Showing papers in "The Canadian Journal of Hospital Pharmacy in 2018"

Heparin-Induced Thrombocytopenia

Abstract: Heparin-induced thrombocytopenia is the most common immune-mediated adverse drug reaction, occurring in 1 % to 3% of postoperative patients receiving unfractionated heparin prophylaxis for 7 to 14 days. Approximately 1 in 100 patients receiving a therapeutic dose of unfractionated heparin for a week or more will experience thrombosis related to heparin-induced thrombocytopenia. Heparin-induced thrombocytopenia is characterized by activation of coagulation and platelets. Diagnosis of the condition should take into account the timing of the thrombocytopenia (which typically occurs on day 5 to 10 after initiation of heparin), the degree of the thrombocytopenia, and the presence of new thrombosis. Use of warfarin alone to treat acute heparin-induced thrombocytopenia complicated by deep venous thrombosis sometimes results in loss of a limb because of venous limb gangrene, probably because warfarin can cause severe reduction in protein C without a simultaneous reduction in the generation of thrombin in these patients. New treatments now available in Canada to reduce thrombin generation in heparin-induced thrombocytopenia (such as danaparoid and lepirudin) are useful in managing the thrombotic consequences of heparin-induced thrombocytopenia. RESUME La thrombocytopenie d'origine heparinique represente la reaction indesirable d'origine immunologique la plus courante. En effet, elle survient chez 1 % a 3 % des patients qui recoivent un traitement prophylactique post-operatoire a l'heparine non fractionnee durant 7 a 14 jours. Environ 1 patient sur 100 qui recoivent une dose therapeutique d'heparine non fractionnee pendant une semaine ou plus souffrira de thrombose associee a une thrombocytopenie d'origine heparinique. La thrombocytopenie d'origine heparinique est caracterisee par l'activation de la coagulation et des plaquettes. Le diagnostic de cette affection devrait tenir compte du moment auquel survient la thrombocytopenie (cette derniere survenant habituellement entre le cinquieme et le dixieme jour apres le debut de l'heparinotherapie), du degre de la thrombocytopenie et de la presence de nouveaux thrombi. Le recours a la warfarine seule pour traiter une thrombocytopenie aigue d'origine heparinique compliquee par une thrombose veineuse profonde peut entrainer quelques fois la perte d'un membre a cause d'une gangrene veineuse du membre, probablement parce que la warfarine cause une diminution prononcee du taux de proteine C sans reduction simultanee du taux de thrombine chez ces patients. Les nouveaux traitements maintenant offerts au Canada pour reduire la production de thrombine dans les cas de thrombocytopenie d'origine heparinique (comme le danaparoicle et la lepirudine) sont utiles dans le traitement des consequences thrombotiques de la thrombocytopenie d'origine heparinique.

Potential Negative Effects of Antimicrobial Allergy Labelling on Patient Care: A Systematic Review

Abstract: Background: Antimicrobial allergy labels, either self-reported or placed in a patient’s medical record, are common, but in many cases they are not associated with a true immunoglobulin E–mediated allergic response. Objective: To assess the impact of antimicrobial allergy labels on anti - microbial prescribing, resource utilization, and clinical outcomes. Data Sources: The MEDLINE, Embase, CINAHL, and Scopus electronic databases were searched for the period 1990 to January 2016. Study Selection: Controlled studies with the objective of assessing antimicrobial prescribing, resource utilization, and/or clinical outcomes associated with antimicrobial allergy labels were included. Results: The search identified 560 unique citations, of which 7 articles met the inclusion criteria. One additional article identified by an expert in the field was also included. Four of the identified papers were limited to penicillin or other s-lactam allergies. Six studies noted differences in antibiotic selection between patients with allergy labels and those without such labels. Broader-spectrum or second-line agents (e.g., vancomycin, clindamycin, and fluoroquinolones) were more commonly prescribed for patients with penicillin allergy labels. Antibiotic therapy costs were significantly higher for patients with allergy labels than for those without. The impact of allergy labels on clinical outcomes was mixed. One study indicated a longer length of hospital stay, 2 studies reported higher readmission rates, and 1 study reported a higher rate of antibiotic-resistant organisms for patients with allergy labels. Conclusions: Most of the available literature is limited to penicillin or s-lactam allergy. The growing body of knowledge supports the concept that s-lactam allergy labels are not benign and that labelling in the absence of a true allergy has a negative effect on patient care. Allergy labelling appears to be associated with suboptimal antibiotic selection, greater treatment costs, prolonged length of stay, greater readmission rates, and higher prevalence of antibiotic-resistant organisms. There is an opportunity for antimicrobial stewardship programs to implement systematic allergy verification to optimize antimicrobial therapy and improve patient care. RESUME Contexte: Les mentions d’allergies aux antimicrobiens, soit autodeclarees soit consignees dans un dossier medical, sont frequentes, mais dans bien des cas elles ne signalent pas une veritable reaction allergique a mediation par l’immunoglobuline E. Objectif : Evaluer l’effet des mentions d’allergie aux antimicrobiens sur les habitudes de prescription d’antimicrobiens, l’utilisation des ressources et les resultats cliniques. Sources des donnees : Les bases de donnees numeriques MEDLINE, Embase, CINAHL et Scopus ont ete interrogees pour la periode allant de 1990 a janvier 2016. Selection des etudes : Les essais cliniques comparatifs dont l’objectif etait d’evaluer les habitudes de prescription d’antimicrobiens, l’utilisation des ressources ou les resultats cliniques associes aux mentions d’allergie aux antimicrobiens ont ete inclus. Resultats : La recherche a permis de trouver 560 citations distinctes et ainsi de reperer sept articles qui repondaient aux criteres d’inclusion. Un article supplementaire signale par un expert du domaine a ete inclus a l’analyse. Quatre de ces articles se limitaient aux allergies a la penicilline ou a d’autres s-lactamines. Six etudes ont note des differences dans le choix des antibiotiques entre les patients ayant une mention d’allergie a leur dossier et ceux n’en ayant pas. Des antibiotiques a plus large spectre ou des medicaments de deuxieme intention (comme la vancomycine, la clindamycine et les fluoroquinolones) etaient plus souvent prescrits pour les patients ayant une mention d’allergie a la penicilline. Les couts des antibiotherapies etaient significativement plus eleves pour les patients ayant une mention d’allergie que pour ceux n’en ayant pas a leur dossier. L’effet des mentions d’allergie sur les resultats cliniques etait inegal. Une etude indiquait un sejour plus long a l’hopital, deux etudes indiquaient des taux de readmission plus eleves et une etude indiquait un taux plus eleve d’organismes resistants aux antibiotiques pour les patients ayant une mention d’allergie comparativement a ceux n’en ayant pas. Conclusions : La majeure partie des articles disponibles se limitent aux allergies a la penicilline ou a d’autres s-lactamines. De plus en plus, le savoir vient appuyer le concept voulant que les mentions d’allergies aux s-lactamines ne soient pas benignes et que leur emploi en l’absence d’une allergie reelle ait un effet negatif sur les soins aux patients. Les mentions d’allergie semblent etre associees a un choix sous-optimal d’antibiotiques, des couts de traitement plus eleves, des sejours plus longs, des taux de readmission plus eleves et une plus grande prevalence d’organismes resistants aux antibiotiques. Or, les programmes de gerance des antimicrobiens pourraient permettre de mettre en oeuvre des procedures de verification systematique des allergies afin d’optimiser l’antibiotherapie et d’ameliorer les soins aux patients.

Deprescribing Proton Pump Inhibitors.

Abstract: -

Effect of Lidocaine-Prilocaine Cream (EMLA®) on Pain of Intramuscular Fluzone® Injection

Abstract: The efficacy of lidocaine-prilocaine cream (EMLA® — Eutectic mixture of Local Anesthetics) in alleviating the pain of intramuscular injections was investigated in a randomized, double-blind, placebo-controlled, parallel group trial. EMLA® or placebo cream was applied to the arms of 60 adult volunteers before receiving influenza virus vaccine (Fluzone®). Twenty-nine subjects received approximately 2.5 g of EMLA® cream and 31 subjects received approximately 2.5 g of an inert placebo cream under occlusion for 60-90 minutes. The cream was then removed and each subject received one 0.5 mL intramuscular injection of influenza virus vaccine using a 22 gauge one inch needle. Pain of needle puncture and pain of injection were both assessed by the subjects using a visual analog scale. EMLA® was associated with decreased needle puncture pain (p < 0.0002) and decreased pain of injection when compared to placebo (p = 0.0139). There was a significant correlation between scores of needle puncture pain and injection pain. Mild skin pallor was a common skin reaction from EMILA®· While the efficacy of EMLA® to alleviate pain of venipuncture is well documented, this is the first study to show the efficacy of EMLA ® for intramuscular injections. RESUME Une etude randomisee a double insu, en controle parallele avec placebo a permis d'evaluer la capacite de la Lidocaine-Prilocaine (creme EMLA® — melange eutectique d'anesthesiques locaux) a soulager la douleur causee par les injections intramusculaires. On a applique la creme EMLA® ou un placebo sur le bras de 60 volontaires adultes avant de leur injecter un vaccin viral contre la grippe (Fluzone®). Vingt-neuf (29) sujets ont ete traites avec la creme EMLA® et 31 avec le placebo. Tous ont recu une application d'environ 2,5 g de creme sous un pansement occlusif pendant 60 a 90 minutes. Apres l'elimination de la creme, on leur a injecte 0,5 mL de vaccin par voie intramusculaire au moyen d'une aiguille calibre 22 d'un pouce. Les sujets ont evalue la douleur causee par l’insertion de l'aiguille et par l'injection au moyen d'une echelle visuelle analogique. Comparativement au placebo, la creme EMLA® a attenue la douleur associee a l'insertion de l’aiguille (p < 0.0002) et a l’injection (P = 0,0139). On a note une correlation significative entre les cotes se rapportant a la douleur provoquee par l'insertion de l'aiguille et celles relatives a la douleur causee par l'injection. L'apparition d'une legere pâleur fut une reaction cutanee courante a l'application de la creme EMLA®. Il est bien etabli que cette derniere soulage la douleur due a la ponction veineuse, mais la presente etude est la premieree a demontrer son efficacite en cas d'injection intramusculaire.

Inappropriate Prescription of Proton Pump Inhibitors in a Community Setting.

