earlier stages (93%). Only 11% of the participants identified weight reduction as a way to prevent BC. Knowledge of breast cancer sign/symptoms were good, as 41-87% of respondents were able to identify at least a single sign/symptom. The lack of awareness of BC among females in the UAE is of concern as it leads to low practices of screening and early detection, which ultimately will result in increased morbidity, mortality, and treatment costs. Further initiatives should be taken to increase practice, knowledge and awareness on early detection and screening for BC in the UAE community.

Prevalence of Depression and the Quality-of-Life of Breast Cancer Patients in Jordan

Objective

The objectives of the current study are to evaluate the prevalence of depression symptoms among breast cancer patients in Jordan and impact of the disease on patient’s quality-of-life.

Methods

A cross-sectional survey-based study was conducted over a 6-month period among breast cancer patients attending two major hospitals in Jordan. A validated questionnaire was used to evaluate the prevalence of depression symptoms and quality-of-life aspects among those patients utilizing Beck’s Depression Inventory-II score and 36-Item Survey Form (SF-36) score, respectively.

Results

The mean age±SD of patients (n=169) was 49.12±6.48 years. Depression symptoms were reported in 30.2% of patients. As for quality-of-life, the physical functioning (PF) subscale was significantly associated with the patient’s age (P=0.03). The role-physical (RP) subscale was associated with number of sleeping hours (P=0.038). Marital status of breast cancer patients was significantly associated with role-emotional (RE) (P=0.015) and mental health (MH) (P=0.009) subscales. The number of patient’s siblings was significantly associated with daily habits such as PF (P=0.031) and RP (P=0.005) subscales. Moreover, the occupation of patients was associated with the PF (P=0.041) and MH (P=0.049).

Conclusion

About one-third of breast cancer patients reported depression symptoms. Quality-of-life subscales among those patients were associated with multiple social and health determinants, such as age, marital status, number of siblings, occupation, and number of sleeping hours. There is urgent need to support this group of patients to help them to cope with depression symptoms and to improve their quality-of-life.

The effect of hawthorn flower and leaf extract (Crataegus Spp.) on cardiac hemostasis and oxidative parameters in Sprague Dawley rats

Cardiovascular diseases are described as disorders of heart and vessels that involve stroke and coronary heart diseases. People in the Middle East converged to complementary medicine as an economic alternative to expensive healthcare services. Crataegus monogyna Jacq. (Lindm.) Rosacea is among the most commonly used herb for the treatment of declining cardiac performance, hypertension, and arrhythmias. Previously, we had shown that Crataegus Spp. (Hawthorn) extract increased the tendency of bleeding among patients undergoing coronary artery bypass grafting. Herein, the effects of Crataegus Spp. extract on oxidative stress, cardiac and hematological parameters were evaluated in Sprague Dawley rats. Male rats were randomly assigned into four groups. Group 1 served as control while groups 2–4 served as the experimental groups and were administered extract at doses of 100, 200, and 500 mg/kg. All the doses were given orally once/day and the treatment was continued for three weeks. Hawthorn treatment resulted in a significant decrease in the liver thiobarbituric acid reactive substances level in a dose-dependent manner compared to the control (1.258 (3, 24); P < 0.0001). We found a significant increase in the cardiac antithrombin III among hawthorn treated group compared to the control (4.18 (3, 24); P < 0.0001). On the other hand, hawthorn treatment decreased significantly the liver factor-X level (0.1341 (3, 22); P < 0.0001), while no significant changes were seen in soluble-platelet endothelial cell adhesion molecule-1 (P-value = 0.0599). In conclusions, hawthorn extract possesses an antioxidant effect and blood-thinning properties. Hence, we recommend attention when using this herbal extract with other anticoagulation and/or antiplatelet drugs or undergoing major cardiac surgery.

Knowledge and Attitude of Medical Residents Towards Cancer Clinical Trials in Jordan

Background

Clinical trials are an important tool to test the efficacy of new treatment modalities for cancer patients. Physicians, including medical residents, should play a major role in carrying out clinical trials to generate a strong body of evidence to determine the best available treatment for their patients. Carrying out clinical trials demands adequate understanding of the research phases and requirements including ethical standards as well as presenting positive attitudes toward the clinical research. Hence, evaluating the knowledge and attitudes of medical residents toward running clinical trials is essential to assess their preparedness and willingness to participate in future studies.

