Prevalence of Dysmagnesemia among Patients with Diabetes Mellitus and the Associated Health Outcomes: A Cross-Sectional Study.

Introduction: Magnesium is a vital intracellular cation crucial for over 320 enzymatic reactions related to energy metabolism, musculoskeletal function, and nucleic acid synthesis and plays a pivotal role in human physiology. This study aimed to explore the prevalence of dysmagnesemia in patients with diabetes mellitus and evaluate its correlations with glycemic control, medication use, and diabetic complications. Methods: A cross-sectional study was conducted at Sultan Qaboos University Hospital, including 316 patients aged 18 years or older with diabetes mellitus. Data included demographics, medical history, medications, and biochemical parameters. Serum total magnesium concentrations were measured, and dysmagnesemia was defined as magnesium ≤ 0.69 mmol/L for hypomagnesemia and ≥1.01 mmol/L for hypermagnesemia. Results: The prevalence of hypomagnesemia in patients with diabetes was 17.1% (95% CI: 13.3-21.7%), and hypermagnesemia was 4.1% (95% CI: 2.4-7.0%). Females were significantly overrepresented in the hypomagnesemia group, while the hypermagnesemia group showed a higher prevalence of hypertension, retinopathy, an increased albumin/creatinine ratio, chronic kidney disease (CKD), elevated creatinine levels, and a lower adjusted calcium concentration. The multinominal logistic regression exhibited that the female sex and higher serum-adjusted calcium were independent risk factors of hypomagnesemia. In contrast, the presence of hypertension, higher levels of albumin/creatinine ratio, and stage 5 CKD were independent risk factors of hypermagnesemia. Conclusions: Hypomagnesemia was common among patients with diabetes mellitus; however, hypermagnesemia was associated with microvascular complications.

Short-term effects of antimicrobial stewardship programs on antibiotics usage, clinical outcomes, and multidrug resistant organisms in the post COVID-19 era.

BACKGROUND: Antimicrobial resistance is associated with increasing mortality rates and the emergence of multidrug-resistant (MDR) organisms. There is scarcity of data on the short-term impact of Antimicrobial Stewardship Programs (ASP) on antibiotic usage, clinical outcome and MDR organisms' pattern following the COVID-19 pandemic. This study evaluated the short-term effects of ASP on antibiotic usage, clinical outcomes and MDR organisms' pattern in the post COVID-19 era. METHODS: Conducted at a tertiary academic health center, this observational study involved adult patients (≥18 years) in the general medical unit, treated with oral or intravenous antibiotics from May 1, 2021, to April 30, 2022. The applied ASP strategy was a prospective audit and feedback where a weekly meeting was held to discuss the antimicrobial therapy of admitted patient, after which recommendations were made regarding antimicrobial use. RESULTS: The study included 301 patients with 166 (55.1%) pre-ASP and 135 (44.9%) post-ASP. The median (IQR) age was 69 (55-77) years with 56.1% were female. Antibiotic usage dropped by 25.2% post-ASP. The length of hospital stay (LOS) was longer post-ASP (7 days vs. 7.9 days, p = 0.001), with MDR infections being a significant predictor (OR: 0.486, p < 0.001). There were no significant differences in 28-day readmission, recurrence of infections and all-cause mortality. Post-ASP, MDR pathogens increased (17.0% vs. 6.6%, p = 0.013), however, after separating post-ASP into two three-months periods, MDROs numbers decreased slightly (13 vs. 10). CONCLUSION: Short-term ASP implementation post COVID-19 reduced antibiotic usage while other clinical outcomes remained unchanged. Nonetheless an increase in MDR pathogens and LOS was observed. Further research is required to assess ASP's long-term impact on MDR infections rates and specific patient group outcomes.

Incidence of Dysmagnesemia among Medically Hospitalized Patients and Associated Clinical Characteristics: A Prospective Cohort Study.