Abstract: Background : Proton pump inhibitors (PPIs) are widely prescribed for gastrointestinal conditions, such as gastroesophageal reflux disease and dyspepsia, and for prevention of gastric ulcer. Although previous reports have described inappropriate prescription of PPIs in the hospital setting, data from the community are lacking. Objective : To assess PPI prescriptions in the ambulatory setting. Methods : Patients presenting to the emergency department of a teaching hospital between June 2016 and March 2017 were prospectively assessed for use of a PPI at home. The appropriateness of PPI prescription was evaluated on the basis of an interview with the patient and review of the medical record. The indication for PPI therapy was verified against current guidelines for the province of Quebec. Results : Over the 9-month study period, 2417 patients were screened, of whom 871 were included in the study. In relation to the Quebec guidelines, PPI prescription was inappropriate for 267 (30.7%) of the patients. When prescription of PPI for ulcer prevention in certain groups of patients (age ≥ 65 years and using acetylsalicylic acid or platelet aggregation inhibitors; age ≥ 75 years and using celecoxib) was re-classified as appropriate, the proportion of inappropriate PPI prescriptions declined to 20.3% (177/871). Conclusions : These findings suggest that inappropriate prescribing of PPIs remains problematic in the community setting in the province of Quebec. RESUME Contexte : Les inhibiteurs de la pompe a protons (IPP) sont largement prescrits pour traiter les troubles gastro-intestinaux, comme le reflux gastro-oesophagien et la dyspepsie, et pour prevenir l’ulcere gastrique. Bien que des rapports anterieurs aient parle de la prescription inadequate des IPP dans les etablissements de sante, il n’y a pas de donnees provenant de la communaute. Objectif : Evaluer la pertinence des prescriptions d’IPP dans un milieu ambulatoire. Methodes : Les patients se presentant au service des urgences d’un hopital universitaire entre juin 2016 et mars 2017 ont ete evalues de facon prospective relativement a l’utilisation d’un IPP a la maison. La pertinence de la prescription d’un IPP a ete jugee d’apres une entrevue avec le patient et l’analyse du dossier medical. On a verifie si l’indication pour un traitement par IPP respectait les lignes directrices actuelles du Quebec. Resultats : Sur une periode de neuf mois, 2 417 patients ont ete evalues et 871 d’entre eux ont ete admis a l’etude. Par rapport aux lignes directrices du Quebec, la prescription d’IPP etait inadequate pour 267 (30,7 %) des patients. Or, si la prescription d’IPP pour prevenir l’ ulcere gastrique chez certains groupes de patients (âges de 65 ans ou plus et prenant de l’acide acetylsalicylique ou un antiagregant plaquettaire; âges de 75 ans ou plus et prenant du celecoxib) etait reclassee comme adequate, la proportion de prescriptions d’IPP inadequates reculait a 20,3 % (177/871). Conclusions : Ces resultats laissent croire que les prescriptions inadequates d’IPP demeurent un probleme dans le contexte communautaire au Quebec.

Clinical pharmacy services in a pediatric hematology/oncology clinic: A description and assessment

Abstract: Objectives: To characterize the drug-related needs of ambulatory HO patients identified by a pharmacist; describe the role of the pharmacist in a pediatric hematology/oncology (HO) clinic; assess the impact of clinical pharmacy services in a pediatric HO clinic on patient care; and make recommendations for the future provision of clinical pharmacy services to patients attending the HO clinic. Design: Prospective descriptive study over 12 weeks. Setting: Hematology/oncology clinic in a 411 bed tertiary/quarternary, university-affiliated pediatric hospital. Patients: Thirty-one children who attended a clinic post-bone marrow transplant (BMT) and 27 children who attended an oncology clinic. Methods: Actual or potential drug-related problems (DRPs) were identified or verified by patient/parent dialogue and interventions were made by the pharmacist in consultation with the responsible physician and/or patient/parent. The impact of a subset of these interventions was assessed by two physicians and two pharmacists. Results: 165 DRPs were identified in 31 BMT and 27 ONC patients. The mean number of DRPs identified per patient was 4.8 in BMT patients and 0.6 in ONC patients. The most frequently identified DRP was "too high a dose" (35%) in BMT patients and ''inappropriate medication administration" (35%) in ONC patients. 177 interventions were made by the pharmacist; 81 % were accepted by the physician and/or patient/parent. The review panel deemed 83.5% of the subset of interventions to have had a positive impact. Conclusions: Children attending the HO clinic have drug-related needs. BMT patients would benefit from dialogue with a pharmacist for assessment, prevention, and resolution of their DRPs while the primary need for newly diagnosed ONC patients is education regarding antineoplastic and supportive therapy. RESUME Objectifs : Determiner les besoins pharmacotherapeutiques des patients ambulatoires en HO (hematologie/oncologie) qu'a identifies le pharmacien; decrier le role du pharmacien au sein d'une clinique d'hematologie/oncologie pour enfants; evaluer l'impact des services de pharmacie clinique dans une clinique d'HO pour enfants sur les soins apportes aux patients; et formuler des recommandations pour la planification de la fourniture des services de pharmacie clinique aux patients qui frequent une clinique d'HO. Plan : etude prospective de prevalence d'une duree de 12 semaines. Milieu : clinique d'hematologie/oncologie dans un hopital pour enfants affilie a une universite, de 411 lits de soins tertiaires/quaternaires. Patients : Trente et un enfants qui ont frequente une clinique apres une greffe de moelle osseuse (GMO) et 27 autres enfants qui ont frequente une clinique d'oncologie (CO). Methodes : Les problemes pharmacotherapeutiques (PP) reels ou potentiels ont ete identifies ou verifies au moyen d'une discussion avec le patient/parent et des interventions ont ete portees par le pharmacien apres consultation avec le medecin traitant et/ou le patient/parent. L’impact d'un sous-groupe de ces interventions a ete evalue par deux medecins et deux pharmaciens. Resultats : 165 PP ont ete identifies chez 31 patients GMO et 27 patients CO. Le nombre moyen de PP identifies par patient etait de 4,8 chez les patients GMO et de 0,6 chez les patients CO. Le PP qui a ete le plus souvent identifie etait «une dose trop elevee» (35 %) chez les patients GMO et «l'administration d'un medicament inadequat» (35 %) chez les patients CO. Un total de 177 interventions ont ete realisees par le pharmacien et 81 % de ces dernieres ont ete acceptees par le medecin et/ou le patient/parent. Le comite de revision a juge que 83,5 % du sous-groupe d'interventions avait eu un impact positif. Conclusions : Les enfants qui frequentent une clinique d'HO ont des besoins pharmacotherapeutiques. Les patients GMO tireraient profit d'une discussion avec le pharmacien pour evaluer, prevenir et resoudre leurs PP, alors que les patients CO qui viennent d'etre diagnostiques ont d'abord un besoin d'education en ce qui a trait aux traitements antineoplasiques et de soutien.

Interaction between Monoamine Oxidase B Inhibitors and Selective Serotonin Reuptake Inhibitors.

Abstract: Background: Monoamine oxidase B (MAO-B) inhibitors are used to treat the motor symptoms of Parkinson disease. Depression is commonly associated with Parkinson disease, and selective serotonin reuptake inhibitors (SSRIs) are often used for its management. Tertiary sources warn that the combination of MAO-B inhibitors and SSRIs can result in increased serotonergic effects, leading to serotonin syndrome. Objective:To explore the mechanism, clinical significance, and management of this potential drug interaction through a review of the supporting evidence. Data Sources: PubMed, MEDLINE (1946 forward), Embase (1947 forward), PsycINFO (1806 forward), and International Pharmaceutical Abstracts (1970 forward) were searched on February 4, 2017. Study Selection and Data Extraction: Studies and case reports describing aspects of the potential interaction between MAO-B inhibitors and SSRIs in patients with Parkinson disease and published in English were identified by both title and abstract. Data Synthesis: The search identified 8 studies evaluating the potential interaction between SSRIs and the MAO-B inhibitors selegiline and rasagiline. The largest, a retrospective cohort study of 1504 patients with Parkinson disease, found no cases of serotonin syndrome with coadministration of rasagiline and an SSRI. A survey of 63 investigators in the Parkinson Study Group identified 11 potential cases of serotonin syndrome among 4568 patients treated with the combination of selegiline and antidepressants (including SSRIs). In addition, 17 case reports describing the onset of serotonin syndrome with coadministration of an SSRI and either selegiline or rasagiline were identified. Following discontinuation or dose reduction of one or both of the agents, the symptoms of serotonin syndrome gradually resolved in most cases, with none being fatal. Conclusions: According to the literature, serotonin syndrome occurs rarely, and the combination of SSRI and MAO-B inhibitor is well tolerated. Therefore, SSRIs and MAO-B inhibitors can be coadministered, provided that their recommended doses are not exceeded and the SSRI dose is kept at the lower end of the therapeutic range. Among the SSRIs, citalopram and sertraline may be preferred. RESUME Contexte : Les inhibiteurs de la monoamine oxydase B (MAO-B) sont employes dans le traitement des symptomes moteurs de la maladie de Parkinson, maladie a laquelle la depression est souvent associee et frequemment traitee a l’aide d’inhibiteurs selectifs de la recapture de la serotonine (ISRS). Des sources tertiaires mettent en garde contre la combinaison d’inhibiteurs de la MAO-B et d’ISRS car elle peut mener a une augmentation des effets serotoninergiques, degenerant en un syndrome serotoninergique. Objectif : Chercher a connaitre le mecanisme, la signification clinique et la prise en charge de cette potentielle interaction medicamenteuse en procedant a une revue des preuves a l’appui. Sources des donnees : Les bases de donnees PubMed, MEDLINE (depuis 1946), Embase (depuis 1947), PscyINFO (depuis 1806), et International Pharmaceutical Abstracts (depuis 1970) ont ete interrogees le 4 fevrier 2017. Selection des etudes et extraction des donnees : Des etudes et des observations cliniques, publiees en anglais, portant sur des aspects de la potentielle interaction entre les inhibiteurs de la MAO-B et les ISRS chez les patients atteints de la maladie de Parkinson ont ete reperees par une recherche ciblant les titres et les resumes. Synthese des donnees : La recherche a permis de trouver 8 etudes analysant la potentielle interaction entre les ISRS et deux inhibiteurs de la MAO-B : la selegiline et la rasagiline. La plus importante d’entre elles, une etude de cohorte retrospective sur 1504 patients atteints de la maladie de Parkinson, n’a releve aucun cas de syndrome serotoninergique en presence d’une prise concomitante de rasagiline et d’un ISRS. Une enquete aupres de 63 chercheurs dans le Parkinson Study Group a permis de relever 11 potentiels cas de syndrome serotoninergique chez 4568 patients traites avec une combinaison de selegiline et d’antidepresseurs (notamment des ISRS). De plus, 17 observations cliniques qui decrivaient un debut de syndrome serotoninergique en presence d’une prise concomitante d’un ISRS et de selegiline ou de rasagiline ont ete recensees. Suivant la reduction de la posologie ou l’interruption d’un ou des deux medicaments, les symptomes du syndrome serotoninergique se sont graduellement resolus dans la plupart des cas, et il n’y a eu aucune mortalite. Conclusions : Selon la documentation, le syndrome serotoninergique est rare et la combinaison d’ISRS et d’inhibiteurs de la MAO-B est bien toleree. Ainsi, les deux types d’inhibiteurs peuvent etre administres conjointement pourvu que l’on ne depasse pas la posologie recommandee et que la dose d’ISRS demeure dans le bas de l’intervalle therapeutique. Parmi les ISRS, il peut etre preferable d’employer le citalopram ou la sertraline.