Methods

This study was a questionnaire-based observational study. It involved medical residents from various specialties who served cancer patients admitted at King Abdullah University Hospital during the period from June 1 to August 15, 2017.

Results

A total number of 83 respondents completed the questionnaire. Of them, 56.7% and 53.0% of the respondents reported either current or previous participation in clinical trials research, respectively. Only 10 residents (12.0%) had previous participation in clinical research where a new investigational cancer treatment was tested. While, 91.6% of respondents believed that physicians should be involved in running clinical cancer research, only 25.3% had previous experience in writing a cancer clinical trial protocol and 28.9% wrote a scientific manuscript on cancer clinical trials for publication. Moreover, 67.5% of residents knew when informed consent should be obtained and 62.7% were aware of the clinical equipoise concept in clinical trials.

Conclusion

Much remains to be done to improve knowledge and attitudes of medical residents toward cancer clinical trials and the main ethical principles that should be followed to assure having an ideal research environment, which will pave the way for the generation of high quality clinical cancer research and reliable evidence-based clinical practice for cancer management.

Nonsteroidal Anti-inflammatory Drugs Utilization Patterns and Risk of Adverse Events due to Drug-Drug Interactions among Elderly Patients: A Study from Jordan

Background

Worldwide, the prescribing pattern of the Nonsteroidal Anti-inflammatory Drugs (NSAIDs) has increased. They are considered highly effective medications in controlling various conditions including inflammatory diseases. They are associated with various adverse effects including gastrointestinal bleeding and ulcer and renal toxicity though. These adverse effects are generally potentiated when NSAIDs are co-prescribed with other drugs that share similar adverse effects and toxicities. Developing severe side effects from NSAIDs is more prone among elderly patients. Hence, it is crucial to evaluate prescribing pattern of these agents to prevent/decrease the number of unwanted side effects caused by NSAIDs.

Aim

The aim of this study is to assess the prescribing pattern of NSAIDs among elderly and the co-prescribing of NSAIDs and different interacting drugs, which could lead to more incidences of NSAIDs-induced toxicities among Jordanian elderly patients.

Settings and Methodology

A multicenter retrospective study was performed during a three months period in Jordan. The study involves a total number of (n = 5916) elderly patient’s records obtained from Four governmental hospitals in Jordan.

Results

A total number of (n = 20450) drugs were prescribed and dispensed for patient. NSAIDs drugs prescribing percentage was 10.3% of total medications number. Aspirin was the most commonly prescribed NSAIDs among patients (70.4%), followed by Diclofenac sodium in all dosage forms (25.1%) and oral Ibuprofen (3.1%. In addition, Aspirin was the highest NSAIDs co-prescribed with ACEI (e.g., Enalapril), ARBs (e.g. Candesartan and Losartan), Diuretics (Furosemide, Indapamide, Hydrochlorothiazide, Amiloride, and Spironolactone), Warfarin and antiplatelets (Clopidogreal and Ticagrelor) followed by Diclofenac and other NSAIDs.

Conclusion

NSAIDs prescribing rate among elderly patients was high. Additionally the co-prescribing of NSAIDs especially Aspirin with other agents, which contributes to NSAIDs nephrotoxicity and gastrointestinal toxicity, were high. Strict measurements and action plans should be taken by prescribers to optimize the medical treatment in elderly through maximizing the benefits and decreasing the unwanted side effects.

Pharmacy Students Perceptions of Their Distance Online Learning Experience During the COVID-19 Pandemic: A Cross-Sectional Survey Study

INTRODUCTION

The COVID-19 pandemic imposed dramatic changes on educational practices worldwide. Many universities and schools have moved into the delivery of their courses and educational programs utilizing fully electronic online modes. This study aims to evaluate the pharmacy student distance online learning experience during the COVID-19 pandemic.

METHODS

A cross-sectional survey was utilized where a 3-domain survey questionnaire focused on preparedness, attitude and barriers was distributed to students at the time of conclusion of the semester. Each domain consists of multiple questions that made up a score that reflects their preparedness, attitude as well as barriers relevant to distance online learning experience. The survey was voluntarily, and all data were collected and recorded via google forms with maintaining anonymity.

