Apixaban and clopidogrel in a fixed-dose combination: Formulation and in vitro evaluation.

Fixed-dose combination (FDC) products represent a novel, safe, and cost-effective formulation. Combined use of anticoagulant and antiplatelet medications is common among comorbid cardiovascular patients. This study aimed to formulate FDC tablets for Apixaban and Clopidogrel, as prophylaxis and treatment of thrombo-embolic events. FDC tablets were developed by combining small tablets of Immediate-Release Clopidogrel 75 mg and Extend-Release Apixaban 5 mg through direct compression and wet granulation. Particularly, Apixaban tablets were developed using design expert software, and various types and concentrations of polymers were entered. For Clopidogrel tablets, various diluents were used to develop the formulation. Then, the dissolution profile for each formula was studied. Finally, the optimized formulations were encapsulated within hard gelatin capsules. Apixaban formulation followed zero-order with super case Ⅱ transport mechanism as the dominant mechanism of drug release. The Apixaban drug release rate was affected by the type and concentration of the polymers in the formulation (P < 0.05). As the HPMC concentration was increased, Apixaban release was retarded. For, Clopidogrel, the formulated tablets with spray-dried lactose filler and sodium stearyl fumarate lubricant were found to be stable with good properties. In conclusion, the optimum formulation yielded Clopidogrel and extended-release Apixaban for 24 h with the desired in vitro drug dissolution.

Characteristics, Risk Factors, and Outcomes in Acute Kidney Injury Patients: A Retrospective Cross-Sectional Study, Palestine.

Background: Acute kidney injury (AKI) is a major medical problem affecting patients' quality of life and healthcare costs. Objectives: This study evaluated the severity, risk factors, and outcomes of patients diagnosed with acute kidney injury (AKI), including community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI), who were admitted to tertiary institutions in Palestine. Methods: This retrospective cross-sectional study was conducted at multiple tertiary care hospitals in Palestine by reviewing patient charts from January 2020 to March 2023. The study included all patients aged ≥18 years who were admitted to the hospital and diagnosed with AKI at admission (CA-AKI) or who developed AKI 48 hours after admission (HA-AKI). Patients with incomplete medical records and those with no reported creatinine levels during their stay, pregnant women, kidney transplant patients, and end-stage renal disease patients were excluded. Data were analyzed using SPSS v22.0. The incidence of AKI in each group was compared using the chi-squared test. Results: This study included 259 participants. HA-AKI was present in 27.3% of the patients, while CA-AKI was 72.7%. The most common stage among patients was stage 3 (55.7%, HA-AKI) (42.9%, CA-AKI), and the most common comorbidity contributing to AKI was CKD. NSAIDs, ACE-I/ARBs, and DIURETICs were the most nephrotoxic drugs contributing to AKI. Patients with hyperphosphatemia, hyperkalemia, severe metabolic acidosis, or stage 3 AKI require renal replacement therapy. In addition, our findings revealed a significant association among AKI mortality, age, and heart disease. Conclusion: CA-AKI was more prevalent than HA-AKI in Palestinian patients admitted for AKI. Risk factors for AKI included diabetes, CKD, and medications (antibiotics, NSAID, diuretics, and ACE-I/ARB). Preventive measures, medication management, and disease state management are necessary to minimize AKI during hospital admission or in the community.

Practices, Efficacy, and Reported Side Effects Associated with Isotretinoin Treatment in Palestine.

Background: Isotretinoin is a commonly prescribed medication for the treatment of acne. It is associated with serious side effects that require monitoring and adherence by patients and healthcare providers. No studies have been conducted in Palestine to explore isotretinoin prescribing and utilization. Objective: This study aims to evaluate the current clinical practices, adherence to clinical guidelines, efficacy, and reported side effects associated with Isotretinoin treatment in Palestine. Methods: A descriptive cross-sectional online questionnaire-based study using social media platforms (eg, Facebook and Telegram) was conducted among Birzeit University students in April 2023. This study included participants aged ≥ 18 years with a history of isotretinoin treatment; subjects with incomplete data were excluded. Statistical significance was set at P < 0.05. SPSS version 27 was used for data analysis. Results: A total of 548 participants were included in the study, the majority of most of whom were female (96%). The most predominant side effects were cracked, dry lips and xeroderma (96.2%). Moreover, 12% of participants had depression. Most respondents were educated about medication side effects and only 39.1% were counseled about blood donation. Of the 59 sexually active women, only 4 (6.8%) were asked for a recent pregnancy test. A total of 60.2% of dermatologists adhered to the American Academy of Dermatology (AAD) guidelines, and 48.7% ordered the required laboratory tests before initiating isotretinoin treatment. Only 1.7% of pharmacists followed the FDA-suggested protocols for dispensing isotretinoin to childbearing females. Conclusion: Adherence to isotretinoin safety prescribing protocols to provide patient education, monitoring, and ordering of laboratories to ensure patient safety can be improved by adapting policies and protocols in pharmacy and medical practice in Palestine to monitor and enforce adherence when prescribing, dispensing, or taking high-risk medications.

