Pharmacist: A Healthcare Professional Serving as Frontline Warrior Completely Overlooked

During the tough times of SARS-CoV-2 (COVID-19), the pharmacy professionals played a significant role by providing their services at various working stations and levels including hospitals, private clinics, community pharmacies, nursing homes, pharmaceutical industries, CROs and various health care programmes. However, the services provided by pharmacists were seldom mentioned and the professionals were not recognized as first line health care professional. The media, authorities and even general public have failed to appreciate the efforts of the pharmacy professionals as a part of essential healthcare team during the disaster. This review is focussed upon the contributions of pharmacists in patient care, healthcare services, patient care and well-being of the public during the COVID-19 pandemic. The various important tasks and roles played by pharmacist are described in the literature which have highly contributed towards a safer and healthier world. We hope that after going through the review and after having the idea about the roles and responsibilities that the pharmacist has played during COVID-19 will change the perspective of the people and the efforts of pharma professionals will be appreciated and recognized.Copyright © The Authors.

A rare case of central post-stroke pain in a patient with migraine and lacunar infarcts in the medulla oblongata

Studies about headaches associated with acute ischemic stroke in patients suffering from migraine were limited, and therefore we present a clinical case of central post-stroke pain (CPSP) in a 47-year-old woman with migraine and lacunar infarcts in the medulla oblongata and also possible mechanisms of CPSP in patients with migraine. Magnetic resonance imaging of the brain revealed lacunar infarction in the medulla oblongata on the right (vertebral artery basin) and a single focus of gliosis in the parietal lobe on the right. Magnetic resonance angiography of cerebral vessels showed the fetal type of structure of both posterior cerebral arteries. This clinical case is a complex clinical situation of a combination of secondary headaches (post-stroke) in a patient with a primary headache (migraine), which was successfully treated by the combined administration of first-line drugs for the treatment of neuropathic pain in a patient with lacunar infarcts in the medulla oblongata. The treatment of CPSP is a difficult task due to the insufficiently unexplored mechanisms of development, the most effective approaches are those aimed at reducing the increased excitability of neurons.Copyright © 2023, Indian Association of Biomedical Scientists. All rights reserved.

Risk of thromboembolism in patients with COVID-19 who are using hormonal contraception: a Cochrane systematic review.

BACKGROUND: The coronavirus disease COVID-19 is associated with an increased risk of thrombotic events. Individuals with COVID-19 using hormonal contraception could be at additional risk for thromboembolism, but evidence is sparse. METHODS: We conducted a systematic review on the risk of thromboembolism with hormonal contraception use in women aged 15-51 years with COVID-19. We searched multiple databases through March 2022, including all studies comparing outcomes of patients with COVID-19 using or not using hormonal contraception. We applied standard risk of bias tools to evaluate studies and GRADE methodology to assess certainty of evidence. Our primary outcomes were venous and arterial thromboembolism. Secondary outcomes included hospitalisation, acute respiratory distress syndrome, intubation, and mortality. RESULTS: Of 2119 studies screened, three comparative non-randomised studies of interventions (NRSIs) and two case series met the inclusion criteria. All studies had serious to critical risk of bias and low study quality. Overall, there may be little to no effect of combined hormonal contraception (CHC) use on odds of mortality for COVID-19-positive patients (OR 1.0, 95% CI 0.41 to 2.4). The odds of hospitalisation for COVID-19-positive CHC users may be slightly decreased compared with non-users for patients with body mass index <35 kg/m2 (OR 0.79, 95% CI 0.64 to 0.97). Use of any type of hormonal contraception may have little to no effect on hospitalisation rates for COVID-19-positive individuals (OR 0.99, 95% CI 0.68 to 1.44). CONCLUSIONS: Not enough evidence exists to draw conclusions regarding risk of thromboembolism in patients with COVID-19 using hormonal contraception. Evidence suggests there may be little to no or slightly decreased odds of hospitalisation, and little to no effect on odds of mortality for hormonal contraception users versus non-users with COVID-19.

