A discursive presentation of community pharmacies: Premises, storage, staff, documentation and legal compliance.

Objectives: This study aimed to assess compliance with legal requirements, safe medication storage and staffing standards in community pharmacies in Punjab, Pakistan. Method: We conducted a three-step cross-sectional study using observations, questionnaires and face-to-face interviews in 544 systematically-selected community pharmacies. We used descriptive statistic and one-way ANOVA to assess the data. Results: Only 23 (4.2 %) pharmacies had accurate area and only 3.9 % had appropriate walls. In total, 23.3 % had glass-fronted shelves and 38.2 % had a glass door. More than half (53.8 %) had separate narcotics shelves and 43.0 % a separate shelf of expired medicines. Less than half (47.5 %) of the pharmacies were able to maintain hygiene. About 36.2 % of the pharmacies segregated different types of product. Drugs were protected from direct sunlight in most (61.3 %) pharmacies, but the refrigerator was working properly in less than half (43.4 %) and only a very small number (2.4 %) had an alternative power supply for the refrigerator. Only 37 (6.8 %) were able to maintain an appropriate room temperature. The vast majority (93.0 %) displayed a valid drug sale license, but a qualified person/pharmacist was only present in 4.8 %. The average number of employees was 4.2, and more than 71.0 % of staff had 10-12 years of formal education. Only 0.2 % of employees could explain term "PRN", although 57.3 % explained "IV" correctly. About 22.8 % replied correctly about the room temperature but the vast majority (97.6 %) did not know about cold chain temperature. The location of the pharmacy (p-value = 0.045) affected its performance. Conclusions: Noncompliance with legal requirements, unsafe drug storage and limited human resources reflect the poor enforcement of drug laws in Pakistan. The findings suggest that there is a need to strengthen inspection and management of community pharmacies.

Risk of Bleeding after Transcatheter Aortic Valve Replacement: impact of Preoperative Antithrombotic Regimens

Abstract Introduction: Bleeding after transcatheter aortic valve replacement (TAVR) has a negative impact on the outcome of the procedure. Risk factors for bleeding vary widely in the literature, and the impact of preoperative antithrombotic agents has not been fully established. The objectives of our study were to assess bleeding after TAVR as defined by the Valve Academic Research Consortium-2 (VARC-2), identify its risk factors, and correlate with antithrombotic treatment in addition to its effect on procedural mortality. Methods: The study included 374 patients who underwent TAVR from 2009 to 2018. We grouped the patients into four groups according to the VARC-2 definition of bleeding. Group 1 included patients without bleeding (n=265), group 2 with minor bleeding (n=22), group 3 with major bleeding (n=61), and group 4 with life-threatening bleeding (n=26). The median age was 78 (25th-75th percentiles: 71-82), and 226 (60.4%) were male. The median EuroSCORE was 3.4 (2-6.3), and there was no difference among groups (P=0.886). The TAVR approach was transfemoral (90.9%), transapical (5.6%), and trans-subclavian (1.9%). Results: Predictors of bleeding were stroke (OR: 2.465; P=0.024) and kidney failure (OR: 2.060; P=0.046). Preoperative single and dual antiplatelet therapy did not increase the risk of bleeding (P=0.163 and 0.1, respectively). Thirty-day mortality occurred in 14 patients (3.7%), and was significantly higher in patients with life-threatening bleeding (n=8 [30.8%]; P<0.001). Conclusion: Bleeding after TAVR is common and can be predicted based on preprocedural comorbidities. Preprocedural antithrombotic therapy did not affect bleeding after TAVR in our population.

Risk of Bleeding after Transcatheter Aortic Valve Replacement: impact of Preoperative Antithrombotic Regimens.