Assessment of adherence to guidelines for testing and treatment of pharyngitis among children in Palestine: A retrospective review study.

Introduction: One of the most common reasons for pediatric outpatient visits is acute pharyngitis, an upper respiratory tract infection. Bacterial pharyngitis is caused by Group A beta-hemolytic Streptococcus (GABHS), also known as Streptococcus pyogenes. This research aimed to assess physicians' adherence to clinical guidelines for diagnosis, management, and selecting appropriate treatment for children suspected of bacterial pharyngitis. Methods: A retrospective, observational study was conducted by reviewing patient charts for childred aged 3 to 13 years old diagnosed with pharyngitis from June 2019 until December 2019 at the Emergency Department of Palestine Medical Complex (PMC). The Modified Centor score, throat swab collections, and assessment of antimicrobial selection were used to assess the extent of physicians' adherence to clinical guidelines for appropriate diagnosis and management of pharyngitis. SPSS was used for data analysis. Results: Out of 290 cases diagnosed with acute pharyngitis, 217 patients (74.8%) had a Modified Centor score of ≥2; 126 received antibiotics, and eight had their throat swabbed to confirm the diagnosis; furthermore, 73 patients (25.2%) had a Modified Centor score of <2; 34 of them received antibiotics. Azithromycin was the most commonly prescribed antibiotic (41.3%), followed by amoxicillin-clavulanic acid (38.1%). The frequency of empirical antibiotics prescribing was significantly higher among children with a Centor score >2, older children, and those presenting with fever. Conclusions: Most cases were not appropriately tested to confirm the diagnosis of bacterial pharyngitis and were mostly treated with inappropriate antimicrobial agents such as azithromycin. Nonadherence to clinical guidelines is very evident in this study.

The Preparation and Evaluation of Cyanocobalamin Mucoadhesive Sublingual Tablets.

Cobalamin (vitamin B12), an essential vitamin with low oral bioavailability, plays a vital role in cellular functions. This research aimed to enhance the absorption of vitamin B12 using sublingual mucoadhesive tablets by increasing the residence time of the drug at the administration site. This research involved the preparation of different 50 mg placebo formulas using different methods. Formulas with disintegration times less than one minute and appropriate physical characteristics were incorporated into 1 mg of cyanocobalamin (S1-S20) using the direct compression method. The tablets obtained were evaluated ex vivo for residence time, and only those remaining for >15 min were included. The final formulas (S5, S8, S11, and S20) were evaluated in several ways, including pre- and post-compression, drug content, mucoadhesive strength, dissolution, and Permeapad® permeation test employed in the Franz diffusion cell. After conducting the evaluation, formula S11 (Eudragit L100-55) emerged as the most favorable formulation. It exhibited a mucoadhesive residence time of 118.2 ± 2.89 min, required a detachment force of 26 ± 1 g, maintained a drug content of 99.124 ± 0.001699%, and achieved a 76.85% drug release over 22 h, fitting well with the Peppas-Sahlin kinetic model (R2: 0.9949). This suggests that the drug release process encompasses the Fickian and non-Fickian kinetic mechanisms. Furthermore, Eudragit L100-55 demonstrated the highest permeability, boasting a flux value of 6.387 ± 1.860 µg/h/cm2; over 6 h. These findings indicate that including this polymer in the formulation leads to an improved residence time, which positively impacts bioavailability.

Understanding the Risks of Diffusion of Cyanobacteria Toxins in Rivers, Lakes, and Potable Water.