SARS-CoV-2 infection, hormonal contraception and pulmonary embolism in a 17-year- old female patient

The paper presents the history of a 17-year-old patient admitted to the paediatric cardiology department in a life-threatening condition with dyspnoea, blood desaturation up to 90% and chest pain. The patient contracted COVID-19 (she was not vaccinated), and additionally treated her acne with oestrogen hormonal drugs. Computed tomography of the chest revealed massive embolic changes in the pulmonary artery and its branches. After introduction of heparin under the control of activated partial thromboplastin time and then warfarin under the control of international normalised ratio (INR), regression of changes was achieved;however, the arterial vessel narrowed up to the upper lobe of the right lung. During cardiac catheterisation, the vessel was widened with a balloon and successfully opened. Follow-up echocardiography showed regression of changes, the dimensions of the right heart decreased, and the features of pulmonary hypertension disappeared. During the exercise test, she reached stage 4. After 2 months, to avoid patient exposure to radiation, follow-up magnetic resonance imaging of pulmonary vessels was performed instead of computed tomography, showing partial restoration of the artery. Currently, the patient is still taking warfarin (INR 2.5-3.5), is in good general condition and a lung scan is planned in the future.

Hands-On Training in a Digital World: A Novel Simulation-Based Virtual Training Program for Placement and Removal of the Subdermal Contraceptive Implant.

OBJECTIVE: The COVID-19 pandemic necessitated a shift from traditional in-person instruction for learning new technical skills to virtual delivery of medical education training. The objectives of this study were to develop and evaluate a virtual simulation-based training program for Canadian health care professionals (HCPs) on the insertion, localization, and removal of the etonogestrel subdermal contraceptive implant. METHODS: A scientific committee of Canadian family planning experts developed a 2-part virtual training program during the COVID-19 pandemic. Core educational content (part 1) was provided in an asynchronous, self-directed, online format. Part 2 consisted of synchronous, simulation-based training using web conferencing. The HCPs were provided with model arms and placebo applicators; the trainers demonstrated implant insertion and removal techniques, and trainees received individual feedback. All trainees were asked to complete an online evaluation upon completion of the program. RESULTS: Between September 22, 2020, and December 31, 2021, 83 trainers conducted 565 virtual training sessions. A total of 3162 HCPs completed part 1 of the training program, of whom 2740 had completed part 2 by December 31, 2021. Participants reported high levels of satisfaction with virtual simulation-based training; 96.5% of respondents (1570/1627) agreed that the virtual format was effective. Additional training prior to inserting the implant in clinical practice was requested by 4.5% of respondents (75/1671). CONCLUSION: Virtual simulation-based learning provides effective education and technique training for etonogestrel implant insertion and removal. Online training for implant use can be scaled, as needed, to reach professionals in remote or underserved locations. This virtual training approach may be appropriate for other technical or minor surgical procedures.

Birth Control Use and Access Including Pharmacist-Prescribed Contraception Services during COVID-19.

The COVID-19 pandemic influenced health care with effects on contraception access emerging. The study objectives were to analyze pandemic impacts on birth control (BC) use and access; and evaluate perceptions of pharmacist-prescribed BC. A 50-item survey was distributed by 31 Michigan community pharmacies to women aged 18-45 over a three-month period. The survey link was also posted on two websites. 147 surveys were analyzed. Respondents were 29 ± 7.9 years old, primarily white (77%) and straight (81%). Fifty-eight percent of respondents used prescription BC, mostly to prevent pregnancy (84%) with oral pills (76%) being the most common formulation. Some BC users (25%) were worried about BC access and 27% had difficulty taking BC regularly. Half of the respondents (50%) would likely use pharmacist-prescribed BC if available, with advantages being more convenient than visiting a doctor's office (71%) and easier access (69%). The major concern about pharmacist-prescribed BC was women not receiving PAP smears and screenings (61%). Respondents reported high confidence (72%) in pharmacist-prescribed BC and believe it would help prevent unintended pregnancies (69%). Some respondents experienced altered BC use and access. Half of the respondents supported pharmacist-prescribed BC. Pharmacist-prescribed BC could help solve pandemic-related access problems.