INTRODUCTION: Bleeding after transcatheter aortic valve replacement (TAVR) has a negative impact on the outcome of the procedure. Risk factors for bleeding vary widely in the literature, and the impact of preoperative antithrombotic agents has not been fully established. The objectives of our study were to assess bleeding after TAVR as defined by the Valve Academic Research Consortium-2 (VARC-2), identify its risk factors, and correlate with antithrombotic treatment in addition to its effect on procedural mortality. METHODS: The study included 374 patients who underwent TAVR from 2009 to 2018. We grouped the patients into four groups according to the VARC-2 definition of bleeding. Group 1 included patients without bleeding (n=265), group 2 with minor bleeding (n=22), group 3 with major bleeding (n=61), and group 4 with life-threatening bleeding (n=26). The median age was 78 (25th-75th percentiles: 71-82), and 226 (60.4%) were male. The median EuroSCORE was 3.4 (2-6.3), and there was no difference among groups (P=0.886). The TAVR approach was transfemoral (90.9%), transapical (5.6%), and trans-subclavian (1.9%). Results: Predictors of bleeding were stroke (OR: 2.465; P=0.024) and kidney failure (OR: 2.060; P=0.046). Preoperative single and dual antiplatelet therapy did not increase the risk of bleeding (P=0.163 and 0.1, respectively). Thirty-day mortality occurred in 14 patients (3.7%), and was significantly higher in patients with life-threatening bleeding (n=8 [30.8%]; P<0.001). Conclusion: Bleeding after TAVR is common and can be predicted based on preprocedural comorbidities. Preprocedural antithrombotic therapy did not affect bleeding after TAVR in our population.

Perspectives of Healthcare Professionals Regarding Factors Associated with Antimicrobial Resistance (AMR) and Their Consequences: A Cross Sectional Study in Eastern Province of Saudi Arabia.

Factors reported in the literature associated with inappropriate prescribing of antimicrobials include physicians with less experience, uncertain diagnosis, and patient caregiver influences on physicians' decisions. Monitoring antimicrobial resistance is critical for identifying emerging resistance patterns, developing, and assessing the effectiveness of mitigation strategies. Improvement in prescribing antimicrobials would minimize the risk of resistance and, consequently, improve patients' clinical and health outcomes. The purpose of the study is to delineate factors associated with antimicrobial resistance, describe the factors influencing prescriber's choice during prescribing of antimicrobial, and examine factors related to consequences of inappropriate prescribing of antimicrobial. A cross-sectional study was conducted among healthcare providers (190) in six tertiary hospitals in the Eastern province of Saudi Arabia. The research panel has developed, validated, and piloted survey specific with closed-ended questions. A value of p < 0.05 was considered to be statistically significant. All data analysis was performed using the Statistical Package for Social Sciences (IBM SPSS version 23.0). 72.7% of the respondents have agreed that poor skills and knowledge are key factors that contribute to the inappropriate prescribing of antimicrobials. All of the respondents acknowledged effectiveness, previous experience with the antimicrobial, and reading scientific materials (such as books, articles, and the internet) as being key factors influencing physicians' choice during antimicrobial prescribing. The current study has identified comprehensive education and training needs for healthcare providers about antimicrobial resistance. Using antimicrobials unnecessarily, insufficient duration of antimicrobial use, and using broad spectrum antimicrobials were reported to be common practices. Furthermore, poor skills and knowledge were a key factor that contributed to the inappropriate use and overuse of antimicrobials, and the use of antimicrobials without a physician's prescription (i.e., self-medication) represent key factors which contribute to AMR from participants' perspectives. Furthermore, internal policy and guidelines are needed to ensure that the antimicrobials are prescribed in accordance with standard protocols and clinical guidelines.

Silver nanoparticles with epigallocatechingallate and zinc sulphate significantly inhibits avian influenza A virus H9N2.

Avian influenza (AI) has become a disease of great importance for human and animal health. Beside adverse side effects, there is resistance mutation for about all the conventional drugs that target viral proteins. This study aimed to evaluate antiviral activity of silver nanoparticles combined with epigallocatechingallate (EGCG-AgNPs) and co-administered with zinc sulphate (Zn+2) as alternative treatment strategy to control AI H9N2. EGCG conjugated silver nanoparticles (EGCG-AgNPs) were synthesized. Virus propagation was performed using embryonated Specific-Pathogen-Free (SPF) hen's eggs. Viral EID50 titers were determined before and after treatments. The antiviral activity was determined as Log virucidal reduction. A commercial tetrazolium MTS assay kit was used to determine cytotoxicity. Results showed that 50 µM EGCG was the most significant concentration reduced the logEID50/mL of AI H9N2. Co-treatment with zinc sulphate (1.3 mg/mL) increased the EGCG antiviral effect. The most effective antiviral activity was obtained when combined EGCG-AgNPs with zinc sulphate with the greatest virucidal log reduction. No cytotoxic effect in Vero cells was observed among all of these forms at concentrations of interest used in this study. In conclusion, the topical application of EGCG-AgNPs/ZnSO4 demands additional antiviral strategies against H9N2 AI. This combination may prevent virus transmission, inhibit virus replication within neighboring cells and inhibit microbial resistance by making microbial adaptability very difficult.