Blue-green algae, or cyanobacteria, may be prevalent in our rivers and tap water. These minuscule bacteria can grow swiftly and form blooms in warm, nutrient-rich water. Toxins produced by cyanobacteria can pollute rivers and streams and harm the liver and nervous system in humans. This review highlights the properties of 25 toxin types produced by 12 different cyanobacteria genera. The review also covered strategies for reducing and controlling cyanobacteria issues. These include using physical or chemical treatments, cutting back on fertilizer input, algal lawn scrubbers, and antagonistic microorganisms for biocontrol. Micro-, nano- and ultrafiltration techniques could be used for the removal of internal and extracellular cyanotoxins, in addition to powdered or granular activated carbon, ozonation, sedimentation, ultraviolet radiation, potassium permanganate, free chlorine, and pre-treatment oxidation techniques. The efficiency of treatment techniques for removing intracellular and extracellular cyanotoxins is also demonstrated. These approaches aim to lessen the risks of cyanobacterial blooms and associated toxins. Effective management of cyanobacteria in water systems depends on early detection and quick action. Cyanobacteria cells and their toxins can be detected using microscopy, molecular methods, chromatography, and spectroscopy. Understanding the causes of blooms and the many ways for their detection and elimination will help the management of this crucial environmental issue.

Assessment of immunoglobin G (spike and nucleocapsid protein) response to COVID-19 vaccination in Palestine.

Introduction: Many countries have begun immunization programs and established protocols to combat pandemics caused by the SARS-CoV-2 virus. Six months after vaccination, the antibody titers produced by the immunization begin to decline, and individuals whose first immunization (either one or two doses) did not provide adequate protection may require a booster dose. Methods: A quantitative cross-sectional survey of 18-year-olds and older was undertaken in the West Bank from June 15 to June 27, 2022. Each participant had 5 mL of blood drawn to be tested for IgG-S, IgG-N, and blood group. Results: All participants had positive IgG-S results; IgG-S values ranged between 77 and 40,000 AU/ml, with a mean value of 1254 AU/ml. The value of IgG-N ranged from 0 to 139.3 U/ml for all participants, with a mean value of 22.4 U/ml. 64 (37.2%) of the participants demonstrated positive IgG-N screening results, with mean values of 51.2 U/ml. Female participants' mean IgG concentration was higher than male participants. Furthermore, the results revealed that smokers had lower levels of vaccine-induced antibodies than nonsmokers. High significance was found in the time from the last vaccine till the blood sample test (T = 3.848, P < .001), and the group between 6 and 9 months was found to have higher mean values than the 9-months group (M = 15952). Conclusions: Participants vaccinated with a higher number of vaccines tend to have higher IgG-S. To elevate total antibodies, booster doses are essential. Additional researchers are needed to examine the positive correlation between IgG-S and IgG-N.

Quality of Life of Palestinian Patients on Hemodialysis: Cross-Sectional Observational Study.

Background: Hemodialysis is life-saving and life-altering, affecting patients' quality of life. The management of dialysis patients often focuses on renal replacement therapy to improve clinical outcomes and remove excess fluid; however, the patient's quality of life is often not factored in. Objective: This study aimed to explore the factors affecting the quality of life of patients on dialysis in Palestine using the Kidney Disease Quality of Life (KDQOL-SFTM) questionnaire. Methods: A multicenter cross-sectional observational study was conducted at multiple dialysis centers in Palestine, including 271 participants receiving renal replacement therapy. Demographics, socioeconomic, and disease status data were collected. The Arabic version of KDQOL-SFTM was used to assess dialysis patient quality of life. Statistical analysis was performed using SPSS to find correlations among patient factors and the questionnaire's three main domains, the kidney disease component summaries (KDCS), mental component summaries (MCS), and physical component summaries (PCS). Results: Mean KDCS, MCS, and PCS scores were 59.86, 47.10, and 41.15, respectively. KDC scores were lower among participants aged 40 years or older, with lower incomes, and with diabetes. PCS and MCS scores were lower among patients aged >40, less educated, and lower-income participants. There was a positive correlation between MCS and KDCS (r = 0.634, P-value <0.001), PCS and KDCS (r = 0.569, P-value <0.001), as well as MCS and PCS (r = 0.680, P-value <0.001). Conclusion: In this study, the KDQOL-SFTM questionnaire revealed lower PCS scores among hemodialysis patients in Palestine. Furthermore, the three domains of the questionnaire were adversely affected by patient income and education status. In addition, physical role, work status, and emotional role showed the lowest scores among the three main domains. Therefore, continuous assessment of patients' quality of life during their journey of hemodialysis using the KDQOL-SFTM along with the clinical assessment will allow the healthcare professionals to provide interventions to optimize their care.

Antibacterial and Anti-Acne Activity of Benzoyl Peroxide Nanoparticles Incorporated in Lemongrass Oil Nanoemulgel.

