Temperature and intraspecific variation affect host-parasite interactions.

Parasites play key roles in regulating aquatic ecosystems, yet the impact of climate warming on their ecology and disease transmission remains poorly understood. Isolating the effect of warming is challenging as transmission involves multiple interacting species and potential intraspecific variation in temperature responses of one or more of these species. Here, we leverage a wide-ranging mosquito species and its facultative parasite as a model system to investigate the impact of temperature on host-parasite interactions and disease transmission. We conducted a common garden experiment measuring parasite growth and infection rates at seven temperatures using 12 field-collected parasite populations and a single mosquito population. We find that both free-living growth rates and infection rates varied with temperature, which were highest at 18-24.5 °C and 13 °C, respectively. Further, we find intraspecific variation in peak performance temperature reflecting patterns of local thermal adaptation-parasite populations from warmer source environments typically had higher thermal optima for free-living growth rates. For infection rates, we found a significant interaction between parasite population and nonlinear effects of temperature. These findings underscore the need to consider both host and parasite thermal responses, as well as intraspecific variation in thermal responses, when predicting the impacts of climate change on disease in aquatic ecosystems.

Temperature and intraspecific variation affect host-parasite interactions.

Parasites play key roles in regulating aquatic ecosystems, yet the impact of climate warming on their ecology and disease transmission remains poorly understood. Isolating the effect of warming is challenging as transmission involves multiple interacting species and potential intraspecific variation in temperature responses of one or more of these species. Here, we leverage a wide-ranging mosquito species and its facultative parasite as a model system to investigate the impact of temperature on host-parasite interactions and disease transmission. We conducted a common garden experiment measuring parasite growth and infection rates at seven temperatures using 12 field-collected parasite populations and a single mosquito population. We find that both free-living growth rates and infection rates varied with temperature, which were highest at 18-24.5°C and 13°C, respectively. Further, we find intraspecific variation in peak performance temperature reflecting patterns of local thermal adaptation-parasite populations from warmer source environments typically had higher thermal optima for free-living growth rates. For infection rates, we found a significant interaction between parasite population and nonlinear effects of temperature. These findings underscore the need to consider both host and parasite thermal responses, as well as intraspecific variation in thermal responses, when predicting the impacts of climate change on disease in aquatic ecosystems.

Evaluation of a pharmacist vs. Haematologist-managed anticoagulation clinic: A retrospective cohort study.

INTRODUCTION: Warfarin is the core component in the management of various thromboembolic disorders, which requires specialized expertise to optimize outcomes. There is limited data comparing a pharmacist vs. a haematologist-managed anticoagulation clinic in our setting, and in the Middle East. We aimed to evaluate the effectiveness and safety of a pharmacist vs. a haematologist-managed anticoagulation clinic in the Ambulatory Care Center at King Abdulaziz Medical City, Jeddah, Saudi Arabia. METHODS: A retrospective cohort study was conducted from 2016 to 2018, which included adult patients who have been followed-up for at least six months and who received warfarin for an extended period. The primary outcome was the proportion of time the patients in the two arms were in the therapeutic range. The secondary outcomes were the differences in expanded time in the therapeutic range, as well as the frequency of bleeding and thromboembolic events between the two arms. RESULTS: We enrolled 104 and 124 patients in the pharmacist and haematologist arms respectively. The median time in the therapeutic range for the pharmacist arm was 71.4%, IQR (60.8-83.8) vs. 65%, IQR (43.5-79.1), in the haematologist arm (p = 0.0049). The median expanded time in the therapeutic range was 86.4%, IQR (77.5-95.3) vs. 81.21%, IQR (67.1-93.3) in the pharmacist vs. haematologist arm (p = 0.015) respectively. Major bleeding events occurred in 5.7 % vs. 3.2 %, and thromboembolic events in 5.7% vs. 4%, in the pharmacist vs. haematologist arm respectively. CONCLUSIONS: Our results demonstrated that the time in the therapeutic range was significantly higher in the pharmacist arm, with no significant difference in bleeding and thromboembolic events compared to the haematologist arm.