Characterization of Serious Adverse Drug Reactions in Hospital to Determine Potential Implications of Mandatory Reporting.

Abstract: Background: The Protecting Canadians from Unsafe Drugs Act will eventu-ally require institutions to report all serious adverse drug reactions (ADRs), although the proposed regulations do not yet define what will need to be reported and by whom. Knowledge about the occurrence of serious ADRs in the hospital setting is needed to optimize the effectiveness of reporting and to determine the potential implications of mandatory reporting. Objectives: To quantify and characterize suspected serious ADRs in patients admitted to a general medicine service, to assess the likelihood of causality, and to determine inter-rater agreement for identification of ADRs and assessment of their likelihood. Methods: This prospective observational study involved 60 consecutive patients admitted to a general medicine service at a tertiary care teaching centre starting on March 28, 2016. The primary outcome was the number of serious ADRs, defined by Health Canada as ADRs that result in hospital admission, congenital malformation, persistent or significant disability or incapacity, or death; that are life-threatening; or that require significant intervention to prevent one of these outcomes. Medical records were reviewed independently by pairs of pharmacists for serious ADRs, and the likelihood of causality was assessed using the World Health Organization–Uppsala Monitoring Centre system. Inter-rater agreement was calculated using the kappa score, and disagreements were resolved by discussion and consensus. Results: Twenty-three serious ADRs occurred in the sample of 60 patients. The proportion of patients experiencing a serious ADR that contributed to the original hospital admission was 19/60 (32%, 95% confidence interval [CI] 20%–43%), and 4 patients (7%, 95% CI 0%–13%) experienced a serious ADR during their hospital stay. Inter-rater agreement for occurrence of serious ADRs was moderate (kappa 0.58, 95% CI 0.35–0.76). Conclusion: Reportable serious ADRs were common among patients admitted to a general medicine service. Canadian hospitals would face difficulties reporting all serious ADRs because of the frequency of their occurrence and the subjectivity of their identification. RESUME Contexte : La Loi visant a proteger les Canadiens contre les drogues dangereuses obligera eventuellement les etablissements a declarer tout cas de reactions indesirables graves aux medicaments (RIM), quoique les re-glements proposes n’indiquent pas encore ce qui devra etre declare et par qui. Des donnees sur la survenue de RIM graves en milieu hospitalier sont necessaires pour optimiser l’efficacite de la declaration et pour determiner les implications potentielles d’une declaration obligatoire. Objectifs : Quantifier les RIM graves soupconnees chez les patients admis a un service de medecine generale et en offrir un portrait, evaluer la probabilite d’une relation de causalite et determiner l’accord interevalua-teurs pour le reperage des RIM et l’evaluation de leur probabilite. Methodes : La presente etude observationnelle prospective comptait 60 patients admis consecutivement a partir du 28 mars 2016 a un service de medecine generale d’un centre hospitalier universitaire de soins tertiaires. Le principal parametre d’evaluation etait le nombre de RIM graves, definies par Sante Canada comme des RIM qui menent a une hospitalisation, a une malformation congenitale, a une invalidite ou a une incapacite persistante ou importante; qui mettent la vie en danger ou entrainent la mort; ou qui necessitent une intervention significative pour prevenir l’un de ces resultats. Les dossiers medicaux ont ete examines independamment par des paires de pharmaciens a la recherche de RIM graves et la probabilite d’une causalite a ete evaluee a l’aide du systeme du Centre de pharmacovigilance d’Uppsala de l’Organisation mondiale de la Sante. L’accord interevaluateurs a ete mesure a l’aide du coefficient kappa et les desaccords ont ete resolus par la discussion et l’atteinte d’un consensus. Resultats : Vingt-trois RIM graves sont survenues dans l’echantillon compose de 60 patients. La proportion de patients ayant subi une RIM grave qui a contribue a l’hospitalisation initiale etait 19/60 (32 %, intervalle de confiance [IC] de 95 % de 20 %–43 %); de plus, 4 patients (7 %, IC de 95 % de 0 %–13 %) avaient subi une RIM grave au cours de leur sejour a l’hopital. L’accord interevaluateurs sur la survenue de RIM graves etait modere (kappa = 0,58, IC de 95 % de 0,35–0,76). Conclusion : Les RIM graves a declaration obligatoire etaient courantes chez les patients admis a un service de medecine generale. Les hopitaux canadiens auraient de la difficulte a declarer tous les cas de RIM graves a cause de leur frequence et de la subjectivite de leur reperage.

Roles and Impacts of the Transplant Pharmacist: A Systematic Review.

Abstract: Background: Pharmacists have been involved in the care of transplant recipients for several decades, and a growing body of literature shows the beneficial effects of clinical pharmacist care on important outcomes for these patients. Objectives: The primary objective was to describe the roles and impacts of pharmacists in a solid organ transplant setting. The secondary objective was to describe and rate the pharmacists’ interventions. Data Sources: Three databases —PubMed, Embase, and Evidence-Based Medicine Reviews —were searched from January 1, 1990, to June 16, 2015. Study Selection and Data Extraction: All studies addressing the roles of pharmacists and the impacts of clinical pharmacy services on the care of solid organ transplant recipients were considered. Only studies providing a statistical analysis were included. Design, setting, sample size, patient characteristics, pharmacists’ interventions, study bias, and outcomes were extracted for analysis. Data Synthesis: Four randomized controlled trials, 4 cohort studies, 3 pre–post studies, and 1 quasi-randomized controlled trial were included in the review, representing a total of 1837 patients. Of the 12 studies included, 8 specifically focused on renal transplant, and 1 each focused on liver, lung, abdominal organ, and general solid organ transplant. The pivotal pharmacist activities leading to the main patient outcomes were medication counselling (n = 8 studies), medication reconciliation (n = 5), and reviewing and optimizing drug therapy (n = 3). Improvements to medication adherence (n = 6 studies), morbidity (n = 4), costs (n = 2), and medication errors (n = 2) were reported. Conclusion: Currently available evidence suggests that pharmacists can improve patient outcomes in the solid organ transplant setting. Adherence, morbidity, costs, and medication errors were identified as the main outcomes that were improved by pharmaceutical interventions. Transplant programs need to invest more in this resource. RESUME Contexte : Les pharmaciens participent aux soins des greffes depuis plusieurs decennies et un nombre croissant de publications revelent les effets benefiques des soins prodigues par les pharmaciens cliniciens quant aux resultats therapeutiques importants pour ces patients. Objectifs : L’objectif principal etait de decrire les roles des pharmaciens et leurs influences par rapport aux greffes d’organes solides. L’objectif secondaire etait de decrire et d’evaluer les interventions des pharmaciens. Sources des donnees : Les bases de donnees PubMed, Embase et Evidence-Based Medicine Reviews ont ete interrogees pour la periode allant du 1er janvier 1990 au 16 juin 2015. Selection des etudes et extraction des donnees : Toutes les etudes abordant les roles des pharmaciens et l’influence des services de pharmacie clinique sur les soins des receveurs d’organes solides ont ete prises en consideration. Seules les etudes presentant des analyses statistiques ont ete retenues. Le plan d’etude, le contexte, la taille de l’echantillon, les caracteristiques des patients, les interventions des pharmaciens, les biais et les resultats therapeutiques ont servi a l’analyse. Synthese des donnees : Quatre etudes controlees a repartition aleatoire, 4 etudes de cohorte, 3 etudes avant-apres et 1 essai comparatif a repartition quasi-aleatoire ont ete retenus pour l’analyse, ce qui representait au total 1837 patients. Parmi les 12 etudes retenues, 8 abordaient specifiquement la greffe renale et chacune des 4 autres concernait respectivement une greffe hepatique, une greffe pulmonaire, une greffe d’organe abdominal et une greffe d’organe solide. Les activites cles des pharmaciens menant aux principaux resultats therapeutiques etaient les conseils sur les medicaments (n = 8 etudes), l’etablissement du bilan comparatif des medicaments (n = 5) ainsi que l’examen et l’optimisation de la pharmacotherapie (n = 3). On a constate des ameliorations des taux d’observance pharmaco -therapeutique (n = 6 etudes), des taux de morbidite (n = 4), des couts (n = 2) et des taux d’erreurs de medicaments (n = 2). Conclusion : Les donnees probantes disponibles laissent croire que les pharmaciens peuvent ameliorer les resultats therapeutiques en ce qui concerne les greffes d’organes solides. Les taux d’observance pharmaco -therapeutique, les taux de morbidite, les couts et les taux d’erreurs de medicaments ont ete designes comme les resultats principaux qui ont ete ameliores par les interventions pharmaceutiques. Les programmes de greffe doivent investir davantage dans cette ressource.