PURPOSE: The goal of this study was to make Benzoyl Peroxide (BPO) nanoemulgel to improve its ability to kill bacteria. BPO has trouble getting into the skin, being absorbed by the skin, staying stable, and being spread out. METHODS: A BPO nanoemulgel formulation was prepared by combining BPO nanoemulsion with Carbopol hydrogel. The drug was tested for solubility in various oils and surfactants in order to select the best oil and surfactant for the drug, and then the drug nanoemulsion formulation was prepared using a self-nano-emulsifying technique with Tween 80, Span 80, and lemongrass oil. The drug nanoemulgel was looked at in terms of its particle size, polydispersity index (PDI), rheological behavior, drug release, and antimicrobial activity. RESULTS: Based on the solubility test results, lemongrass oil was the best solubilizing oil for drugs, while Tween 80 and Span 80 demonstrated the highest solubilizing ability for drugs among the surfactants. The optimum self-nano-emulsifying formulation had particle sizes of less than 200 nm and a PDI of close to zero. The results showed that incorporating the SNEDDS formulation of the drug with Carbopol at various concentrations did not cause a significant change in the particle size and PDI of the drug. The zeta potential results for drug nanoemulgel were negative, with more than 30 mV. All nanoemulgel formulations exhibited pseudo-plastic behavior, with 0.4% Carbopol exhibiting the highest release pattern. The drug nanoemulgel formulation worked better against bacteria and acne than the product on the market. CONCLUSION: Nanoemulgel is a promising way to deliver BPO because it makes the drug more stable and increases its ability to kill bacteria.

Prevalence and Safety of Prescribing PPIs with Clopidogrel in Palestine.

Background: Proton pump inhibitors (PPIs) are commonly prescribed medications that are thought to increase the risk of cardiovascular events because they reduce the effectiveness of clopidogrel via shared hepatic pathways. Objective: This study examined the prevalence of concomitant prescribing of clopidogrel/PPI among patients diagnosed with acute coronary syndrome and the adverse cardiovascular event associated with this interaction. Methods: A retrospective cohort study was conducted by retrieving patient data from the Nat Health Insurance claims processor database in Palestine. Adults diagnosed with Acute Coronary Syndrome (ACS) from 2019 through 2021 who were prescribed clopidogrel or clopidogrel in combination with a PPI were included in the study. Endpoints were adverse cardiac events, including readmission for revascularization during the first year of treatment. Results: The study included 443 patients; the prevalence of prescribing concomitant clopidogrel with a PPI was 74.7%, whereas 49.2% were prescribed interacting PPI (omeprazole, esomeprazole, and lansoprazole). 59 (13.3%) of participants experienced a cardiovascular event within 1 year of starting therapy, including 27 (12.4%) patients who had a cardiovascular event while taking an interacting PPI. No significant association was found between PPI administration and increased CV event risk in patients receiving concomitant clopidogrel and PPIs therapy (p = 0.579). Conclusion: In this study, we observed a high prevalence of prescribing a PPI in combination with clopidogrel, regardless of the FDA recommendations. No significant increase in cardiovascular events was observed in patients receiving concomitant clopidogrel and PPI therapy.

Side effects of Pfizer/BioNTech (BNT162b2) COVID-19 vaccine reported by the Birzeit University community.

BACKGROUND: The Pfizer BioNTech COVID-19 vaccine was the first to receive emergency authorization and approval from the FDA. Therefore, it is preferred by most recipients; however, many people are concerned about the vaccine's side effects. At the time of the study, December 2021, Palestine lacked a national reporting system for monitoring adverse vaccine effects. Therefore, this study investigates the post-vaccine adverse events following the Pfizer/BioNTech COVID-19 Vaccine administration in Palestine and identifies the occurrence, extent, and severity among university staff, employees, and students at Birzeit University. METHOD: A questionnaire-based retrospective cross-sectional study was conducted using a university website (Ritaj), social media platforms (e.g., Facebook and Telegram), and in-person interviews. The Chi-square, Fisher's exact, and McNemar's tests were used to investigate significant relationships. Data were analyzed using SPSS version 22. RESULTS: In total, 1137 participants completed the questionnaire, 33.2% were males, and the mean age was 21.163 years. All participants received at least one dose of the Pfizer-BioNTech COVID-19 vaccine. Approximately one-third of participants reported no adverse effects after receiving the first, second, or third doses (34%, 33.6%, and 32.5%, respectively). The most commonly reported adverse events were fever, chills, headache, fatigue, pain and swelling at the injection site, muscle pain, and joint pain. Allergic reactions were reported by 12.7% of the participants; furthermore, participants with a history of allergy or anaphylaxis before vaccination had a significantly higher tendency for post-vaccination allergic reactions. Eight participants reported rare side effects, including 7 (0.6%) cases of thrombocytopenia and one (0.1%) case of myocarditis. Males aged less than 20 years and smokers were significantly less likely to complain of adverse events. The number of reported side effects was significantly higher after the second vaccine dose than after the first dose. Finally, participants infected with COVID-19 before vaccination was significantly associated with side effects such as fever, chills, shortness of breath, and persistent cough. CONCLUSION: In this study, the most common post- BNT162b2 Vaccination reported self-limiting side effects similar to those reported by Pfizer/BioNTech Company. However, higher rates of allergic reactions were reported in this sample. Rare side effects, such as thrombocytopenia and myocarditis, were reported by 8 participants. COVID vaccines have been developed at an accelerated pace, and vaccine safety is a top priority; therefore, standard monitoring through a national adverse event reporting system is necessary for safety assurance. Continuous monitoring and long-term studies are required to ensure vaccine safety.