The Impact of Role of Pharmacists in Renal Dosage Adjustment Program on Renal Drug Dosing Errors: A Quasi-Experimental Study.

Studies have reported high prevalence of inappropriate dosing in patients with renal impairment, which was significantly reduced with pharmacists' interventions. The objective of this study was to assess the proportions of renal drug dosing errors following the implementation of pharmacists-led renal drug dosing adjustment program. This was a quasi-experimental study conducted at the King Abdul Aziz Medical City, a tertiary teaching hospital, Jeddah, Saudi Arabia. The study comprised of 3 phases. The pre-phase and post-phase evaluated drug orders for dosing appropriateness. During the intervention phase, a renal drug dosing adjustment program was implemented, which included educational sessions on dosing in renal insufficiency and a renal drug dosing guidance. The primary outcome was to assess the change in the proportions of dosing errors following the intervention. In the pre-phase, inappropriate dosing was noted in 20.1% (70/348) of orders that required dosing adjustment. Among the total dosing errors, 44.2% (31/70) were further corrected, and pharmacists have documented intervention in 48.3% (15/31) of the corrected orders. In the post-phase, inappropriate dosing was noted in 21.9% (76/346) of orders that required dosing adjustment. Among the total dosing errors, 39.4% (30/76) were further corrected, and pharmacists have documented intervention in 66.6% (20/30) of the corrected orders. There was no statistically significant difference in inappropriate drug dosing between pre-phase and post-phase with a P = 0.56. The intervention was not associated with significant reduction in renal dosing errors, although pharmacist involvement in the corrected orders orders increased after the implementation of the intervention. This may indicate the need to integrate renal dosing guidance into the hospital prescribing system to optimize drug dosing in renal patients.

Prevalence of Non-Adherence to Immunosuppressive Medications in Kidney Transplant Recipients: Barriers and Predictors.

BACKGROUND Non-adherence to immunosuppressant therapy (IST) is a major risk factor for graft rejection. Limited reports are available regarding the prevalence of non-adherence to IST in kidney transplant recipients (KTRs) as well as the predictors and barriers of non-adherence. MATERIAL AND METHODS The study included ambulatory KTRs, ≥18 years of age, with a functional kidney, from January 2017 to November 2018. The primary outcome was the prevalence of non-adherence, assessed with: 1) A telephone interview to complete the Arabic-translated and validated Immunosuppressant Therapy Adherence Instrument Scale (ITAS) and 2) IST serum blood levels within therapeutic levels. The secondary outcomes were the barriers to adherence using the validated Immunosuppressant Therapy Barriers of Adherence Scale (ITBS). RESULTS We enrolled 102 of 141 patients screened. The mean±SD for age, body mass index, and the baseline of the estimated glomerular filtration rate were 45.5±15.6 years, 29.1±6 kg/m², and 72.7±21.9 ml/min/1.73 m², respectively. The prevalence of non-adherence was 5.9%, 95% CI (2.19-12.36%) and 14.7%, 95% CI (8.47-23.09%) using the ITAS and the average blood serum drug levels, respectively. The concordance of the 2 methods demonstrated an agreement of 81.3%, kappa of 0.01, and 95% CI (-0.16 to 0.18). The median, interquartile range (IQR) for ITBS, and uncontrollable and controllable barriers for adherence were 21, (18-25), 15, (12-18), and 6, (5-8), respectively. CONCLUSIONS The current study demonstrated a low to moderate prevalence of non-adherence to IST in KTRs. The barriers for adherence with IST necessitate additional targeted interventions to manage and optimize therapeutic and clinical outcomes.

Impact of Colistin Dosing on the Incidence of Nephrotoxicity in a Tertiary Care Hospital in Saudi Arabia.