Health Care System and Pharmacy Practice in Hong Kong

Abstract: Located on the southeast coast of China, Hong Kong is one of the world’s major financial centres. It is consistently ranked as a highly competitive economic region. Historical shifts involving Chinese immigration and British colonization left the city with a unique “East-meets-West” heritage. Chinese and English are the official languages of Hong Kong, with English being widely used in the government and by the legal, educational, professional, and business sectors.1 After the transfer of sovereignty from Britain to China in 1997, Hong Kong became a special administrative region of the People’s Republic of China, ruled under the principle of “one country, two systems”. This principle ensures that Hong Kong maintains separate political and economic systems from those of China, and that it will have a high degree of autonomy until 2047 (i.e., 50 years after the transfer of sovereignty).1 The population of Hong Kong was estimated at 7.39 million in 2017, making it the sixth most densely populated city worldwide.2,3 In addition to being overpopulated and having the largest number of skyscrapers in the world, Hong Kong is notorious for its high property values and a spectacular night lookout from the Victoria Peak. In terms of population health, the most challenging event in recent history was the epidemic outbreak of severe acute respiratory syndrome (widely known as SARS) in 2003, which led to the deaths of 286 people in Hong Kong, along with pronounced social, economic, and humanitarian repercussions.4 Although there is some cultural affinity with traditional Chinese medicine, people in Hong Kong see Western medicine as the mainstream of medical care. This paper discusses the unique health care system of Hong Kong, including pharmacy practice in the city, based on the building blocks outlined by the Health Systems Framework of the World Health Organization (WHO). HEALTH SYSTEM LEADERSHIP, GOVERNANCE, AND HEALTH CARE FINANCING

Antimicrobial Use at Acute Care Hospitals in Nova Scotia: A Point Prevalence Survey

Abstract: Background: Point prevalence surveys are used to monitor antimicrobial use and identify targets for improvement through antimicrobial stewardship activities Few studies have evaluated antimicrobial use in Nova Scotia acute care institutions Objectives: To determine the prevalence and characteristics of antimicrobial use in Nova Scotia hospitals Methods: A point prevalence survey was conducted between June and November 2015 for patients admitted to hospitals with at least 30 acute care beds On each survey day, charts were reviewed to identify patients receiving antimicrobial agents on that day Data were gathered on the type of antimicrobial agent prescribed, route of administration, intended duration of use, and indication Adherence to regional and local treatment guidelines was assessed Results were summarized descriptively Findings were compared using the Fisher exact test or the Cochran–Armitage trend test Results: Twelve of the 13 eligible hospitals participated, and a total of 1499 patient charts were examined The overall prevalence of antimicrobial use was 306% (458/1499) The prevalence of antimicrobial use differed significantly according to area of specialty, with the highest prevalence occurring in intensive care wards (472%, 50/106) and surgical wards (434%, 179/412), as compared with medical wards (279%, 192/687) and “other” specialty wards (111%, 32/289) (p < 0001) Among the 520 indications for antimicrobial use, the most common was respiratory tract infection (81 or 156%) In total, 660 antimicrobial agents were prescribed to the 458 patients; a third of these patients (152 or 332%) received more than 1 antimicrobial agent The class of antimicrobials most frequently prescribed was “other beta-lactam antimicrobials” (312%, 206/660) The majority of antimicrobials (620%, 409/660) were prescribed for administration via the parenteral route Adherence to regional treatment guidelines was 299% (26 of 87 indications analyzed) Documentation of indication was lacking for 104 (200%) of the 520 indications, and documentation of the intended duration of antimicrobial use was lacking for 326 (627%) of the 520 indications Conclusions: Antimicrobial agents were prescribed for about one-third of acute care patients in Nova Scotia Specific targets for improvement in antimicrobial use include decreases in prescribing of broad-spectrum and parenteral antimicrobials, better adherence to guidelines, and improved documentation In developing initiatives, antimicrobial stewardship programs in Nova Scotia should focus on identified targets for improvement RESUME Contexte: Les enquetes de prevalence ponctuelle sont employees pour surveiller l’utilisation des antimicrobiens et cibler des points a ameliorer grâce aux activites de gestion responsable des antimicrobiens Peu d’etudes se sont penchees sur l’utilisation des antimicrobiens dans les etablissements de soins de courte duree en Nouvelle-Ecosse Objectifs : Determiner quelle est la prevalence de l’utilisation des anti -microbiens dans les hopitaux de la Nouvelle-Ecosse et offrir un portrait de cette utilisation Methodes : Une enquete de prevalence ponctuelle a ete menee entre juin et novembre 2015 pour les patients admis aux hopitaux dotes d’au moins 30 lits de soins de courte duree A chaque jour d’enquete, des dossiers medicaux ont ete examines afin de reperer les patients ayant recu des agents antimicrobiens cette journee-la On a recueilli des donnees sur le type d’agent antimicrobien prescrit, la voie d’administration, la duree attendue d’utilisation et l’indication Le respect des lignes directrices therapeutiques regionales et locales a aussi ete evalue Les resultats ont ete resumes de facon descriptive Les comparaisons ont ete verifiees a l’aide du test exact de Fisher ou du test de tendance de Cochran-Armitage Resultats : Douze des 13 hopitaux admissibles ont ete inclus et un total de 1 499 dossiers medicaux de patients ont ete examines Le taux de prevalence globale d’utilisation d’antimicrobiens etait de 30,6 % (458/1499) La prevalence d’utilisation d’antimicrobiens variait significativement selon les unites de soins : en tete de liste, les unites de soins intensifs (47,2 %, 50/106) et les unites de chirurgie (43,4 %, 179/412) comparativement aux unites de medecine (27,9 %, 192/687) et aux « autres » unites de soins (11,1 %, 32/289) (p < 0001) Parmi les 520 indications pour l’utilisation des antimicrobiens, la plus frequente etait l’infection des voies respiratoires (81 ou 15,6 %) Au total, 660 agents antimicrobiens ont ete prescrits aux 458 patients et le tiers de ces patients (152 ou 33,2 %) ont recu plus d’un agent antimicrobien La classe d’antimicrobien la plus souvent prescrite etait les « autres betalactamines » (31,2 %, 206/660) La voie parenterale etait prescrite pour l’administration de la majorite desantimicrobiens (62,0%, 409/660) Le respect des lignes directrices regionales de traitement etait de 29,9 % (26 des 87 indications analysees) Parmi les 520 indications, 104 (20,0 %) n’etaient pas mentionnees au dossier et 326 (62,7 %) etaient depourvues de mention de la duree du traitement antimicrobien au dossier Conclusions : Des agents antimicrobiens ont ete prescrits a environ un tiers des patients recevant des soins de courte duree en Nouvelle-Ecosse L’amelioration de l’utilisation des antimicrobiens devrait cibler precisement les reductions de la prescription d’antibiotiques a large spectre et du recours a la voie parenterale, un plus grand respect des lignes directrices et une meilleure consignation Les programmes de gestion responsable des antimicrobiens en Nouvelle-Ecosse devraient etre axes sur des objectifs d’amelioration definis afin de mettre au point des strategies

Perceptions of Hospital Pharmacists Concerning Clinical Research: A Survey Study

Abstract: Background: Few studies have attempted to determine the proportion of Canadian hospital pharmacists involved in clinical research, despite a general consensus that research should be an essential component of a pharmacist’s professional role. Objectives: The primary objective was to characterize the involvement in clinical pharmacy research of hospital pharmacists in the 4 health authorities of the Lower Mainland of British Columbia (collectively known as the Lower Mainland Pharmacy Services). The secondary objective was to identify perceived barriers to conducting research. Methods: Pharmacists employed within Lower Mainland Pharmacy Services were invited to participate in an online cross-sectional survey, for completion in August and September 2015. Descriptive statistics were used to analyze the results. Groups of survey participants were compared to examine differences in measured outcomes. Results: A total of 534 pharmacists were surveyed, with a response rate of 16% (85/534). Overall, 77% (55/71) of the respondents reported having participated in research, and 87% (62/71) expressed interest in conducting future research. Chart reviews (78%, 36/46) and surveys (41%, 19/46) were the most common study designs used in prior research. Participants self-identified their research-related strengths as literature evaluation (46%, 27/59) and hypothesis generation (44%, 26/59). Conversely, 81% (48/59) of respondents self-identified statistical analysis as a weakness. Most respondents stated that personal satisfaction (82%, 49/60) and the opportunity to learn about disease states (78%, 47/60) were the driving factors for conducting research. The most commonly cited barrier to conducting research was lack of time (92%, 55/60). Opportunities to join existing teams (73%, 44/60) and mentorship programs (70%, 42/60) were identified as the most popular arrangements for encouraging future research. Conclusions: Most of the pharmacists who responded to this survey reported having participated in clinical pharmacy research, but a lack of dedicated time appears to be a major hurdle to greater research participation. A targeted program increasing exposure to existing research teams and mentorship opportunities is recommended for promoting future research. RESUME Contexte : Peu d’etudes ont cherche a determiner la proportion de “pharmaciens d’hopitaux canadiens qui contribuent a la recherche clinique, et ce, malgre un consensus voulant que la recherche doive etre un element essentiel du role professionnel des pharmaciens. Objectifs : L’objectif principal etait d’offrir un portrait de la contribution a la recherche sur la pharmacie clinique des pharmaciens d’hopitaux des quatre regies regionales des basses-terres continentales de la Colombie-Britannique (appelees collectivement Lower Mainland Pharmacy Services , c.-a-d. services de pharmacie des basses-terres continentales). L’objectif secondaire etait de recenser les elements percus comme des obstacles a la realisation de recherches. Methodes : Les pharmaciens employes au sein des services de pharmacie des basses-terres continentales ont ete invites a participer par voie electronique a une enquete transversale qui devait etre completee en aout et en septembre 2015. Des statistiques descriptives ont ete employees pour analyser les resultats. On a aussi compare des groupes de participants a l’enquete afin d’examiner les differences entre les resultats mesures. Resultats : Au total, 534 pharmaciens ont ete sondes et le taux de reponse etait de 16 % (85/534). Dans l’ensemble, 77 % (55/71) des repondants indiquaient avoir participe a des recherches et 87 % (62/71) souhaitaient faire de la recherche dans l’avenir. L’analyse de dossiers medicaux (78 %, 36/46) et les sondages (41 %, 19/46) representaient les plans d’etude les plus utilises par les repondants au cours de recherches anterieures. Les participants ont indique que leurs forces en lien avec la recherche etaient leur capacite d’evaluer la litterature (46 %, 27/59) et de formuler des hypotheses (44 %, 26/59). En revanche, 81 % (48/59) ont signale l’analyse statistique comme leur point faible. La plupart des repondants croyaient que la satisfaction personnelle (82 %, 49/60) et la perspective d’acquerir des connaissances sur les maladies (78 %, 47/60) representaient les principaux facteurs les motivant a faire de la recherche. Ce qui etait evoque le plus souvent comme un obstacle a la recherche etait le manque de temps (92 %, 55/60). Les occasions de se joindre a des equipes en place (73 %, 44/60) et les programmes de mentorat (70 %, 42/60) ont ete designes comme les dispositions les plus attrayantes pour encourager a poursuivre de futures recherches. Conclusions : La plupart des pharmaciens ayant repondu au sondage ont indique avoir contribue a des recherches en pharmacie clinique, mais le manque de temps reserve pour la recherche semblait etre un obstacle important a une plus grande participation aux activites de recherche. Un programme cible multipliant les possibilites de frequenter des equipes de recherche deja etablies et offrant plus d’occasions de mentorat serait une facon de promouvoir de futures recherches.

