Anita Elaine Weidmann

Dihydroquercetin: More than just an impurity?

Dihydroquercetin (taxifolin) is a potent flavonoid found in onions, French maritime bark, milk thistle, tamarind seeds and commercially available semi-synthetic monoHER marketed as Venoruton. This review focuses on the therapeutic promise of dihydroquercetin in major disease states such as cancer, cardiovascular disease and liver disease by reviewing the proposed mechanism(s) of action, including the activation of the antioxidant response element (ARE) and detoxifying phase II enzymes, inhibition of cytochrome P(450) and fatty acid synthase in carcinogenesis. TNF-alpha and NF-ĸB dependent transcription in hepatitis C infections, the scavenging effect of myeloperoxidase (MPO) derived reactive nitrogen species and subsequent effects on cholesterol biosynthesis as well as the effects on apob/apoA-I, HMG-CoA reductase and apoptosis are reviewed. The stereochemistry and pro-oxidant effect of dihydroquercetin are also considered. Although the majority of research on dihydroquercetin to date has focused on the identification of molecular targets in vitro, this review will bring together evidence of the potency and mode of action of dihydroquercetin and will propose a role for the therapeutic potential of flavonoid antioxidants.

Hospital discharge information communication and prescribing errors: a narrative literature overview

Objectives To provide a narrative overview of the literature on discharge information communication and medicines discharge prescribing error rate in the UK and other similar healthcare systems. Methods A narrative review of the peer reviewed literature (2000–2014) on communication of discharge information from hospitals to general practitioners. Databases included were MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Applied Social Sciences Index and Abstracts, and International Pharmacy Abstracts database. Results The search yielded 673 results with 15 papers satisfying all inclusion criteria. Direct comparison of studies was not feasible due to differences in study populations and outcome measures. No studies reported post Hospital Electronic Prescribing and Medicine Administration (HEPMA) implementation. Studies (n=6) investigating handwritten discharge communication systems demonstrated medicine information inaccuracy ranging from 0.81 errors per patient to 17.5% medicines with errors and 67% letters missing medicines change information; with 77% assessed as legible. Studies (n=4) comparing interim electronic solutions with traditional showed variable results: improved, unchanged or decreased medicine information accuracy. Studies researching solely interim electronic solutions (n=5) with one including prescribing error rate assessment at 8.4% of prescribed items and identification of a new electronic system-related error type. Conclusion Implementation of interim electronic discharge solutions resulted in complete legibility but did not eradicate information and prescribing errors. A paucity of information is available about HEPMA implementation impact on discharge information communication and prescribing error rates. There is urgent need for formal evaluation in this area.

Promoting weight management services in community pharmacy: perspectives of the pharmacy team in Scotland

Background Obesity has reached pandemic levels with more than 1.4 billion adults affected worldwide. While there is a need to systematically develop and evaluate community pharmacy based models of weight management, it is imperative to describe and understand the perspectives of pharmacy staff. In the UK, trained and accredited community pharmacy medicines counter assistants (MCAs) are commonly the front line staff involved in patient consultations and sale of over-the-counter medicines. Objective To explore the beliefs and experiences of pharmacists and MCAs in the North-East of Scotland on community pharmacy weight management. Setting All 135 community pharmacies in the North-East of Scotland. Method A qualitative approach of semi-structured telephone interviews with 31 pharmacists and 20 MCAs in the North-East of Scotland. The semi-structured interview schedule was developed with reference to key domains describing professional practice (i.e. awareness and knowledge, skills, practicalities, motivation, acceptance and beliefs) and contextualised with policy documents and published research on community pharmacy based weight management. Interviews were audio-recorded, transcribed and analysed thematically. Main outcome measure Pharmacists’ and MCAs’ beliefs and experiences with delivering weight management services in community pharmacy. Results There were mixed responses from pharmacists and MCAs around pharmacy based weight management services from positive views of providing the service in community pharmacy to those more reticent who would always favour patients visiting their physician. While all described similar services e.g. measurement of weight, healthy eating advice, supply of products, they acknowledged that support was often opportunistic at the request of customers, with little integration of other providers. Roles described varied from pharmacist only functions to any staff member. While pharmacists generally felt comfortable and confident, MCAs gave more diverse responses. Both Pharmacist and MCAs highlighted the need for a practice model which is systematically developed and suggested a scheme akin to the successful smoking cessation 12-week nicotine replacement therapy service already available in community pharmacies in Scotland. Conclusion Pharmacists and MCAs interviewed in this study reported their perceptions of benefits to providing community pharmacy based weight management as part of a wider public health function. They described services as opportunistic and customer driven based on ease of access. There was a notable variation in pharmacist and MCA training, reflected in their levels of comfort and confidence. There is a clear need to systematically develop and provide evidence of effectiveness and cost effectiveness for a pharmacy based practice model with key roles and functions for the full pharmacy team.