Colistin therapy is associated with the development of nephrotoxicity. We examined the incidence and risk factors of nephrotoxicity associated with colistin dosing. We included adult hospitalized patients who received intravenous (IV) colistin for >72 h between January 2014 and December 2015. The primary endpoint was the incidence of colistin-associated acute kidney injury (AKI). The secondary analyses were predictors of nephrotoxicity, proportions of patients inappropriately dosed with colistin according to the Food and Drug Administration (FDA), European Medicines Agency (EMA), and Garonzik formula and clinical cure rate. We enrolled 198 patients with a mean age of 55.67 ± 19.35 years, 62% were men, and 60% were infected with multidrug-resistant organisms. AKI occurred in 44.4% (95% CI: 37.4-51.7). Multivariable analysis demonstrated that daily colistin dose per body weight (kg) was associated with AKI (OR: 1.57, 95% CI: 1.08-2.30; p = 0.02). Other significant predictors included serum albumin level, body mass index (BMI), and severity of illness. None of the patients received loading doses, however FDA-recommended dosing was achieved in 70.2% and the clinical cure rate was 13%. The incidence of colistin-associated AKI is high. Daily colistin dose, BMI, serum albumin level, and severity of illness are independent predictors of nephrotoxicity.

Patient-centered Pharmacist Care in the Hemodialysis Unit: a quasi-experimental interrupted time series study.

BACKGROUND: Nonadherence to medications by patients requiring hemodialysis (HD) leads to unfavorable clinical outcomes. Limited data exist to demonstrate the effect of incorporating patient-centered interventions using concepts of medication therapy management and motivational interview by pharmacists on pharmacoadherence in patients requiring HD. Therefore, we assessed the impact of patient-centered pharmacist care on pharmacoadherence and its outcomes in patients requiring HD. METHODS: Adult patients who had received outpatient HD for at least 3 months were enrolled. The study was conducted from October 2016 to April 2017. Pharmacists interviewed the patients at month 1, 2, 4 and 6, and the intervention (comprehensive review) occurred at months 3 and 5. The primary outcome was the change in pharmacoadherence as assessed by pre-HD serum phosphate levels and the differences in the number of medications between patient' self-report and medications records at the electronic healthcare records (EHRs). The secondary outcomes included changes in systolic blood pressure (SBP), glycosylated hemoglobin levels, serum low-density lipoprotein (LDL) levels, and the prevalence and types of medication-related problems (MRPs). RESULTS: Seventy-two patients were enrolled. Their median age was 59 (interquartile range: 47-67.5) years, and 53% were men. Pre- and post-intervention pharmacoadherence, as indicated by serum phosphate levels and the differences in the number of medications between patient' self-report and the medication records at the EHRs, did not significantly differ (p = 0.682 and 0.348, respectively). Mean SBP and mean LDL did not significantly change post-intervention. The median number of MRPs declined between Months 3 and 5 (p = 0.002): the prevalence of MRPs at Month 3 was 44.9% (95 confidence interval [CI]: 40.4-49.3) and decreased to 29.8% (95 CI: 25.6-34.3) at Month 5. Drug use without indication was the most frequent MRP (23.9%). CONCLUSIONS: Patient-centered pharmacist care did not result in significant changes in pharmacoadherence. However, its clinical utility as a tool to identify and mitigate MRPs in patients requiring HD is indisputable. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03576404 (retrospectively registered on July 3rd, 2018).

Bridging the Gap between Theory and Practice; the Active Role of Inpatient Pharmacists in Therapeutic Drug Monitoring.

Many hospitals face barriers in the implementation of TDM services, this study aimed to evaluate a pharmacist-led TDM service to optimize patients' outcomes. Adult patients who were administered vancomycin, gentamicin, or amikacin were included. The pre-phase included a retrospective assessment of patients and the intervention phase consisted of an educational program. The post-phase assessed patients based on TDM services provided by inpatient pharmacists on a 24-h, 7-day basis for 3 months. The primary outcome was to assess the mean difference in proportion of correct initial doses of prescribing orders. Secondary outcomes included assessing the mean differences in proportions of correct dose adjustments and correct drug sampling time. Seventy-five patients in each phase were eligible. Patients who received optimal initial dosing in the post-phase showed a higher statistical significance, mean difference of 0.31, [95% CI (0.181⁻0.4438), p < 0.0001]. Patients in the post-phase received more optimal dose adjustments, mean difference of 0.1, [95% CI (-0.560⁻0.260), p = 0.2113]. Drug levels were ordered more correctly in the post-phase, mean difference of 0.03, [95% CI (-0.129⁻0.189), p = 0.7110]. This study demonstrated the important role of TDM services led by pharmacists in optimizing the initial dosing for these antibiotics.