Quantifying Candidacy for Deprescribing of Proton Pump Inhibitors among Long-Term Care Residents

Abstract: Background : Proton pump inhibitors (PPIs) are a commonly prescribed drug class used to inhibit gastric acid secretion. They are prescribed for both treatment and prophylaxis of several gastrointestinal conditions. Although PPIs can be used safely in the short term, several serious adverse effects have been reported following long-term use, including increased risk of falls and fragility fractures. Long-term care home (LTCH) residents represent a population in which the long-term adverse effects of PPIs can be significant and PPI deprescribing should be considered when appropriate. Objectives: To determine the proportion of LTCH residents with PPI prescriptions who were eligible for PPI deprescribing, and to examine vitamin B12 deficiencies and fall risk in the study population. Methods: This cross-sectional, multisite chart review involved LTCH residents who had an active PPI prescription during October 2016. A convenience sample of 150 charts was randomly selected, and the appropriateness of PPI deprescribing was determined using Canadian guidelines. Descriptive statistics were used to examine demographic characteristics, PPI dosing and indication, vitamin B12 supplementation, fall history, and fall risk. Results: Three of the selected charts were excluded because of missing information. Of the 147 residents included in the chart review, 93 (63%) were candidates for deprescribing. PPI use for gastroesophageal reflux disease for more than 8 weeks without a deprescribing attempt in the past year was the most frequently observed opportunity for deprescribing (49/93 [53%]). Twenty-nine residents (20%) had no documented indication for PPI use. Thirteen residents (9%) had had a fall within the past 30 days, and 53 (36%) had a prescription for vitamin B12 supplements and/or had low serum vitamin B12 levels. Conclusions: A majority of the residents whose charts were reviewed were candidates for PPI deprescribing. This finding suggests an opportunity for clinicians who care for LTCH residents to increase their deprescribing efforts. RESUME Contexte : Les inhibiteurs de la pompe a protons (IPP) sont des medicaments couramment prescrits pour inhiber la secretion d’acide gastrique. Ils sont prescrits comme traitement et comme prophylaxie pour plusieurs troubles gastro-intestinaux. Bien que les IPP puissent etre utilises de facon securitaire a court terme, plusieurs effets indesirables graves ont ete signales a la suite d’une utilisation a long terme, notamment une augmentation des risques de chutes et de fractures de fragilite. Les residents de centres d’hebergement et de soins de longue duree (CHSLD) representent une population chez qui les effets indesirables d’un traitement a long terme par IPP peuvent etre significatifs et la deprescription des IPP doit etre envisagee lorsque cela est approprie. Objectifs : Determiner la proportion de residents de CHSLD ayant une ordonnance d’IPP qui satisfaisaient aux conditions requises pour une deprescription des IPP. De plus, examiner au sein de la population a l’etude les carences en vitamine B12 et les risques de chutes. Methodes : La presente etude transversale menee dans plusieurs centres comportait une analyse des dossiers medicaux de residents de CHSLD qui avaient une ordonnance active d’IPP en octobre 2016. Un echantillon de commodite de 150 dossiers medicaux a ete choisi au hasard et la pertinence d’une deprescription des IPP a ete determinee a l’aide des lignes directrices canadiennes. Des statistiques descriptives ont ete employees pour analyser les caracteristiques demographiques, les posologies et les indications des IPP, la prise de supplements de vitamine B12, les antecedents de chute et les risques de chute. Resultats : Trois des dossiers selectionnes ont ete exclus parce qu’il y manquait des renseignements. Des 147 residents dont les dossiers ont ete analyses, 93 (63 %) satisfaisaient aux conditions requises pour une deprescription. L’emploi d’IPP pour traiter le reflux gastro-œsophagien pendant plus de huit semaines sans qu’il y ait eu de tentative de deprescription dans la derniere annee representait l’occasion la plus frequemment observee pour proceder a une deprescription (49/93 ou 53 %). Vingt-neuf residents (20 %) utilisaient des IPP sans qu’une indication apparaisse aux dossiers. Treize residents (9 %) avaient subi une chute au cours des 30 derniers jours et 53 (36 %) avaient une prescription pour des supplements de vitamine B12 ou affichaient des taux seriques faibles de vitamine B12. Conclusions : La majorite des residents dont les dossiers ont ete examines remplissaient les conditions requises pour une deprescription des IPP. Ce resultat suggere qu’il y a la une occasion pour les cliniciens qui prennent soin de residents de CHSLD d’accroitre leur travail de deprescription.

Stability and Compatibility of Combinations of Hydromorphone and a Second Drug

Abstract: The stability and compatibility of binary combinations of hydromorphone at three concentrations (2, 10 and 40 mg/ml) and seven other medications (ampicillin, cefazolin, ceftazidime, cloxacillin, diazepam, phenytoin and phenobarbital) were evaluated for 24 hours at room temperature. In addition to visual inspection and pH, the concentration of each component in the binary mixture was determined by a stability indicating liquid chromatographic method. Each test was completed at time zero, 4, 8 and 24 hours after mixing equal volumes of each medication. Incompatibilities were observed when equal volumes of hydromorphone were mixed with either diazepam (5 mg/mL), phenobarbital (120 mg/ml) or phenytoin (50 mg/ml). Cefazolin was observed to be incompatible only when concentrations of cefazolin exceeded 200 mg/mL. Cloxacillin was observed to be incompatible with hydromorphone only when cloxacillin had been diluted with 5% dextrose in water (D5W) and the concentration exceeded 24 mg/ml. Cloxacillin is compatible with hydromorphone when an equal volume of a 250 mg/ml solution (reconstituted according to the manufacturer's directions) is mixed with hydromorphone. Ampicillin was observed to be compatible at concentrations of 20 mg/ml (diluted in D5W) and 250 mg/mL, but ampicillin retained more than 90% of the initial concentration for only four hours. Ceftazidime (40 mg/ml in D5W or 250 mg/ml) was physically compatible and chemical stable in the presence of hydromorphone. Hydromorphone was chemically stable in all solutions and never precipitated. RESUME Les stabilites et compatibilites d'associations binaires d'hydromorphone a trois concentrations (2, 10 et 40 mg/ml) et de sept autres medicaments (ampiciline, cefazoline, ceftazidine, cloxacillin, diazepam, phenytoine et phenobarbital) furent evaluees pendant une periode de 24 heures a la temperature de la piece. En plus d'une inspection visuelle et au pH, la concentration de chaque element du melange binaire fut determinee en utilisant la methode d'un solvant chromatographique determinant la stabilite. Chaque examen fut complete aux temps 0, 4, 8 et 24 heures apres avoir melange en volumes egaux chaque medication. Des incompatibilites furent observees lorsque des volumes egaux d'hydromorphone et de diazepam (5 mg/mL), de phenobarbital (l20 mg/ml,) ou de phenytoine (50 mg/mL) furent melanges. Il y eu incompatibilite seulement lorsque les concentrations de cefazoline depassaient 200 mg/mL. La cloxacilline etait incompatible avec l'hydromorphone, seulement quant elle etait diluee dans l'eau avec 5 p.c. de dextrose (D5W) et que la concentration depassait 24 mg/mL. Elle etait compatible avec l’hydromorphone lorsque melangee en volumes egaux d'une solution a 250 mg/mL (reconstituee selon les directives du fabricant). L'ampicilline etait compatible (diluee dans le D5W) a des concentrations de 20 mg/mL et de 250 mg/mL, mais conservait retenu plus de 90 p.c. de la concentration initiale pendant quatre heures seulement. La ceftazidime etait compatible physiquement (40 mg/mL dans D5W ou 250 mg/mL) et chimiquement stable en presence de l'hydromorphone. L’hydromorphone etait stable chimiquement dans toutes solutions et ne precipitait jamais.

Urosepsis Due to Extended-Spectrum β-Lactamase-Producing Escherichia coli: A Retrospective, Single-Centre Review of Risk Factors and Clinical Outcomes.