Interprofessional student-run primary health care clinics: Educational experiences for pharmacy students.

Student-run primary health care clinics (SRPHCCs) are prevalent in the United States and have reported benefits not only by providing medical care for underserved patients but also by acting as a valuable learning experience for medical students.1 There are currently 7 SRPHCCs in Canada.2 The Community Health Initiative by University Students (CHIUS) in Vancouver, British Columbia, was the first to open its doors in April 2000. Subsequently, 6 additional SRPHCCs have opened in Alberta, Saskatchewan, Manitoba and Ontario.2 These Canadian student-run primary health care clinics offer medical services that are similar to those available in typical family doctors’ offices; however, most patients of the SRPHCCs seek care on a walk-in basis, in contrast to appointment-based encounters. What makes these SRPHCCs unique (in addition to the fact that they are operated by students) is that they use a collaborative, interprofessional approach and that patients can access a wide variety of educational and social services at the clinics, not exclusively medical care. The purpose of this article is to describe the function of interprofessional SRPHCCs in Canada and to discuss potential benefits of the model for educating undergraduate pharmacy students.

Interprofessional student-run primary health care clinics Implications for pharmacy education in Scotland

Introduction: Interprofessional student-run primary health care clinics have been a flagship model of health professional education in Canada for many years. The purpose of this study was to determine if there is support for implementing this educational model in the United Kingdom and to highlight the implications for pharmacy education in Scotland. Method: A cross-sectional postal survey of 3000 randomly selected citizens of Aberdeen city and shire, Scotland, aged 18 years and older. Results: Of the 824 questionnaires that were returned (response rate 27.5%), more than half of the respondents (62.4%; n = 514) would consider accessing health care from a student-led, walk-in service. The range of services they expect to see includes general health checks (60%; n = 494), help for sexually transmitted diseases (57.5%; n = 474), weight management (56.8%; n = 468), smoking cessation (54.4%; n = 448) and drug misuse services (47.2%; n = 387). Concerns raised pertained to student ability, suitability for children and accessibility. Many comments pertained to the improvement of the current system by offering after-hours care. Discussion: The positive response from the general public towards an interprofessional student-run primary health care clinic in Aberdeen suggests that this Canadian model of interdisciplinary health professional education would likely be a successful addition to the pharmacy curriculum in Scotland.

4CPS-209 A clinical pharmacist-led medication reconciliation service in geriatric patients upon admission to hospital

Background At the points of admission and discharge from hospital, patient or medication-related factors such as older age and an increased number of drugs can lead to medication errors.1 In 2006, the World Health Organisation initiated the High 5 s Project where it recommended medication reconciliation to prevent medication errors at transition points.2 Purpose To implement and evaluate a clinical pharmacist-led medication reconciliation service in geriatric patients upon admission to hospital, in terms of frequency, type and potential severity of the medication errors identified. Material and methods Medication reconciliation interviews were conducted to record the best possible list of all the medications a patient was taking upon admission to hospital. This list was then compared with the drug history initially recorded by the physician. Any discrepancies were considered as medication errors. Errors were categorised by type and therapeutic group. An expert panel rated each medication error for its potential severity. A secondary outcome included studying the relationship between the number of errors and patient demographics or medication-related factors. Results A total of 154 patients were eligible for inclusion; 136 (88.31%) patients had at least one error. Four hundred and ninety-eight medication errors (mean of 3.23 errors per patient) were determined with the most common type being that of drug omission (n=252, 50.6%). The therapeutic group with the highest number of errors was that of the alimentary tract and metabolism (n=132, 26.51%). With regards to severity, 208 (41.77%) of the medication errors potentially required monitoring or intervention to prevent harm while 33 (6.63%) had the potential to cause harm. Medication errors were found to be correlated with the number of drugs at admission and total sources of information (p<0.05). Conclusion A clinical pharmacist-led medication reconciliation was an effective procedure to identify and resolve medication errors. Results obtained formed the basis for the development of such a service to optimise patient care and safety. References and/or Acknowledgements 1. Salanitro AH, et al. Effect of patient- and medication-related factors on inpatient medication reconciliation errors. J Gen Intl Med2012;27(8):924–32. 2. Joint Commission International(JCI). Projects supporting our mission[online] 2017. USA: Joint Commission International. Available from: http://www. jointcommissioninternational. org/about-jci/projects-supporting-our-mission/(Accessed: 10 October 2017). No conflict of interest