RESULTS

The response rate was about 75% (n = 309). The results' analysis revealed no gender differences in any of these domains. However, there were some variable responses among different educational levels. The average preparedness score was 32.8 ± 7.2 (Max 45), the average attitude score was 66.8 ± 16.6 (Max 105), and the average barrier score was 43.6 ± 12.0 (Max 75). There was statistical significance difference in both preparedness score and attitude scores between different professional years (P-value <.05). However, there was no difference in barrier scores among all professional years. The results indicated that about 61.4% of the students agreed on that college of pharmacy was well-prepared and ready for the online education during the emerging COVID-19 pandemic with complete transition into online education. The results also indicated that 49.2% of the students showed positive attitude toward the provided online learning. The results indicated that about 34% of the students identify some barriers toward the provided online learning. Finally, there were strong association between the need for training on how to receive online courses and preparedness and barriers scores.

DISCUSSION AND CONCLUSION

E-learning experience pose challenges and presents opportunities during emergency situations. The need for training for students and faculty was highly associated with the preparedness and barriers domains rather than the infrastructure or computer literacy, so the school can improve their experience by addressing these needs.

Potentially inappropriate medications prescribing according to Beers criteria among elderly outpatients in Jordan: a cross sectional study

Background

Due to aging, along with its associated physiological changes, older adults are extremely vulnerable to be afflicted with multiple chronic conditions (multimorbidity). Accordingly, prescribing a large number of drugs to older adults would be inevitable. Resulted complex drug regimens can lead to prescribing of Potentially Inappropriate Medications (PIMs) with subsequent negative health and economic outcomes.

Objectives

The main objective of this study is to investigate the prevalence and predictors of PIMs prescribing among Jordanian elderly outpatients, using the last updated version of the American Geriatrics Society (AGS) Beers Criteria (2015 version).

Methods

A Unicenter, cross-sectional study were data was assessed using medical records of included study subjects conducted over three months period from beginning of October to the end of December 2016 at King Abdullah University Hospital, Al Ramtha, Jordan. Our study included patients aged 65 years or above who visited the outpatient clinics at King Abdullah University hospital (KAUH) and were prescribed at least one oral medication during the study period. PIMs were identified for these patients and further classified according to the 2015 AGS Beers Criteria. We measured the prevalence of PIMs prescribed among elderly outpatients in Jordan.

Results

A total of 4622 eligible older adults were evaluated in this study, of whom 62.5% (n=2891) were found to have at least one PIM prescribed during the three months study period. 69% of identified PIMs were medications to be used with caution in elderly, 22% were medications to avoid in many or most older adults, 6.3% were medications to be avoided or have their dosage adjusted based on kidney function in older adults, 2.04% medications were to avoid in older adults with specific diseases/syndromes, and 1.6% were potentially clinically important non-anti-infective drug-drug interactions to be avoided in older adults. Female gender and polypharmacy were found to be significant predictors of PIMs use among elderly.

Conclusions

Potentially Inappropriate Medication prescribing is common among Jordanian elderly outpatients. Female gender and polypharmacy are associated with more PIMs prescribing and so need further attention.

Evaluation of Jordanian Healthcare Providers' Knowledge, Attitudes, and Practice Patterns towards Probiotics

Objectives: The current study aimed to evaluate knowledge, attitudes, and practice patterns of health-care providers (HCPs) toward probiotics.Methods: This was a face-to-face interview in a random sample (n = 205) of physicians and clinical pharmacist in different Jordanian health-care institutions during the period of 1, June 2017-31, August 2017. A structured validated questionnaire was used to achieve study objectives.Results: Half of HCPs (51.5%) had fair knowledge about probiotics, and pediatricians were the most knowledgeable group of HCPs. Around Fifty-nine percent of HCPs had positive attitudes toward probiotics. However, less than half of HCPs (41.0%) had ever recommended or prescribed probiotics to patients.Conclusion: The results of this study reveal that HCPs have limited knowledge of probiotics although they have positive attitudes toward them. This is not reflected in their own clinical practice. Additional training and education about probiotics among HCPs are very imperative to enhance patient's care.

A focus group study of patient's perspective and experiences of type 2 diabetes and its management in Jordan

Background

Diabetes is increasingly becoming a major health problem in Jordan and glycemic goals are often not achieved.

Objective

To explore the patients’ perspectives regarding type 2 diabetes and its management in order to “fine-tune” future pharmaceutical care intervention programs.

Method

Focus groups method was used to explore views from individuals with type 2 diabetes attending outpatient diabetes clinic at the Royal Medical Services Hospital. All interviews were recorded, transcribed and analyzed using a thematic analysis approach.