Evaluation of Proton Pump Inhibitors Prescribing Among Hospitalized Patients: A Cross-Sectional Study.

Background: Proton pump inhibitors (PPIs) are the most effective agents for managing acid-related disorders. However, inappropriate prescribing of PPIs is becoming an issue of concern. Objective: This study aimed to assess the appropriate utilization of PPIs in terms of indication, dose, frequency, and route of administration during admission and discharge. Furthermore, direct costs associated with inappropriate PPI use were calculated. Methods: A descriptive cross-sectional study was conducted at the internal medicine department of a tertiary hospital in Palestine from January 1, 2021, to June 30, 2021. The medical records of patients aged 18 years or older, hospitalized for 48 hours or more, and receiving oral or intravenous (IV) PPIs during their stay were collected and evaluated for the appropriateness of PPIs prescribed according to clinical guidelines. Results: Of 262 patients, 80.2% had an appropriate indication for prophylaxis (67.6%) or treatment (12.6%). A total of 230 patients were prescribed IV pantoprazole.182 (79.1%) had an appropriate indication, whereas 122/182 (67%) received IV PPI instead of oral without an appropriate indication. Of the 32 patients who received 20 mg of oral omeprazole, 28 (87.5%) had an appropriate indication, dose, and route of administration, whereas 16/28 (57.1%) had an inappropriate frequency. At discharge, 32.5% of patients were discharged with unnecessary PPI prescriptions. The total direct cost of inappropriate PPI Indications and route of administration in 188 patients over six months was $1518. Conclusion: This study showed that most patients received a PPI for an appropriate indication with the correct dose. However, a high prevalence of inappropriate IV pantoprazole administration was observed, resulting in the highest costs, demonstrating the importance of correctly ordering IV medications. Adherence to clinical guidelines, such as those of the American College of Gastroenterology (ACG), will improve the appropriateness of PPI prescribing, prevent complications, and reduce healthcare costs.

A retrospective evaluation of drug-drug interactions in patients admitted to Internal Medicine Departments in Palestinian Hospitals.

Objective: To measure the prevalence and identify risk factors associated with drug-drug interactions among patients admitted to internal medicine departments in Palestinian hospitals. Methods: A retrospective cross-sectional observational study was conducted. Data were obtained from patient files from the internal medicine departments in Palestinian hospitals from 1 September 2017, to 31 March 2018. The data collected included patient gender, age, length of hospitalization, medications prescribed, and the number of medications. The digital clinical decision support system IBM Micromedex® was used to assess potential drug-drug interactions. Results: The number of patients included in this study is 513. The total number of potential drug-drug interactions detected in study participants is 1558. The average number of potential drug-drug interactions per patient was found to be 3 ± 3.9. Among study participants, 66.1% (n = 339) were found to have potential drug-drug interactions in their current medications. The most commonly encountered drug-drug interactions type was "major" drug-drug interaction, which was encountered in 43.6% (n = 681) of total detected drug-drug interactions. Other types of drug-drug interactions were encountered in 42% (n = 647), 14% (n = 224), and 0.4% (n = 6) which were moderate, minor, and contraindicated drug-drug interactions, respectively. Patients' age, number of medications, and length of hospitalization were associated with the increased risk of potential drug-drug interactions. Conclusion: The results indicated a high prevalence of potential drug-drug interactions in Palestinian hospitals, associated with polypharmacy, increased age, and increased length of hospitalization. Therefore, managing patient medication by a drug expert such as a clinical pharmacist to identify and resolve potential drug-drug interactions will possibly decrease the high prevalence of drug-drug interactions, prevent patient harm, and decrease the cost of hospitalization.