Hospital staff views of prescribing and discharge communication before and after electronic prescribing system implementation

Background Electronic prescribing system implementation is recommended to improve patient safety and general practitioners discharge information communication. There is a paucity of information about hospital staff perspectives before and after system implementation. Objective To explore hospital staff views regarding prescribing and discharge communication systems before and after hospital electronic prescribing and medicines administration (HEPMA) system implementation. Setting A 560 bed United Kingdom district general hospital. Methods Semi-structured face-to-face qualitative interviews with a purposive sample of hospital staff involved in the prescribing and discharge communication process. Interviews transcribed verbatim and coded using the Framework Approach. Behavioural aspects mapped to Theoretical Domains Framework (TDF) to highlight associated behavioural change determinants. Main outcome measure Staff perceptions before and after implementation. Results Nineteen hospital staff (consultant doctors, junior doctors, pharmacists and advanced nurse practitioners) participated before and after implementation. Pre-implementation main themes were inpatient chart and discharge letter design and discharge communication process with issues of illegible and inaccurate information. Improved safety was anticipated after implementation. Post-implementation themes were improved inpatient chart clarity and discharge letter quality. TDF domains relevant to staff behavioural determinants preimplementation were knowledge (task or environment); skills (competence); social/professional roles and identity; beliefs about capabilities; environmental context and resources (including incidents). An additional two were relevant post-implementation: social influences and behavioural regulation (including self-monitoring). Participants described challenges and patient safety concerns pre-implementation which were mostly resolved post-implementation. Conclusion HEPMA implementation produced perceptions of patient safety improvement. TDF use enabled behaviour change analysis due to implementation, for example, staff adoption of behaviours to ensure general practitioners receive good quality discharge information.

CP-116 Evaluation of the clinical significance and value of a clinical pharmacy service at a teaching hospital

Background Clinical pharmacy services (CPS) have been shown to provide significant clinical benefits for patient care. The paucity of literature reports within the Austrian healthcare system highlights the urgent need for studies providing evidence for CPS. Purpose To assess the clinical significance and value of CPS by determining the number, type and clinical significance of identified drug related problems (DRPs), acceptance rate of suggested interventions and their benefit to inpatient care. Material and methods This was a two phase mixed method study: (1) prospective descriptive study of number and type of identified DRPs, suggested interventions and their acceptance rate based on a validated classification system1; (2) independent expert panel rating of the clinical significance of identified DRPs and the clinical value of suggested interventions based on a reliable rating method.2 The setting was a 455 bed teaching hospital in Vienna. The CPS was across two surgical, two trauma, one cardiology and two internal medicine wards. Results The pharmacists identified 200 DRPs in 162 patients giving an average of 1.2 (±1.8) DRPs/patient: the most common DRPs included ‘drug interaction’ (23%), ‘drug without indication’ (20%) and ‘non-conformity to guidelines/contraindication’ (14%). The most frequently suggested interventions were ‘drug discontinuation’ (32%), ‘dose adjustment’ (18%) and ‘drug monitoring’ (18%). 70% of the suggested interventions were accepted by the medical professionals. The experts assessed 84% of the DRPs as clinically significant (67%) or serious (17%), and 83% of the suggested interventions as significant (60%), very significant (22%) or extremely significant (1%). The overall inter-rater agreement was moderate for both the severity of error/event and the value of the pharmacy service (Kendall-W 0.525 and 0.461, respectively). Conclusion The expert panel assessed the CPS as of great clinical significance and of high clinical value to inpatient care. The prevalence of identified DRPs and the high rate of accepted interventions reflect the contribution of the service to the reduction and prevention of adverse drug events, treatment failure and the achievement of therapy goals. This suggests that the CPS is a valuable contribution to improve patient safety and patient care. References and/or acknowledgements 1. Allenet B, et al. Pharm World Sci2006;28:181–8. 2. Overhage JM, Lukes A. Am J Health Syst Pharm1999;56:2444–50. Many thanks to the expert panel members for their invaluable contribution. No conflict of interest