Results

A total of 6 focus groups, with 6 participants in each one, were conducted. Participants in the present study demonstrated a great information needs about diabetes and the prescribed treatment. Medication regimen characteristics including rout of administration, number of prescribed medications and dosage frequency in addition to perceived side effects represented the major barriers to medication adherence. In addition to demonstrating negative beliefs about the illness and the prescribed medications, participants showed negative attitudes and low self-efficacy to adhere to necessary self-care activities including diet, physical activity and self-monitoring of blood glucose.

Conclusion

Future pharmaceutical care interventions designed to improve patients’ adherence and health outcomes in patients with type 2 diabetes should consider improving patients’ understanding of type 2 diabetes and its management, simplifying dosage regimen, improving patient's beliefs and attitudes toward type 2 diabetes, prescribed medications and different self-care activities in addition to improving patient's self efficacy to perform different treatment recommendations.

Akt1 promotes stimuli-induced endothelial-barrier protection through FoxO-mediated tight-junction protein turnover

Vascular permeability regulated by the vascular endothelial growth factor (VEGF) through endothelial-barrier junctions is essential for inflammation. Mechanisms regulating vascular permeability remain elusive. Although 'Akt' and 'Src' have been implicated in the endothelial-barrier regulation, it is puzzling how both agents that protect and disrupt the endothelial-barrier activate these kinases to reciprocally regulate vascular permeability. To delineate the role of Akt1 in endothelial-barrier regulation, we created endothelial-specific, tamoxifen-inducible Akt1 knockout mice and stable ShRNA-mediated Akt1 knockdown in human microvascular endothelial cells. Akt1 loss leads to decreased basal and angiopoietin1-induced endothelial-barrier resistance, and enhanced VEGF-induced endothelial-barrier breakdown. Endothelial Akt1 deficiency resulted in enhanced VEGF-induced vascular leakage in mice ears, which was rescued upon re-expression with Adeno-myrAkt1. Furthermore, co-treatment with angiopoietin1 reversed VEGF-induced vascular leakage in an Akt1-dependent manner. Mechanistically, our study revealed that while VEGF-induced short-term vascular permeability is independent of Akt1, its recovery is reliant on Akt1 and FoxO-mediated claudin expression. Pharmacological inhibition of FoxO transcription factors rescued the defective endothelial barrier due to Akt1 deficiency. Here we provide novel insights on the endothelial-barrier protective role of VEGF in the long term and the importance of Akt1-FoxO signaling on tight-junction stabilization and prevention of vascular leakage through claudin expression.

P21 activated kinase-1 mediates transforming growth factor β1-induced prostate cancer cell epithelial to mesenchymal transition

Transforming growth factor beta (TGFβ) is believed to play a dual role in prostate cancer. Molecular mechanism by which TGFβ1 suppresses early prostate tumor growth and induces epithelial-to-mesenchymal transition (EMT) in advanced stages is not known. We determined if P21-activated kinase1 (Pak1), which mediates cytoskeletal remodeling is necessary for the TGFβ1 induced prostate cancer EMT. Effects of TGFβ1 on control prostate cancer PC3 and DU145 cells and those with IPA 3 and siRNA mediated Pak1 inhibition were tested for prostate tumor xenograft in vivo and EMT in vitro. TGFβ1 inhibited PC3 tumor xenograft growth via activation of P38-MAPK and caspase-3, 9. Long-term stimulation with TGFβ1 induced PC3 and DU145 cell scattering and increased expression of EMT markers such as Snail and N-cadherin through tumor necrosis factor receptor-associated factor-6 (TRAF6)-mediated activation of Rac1/Pak1 pathway. Selective inhibition of Pak1 using IPA 3 or knockdown using siRNA both significantly inhibited TGFβ1-induced prostate cancer cell EMT and expression of mesenchymal markers. Our study demonstrated that TGFβ1 induces apoptosis and EMT in prostate cancer cells via activation of P38-MAPK and Rac1/Pak1 respectively. Our results reveal the potential therapeutic benefits of targeting TGFβ1-Pak1 pathway for advanced-stage prostate cancer.