Vitamin D Deficiency Association with Comorbid Diseases in Palestine: "A Cross-Sectional Observation Study".

Background: Vitamin D deficiency (VDD) is a global health concern. This study aimed to determine the prevalence of vitamin D deficiency and its associated comorbidities in Palestine, such as diabetes mellitus, hypertension, hyperlipidemia, and cardiovascular and autoimmune diseases. Methods: A retrospective, descriptive study retrieved medical data from the Nat Health insurance processor database from 2014 to 2020. Patient information included age, sex, vitamin D laboratory order, symptoms, and comorbidities. This study included patients prescribed vitamin D at a dose of 50000IU for vitamin D deficiency confirmed by a serum vitamin D laboratory test. The collected data were analyzed using IBM SPSS. In addition, a chi-square test was conducted to assess the association between vitamin D deficiency, symptoms, and comorbidities. Results: Data of 3011 patients were collected; 639 patients were diagnosed with osteoporosis, and 39 patients prescribed vitamin D without a laboratory test were excluded. Approximately, 1837 (78%) participants had vitamin D deficiency. A total of 1330 women (81.3%) were significantly more likely to have vitamin D deficiency than males, 507 (72.7%; P < 0.001). Joint pain, back pain, and cervicalgia were significantly associated with vitamin D deficiency (P < 0.001). Asymptomatic participants (2.1%) were significantly less likely to have vitamin D deficiency than symptomatic participants (9.5%, p < 0.001). Hypothyroidism is significantly associated with vitamin D deficiency (p = 0.048). Conclusion: In this retrospective study, the prevalence of vitamin D was high and alarming. There was a significant association between VDD, patients who presented with back pain, arthritis, and cervicalgia symptoms, and patients diagnosed with hypothyroidism. Therefore, health initiative programs are warranted to increase awareness regarding screening, prevention, and treatment. Further studies are needed to confirm the relationship between vitamin D supplementation and the reduced risk of comorbid diseases.

Evaluating Inappropriate Medication Prescribing Among Elderly Patients in Palestine Using the STOPP/ START Criteria.

Background: Elderly patients suffer from chronic diseases and are prone to polypharmacy and potentially inappropriate prescribing (PIP). This study aimed to identify potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among elderly patients in a tertiary care hospital setting and to estimate the prevalence of polypharmacy. Methods: This multicenter retrospective observational study reviewed patient data from two major Palestinian hospitals. The collected data included patient demographics, comorbidities, and medications administered during hospitalization and discharge. The study included 247 patients aged ≥ 65 years hospitalized between January 2019 and December 2019. The STOPP/START criteria version 2 was used to identify the prevalence of PIMs and PPOs. Clinical pharmacists verified the data, and SPSS was used for data analysis. Descriptive statistics, one-tailed bivariate correlations, and Pearson's test were applied to the variables of interest to examine their association with the STOPP/START criteria. Results: A total of 247 patients were included in the study, and 50.2% were females. As a result, 165 (66.8%) participants were identified with PIPs, including 30 patients with PPOs, 91 with PIMs, and 44 with both. Furthermore, the prevalence of PIP during hospitalization and discharge was 56.29% and 64.39%, respectively. Polypharmacy (5-9 medications) was 44.5% and 52.1% during hospitalization and discharge, respectively, and excessive polypharmacy (ten medications or more) was 33.6% and 16.4% during hospitalization and discharge, respectively. Moreover, 47.3% of the patients had a comorbidity index of ≥ 5. Conclusion: This study identified a high prevalence of PIPs among elderly patients during hospital admission and discharge. In addition, more than half of the geriatric patients in this study had PIP and a high prevalence of polypharmacy. Therefore, this study emphasizes the importance of adapting evidence-based tools, such as the STOPP/START criteria, to optimize patient medication therapy and guide prescribers in identifying and resolving PIMs and PPOs.

Evaluation of Self-Medication with Antibiotics in Primary Care Clinics in Palestine.