Polypharmacy and Medication-Related Problems in Hemodialysis Patients: A Call for Deprescribing.

Polypharmacy is a common problem among hemodialysis patients. It is associated with increased hospital admissions, morbidity, mortality, Medication-Related Problems (MRPs), and expenditures. There is a paucity of data on the prevalence of polypharmacy in our setting. This study aims to determine the prevalence of polypharmacy and MRPs and to assess its predictors. We conducted a cross-sectional study in the outpatient hemodialysis unit. A pharmacy resident assessed electronic prescribing records to identify MRPs and discussed therapeutic interventions to enhance effective therapeutic regimens over a three months period. Eighty-three patients were included. The median age was 63 (Interquartile range; IQR = 22), 50% were males, and the mean number of co-morbidities was 3.14 ± 1.64. The prevalence of polypharmacy was 97.6% with a 95% CI (91.6%⁻99.7%). Medication use without indication, was the highest identified MRPs at 36% (102/280), followed by subtherapeutic dosing at 23% (65/280), and overdosing at 15% (41/280). The number of comorbidities, the presence of ischemic heart disease, and respiratory diseases were the main predictors of the increased number of medications. Polypharmacy is highly prevalent among the Saudi hemodialysis population. A review of the medications prescribed by the pharmacist facilitated the identification of MRPs and provided opportunities for deprescribing to optimize medication use and to reduce polypharmacy in hemodialysis patients.

P&T Committee Drug Prioritization Criteria: A Tool Developed by a Saudi Health Care System.

INTRODUCTION: The workflow of a P&T committee can become overwhelming and may be affected by many internal and external factors. Organization, standardization, and an enhanced systematic approach for drug evaluations are necessary to ensure that all requested drugs receive an equal and unbiased evaluation and consideration for addition based on the institution's objectives, priorities, and budget. Our aim was to create a scoring tool that would assist in systematically prioritizing drugs being requested for formulary addition and to eliminate cumbersome evaluations for drugs that clearly do not offer any additional advantage. METHODS: A working group consisting of P&T committee members met with the task of creating initial screening criteria for prioritizing drugs requested for formulary addition. Members conducted independent literature searches and focused meetings to develop a scoring tool that would be piloted on drugs being requested for addition. RESULTS: We developed a scoring tool to prioritize drugs requested for formulary addition. The tool assigns a score for each drug that allows it to be classified into one of three categories: 1) for expedited review, 2) for routine review, or 3) for rejection without the need for a full evaluation. CONCLUSIONS: We believe that this scoring tool will assist in prioritizing drugs requested for formulary addition while allowing for full consideration of the most important decision-making factors. In an era of expected U.S. Food and Drug Administration deregulation and economic constraints, P&T committees must create tools that ease their workflow and organize their priorities.

Pharmacists as Interprofessional Collaborators and Leaders through Clinical Pathways.

Pharmacists possess pivotal competencies and expertise in developing clinical pathways (CPs). We present a tertiary care facility experience of pharmacists vis-a-vis interprofessional collaboration for designing and implementing CPs. We participated in the development of CPs as leading members of a collaborative team of healthcare professionals. We reviewed literature, aligning it with hospital formulary and institutional standards, and participated in weekly team meetings for six months. Several tools and services were adapted to guide prescribing and standardization of care through time-bound order sets. Fifteen CPs leading to admissions in medical wards were developed and integrated into Computerized Prescriber Order Entry (CPOE) sets. Tools and services included (1) reporting of creatinine clearance to guide optimum dosing; (2) advisory flags for dosing and infusion rates; (3) piloting of medication reconciliation and counseling services before discharge were initiated; (4) Arabic drug leaflets were designed to educate patients; and (5) five CPs were included in pragmatic randomized control trials with a clinical pharmacist as co-investigator. Clinical pharmacists conducted continuous orientation to various healthcare professionals throughout the process. CPs provide unique opportunities for establishing and evaluating patient-centered pharmaceutical services and allow clinical pharmacists to demonstrate interprofessional leadership in collaboration with multidisciplinary teams.