Clinically relevant doses of candesartan inhibit growth of prostate tumor xenografts in vivo through modulation of tumor angiogenesis

Angiotensin II receptor type 1 blockers (ARBs), widely used antihypertensive drugs, have also been investigated for their anticancer effects. The effect of ARBs on prostate cancer in experimental models compared with meta-analysis data from clinical trials is conflicting. Whereas this discrepancy might be due to the use of supratherapeutic doses of ARBs in cellular and animal models as compared with the clinical doses used in human trials, further investigation of the effects of clinical doses of ARBs on prostate cancer in experimental models is warranted. In the current study, we sought to determine the effects of candesartan on prostate cancer cellular function in vitro and tumor growth in vivo, and characterize the underlying mechanisms. Our analysis indicated that clinically relevant doses of candesartan significantly inhibited growth of PC3 cell tumor xenografts in mice. Interestingly, the same concentrations of candesartan actually promoted prostate cancer cellular function in vitro, through a modest but significant inhibition in apoptosis. Inhibition of tumor growth by candesartan was associated with a decrease in vascular endothelial growth factor (VEGF) expression in tumors and inhibition of tumor angiogenesis, but normalization of tumor vasculature. Although candesartan did not impair PC3 cell viability, it inhibited endothelial-barrier disruption by tumor-derived factors. Furthermore, candesartan significantly inhibited expression of VEGF in PC3 and DU145 cell lines independent of angiotensin II type 2 receptor, but potentially via angiotensin II type 1 receptor inhibition. Our findings clearly demonstrate the therapeutic potential of candesartan for prostate cancer and establish a link between ARBs, VEGF expression, and prostate tumor angiogenesis.

Pronerve growth factor induces angiogenesis via activation of TrkA: possible role in proliferative diabetic retinopathy

Proliferative diabetic retinopathy (PDR) is the leading cause of blindness in working age Americans. We demonstrated that diabetes disturbs the homeostasis of nerve growth factor (NGF) resulting in accumulation of its precursor proNGF. Increases in proNGF were positively correlated with progression of diabetic retinopathy, having the highest level in ocular fluids from PDR patients compared to nondiabetic patients. Here, we attempted to evaluate the contribution and the possible mechanism of proNGF to PDR. The angiogenic response of aqueous humor samples from PDR patients was examined in human retinal endothelial cells in the presence or absence of anti-proNGF antibody. Additional cultures were treated with mutant-proNGF in the presence of specific pharmacological inhibitors of TrkA and p75(NTR) receptors. PDR-aqueous humor samples exerted significant angiogenic response including cell proliferation, migration, and alignment into tube-like structures. These effects were significantly reduced by anti-proNGF antibody but not by IgG. Treatment of retinal endothelial cells with mutant-proNGF activated phosphorylation of TrkA and p38MAPK; however, it did not alter p75(NTR) expression. Inhibition of TrkA but not p75(NTR) significantly reduced mutant-proNGF-induced cell proliferation, cell migration, and tube formation. Taken together, these results provide evidence that proNGF can contribute to PDR at least in part via activation of TrkA.

P21 activated kinase-1 (Pak1) promotes prostate tumor growth and microinvasion via inhibition of transforming growth factor β expression and enhanced matrix metalloproteinase 9 secretion

P21-activated kinases (Paks) are major effectors downstream of the small Rho family of GTPases. Among the six isoforms, Pak1 is the most ubiquitous and the best characterized member. Previous studies have shown that inhibition of Pak6, which is predominantly present in the prostate compared with other tissues, inhibits prostate tumor growth in vivo. Even though Pak1 has been identified in normal prostatic epithelial cells and cancer cells, its specific role in the development of prostate cancer remains unclear. We report here that highly invasive prostate cancer cells express significantly higher levels of Pak1 protein compared with non-invasive prostate cancer cells. Furthermore, prostate tumor tissues and prostate cancer metastasized to lungs showed a higher expression of Pak1 compared with normal tissues. Interestingly, Pak6 protein expression levels did not change with the invasive/metastatic potential of the cancer cells or tumors. Although inhibition of Pak1, and not Pak6, resulted in impaired PC3 cell migration, the effects of Pak1 knockdown on transendothelial migration (microinvasion), tumor growth, and tumor angiogenesis was higher compared with Pak6 knockdown. Finally, gene array data revealed reduced expression of matrix metalloproteinase 9 with the ablation of either Pak1 or Pak6 gene expression in PC3 cells, whereas protein levels of TGFβ was elevated significantly with specific modulation of Pak1 activity or ablation of the Pak1 gene. Our observations suggest that although some level of functional redundancy exists between Pak1 and Pak6 in prostate cancer cells, targeting Pak1 is a potential option for the management of prostate tumor growth, microinvasion, and metastasis.