Abstract: Background: Extended-spectrum s-lactamase (ESBL)–producing Enterobacteriaceae are pathogens that are implicated in urosepsis and may be associated with greater morbidity and mortality than non-ESBL Enterobacteriaceae. Identification of risk factors for ESBL infection may facilitate the selection of appropriate empiric therapy. Objectives: The primary objectives were to determine the cumulative incidence of ESBL urosepsis, to identify major risk factors for ESBL urosepsis, and to determine the impact of international travel on development of ESBL urosepsis in an ethnically diverse Canadian population. The secondary objective was to characterize the outcomes of patients with ESBL urosepsis. Methods: A single-centre retrospective nested case–control study was conducted from January 2011 to June 2013. The study cohort consisted of adult patients with urosepsis and positive results on blood culture for ESBL-producing and non–ESBL-producing Enterobacteriaceae. Multivariate analysis was then used to determine risk factors for ESBL urosepsis. Results: The cumulative incidence of ESBL urosepsis at the study site was 19.4% (58/299) over 2.5 years. The 58 cases of ESBL urosepsis were compared with 118 controls (patients with urosepsis caused by non-ESBL Enterobacteriaceae). Significant predictors of ESBL urosepsis were chronic renal insufficiency (odds ratio [OR] 4.66, 95% confidence interval [CI] 1.96–11.08; p < 0.001) and travel to an endemic region in the previous 6 months (OR 4.62, 95% CI 1.17–18.19; p = 0.029), as well as Punjabi or Hindi as the primary language (OR 3.25, 95% CI 1.45–7.29; p = 0.004) and male sex (OR 2.65, 95% CI 1.21–5.80; p = 0.015). Patients with ESBL urosepsis had worse prognosis—in terms of death or discharge with palliative measures only—than those with non-ESBL urosepsis (7/58 [12.1%] versus 4/118 [3.4%]; p = 0.042). Conclusions: Institution-specific data support prompt recognition of patients at risk for ESBL infections. Chronic renal insufficiency, recent travel to regions endemic for ESBL-producing organisms, primary language of Punjabi or Hindi, and male sex were the strongest risk factors for ESBL urosepsis at the study centre. However, findings from this single-centre study may not be generalizable to other institutions. RESUME Contexte : Les enterobacteriacees productrices de s-lactamases a spectre etendu (BLSE) sont des pathogenes en cause dans les cas d’urosepsie et peuvent etre associees a des taux de morbidite et de mortalite superieurs a ceux lies aux enterobacteriacees ne produisant pas de BLSE. L’identification des facteurs de risque pour l’infection a BLSE pourrait faciliter le choix d’une antibiotherapie empirique appropriee. Objectifs : Les objectifs principaux etaient de determiner l’incidence cumulative des cas d’urosepsie a BLSE, d’identifier les facteurs de risque importants d’urosepsie a BLSE et de decouvrir les effets des voyages a l’etranger sur l’apparition d’urosepsie a BLSE dans une population multiethnique canadienne. L’objectif secondaire etait d’offrir un portrait de l’issue des patients atteints d’urosepsie a BLSE. Methodes : Une etude cas-temoins emboitee retrospective a ete menee dans un seul centre entre janvier 2011 et juin 2013. La cohorte etait composee de patients adultes atteints d’urosepsie dont les resultats d’hemoculture etaient positifs pour des enterobacteriacees produisant des BLSE ou pour des enterobacteriacees ne produisant pas de BLSE. Une analyse multivariee a ensuite ete utilisee afin de discerner les facteurs de risque pour l’urosepsie a BLSE. Resultats : L’incidence cumulative des cas d’urosepsie a BLSE dans l’etablissement a l’etude etait de 19,4 % (58/299) sur 2,5 ans. Les 58 cas d’urosepsie a BLSE ont ete compares a 118 temoins (des patients atteints d’urosepsie causee par des enterobacteriacees ne produisant pas de BLSE). Les meilleures variables explicatives d’urosepsie a BLSE etaient : l’insuffisance renale chronique (risque relatif approche [RRA] de 4,66, intervalle de confiance [IC] a 95 % de 1,96–11,08; p < 0,001) et les voyages dans une region endemique au cours des six derniers mois (RRA de 4,62, IC a 95 % de 1,17–18,19; p = 0,029) ainsi que le punjabi ou l’hindi comme langue principale (RRA de 3,25, IC a 95 % de 1,45–7,29; p = 0,004) et le sexe masculin (RRA de 2,65, IC a 95 % de 1,21–5,80; p = 0,015). Les patients atteints d’urosepsie a BLSE presentaient un pronostic plus sombre – en ce qui touche le deces ou le conge avec pour seule prescription des mesures palliatives – que ceux atteints d’urosepsie causee par des enterobacteriacees non productrices de BLSE (7/58 [12,1 %] contre 4/118 [3,4 %], p = 0,042). Conclusions : Des donnees propres a l’etablissement incitent a depister rapidement les patients a risque d’infection a BLSE. L’insuffisance renale chronique, les voyages recents dans des regions ou les organismes producteurs de BLSE sont endemiques, le punjabi ou l’hindi comme langue principale et le sexe masculin representaient les facteurs de risques les plus importants pour l’urosepsie a BLSE au centre a l’etude. Cependant, il se pourrait que les resultats provenant de la presente etude realisee dans un seul centre ne puissent pas etre generalises a d’autres etablissements.

Stability of meropenem in saline and dextrose solutions and compatibility with potassium chloride

Abstract: Objectives: The stability and compatibility of meropenem, 50 mg and 2000 mg added to 50 mL of normal saline (NS) or 5% dextrose in water (D5W) was evaluated at -20°C and 4°C over 14 days and at 23°C over 36 hours. The stability and compatibility of meropenem in NS or D5W with potassium chloride (I0 mmol/mL and 40 mmol/mL, diluted in either NS or D5W) was also evaluated at 23°C over 36 hours. Methods: In addition to visual inspection and pH, the meropenem concentration of solution was determined by a stability-indicating liquid chromatographic method. Meropenem concentrations were considered acceptable if the concentration on any day of analysis was greater than 90% of the initial (day zero) concentration. Results: Meropenem is more stable in NS than in D5W. The more concentrated solutions degrade faster in NS. Temperature also significantly affects stability. Solutions stored at room temperature lost more than I0% within 24 hours, while at 4°C, solutions retained 90% of the initial concentration for 1 to 7 days. At -20°C, NS solutions retained 90% of the initial concentration for at least 11 days. Meropenem is compatible with potassium chloride (KCl) in concentrations of IO mmol/L and 40 mmol/L in NS and D5W at 23°C. The presence of KCl did not affect the stability of meropenem. No significant change in pH was observed during the study period. Conclusions: This study demonstrates that at least three factors: temperature, concentration and diluent (presence of dextrose) affect the stability of meropenem. Once reconstituted, meropenem is more stable when diluted in NS than D5W. Potassium chloride solutions are compatible with meropenem solutions and do not appear to alter the stability of meropenem. RESUME Objectifs : Evaluer la stabilite et la compatibilite du meropenem dans des proportions de 50 mg et 2000 mg dans 50 mL de solute physiologique normal (NS) de dextrose a 5% dans l'eau (D5W), a des temperatures de -20 °Cet de 4 °C durant 14 jour et de 23 °C durant 36 heures. La stabilite et la compatibilite du meropenem dans du NS ou du D5W avec du chlorure de potassium (1O mmol/mL et 40 mmol/mL, dilue dans du NS ou du D5W) ont aussi ete evaluees a une temperature de 23 °C durant 36 heures. Methodes : Outre l'inspection visuelle et la verification du pH, on a determine la concentration des solutions en meropenem, au moyen d'une epreuve destabilise par chromatographie liquide. Les concentrations en meropenem etaient considerees acceptables si a n'importe quel jour d'une analyse, elles etaient superieures a 90 % des concentrations initiales (au jour 0). Resultats : Le meropenem est plus stable dans le NS que dans le D5W Les solutions a concentration plus elevee se degradent plus rapidement dans le NS. La temperature affecte aussi grandement la stabilite. Les solutions entreposees a la temperature ambiante ont perdu plus de 1O % de leurs concentrations initiales en 24 heures, a lorsqu'entreposees a 4 °C elles ont conserve plus de 90 % de leurs concentrations initiales durant 1 a 7 jours. Les solutions de meropenem dans du NS, entreposees a 20 °C ont conserve 90 % de leur concentration initiale en meropenem pendant au moins 11 jours. Le meropenem est compatible avec le chlorure de potassium (KCI) dans des concentrations de 10 mmol/L et de 40 mmol/L dans du NS et du D5W a 23 °C. La presence de KCI n'a pas affecte la stabilite du meropenem. Aucun changement significatif du pH n'a ete observe au cours de la periode d'etude. Conclusions : Cette etude a demontre qu'au moins trois facteurs affectent la stabilite du meropenem : la temperature, la concentration et le diluent (presence de dextrose). Apres sa reconstitution, le meropenem est plus stable lorsqu'il est dilue dans du NS que dans du D5W. Les solutions de chlorure de potassium sont compatibles avec les solutions de meropenem et elles ne semble pas alterer la stabilite du meropenem.

Successful Treatment of Stevens-Johnson Syndrome with Cyclosporine and Corticosteroid.

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Implementation and Evaluation of a Pharmacist-Assisted Warfarin Dosing Program

Abstract: The purpose of this study was to implement a Pharmacy-Assisted Warfarin Dosing (PAWD) Pilot Program and assess its effects on efficiency, effectiveness, and safety during warfarin anticoagulation. A protocol was developed based on institutional anticoagulation guidelines. Pharmacists on three musing units anticoagulated patients by protocol upon physician request (PAWD group, n=24). All warfarin orders were written by a pharmacist in accordance with hospital policies. The study group was compared with a baseline sample of patients started on warfarin therapy by physicians (Control group, n=34). The number of patients achieving the target INR by day 5 (Control - 41.1 % and PAWD - 32 %) was not significantly different among the 2 groups. The PAWD program resulted in significant improvements to the number of warfarin doses administered on time (99.1 %) compared to the Control group (46.2 %). Both groups had a low incidence of bleeding (Control 6.06 % and PAWD - 8 %) and thromboembolic events (Control - 3.03 % and PAWD - 0 %). Overall, the PAWD program resulted in equally effective and safe anticoagulation of patients and improved compliance with timely administration of doses. RESUME Le but de cette etude etait de mettre sur pied un programme pilote de dosage de la warfarine assistee par le pharmacien (DWAP) et d'en evaluer sur l'efficience, l'efficacite et la securite dans le cadre d'une anticoagulotherapie a la warfarine. Un protocole a ete elabore, a partir des lignes directrices institutionelles sur l'anticoagulotherapie. Les pharmaciens de trois unites de soins ont amorce une anticoagulotherapie a des patients selon le protocole etabli, a la demande du medecin (groupe DWAP, N=24). Toutes les demandes de warfarine ont ete ecrites par un pharmacien, selon les politiques de l'hopital. Le groupe experimental a ete compare a un groupe de patients chez qui l'anticoagulotherapie a ete amorcee par des medecins (groupe temoin; N = 34). Le nombre de patients qui a atteint le RIN cible au jour 5 (temoins : 41, 1 % et DWAP : 32 %) n'etait pas significativement different entre les cieux groupes. Le programme DWAP a entraine des ameliorations notables du nombre de doses De warfarine administrees selon l'horaire etabli (99,1 %), comparativement au groupe temoin (46,2 %). L'incidence des saignements (temoins : 6,06 % et DWAP : 8 %) et des thromboembolies (temoins : 3,03 % et DWAP : 0 %) etait faible clans les deux groupes. Dans l'ensemble, le programme DWAP a permis d'administrer d'une facon aussi sure et efficace qu'avec la methode classique l'anticoagulotherapie et de respecter davantage l'horaire d'administration des doses.