Background: Antibiotics are highly effective medications and essential in curing infectious diseases; however, their inappropriate use, such as self-medication, is a significant factor in developing antimicrobial resistance. Objective: This study aimed to evaluate the level of antibiotic self-medication among patients who visited primary care clinics in Palestine. Methods: Data were collected via a self-administered questionnaire, either printed or electronically, using google forms (Google Inc., USA). The sample size needed to provide a 95% confidence level and 5% margin error and assuming a prevalence of 50% of SM with antibiotics was 377 patients. A total of 700 questionnaires were randomly distributed to patients aged 18 years or older. However, 87 were excluded due to duplication, incomplete responses, or participants under 18 years old. Finally, 423 patients were included in this study, with 254 patients completing the electronic Google Forms and 181 completing the written survey. The questionnaire consists of patients' demographics, antibiotics knowledge, and self-medication behavior. In addition, descriptive statistics and knowledge scales were performed using SPSS 22 IBM to measure and assess the scope of the problem and find the association between self-medication demographics, education, and socioeconomic status. Results: Approximately 50% of participants reported self-medication with antibiotics, with a very high use among participants with medical knowledge. Most people have adequate awareness of antibiotics, whereas out of 423 respondents, (40.2%, n = 170) had GKL, (50.4%, n= 213) had AKL, and only (9.5%, n=40) presented PKL. The primary source for self-treatment with antibiotics was community pharmacies (87.1%, n=223), whereas (14.1%, n=36) got antibiotics from family and friends. Convenience, easy access, and experience with community pharmacists contributed to self-medications. The most commonly used antibiotic for self-medication was amoxicillin/clavulanic acid. Conclusion: Self-medication with antibiotics is a common practice in Palestine, regardless of socioeconomic or educational status. Patients' educations about complications from inappropriate use and the possibility of side effects are essential steps to decrease patients' demands for antibiotics. Furthermore, compliance and adherence of community pharmacists in dispensing antibiotics only with a prescription is necessary.

VTE Prophylaxis Therapy: Clinical Practice vs Clinical Guidelines.

Introduction: Venous thromboembolism (VTE) is the most preventable complication in hospitalized patients. The main objective of this study was to evaluate the adherence of current clinical practice to the established guidelines at a Palestinian teaching hospital. Methods: This cross-sectional, retrospective, observational study was conducted at a Palestinian Teaching Hospital. The medical records of patients admitted to the medical floor over 18 years of age and hospitalized for longer than 24 hours between January 1 and May 31, 2019, were included. Patients taking anticoagulants with incomplete or duplicated medical records were excluded from the study. A data collection sheet was developed, and clotting and bleeding risks were assessed using the Padua and IMPROVE risk assessment models (scores). The data were analyzed using IBM SPSS (version 25). Results: In total, 408 patients were included in the study, 222 of whom received thromboprophylaxis (54.4%). Of the hospitalized patients, 112 (27.5%) had a high risk of developing VTE (Padua score ≥ 4), and 73 patients were eligible for VTE pharmacological prophylaxis; however, only 44 (60.3%) received the appropriate prophylaxis. In addition, 296 patients had low Padua scores, indicating that pharmacological prophylaxis was not indicated. However, 144 (48.6%) patients received prophylaxis. The mean Padua and IMPROVE risk scores were 2.25 ± 2.08 and 4.44 ± 2.72, respectively. Among the patients, 17.6% had a high risk of bleeding (IMPROVE score ≥ 7). Conclusion: VTE prophylaxis among hospitalized medically ill patients was mostly inappropriate; 80.18% of the patients received inappropriate prophylaxis, and only 60.3% of eligible patients received appropriate prophylaxis. Adapting assessment models or checklists in clinical practice based on clinical guidelines for VTE risk stratification is a practical and effective method to improve VTE prophylaxis management and select the appropriate therapy to prevent toxicity or complication.

Novel Fusidic Acid Cream Containing Metal Ions and Natural Products against Multidrug-Resistant Bacteria.

BACKGROUND: Drug design and development to overcome antimicrobial resistance continues to be an area of research due to the evolution of microbial resistance mechanisms and the necessity for new treatments. Natural products have been used since the dawn of medicine to heal skin infections. The antimicrobial properties of fusidic acid, zinc sulfate, and copper sulfate have been studied and are well known. Furthermore, these compounds have different mechanisms of action in targeting microorganisms, either by inhibiting protein synthesis or bacterial cell walls. Therefore, their combination is expected to have synergistic activity in killing bacteria. However, the synergistic antimicrobial activity has not been evaluated in a cream formulation. Therefore, the objectives of this in vitro study were to develop and evaluate the synergistic efficacy of fusidic acid in combinations with natural products, including oleuropein, thyme oil, zinc sulfate, and copper sulfate, as a cream to eradicate fusidic-acid-resistant microorganisms in skin infections. METHODS: Three different cream formulations were developed, compared, and labeled F1, F2, and F3. The compounds were studied for their antibacterial activity. In addition, the stability of the cream was investigated at 25 °C and 40 °C in plastic jars over three months. RESULTS: The F2 formula has adequate physicochemical properties. Furthermore, it displays stable and better results than the marketed trade product and has potential inhibition zones (ZOI). Interestingly, considerable numbers (9.5%) of fusidic-acid-resistant Staphylococcus aureus (FRSA) isolates possessed a high resistance pattern with MIC ≥ 128 µg/mL. In contrast, most tested FRSA isolates (90.5%) had a low resistance pattern with MIC ≤ 8 µg/mL. CONCLUSION: In conclusion, the F2 cream made with fusidic acid, oleuropein, thyme oil, zinc sulfate, and copper sulfate in the right amounts has stable physical and chemical properties and has potential against FRSA as an antimicrobial agent.