TGFβ1 induces apoptosis in invasive prostate cancer and bladder cancer cells via Akt-independent, p38 MAPK and JNK/SAPK-mediated activation of caspases

Recent findings indicate that advanced stage cancers shun the tumor suppressive actions of TGFβ and inexplicably utilize the cytokine as a tumor promoter. We investigated the effect of TGFβ1 on the survival and proliferation of invasive prostate (PC3) and bladder (T24) cancer cells. Our study indicated that TGFβ1 decreased cell viability and induced apoptosis in invasive human PC3 and T24 cells via activation of p38 MAPK-JNK-Caspase9/8/3 pathway. Surprisingly, no change in the phosphorylation of pro-survival Akt kinase was observed. We postulate that TGFβ1 pathway may be utilized for specifically targeting urological cancers without inflicting side effects on normal tissues.

Simultaneous modulation of the intrinsic and extrinsic pathways by simvastatin in mediating prostate cancer cell apoptosis

Background

Recent studies suggest the potential benefits of statins as anti-cancer agents. Mechanisms by which statins induce apoptosis in cancer cells are not clear. We previously showed that simvastatin inhibit prostate cancer cell functions and tumor growth. Molecular mechanisms by which simvastatin induce apoptosis in prostate cancer cells is not completely understood.

Methods

Effect of simvastatin on PC3 cell apoptosis was compared with docetaxel using apoptosis, TUNEL and trypan blue viability assays. Protein expression of major candidates of the intrinsic pathway downstream of simvastatin-mediated Akt inactivation was analyzed. Gene arrays and western analysis of PC3 cells and tumor lysates were performed to identify the candidate genes mediating extrinsic apoptosis pathway by simvastatin.

Results

Data indicated that simvastatin inhibited intrinsic cell survival pathway in PC3 cells by enhancing phosphorylation of Bad, reducing the protein expression of Bcl-2, Bcl-xL and cleaved caspases 9/3. Over-expression of PC3 cells with Bcl-2 or DN-caspase 9 did not rescue the simvastatin-induced apoptosis. Simvastatin treatment resulted in increased mRNA and protein expression of molecules such as TNF, Fas-L, Traf1 and cleaved caspase 8, major mediators of intrinsic apoptosis pathway and reduced protein levels of pro-survival genes Lhx4 and Nme5.

Conclusions

Our study provides the first report that simvastatin simultaneously modulates intrinsic and extrinsic pathways in the regulation of prostate cancer cell apoptosis in vitro and in vivo, and render reasonable optimism that statins could become an attractive anti-cancer agent.

Tuning cell cycle regulation with an iron key

14-3-3 proteins are ubiquitously expressed dimeric adaptor proteins that have emerged as key mediators of many cell signaling pathways in multiple cell types. Its effects are mainly mediated by binding to selective phosphoserine/threonine proteins. The importance of 14-3-3 proteins in cancer have only started to become apparent and its exact role in cancer progression as well as the mechanisms by which 14-3-3 proteins mediate cancer cell function remain unknown. While protein 14-3-3σ is widely accepted as a tumor suppressor, 14-3-3ζ, β and γ isoforms have been shown to have tumor promoting effects. Despite the importance of 14-3-3 family in mediating various cell processes, the exact role and mechanism of 14-3-3ζ remain unexplored. In the current study, we investigated the role of protein 14-3-3ζ in prostate cancer cell motility and transendothelial migration using biochemical, molecular biology and electric cell-substrate impedance sensing approaches as well as cell based functional assays. Our study indicated that expression with wild-type protein 14-3-3ζ significantly enhanced Rac activity in PC3 cells. In contrast, expression of dimer-resistant mutant of protein 14-3-3ζ (DM-14-3-3) inhibited Rac activity and associated phosphorylation of p21 activated kinase-1 and 2. Expression with wild-type 14-3-3ζ or constitutively active Rac1 enhanced extracellular matrix recognition, lamellipodia formation, cell migration and trans-endothelial migration by PC3 cells. In contrast, expression with DM 14-3-3ζ or DN-Rac1 in PC3 cells significantly inhibited these cell functions. Our results demonstrate for the first time that 14-3-3ζ enhances prostate cancer cell-matrix interactions, motility and transendothelial migration in vitro via activation of Rac1-GTPase and is an important target for therapeutic interventions for prostate cancer.