SARS-CoV-2 infection, hormonal contraception and pulmonary embolism in a 17-year-old female patient

The paper presents the history of a 17-year-old patient admitted to the paediatric cardiology department in a life-threatening condition with dyspnoea, blood desaturation up to 90% and chest pain. The patient contracted COVID-19 (she was not vaccinated), and additionally treated her acne with oestrogen hormonal drugs. Computed tomography of the chest revealed massive embolic changes in the pulmonary artery and its branches. After introduction of heparin under the control of activated partial thromboplastin time and then warfarin under the control of international normalised ratio (INR), regression of changes was achieved;however, the arterial vessel narrowed up to the upper lobe of the right lung. During cardiac catheterisation, the vessel was widened with a balloon and successfully opened. Follow-up echocardiography showed regression of changes, the dimensions of the right heart decreased, and the features of pulmonary hypertension disappeared. During the exercise test, she reached stage 4. After 2 months, to avoid patient exposure to radiation, follow-up magnetic resonance imaging of pulmonary vessels was performed instead of computed tomography, showing partial restoration of the artery. Currently, the patient is still taking warfarin (INR 2.5–3.5), is in good general condition and a lung scan is planned in the future.

Telemedicine for Adolescent and Young Adult Long-acting Reversible Contraception Care Amidst a Global Pandemic

Background: The COVID-19 pandemic necessitated telemedicine contraception care, including long-acting reversible contraception (LARC) follow-up, and use of telemedicine services for adolescents and young adults (AYAs) is understudied. We describe virtual LARC care and assess patient outcomes over 1 year. Methods: This retrospective cohort study (IRBP00030775) includes patients seeking LARC follow-up at any time point within 1 year of telemedicine initiation (4/1/20-3/31/21) at 3 US Adolescent Medicine clinics. Eligible patients were 13-26 years old and had LARC inserted at a participating site without sedation. Covariates included demographics, clinical characteristics, and side effects. Outcomes were LARC-related bleeding management and need for rapid follow-up after the index visit (within 2 weeks of the first follow-up in the study period). A sub-analysis compared rates of initial follow-up visit (within 3 months of insertion) pre- and post-COVID (insertions 3/1/19-11/30/19 vs. 4/1/20-12/31/20). Descriptive statistics, χ2 tests, and t-tests were used to describe the sample and to compare groups. General estimating equations were used to determine predictors of telemedicine visit and to examine outcomes. Results: Our study included 319 patients, ages 13.6-25.7 years (mean 18.7 +/- 2.3), of whom 180 (56.4%) received the intrauterine device and 139 (43.6%) received the implant (Table 1). 128 (40.1%) patients attended at least 1 LARC telemedicine visit. Of the 426 LARC follow-up visits, 36.6% were via telemedicine. Unadjusted bivariate analyses showed telemedicine visits had higher reports of any reported patient side effect;however, reports of the most common side effects were similar between modalities (Table 2). Menstrual concern at insertion (OR 0.74, p =.26), uterine bleeding at follow-up (OR 1.26, p =.32), or report of any (OR 1.40, p =.10) or more than 2 LARC side effects (OR 1.22, p =.52) did not predict modality of follow-up. Telemedicine did not influence bleeding management (OR 1.27, p =.57). Few patients (2.8%) required rapid follow-up;index visit modality did not influence this rate (3.8% telemedicine vs. 2.2% in-person, p =.33). Follow-up within 3 months of insertion increased post-COVID (n = 525, 30% vs. 46%, p = <.001). Patients seeking LARC care pre- and post-COVID did not differ with respect to age (p =.28), race/ethnicity (p =.07), indication for LARC (p =.94), or prior use of hormonal contraception (p =.28). Conclusions: Patients seeking virtual and in-person LARC follow-up care and outcomes associated with visits were similar. Follow-up rates were higher post-COVID, which may have been influenced by the availability of telemedicine. Telemedicine may play an important role in increasing access to AYA LARC care.