Patterns of infections and antimicrobial drugs' prescribing among pregnant women in Saudi Arabia: a cross sectional study.

BACKGROUND: Antimicrobial agents are among the most commonly prescribed drugs in pregnancy due to the increased susceptibility to infections during pregnancy. Antimicrobials can contribute to different maternal complications. Therefore, it is important to study their patterns in prescription and utilization. The data regarding this issue is scarce in Saudi Arabia. Therefore, the aim of this study is to generate data on the antimicrobial agents that are most commonly prescribed during pregnancy as well as their indications and safety. METHODS: This is a retrospective study focusing on pregnant women with a known antimicrobial use at Johns Hopkins Aramco Healthcare (JHAH). The sample included 344 pregnant women with a total of 688 antimicrobial agents prescribed. Data was collected on the proportion of pregnant women who received antimicrobial agents and on the drug safety during pregnancy using the risk categorization system of the U.S. Food and Drug Administration (FDA). RESULTS: The results showed that urinary tract infections (UTIs) were the most reported (59%) infectious diseases. Around 48% of pregnant women received antimicrobial medications at some point during pregnancy. The top two antimicrobial agents based on prescription frequency were B-lactams (44.6%) and azole anti-fungals (30%). The prescribed drugs in the study were found to be from classes B, C and D under the FDA risk classification system. CONCLUSION: The study revealed a high proportion of antimicrobials prescribed during pregnancy that might pose risks to mothers and their fetuses. Future multicenter studies are warranted to evaluate the rational prescription of antimicrobial medications during pregnancy.

Prevalence of cerebral venous thrombosis with the use of oral contraceptive pills during the Holy month of Ramadan.

OBJECTIVES: To identify the epidemiologic profile of cerebral vein thrombosis (CVT) among fasting women using oral contraceptive pills  (OCPs) during the holy month of Ramadan. Methods: This retrospective study was conducted on all patients diagnosed with CVT and using OCPs from records at a tertiary care hospital in Riyadh, Saudi Arabia during 2016-2017. The study participants were categorized into 2 groups (an intermittently fasting group during the holy month of Ramadan and a non-fasting group).  Results: Out of 108 female patients with CVT, 36.1% were secondary to OCP, of whom 41% participants were fasting. The most affected site was the transverse sinus. Holocephalic headache was more common amongst fasting group (68.8%) compared to non-fasting group (30.4%) (p=0.025). Dehydration (p=0.003) amongst the fasting group and protein S deficiency (p=0.027) in the non-fasting group were identified as the 2 prominent risk factors. Unfractionated heparin was the most common anticoagulant therapies used during the initiation phase for non-fasting (36.4%) and fasting groups (50%). Conclusion: All women who are using OCP should undergo formal written risk assessments for factors of CVT. Our study suggests that the negative effects of OCPs use might outweigh its benefits; thus, it should be prescribed with caution, more so in fasting patients.

Integrating simulation into advanced pharmacy practice experience curriculum: An innovative approach to training.

BACKGROUND: The use of simulation-based education (SBE) in pharmacy education can help students acquire the essential clinical knowledge and skills for practice and can enhance patients' safety. Simulation-based training has been implemented in inter-professional education training, introductory pharmacy practice experiences, pharmacy residency training. Still, there is limited information in the literature that assesses the use of simulation in advanced pharmacy practice experience (APPE). OBJECTIVE: To evaluate the impact of integrating SBE into APPE on students' learning outcomes, training costs, and satisfaction. METHOD: This study presents a new training model of a 5-week clerkship experience where sixth-year pharmacy students alternate between hospital wards and simulation rooms. Student assessment rubrics were used to measure students' achievements and report faculty feedback. Students filled scenario evaluation forms to assess their simulation satisfaction rate. RESULTS: A total of 57 students completed a full block of simulation-based, followed by hospital-based blocks practicing in the same medical specialty in both blocks. This newly structured experience provided fourteen direct patient care training seats per rotation and saved around 25,000 Saudi Riyals per rotation. The mean grades in both simulation and hospital-based blocks were mostly above 90% in all learning outcomes. Cognitive skills and affect learning outcomes mean grades were higher in the simulation-based group-most of the students being satisfied with the simulation scenarios. CONCLUSION: SBE integration into APPE can supplement hospital-based experiential training to achieve the best learning outcomes with improved students' satisfaction.