Adherence to Clinical Guidelines on STATIN Prescribing Among Diabetic Patients Aged 40-75 Years Old in a Primary Care Setting: A Cross-Sectional Study.

Background: Diabetes mellitus (D.M.) is a chronic metabolic disease caused by decreased insulin secretion, which increases the risk of cardiovascular diseases. Evidence has shown that statins reduce cardiovascular risk in patients with diabetes; moreover, most clinical guidelines recommend statins. Objective: This study aimed to assess the level and status of adherence to guidelines on statin prescription in patients with diabetes mellitus in a primary care setting in Palestine. Methods: A retrospective cross-sectional descriptive study was conducted at an ambulatory center in Palestine. Data were collected by auditing prescription records and reviewing medical charts of patients with diabetes who visited the clinic from February 15 to March 17, 2021. The collected data included patient characteristics, comorbidities, lipid profiles, and statin prescription. A chi-square test was used to evaluate the appropriateness of the prescribed statins with different demographic and clinical variables. Statistical significance was set at p < 0.05. Statistical Package for Social Sciences (SPSS) version 22 was used to analyze the data. Results: Out Of 262 diabetic patients included in the analysis, 74% were prescribed appropriate statin therapy according to the American Diabetes Association (ADA) guidelines, and 24% of patients had inappropriate statin therapy or needed statins. Furthermore, 82.8% were on high-intensity statins, while 11% were not taking any statins. More than 60% of patients had uncontrolled diabetes and hypertension. Conclusion: Most guidelines recommend statin therapy in diabetic patients owing to its benefits in preventing cardiovascular complications. In this study, most patients were on appropriate STATIN therapy; however, 50% of diabetic patients had LDL of more than 100 mg/dl, and 25% were not prescribed statins, increasing their risk of ASCVD. Therefore, we recommend strict adherence to the established guidelines on statins prescribed to patients with diabetes to prevent cardiovascular complications, save lives, and reduce healthcare costs.

Bacterial and fungal co-infections among ICU COVID-19 hospitalized patients in a Palestinian hospital: a retrospective cross-sectional study.

Background: Diagnosis of co-infections with multiple pathogens among hospitalized coronavirus disease 2019 (COVID-19) patients can be jointly challenging and essential for appropriate treatment, shortening hospital stays and preventing antimicrobial resistance. This study proposes to investigate the burden of bacterial and fungal co-infections outcomes on COVID-19 patients. It is a single center cross-sectional study of hospitalized COVID-19 patients at Beit-Jala hospital in Palestine. Methods: The study included 321 hospitalized patients admitted to the ICU between June 2020 and March 2021 aged ≥20 years, with a confirmed diagnosis of COVID-19 via reverse transcriptase-polymerase chain reaction assay conducted on a nasopharyngeal swab. The patient's information was gathered using graded data forms from electronic medical reports. Results: The diagnosis of bacterial and fungal infection was proved through the patient's clinical presentation and positive blood or sputum culture results. All cases had received empirical antimicrobial therapy before the intensive care unit (ICU) admission, and different regimens during the ICU stay. The rate of bacterial co-infection was 51.1%, mainly from gram-negative isolates ( Enterobacter species and K.pneumoniae). The rate of fungal co-infection caused by A.fumigatus was 48.9%, and the mortality rate was 8.1%. However, it is unclear if it had been attributed to SARS-CoV-2 or coincidental. Conclusions: Bacterial and fungal co-infection is common among COVID-19 patients at the ICU in Palestine, but it is not obvious if these cases are attributed to SARS-CoV-2 or coincidental, because little data is available to compare it with the rates of secondary infection in local ICU departments before the pandemic. Comprehensively, those conclusions present data supporting a conservative antibiotic administration for severely unwell COVID-19 infected patients. Our examination regarding the impacts of employing antifungals to manage COVID-19 patients can work as a successful reference for future COVID-19 therapy.