Hormonal therapies and venous thrombosis: Considerations for prevention and management.

Background: Venous thromboses are well-established complications of hormonal therapy. Thrombosis risk is seen with both hormonal contraceptive agents and with hormone replacement therapy for menopause and gender transition. Over the past several decades, large epidemiological studies have helped better define these risks. Objectives: To review and discuss the differences in thrombosis risk of the many of hormonal preparations available as well as their interaction with patient-specific factors. Methods: We conducted a narrative review of the available literature regarding venous thrombosis and hormonal therapies including for contraception, menopausal symptoms, and gender transition. Results: Thrombosis risk with estrogen-containing compounds increases with increasing systemic dose of estrogen. While progesterone-only-containing products are not associated with thrombosis, when paired with estrogen in combined oral contraceptives, the formulation of progesterone does impact the risk. These components, along with patient-specific factors, may influence the choice of hormonal preparation. For patients who develop thrombosis on hormonal treatment, anticoagulation is protective against future thrombosis. Duration of anticoagulation is dependent on ongoing and future hormone therapy choice. Finally, the optimal management of hormone therapy for individuals diagnosed with prothrombotic illnesses such as COVID-19 remains unclear. Conclusions: When contemplating hormonal contraception or hormone replacement therapy, clinicians must consider a variety of factors including hormone type, dose, route, personal and family history of thrombosis, and other prothrombotic risk factors to make informed, personalized decisions regarding the risk of venous thrombosis.

Proceedings of the New Zealand Society for the Study of Diabetes Annual Scientific Meeting

The proceedings contain 17 papers. The topics discussed include: HIV patient preferences for care: resetting for a new normal;who accesses emergency hormonal contraception through an online sexual health service?;menstrual, sexual, and reproductive health interventions in out-of-school girls: a systematic review;three cycle QIP: improving testing and management of mycoplasma genitalium in a tertiary sexual health center 2019 - 2021;the weekend effect in GUM: a preliminary audit into genital herpes management across the week;comparing trichomonas vaginalis clinical care before and after the COVID-19 pandemic;time to start testing for latent tb infection(LTBI) - a quality improvement project;who, what, when, where, how and why? addressing the challenges of patient and public involvement and engagement (PPIE) within STI research and co-producing and applying a PPIE strategy within the SEQUENCE digital research program;an analysis of service users accessing a routine contraception service via an online platform during the COVID-19 pandemic;and effect of the COVID-19 pandemic on chlamydia testing and diagnosis within Scotland's largest sexual health service.

WHO ACCESSES EMERGENCY HORMONAL CONTRACEPTION THROUGH AN ONLINE SEXUAL HEALTH SERVICE?

Introduction The COVID-19 pandemic has shifted services offered in clinic online, with some local authorities starting to offer Emergency Hormonal Contraception (EHC) through a sexual health e-service. After completing an online, asynchronous consultation, EHC could be delivered or collected in pharmacy. Method Retrospective analysis of 12,016 EHC consultations completed between 1st January 2021 and 31st December 2021, from 11 local authority areas in London. Age, ethnicity, and deprivation deciles were used to identify demographic trends. Results The majority of EHC consultations were completed by 25-34 year olds (41.0%, n=4922). 53.4% (n=6422) of consultations were completed by users from the bottom 3 deciles of deprivation. 74.6% (n=8967) of consultation were from racially minoritised groups. Amongst 16-17 year olds and 35-44 year olds, the majority of consultations were completed by users in the bottom 3 deciles of deprivation (58.5% (n=197) and 58.6% (n=495) respectively). 66.2% (n=1289) of Black African women were from the bottom 3 deciles of deprivation, as were 58.6% (n=1498) of Black Caribbean women and 46.4% (n=1416) of White British women. 53.1% (n=1033) of Black African women, 54.3% (n1388) of Black Caribbean women, and 47.1% (n=1435) of White British women, were 16-24 years old. Discussion The majority of individuals accessing online EHC are young and racially minoritised, experiencing significant levels of deprivation. This approach to helping users access online EHC could help reduce unintended pregnancies and mitigate health inequalities. Local authorities could consider whether an online EHC service would help in their local area.