From abstract to publication: What makes the grade?

Abstract: Objectives: To determine the proportion of abstracts published in the Canadian Journal of Hospital Pharmacy ( CJHP ) that become full-length papers in professional journals and to identify the determinant(s) of whether or not an abstract is published as a full paper. Methods: Our database consisted of all abstracts published in CJHP from 1992 through 1996. We determined the publication status of associated full papers from questionnaire responses, a Medline search, and an author index search of CJHP . Results: Of 363 abstracts, 89 (25%) became full-length papers. Thirty-six (40%) of these papers appeared in CJHP . With the exception of 1992 when the publication rate was 82%, overall publication rates from year to year were similar and ranged between 20 to 26%. Award winning abstracts were published more frequently than non-award winners at a rate of 49% vs. 21%, respectively ( p < 0.0001). However, the publication rate of awards authored by residents (44%) was not significantly different than that of non-resident projects (46%; p = 1.000). Likewise, single author papers had a lower, but not significantly lower, publication rate (19%) than did multiple author papers (27%; p = 0.1091). Conclusions: Only one-quarter of abstracts published in CJHP from 1992 through 1996 have been published as full-length papers. The only significant determinant of whether or not an abstract became a full paper was its status as an award winning abstract in that these were more likely to be published in full form than were non-award winning abstracts. RESUME Objectifs: Determiner la proportion de resumes publies dans le Journal canadien de la pharmacie hospitaliere (JCPH) dont l'article correspondant dans sa version integrale fera l'objet d'une parution dans un magazine professionnel, et identifier le ou les determinants qui font qu'un resume fera ou non l'objet d'une publication de l'article correspondant dans sa version integrale. Methodes: Nous avons utilise notre base de donnees contenant tous les resumes publies clans le JCPH entre 1992 et 1996 inclusivement. Nous avons determine l'etat des projets de publication associe aux manuscrits integraux, a partir des reponses aux questionnaires, d'une recherche dans Medicine, et d'une recherche indexee par auteur clans le JCPH. Resultats: Des 363 resumes, 89 (25 %) ont fait l'objet d'une publication de l'article correspondant dans sa version integrale, dont 36 (40 %) dans le JCPH. A l'exception de 1992, annee ou le taux dc publication etait de 82 %, le taux de publication global d'une annee a l'autre etait semblable et variait de 20 a 26 %. Les resumes primes ont ete publies plus frequemment que ceux qui ne l'etaient pas, pour un taux de publication de 49 % c. a 21 %, respectivement (p < 0,0001). Cependant, le taux de publication des resumes primes ecrits par des residents (44 %) n'etait pas significativement different du taux des resumes ecrits par des non residents (48 %; p = 1,000). De facon semblable, les articles a auteur unique avaient un taux de publication inferieur (19 %), quoique non significatif, aux articles a auteurs multiples (27 %; p = 0,1091). Conclusions: Seulement le quart des resumes publies dans le JCPH de 1992 ci 1996 inclusivement ont fait l'objet d'une publication de 1'article correspondant dans sa version integrale. Le seul determinant significatif qui fait qu'un resume fera ou non l'objet d'une publication de l'article correspondant dans sa version integrale etait le fait qu'il avait ete prime. En effet les resumes primes avaient plus de chance de faire l'objet d'une publication de l'article correspondent dans sa version integrale.

Implementation of a Pharmacist-Led Inpatient Tobacco Cessation Intervention in a Rehabilitation Hospital: A Before-and-After Pilot Study.

Abstract: Background: Inpatient rehabilitation presents a unique opportunity for smoking interventions, given the typical lengths of stay, the relevance of smoking to the admission diagnosis of many patients, and the occurrence of nicotine withdrawal during the hospital stay. Objective: To evaluate the feasibility of implementing a pharmacist-led version of the Ottawa Model for Smoking Cessation (OMSC) program at a rehabilitation hospital, using the indicators of reach, effectiveness, adoption, and implementation. Methods: A before-and-after pilot study was conducted. Smoking cessation data were collected from 2 cohorts of eligible smokers identified during 4-month periods before (control) and after (intervention) implementation of the OMSC program. Control participants received usual care (i.e., no cessation intervention). Intervention participants received initial in-hospital smoking cessation support (counselling and nicotine replacement therapy), inpatient follow-up during the hospital stay, and 3 months of postdischarge follow-up calls, with all aspects led by hospital pharmacists. Results: Among all patients admitted to participating inpatient rehabilitation units during the 2 study periods, smoking prevalence was 7.8% (127/1626). After exclusions, deaths, and withdrawals, 111 patients were retained for analysis: 55 in the control group and 56 in the intervention group. The overall mean age of participants was 64.9 (standard deviation [SD] 14.3) years, with a mean smoking history of 35.0 (SD 24.8) pack-years. There were no significant differences between groups in terms of baseline characteristics. Self-reported abstinence rates (determined 3 months after discharge) were higher after compared with before implementation of the OMSC program: for continuous abstinence, 16/56 (28.6%) versus 9/55 (16.4%), _ 2 = 4.462, p = 0.035; for 7-day point prevalence abstinence, 21/56 (37.5%) versus 10/55 (18.2%), _ 2 = 6.807, p = 0.009. Conclusions: Implementation of the OMSC program at a large rehabilitation hospital was feasible and led to an increase in 3-month smoking abstinence. This study provides preliminary evidence to support inclusion of smoking interventions as part of inpatient rehabilitation care. RESUME Contexte : La readaptation des patients hospitalises represente une occasion unique de proceder a des interventions de desaccoutumance du tabac, notamment en raison de la duree habituelle des sejours, du rapport entre le tabagisme et le diagnostic pose a l’admission, et de la survenue du syndrome de sevrage de la nicotine durant le sejour. Objectif : Etudier la possibilite de mettre en oeuvre une version dirigee par des pharmaciens du programme Modele d’Ottawa pour l’abandon du tabac (MOAT) dans un centre de readaptation en employant les indicateurs pour la portee, l’efficacite, l’adoption et la mise en oeuvre. Methodes : Une etude pilote avant-apres a ete menee. Des donnees sur la desaccoutumance ont ete recueillies aupres de deux cohortes de fumeurs admissibles qui ont ete reperes pendant des periodes de quatre mois avant (groupe temoin) et apres (groupe experimental) la mise en oeuvre du programme du MOAT. Les participants du groupe temoin ont recu les soins habituels (c.-a-d. sans intervention de desaccoutumance). Les participants du groupe experimental ont recu un soutien initial a l’hopital pour la desaccoutumance du tabac (des conseils et un traitement de remplacement de la nicotine), un suivi pendant le sejour a l’hopital, et des appels de suivi pendant les trois mois suivant le conge, le tout sous la direction de pharmaciens d’hopitaux. Resultats : Parmi l’ensemble des patients admis dans les unites de readaptation participantes au cours des deux periodes de l’etude, la prevalence du tabagisme etait de 7,8 % (127/1626). Mis a part les exclusions, les deces et les abandons, 111 patients ont ete retenus pour l’analyse : 55 dans le groupe temoin et 56 dans le groupe experimental. L’âge moyen des participants etait de 64,9 (ecart-type de 14,3) ans et leur antecedent de tabagisme moyen etait de 35,0 (ecart-type de 24,8) paquets-annees. Aucune difference significative n’a ete relevee entre les groupes en ce qui touche aux caracteristiques de base. Les taux d’abstinence autodeclaree (determinee 3 mois apres le conge) etaient plus eleves apres la mise en oeuvre du programme du MOAT : pour une abstinence continue, 16/56 (28,6 %) contre 9/55 (16,4 %), _ 2 = 4,462, p = 0,035; pour une abstinence ponctuelle de sept jours consecutifs, 21/56 (37,5 %) contre 10/55 (18,2 %), _ 2 = 6,807, p = 0,009. Conclusions : La mise en oeuvre du programme du MOAT dans un important centre de readaptation a ete possible et a mene a une amelioration de l’abstinence du tabac a trois mois. Cette etude donne des resultats preliminaires en appui a l’inclusion d’interventions de desaccoutumance du tabac aux soins de readaptation de patients hospitalises.

Is There a Reason for the Proton Pump Inhibitor? An Assessment of Prescribing for Residential Care Patients in British Columbia.