A pragmatic randomized controlled trial comparing pathway-based versus usual care in community-acquired acute kidney injury.

Clinical pathways have shown conflicting evidence in improvement of several patient-centered outcomes across different clinical settings. However, the effectiveness of clinical pathway in management of acute kidney injury (AKI) has not been reported. Therefore, we aimed to assess the length of hospital stay (LOS) and patient-centered outcomes in community acquired AKI and compared pathway care (PC) versus usual care (UC). The CHAMP-Path AKI Trial is a pragmatic, parallel, single-blind randomized controlled trial. Physicians were randomized to provide either UC or PC. Patients were randomized through a computer-generated sequence. Allocation was concealed. Patients presenting to the emergency department with AKI and hemodynamic stability, who were over 14 years with a serum creatinine greater than 1.5 times the baseline were eligible. Patients with chronic kidney disease stages 4 or 5, kidney transplantation recipients, those admitted with obstructive uropathy, suspected glomerular or interstitial disease, and pregnant women were excluded. Thirty-eight patients were enrolled from March 2012 to December 2013. The primary outcome was LOS. Secondary outcomes included: 30-day readmission, in-hospital mortality, determinants of LOS, and patient-centered outcomes. Eighteen patients were randomized to PC, and 20 to UC. Baseline characteristics were comparable in both groups. Using an intention-to-treat analysis, the median LOS was 4.96 [interquartile range (IQR) 6.57] and 4.80 days (IQR 6.84) for PC and UC, respectively (P = 0.770). Of the five readmissions, none were for AKI. No in-hospital mortality was reported. The CHAMP-Path AKI pragmatic trial demonstrated that PC was not different than UC in reducing LOS. There was no difference in 30-day re- admission, in-hospital mortality, and patient-centered outcomes.

From Learning to Decision-Making: A Cross-Sectional Survey of a Clinical Pharmacist-Steered Journal Club.

Journal clubs have been traditionally incorporated into academic training programs to enhance competency in the interpretation of literature. We designed a structured journal club (JC) to improve skills in the interpretation of literature; however, we were not aware of how learners (interns, residents, clinical pharmacists, etc.) would perceive it. We aimed to assess the perception of learners at different levels of pharmacy training. A cross-sectional design was used. A self-administered online survey was emailed to JC attendees from 2010-2014 at King Abdulaziz Medical City, Jeddah, Saudi Arabia. The survey questions included: introduction sessions, topic selection, JC layout, interaction with the moderator, and decision-making skills by clinical pharmacists. The response rate was 58/89 (65%); 52/54 (96%) respondents believed that JC adds to their knowledge in interpreting literature. Topic selection met the core curriculum requirements for credentials exams for 16/36 (44.4%), while 16/22 (73%) presenters had good to excellent interaction with the moderator. JC facilitated decision-making for 10/12 (83%) of clinical pharmacists. The results suggest that clinical pharmacist-steered JC may serve as an effective tool to empower learners at different levels of pharmacy practice, with evidence-based principles for interpretation of literature and guide informed decision-making.

Five-year review of an international clinical research-training program.

The exponential increase in clinical research has profoundly changed medical sciences. Evidence that has accumulated in the past three decades from clinical trials has led to the proposal that clinical care should not be based solely on clinical expertise and patient values, and should integrate robust data from systematic research. As a consequence, clinical research has become more complex and methods have become more rigorous, and evidence is usually not easily translated into clinical practice. Therefore, the instruction of clinical research methods for scientists and clinicians must adapt to this new reality. To address this challenge, a global distance-learning clinical research-training program was developed, based on collaborative learning, the pedagogical goal of which was to develop critical thinking skills in clinical research. We describe and analyze the challenges and possible solutions of this course after 5 years of experience (2008-2012) with this program. Through evaluation by students and faculty, we identified and reviewed the following challenges of our program: 1) student engagement and motivation, 2) impact of heterogeneous audience on learning, 3) learning in large groups, 4) enhancing group learning, 5) enhancing social presence, 6) dropouts, 7) quality control, and 8) course management. We discuss these issues and potential alternatives with regard to our research and background.