BASHH 2022 Abstracts

The proceedings contain 159 papers. The topics discussed include: HIV patient preferences for care: resetting for a new normal;who accesses emergency hormonal contraception through an online sexual health service?;menstrual, sexual, and reproductive health interventions in out-of-school girls: a systematic review;three cycle QIP: improving testing and management of mycoplasma genitalium in a tertiary sexual health center 2019 - 2021;the weekend effect in gum: a preliminary audit into genital herpes management across the week;comparing trichomonas vaginalis clinical care before and after the COVID-19 pandemic;and time to start testing for latent tb infection(LTBI)- a quality improvement project.

Menstrual Cycle Influence on COVID-19 Detection Using Machine Learning and a Wearable Medical Device

INTRODUCTION: Prior research has demonstrated how immune functioning and physiological signals fluctuate across the menstrual cycle, with eumenorrheic womenmore likely to become ill during the luteal phase. Examining such changes during the current pandemic, we explored how the relationship betweenmenstrual cycle phase and physiological signals impacts a wearable medical device's ability to detect COVID-19. METHODS: The largest institutional review board-approved wearable device study monitoring SARS-CoV-2's effects on biophysiology to date, COVID-RED aims to develop a machine learning algorithm predicting an infection up to 3 days prior to symptom onset. Wearing the device nightly, participants (N=17,824) sync it with a mobile application and log SARS-CoV-2 diagnostic tests, symptoms, and menses in the app's Daily Diary. The algorithm ingests physiological and selfreported features to provide each user with a real-time update about their likelihood of infection. RESULTS: Daily infection likelihood and predictions of ovulation using proprietary algorithms were generated during a 9-month period for 1,574 eumenorrheic women (n=3,281 menstrual cycles) not currently on hormonal birth control. The negative/positive ratio of predicted COVID-19 cases during the 5-day period preceding ovulation was 2.94 compared to 4.83 in the 5 days post-ovulation (chi-square (1, N=33,920)5343.34, P<.0001). Participants reported 22 SARS-CoV-2 positive test results, with five times as many confirmed infections occurring in the postovulatory period (n510) compared to the preceding 10-day window (n=2). CONCLUSION: Demonstrating that machine-learning algorithms ingesting wearable data should consider menstrual cycle impact, our findings suggest that women may be more susceptible to SARS-CoV-2 during their luteal phase, with further studies needed to disentangle underlying mechanisms.

COMMUNITY-BASED, PEER-LED SRH SERVICES INCREASE COVERAGE in AYP (YATHU YATHU TRIAL)