CP-038 Co-medication in an infectious diseases clinic: The rate of co-medication omissions and the significance of interactions between co-medications and antiretrovirals

Background Drug interactions are prevalent among HIV-infected patients, potentially resulting in drug toxicity, therapeutic failure and/ or viral resistance. HIV-infected patients are at higher risk of drug interactions given the multiple ARV agents required for treatment and the potential for co-morbidities. Previous research has shown interaction incidence with ARVs (antiretrovirals) to be high, with the majority of interactions occurring between ARVs and co-medication (non-ARV medication). Purpose The aim of this research was to ascertain the rate of co-medication omissions from patients’ medical charts and to determine the significance of drug interactions between ARV agents and co-medications in an ID (infectious diseases) clinic. Material and methods This mixed methods study incorporated face to face patient interviews and was conducted in an outpatient ID clinic. All patients over 18 and on at least one ARV (for HIV) attending the clinic over an eight week period were eligible for inclusion. 92 participants were interviewed and co-medications analysed for potential interactions with concurrent ARVs. Co-medication omissions were determined by analysing participants’ medical charts. Data was analysed using descriptive and non-parametric statistics in SPSS (vs 21). Mann-Whitney U (p < 0.05), Spearman’s (p < 0.05) and Kruskal Wallis test (p < 0.05) were used to determine the number of omissions, interactions and severity. Results 179 omissions and 114 interactions were identified. 72.5% of co-medications were omitted (only 7.1% of ARVs were omitted). Interaction incidence was 46.2% with 41.2% of interactions considered high risk (contraindicated, major or moderate). 41.9% of co-medication omissions led to an interaction and 16.8% led to a high risk interaction. 49.4% of co-medications were prescribed by GPs while ID doctors accounted for only 8.1% of prescriptions. Number of co-medications was a significant factor for omissions and interactions.* Age influenced interactions** but not independently.*** *(Spearman’s: p < 0.01);**(Spearman’s: p < 0.01);***(Multiple Regression: p > 0.1). Conclusion Rates of co-medication omissions and interactions was alarming, but comparable with other studies. High risk interactions being overlooked may have serious consequences for patients. Ageing HIV populations suggest increased medicines use and hence risk for interactions. Polypharmacy and communication improvement were issues identified for reducing interaction rates. Recommendations to reduce omissions included pharmacist led medicine reconciliation and prescriber education. References and/or Acknowledgements n/a No conflict of interest.

CP-057 Development of an oncology inpatient service at Sir Paul Boffa Hospital, Malta: a pilot study

Background Scientific evidence exists on integration of pharmacists within the oncology team and their positive influence on patient care. Investigation into the effect of pharmacist involvement for oncology inpatients at Sir Paul Boffa Hospital, Malta, is required to initiate clinical pharmacy services. Purpose The study aimed to determine the effect of pharmacist involvement in the treatment of oncology inpatients at Sir Paul Boffa Hospital, Malta, in terms of clinical significance on patient care. Materials and methods Study design followed non-randomised purposive sampling including all patients at the two oncology inpatient wards at Sir Paul Boffa Hospital, Malta. Data was collected prospectively over a period of nine weeks through drug reviews and drug chart checking, using a modified French Society of Clinical Pharmacy documentation tool. A multidisciplinary panel independently and retrospectively assessed the pharmacist’s interventions in terms of clinical significance on patient care using a 4-point Likert scale. Group differences were analysed using the Kruskal-Wallis test at a 0.05 level of significance. Strengths of relationships were measured using Spearman’s correlation coefficient. Results For 72 patients reviewed, 80 drug-related problems (DRPs) and pharmacist interventions were documented. In line with published data for oncology settings, the majority of interventions were related to comorbidities and concomitant medications (63.8%). The most common DRPs (adverse drug reactions, untreated indications, subtherapeutic dosage, drug monitoring) and pharmacist interventions (dose adjustment, drug switch, addition of a new drug, drug discontinuation) identified were in agreement with studies for oncology inpatients conducted elsewhere. More than half of the pharmacist’s interventions were rated as having major or moderate clinical significance on patient care (68.8%). Conclusions Pharmacist involvement for oncology inpatients at Sir Paul Boffa Hospital, Malta, has improved patient care by enhancing patient safety and ensuring treatment optimisation. Thus, high-quality cancer services are provided when pharmacists are involved within a multidisciplinary team. No conflict of interest.