Abstract: Background: The use of proton pump inhibitors (PPis) may cause significant harm to patients in the residential care setting, as these patients are often frail with multiple morbidities. The extent of non-evidence­ based use of PPis in residential care sites of the Fraser Health Authority in British Columbia is unknown. Objectives:: To determine the proportion of non-evidence-based use of PPI therapy for residential care patients of the Fraser Health Authority. Methods: This retrospective cross-sectional study was conducted in 6 Fraser Health residential care facilities in British Columbia between April 1, 2015, and March 31, 2016. Two definitions of "evidence-based indications" were used. The first definition encompassed broad evidence­ based indications for PPI use, specifically gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), gastritis, esophagitis, Barrett esophagus, and gastrointestinal protection from concurrent oral steroids, oral nonsteroidal anti-inflammatory drugs, antiplatelet agents, and anticoagulants. The second definition involved common evidence-based indications for PPI use, specifically GERD or PUD. Descriptive statistics were used to evaluate the primary outcome: the proportion of PPI orders without a documented broad or common evidence-based indication for PPI treatment. Results: A total of 331 residential care patients and 407 PPI orders were assessed. The proportion of PPI orders without a documented broad evidence-based indication was 16.2% (66/407). The proportion of PPI orders without a documented common evidence-based indication was 43.7% (178/407). The most frequently documented reason for a PPI order was GERD (214/407 or 52.6%). PPI orders for patients with GERD and gastrointestinal bleeding had the longest duration of therapy during residential care admission, averaging 205.1 and 218.1 days, respectively. Conclusion: About 1 in 6 PPI orders for Fraser Health residential care patients did not have a documented broad evidence-based indication, and about 2 in 5 PPI orders did not have a documented common evidence­ based indication. These results indicate a need to assess the appropriateness of therapy for every patient with an active PPI order in residential care facilities. Resume Contexte : L'emploi d'inhibiteurs de la pompe a protons (IPP) peut causer des torts importants aux patients qui resident en centre d'hebergement et desoins de longue duree, car souvent ces personnes sont fragiles et souffient de multiples maladies. On ignore quelle est la proportion d'utilisation d'IPP ne reposant pas sur des donnees probantes clans !es centres d'hebergement et de soins de longue duree de la Fraser Health Authority en Colombie-Britannique. Objectif: Determiner la proportion d'utilisation de traitement par IPP ne reposant pas sur des donnees probantes chez Jes patients en centre d'hebergement et de soins de longue duree de la Fraser Health Authority. Methodes : Cette etude retrospective transversale a ete menee clans six centres d'hebergement et de soins de longue duree de la Fraser Health en Colombie-Britannique, entre le l" avril 2015 et le 31 mars 2016. Deux definitions du terme « indications fondees sur des donnees probantes » Ont ete utilisees. La premiere definition englobait des indications larges fondees sur des donnees probantes appuyant !'utilisation d'IPP, plus particulierement : pour traiter le reflux gastro-resophagien, l'ulcere gastroduodenal, la gastrite, !' resophagite et !'resophage de Barrett ainsi que pour fournir une protection gastrique contre !es effets indesirables de la prise de medicaments anti-inflammatoires oraux steroidiens ou non steroidiens, d'antiplaquettaires et d'anticoagulants. La seconde definition comprenait !es indications usuelles fondees sur des donnees probantes pour appuyer !'utilisation d'IPP, plus precisement: le reflux gastro-resophagien ou l'ulcere gastroduodenal. Des statistiques descriptives ont ete employees pour analyser le principal parametre d'evaluation : la proportion d'ordonnances d'IPP pour lesquelles aucune indication, large ou usuelle, fondee sur des donnees probantes n'a ete consignee. Resultats : Au total,!es dossiers de 331 residents de centres d'hebergement et de soins de longue duree et 407 ordonnances d'IPP Ont ete evalues. La proportion d'ordonnances d'IPP pour lesquelles aucune indication large fondee sur des donnees probantes n'a ete consignee etait de 16,2 % (66/407). La proportion d'ordonnances d'IPP pour lesquelles aucune indication usuelle fondee sur des donnees probantes n'a ete consignee etait de 43,7 % (178/407). La raison la plus souvent consignee pour!'emission d'une ordonnance d'IPP etait le reflux gastro-resophagien (214/407 ou 52,6 %). Les ordonnances d'IPP destinees aux patients souffrant de reflux gastro-resophagien ou d'hemorragie gastro-intestinale etaient celles pour lesquelles la duree du traitement etait la plus longue au cours du sejour en centre d'hebergement et de soins de longue duree, soit respectivement de 205,1 et 218,1 jours en moyenne. Conclusion : Environ 1 ordonnance d'IPP sur 6 pour !es patients de centres d'hebergement et de soins de longue duree de la Fraser Health ne reposait pas sur une indication large consignee et fondee sur des donnees probantes et environ 2 ordonnances d'IPP sur 5 ne s'appuyaient pas sur une indication usuelle consignee et fondee sur des donnees probantes. Les resultats revelent la necessite d' evaluer la pertinence des traitements par IPP pour chaque patient ayant une ordonnance active d'IPP clans !es centres d'hebergement et de soins de longue duree.

Pharmacists’ Roles in Critical Care: Environmental Scan of Current Practices in Canadian Intensive Care Units

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Stability of Dapsone in Extemporaneously Compounded Oral Suspensions

Abstract: Dapsone is a sulphone antibiotic with anti-inflammatory properties.1 It is used as a first-line treatment for multibacillary and paucibacillary leprosy, and its mechanism of action is to reduce the synthesis of dihydrofolic acid.2,3 Its structure is illustrated in Appendix 1 (available at https://www.cjhp-online.ca/index.php/cjhp/issue/ view/126/showToc). It has a solubility of 0.284 mg/mL in water and a pKa of 2.39.4,5 The very low solubility of dapsone over the acceptable range of pH for an oral preparation does not allow formulation of a solution. In the absence of commercial alternatives, compounded liquid suspensions are required for children and when administration of solid dosage forms is not suitable. Liquid preparations in Ora-Blend (Paddock Laboratories; constituents sucrose, glycerin, sorbitol, flavouring, microcrystalline cellulose, carboxymethylcellulose sodium, xantham gum, carrageenan, calcium sulphate, trisodium phosphate, citric acid, sodium phosphate, dimethicone, methylparaben, and potassium sorbate), SyrSpend (Fagron Inc; constituents modified food starch, sodium citrate, citric acid, malic acid, sodium benzoate, and simethicone), and other noncommercial aqueous vehicles have been reported, with stability of at least 3 months under refrigerated conditions and between 1 and 3 months at room temperature.6-8 SyrSpend is not readily available in North America, and there may in future be shortages of (or a patient may be intolerant of) Ora-Blend. Therefore, this study was conducted to assess the stability of dapsone in Oral Mix and Oral Mix SF vehicles, which are suitable as alternative dye-free formulations for children. These agents are easy to work with and are globally available. Suspensions were compounded on March 29, 2016, from dapsone tablets (5 × 100 mg, Jacobus Pharmaceutical, Princeton, New Jersey; lot 16387, expiry November 2017), which were pulverized with mortar and pestle. Oral Mix (Medisca Pharmaceutique Inc, Montréal, Quebec; lot I185/A, expiry January 2018; constituents glycerin, sorbitol, flavouring, microcrystalline cellulose, carboxymethylcellulose sodium, sodium saccharin, xantham gum, carrageenan, sodium citrate, citric acid, methylparaben, propylparaben, potassium sorbate, and simethicone) or Oral Mix SF (Medisca Pharmaceutique Inc; lot H1136, expiry October 2017; constituents sucrose, glycerin, sorbitol, flavouring, microcrystalline cellulose, carboxymethylcellulose sodium, xantham gum, carrageenan, sodium citrate, citric acid, methylparaben, potassium sorbate, and simethicone) was then geometrically incorporated to a final volume of 250 mL. Each preparation was packaged in 50-mL amber plastic bottles (6 bottles containing 30 mL per preparation; polyethylene terephthalate [PET] with black phenolic cap, Medisca Pharmaceutique Inc) and 3-mL amber polypropylene syringes (48 syringes containing 1 mL per preparation; PreciseDose syringes with tip cap, Medisca Pharmaceutique Inc). Three bottles of each preparation and 3 syringes for each time point were stored at a mean temperature of 5°C (standard deviation [SD] 2°C) or 25°C (SD 2°C), with relative humidity 60% (SD 5%). At predetermined time points (0, 7, 14, 30, 45, 60, 75, and 90 days), a 1-mL aliquot was retrieved from each bottle and 3 syringes were retrieved from each temperature condition. The bottles and syringes were vigorously shaken until complete resuspension before sampling. On each study day, the appearance of each test sample was inspected. The pH was evaluated (pH 211 model pH meter, Hanna Instruments, Montréal, Quebec) and concentration was

Validation of Pictograms for Safer Handling of Medications: Comprehension and Recall among Pharmacy Students.

Abstract: Background : Medication preparation and administration are higher-risk steps in the medication management process Therefore, medication management strategies, such as warnings and education about medication safety, are essential in preventing errors and improving the safe handling of medications by health care workers Objectives : To validate comprehension of 9 pictograms designed to improve medication safety, and to assess long term recall of these pictograms in a sample of pharmacy students Methods : First- and second-year pharmacy students were recruited as participants The study was divided into 2 phases: comprehension (Phase 1) and long-term recall (Phase 2) In Phase 1, a slideshow of the 9 pictograms was presented to participants, who were asked to write the meaning of and required action for each pictogram The intended meaning of each pictogram was then presented to the participants Four weeks later, long-term recall was assessed in Phase 2 of the study using the same method The meaning and required action that participants provided for each pictogram were reviewed by 3 independent raters A pictogram was considered to be validated in the pharmacy student population if at least 67% of participants identified the correct meaning or required action during the recall phase Results : A total of 101 pharmacy students participated in Phase 1 and 67 in Phase 2 In Phase 1, 4 pictograms met the 67% threshold for comprehension In Phase 2, after training, 7 of the 9 pictograms were validated Conclusions : Given the results obtained with pharmacy students, redesign may be necessary for 2 of the pictograms The use of validated medication safety pictograms on medication labels and other identifiers may prevent errors during medication handling and administration; this is an important avenue of investigation for future studies RESUME Contexte : La preparation et l’administration des medicaments sont des etapes a risque plus eleve dans le processus de gestion des medicaments Or, les strategies de gestion des medicaments, dont les mises en garde et les informations sur la securite des medicaments, sont essentielles a la prevention des erreurs et a une manipulation plus securitaire des medicaments par les travailleurs de la sante Objectifs : Valider la comprehension de neuf pictogrammes concus pour accroitre la securite des medicaments et verifier si ces pictogrammes s’inscrivent dans la memoire a long terme des etudiants en pharmacie Methodes : On a recrute des participants aupres des etudiants de premiere et de deuxieme annee en pharmacie L’etude etait composee de deux phases : comprehension (phase 1) et memoire a long terme (phase 2) Dans la phase 1, un diaporama de neuf pictogrammes a ete presente aux participants a qui l’on a demande d’interpreter chaque pictogramme et la mesure qu’il impose On a ensuite presente aux participants la signification qu’on voulait donner a chaque pictogramme Quatre semaines plus tard durant la phase 2, un test de memoire a long terme employant la methode de la phase 1 a ete effectue Les reponses des participants quant a la signification et a la mesure a prendre pour chaque pictogramme ont ete analysees par trois evaluateurs independants Un pictogramme etait considere comme valide dans la population des etudiants en pharmacie si un minimum de 67 % des participants se souvenait de la signification adequate et de la mesure a prendre recherchee pendant la phase de test de memoire a long terme Resultats : Au total, 101 etudiants en pharmacie ont participe a la phase 1 et 67 a la phase 2 Dans la phase 1, quatre pictogrammes ont atteint le seuil de 67 % pour la comprehension Dans la phase 2, apres une formation, 7 pictogrammes sur 9 ont ete valides Conclusions : Compte tenu des resultats obtenus aupres des etudiants en pharmacie, deux des pictogrammes pourraient etre appeles a retourner a la planche a dessin L’ajout de pictogrammes valides de securite des medicaments sur les etiquettes et autres marques d’identification de medicaments pourrait eviter des erreurs pendant la manipulation et l’administration de medicaments Il s’agit la d’une piste de recherche importante pour de futures etudes