Background: Ensuring adolescents and young people (AYP) have access to comprehensive sexual and reproductive health services (SRHS), including HIV testing and prevention, is critical if we are to reduce HIV incidence and improve wellbeing. Following HPTN 071 (PopART) in Zambia, AYP stated that they needed improved access to SRHS and that these services should be provided from locations other than the health facility. The Yathu Yathu ("For us, by us") trial was co-developed from this request. We report on a secondary outcome of this trial, coverage of 6 predefined key SRHS (HIV testing, ART initiation, PrEP initiation, condom collection, VMMC and hormonal contraception) by trial arm Methods: Yathu Yathu is a cluster randomized trial conducted 2019-2021 in 2 urban communities in Lusaka, Zambia. The communities were divided into 20 zones which were randomly allocated to the Yathu Yathu intervention (YY) or standard of care (SoC) arms. In intervention zones, a YY hub, staffed by supervised peers, provided SRHS. In both arms, a census was conducted in 2019 where AYP (15-24 years) were invited to participate in the trial. Each was offered a Yathu Yathu card, which allowed them to collect "prevention points" for accessing SRHS at the health facility (SoC arm) or at the hub and health facility (YY arm). In both arms, points could be exchanged for health rewards, thus acting as an incentive to access services and as a tool to record service use. We use this YY card data to assess coverage of key SRHS Results: Of the 40,864 AYP enumerated, 29,370 (71.9%) consented to participate and accepted a Yathu Yathu card (14, 872, 71.6% YY arm, 14,498, 72.2% SoC arm). In the YY arm, 9493/14878 (63.8%) accessed at least one key service compared to 775/14498 (5.4%) in the SoC arm (adj RR 12.5;95%CI 9.9-15.8, p<0.001). Results were similar by age and sex (Table 1). The median number of visits in the YY arm was 1 (IQR 0-31) compared to 0 (IQR 0-0) in SoC. Of those accessing any service, HIV testing was the most common service in both arms (8841/9493 (93.1%) and 568/775 (73.3%), respectively) followed by collection of condoms (4701/9493 (49.5%) and 386/775 (49.8%) respectively) Conclusion: The Yathu Yathu intervention increased uptake of key SRHS, especially HIV testing. While YY hubs closed for 3months during COVID-19, health facility attendance may have also decreased thus affecting the difference in coverage. Nonetheless, our findings demonstrate the potential of peer-led community hubs to increase coverage of SRHS.

Predictors of thromboembolic events in COVID-19 ambulatory patients

Introduction: Unlikely COVID-19 hospitalized patients, there are not clear data about the incidence and the predictors of arterial and venous thromboembolic events in COVID-19 outpatients patients. Objectives: To determine the incidence of TE in COVID-19 ambulatory setting. Patients and methods: We conducted an observational study in our study including COVID-19 ambulatory patients and we analysed the predictors of TE events at 30 days. Results: We included 2089 patients with a mean age of 43 ± 16 years. The incidence of primary outcomes was 1.6% and the incidence of venous and arterial TE complications was 0.9%. The predictors of arterial and venous TE complications were hormonal contraception (OR = 23), moderate clinical presentation (OR = 3.5), recent surgery or miscarriage during the last month before COVID-19 infection (OR = 9.2) and COVID-19 signs on CT scan (OR = 4.9). While physical activity proved to be a protective factor. Conclusions: The incidence of TE events is low in COVID-19 patients. Thromboprophylaxis should be prescribed in selected people.

More than just contraception: the impact of the levonorgestrel-releasing intrauterine system on public health over 30 years.

Universal access to sexual and reproductive health services is essential to facilitate the empowerment of women and achievement of gender equality. Increasing access to modern methods of contraception can reduce the incidence of unplanned pregnancy and decrease maternal mortality. Long-acting reversible contraceptives (LARCs) offer high contraceptive efficacy as well as cost-efficacy, providing benefits for both women and healthcare systems. The levonorgestrel-releasing intrauterine system (LNG-IUS) first became available in 1990 with the introduction of Mirena (LNG-IUS 20), a highly effective contraceptive which can reduce menstrual blood loss and provide other therapeutic benefits. The impact of the LNG-IUS on society has been wide ranging, including decreasing the need for abortion, reducing the number of surgical sterilisation procedures performed, as well as reducing the number of hysterectomies carried out for issues such as heavy menstrual bleeding (HMB). In the context of the COVID-19 pandemic, Mirena can provide a treatment option for women with gynaecological issues such as HMB without organic pathology, minimising exposure to the hospital environment and reducing waiting times for surgical appointments. Looking to the future, research and development in the field of the LNG-IUS continues to expand our understanding of these contraceptives in clinical practice and offers the potential to further expand the choices available to women, allowing them to select the option that best meets their needs.