Background: Magnesium (Mg) disorders are common among hospitalized patients and are linked to poor health outcomes. We aimed to determine the incidence of dysmagnesemia among medically hospitalized patients and to identify factors that are associated with dysmagnesemia. Methods: A prospective cohort study was conducted at Sultan Qaboos University Hospital (SQUH) from April 1st, 2022, to October 31st, 2022, and involved hospitalized adult patients (≥18 years) under the care of the general internal medicine unit. The patients' serum total magnesium (Mg) concentrations were categorized as hypomagnesemia (≤0.69 mmol/L), hypermagnesemia (≥1.01 mmol/L), or dysmagnesemia, which encompassed either hypomagnesemia or hypermagnesemia. Results: Of the 304 patients evaluated, dysmagnesemia was observed in 22.0%, which comprised of 17.4% with hypomagnesemia and 4.6% with hypermagnesemia. Statistically significant associations were identified between hypermagnesemia and chronic kidney disease (CKD) (p = 0.05) and elevated creatinine levels (p < 0.01) and lower estimated glomerular filtration rate (eGFR) (p < 0.01). Hypomagnesemia was linked to lower ionized calcium (p = 0.03) and admission due to infectious diseases (p = 0.02). However, ordered regression analysis did not find any significant associations with the different magnesium groups. Conclusion: Dysmagnesemia was prevalent among hospitalized patients and was associated with different factors; however, ordered regression analysis did not find any association with the different magnesium group, probably due to the limited number of included individuals.

Association between Non-Steroidal Anti-Inflammatory Drug Use and Major Cardiovascular Outcomes in Patients with Acute Coronary Syndrome in the Arabian Gulf.

Objectives: Studies on the association between non-steroidal anti-inflammatory drugs (NSAIDs) and major adverse cardiovascular events (MACE) in the Arabian Gulf are scarce. The aim of this study was to evaluate the association between NSAIDs use and MACE in acute coronary syndrome (ACS) patients in the Arabian Gulf region. Methods: Data were analyzed from 3007 consecutive patients diagnosed with ACS admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013, as well as being on prior NSAIDs use during the index admission. The MACE included stroke/transient ischemic attacks (TIAs), myocardial infarction (MI), all-cause mortality and readmissions for cardiac reasons. Results: The overall mean age of the cohort was 62 ± 12 years, and 9.6% (n = 290) of the patients were on prior NSAID use during the index admission. At 12-months follow-up, after adjusting for confounding factors, patients on NSAIDs were significantly more likely to have had MACE (adjusted OR (aOR), 1.89; 95% confidence interval (CI): 1.44-2.48; p < 0.001). Specifically, the higher event rates observed were stroke/TIA (aOR, 2.50; 95% CI: 1.51-4.14; p < 0.001) and readmissions for cardiac reasons (aOR, 2.09; 95% CI: 1.59-2.74; p < 0.001), but not MI (aOR, 1.26; 95% CI: 0.80-1.99; p = 0.320) and all-cause mortality (aOR, 0.79; 95% CI: 0.46-1.34; p = 0.383). Conclusions: NSAIDs use was associated with significant stroke/TIA events as well as readmissions for cardiac reasons. However, NSAIDs were not associated with increased MIs or all-cause mortality rates in patients with ACS in the Arabian Gulf.

The Stability of Analytes of Ionized Magnesium Concentration and Its Reference Range in Healthy Volunteers.

This study aimed to determine the stability of refrigerated analytes of iMg concentration at different time intervals and to establish iMg reference range in a cohort of healthy Omani volunteers (≥18 years). The concentrations of iMg were measured using the direct ion-selective electrode technique. Pearson's and Lin's concordance correlation coefficients along with the Bland-Altman plot were used to assess the levels of agreement between iMg concentrations of fresh and refrigerated blood samples at different time intervals. The study included 167 volunteers (51% females) with a median age of 21 (range: 20-25) years. The median, 2.5th, and 97.5th percentiles for fresh iMg reference ranges were 0.55, 0.47, and 0.68 mmol/L, respectively. The overall agreement between the fresh and refrigerated iMg concentrations was poor (rho-c = 0.51; p < 0.001). However, according to Altman's definition, iMg concentrations of the refrigerated samples for a period of ≤1 h had an excellent correlation with the fresh iMg concentrations (Lin's rho-c = 0.80), with a small average bias difference of 0.009 (95%CI; -0.025-0.043). A cut-off refrigeration period within ≤1 h at 2-8 °C can be considered an alternate time frame for the gold standard measurement (fresh or within 0.5 h).

Delirium and Its Association with Short- and Long-Term Health Outcomes in Medically Admitted Patients: A Prospective Study.

BACKGROUND: Delirium is highly prevalent among elderly hospitalized patients in various healthcare settings. This study aimed to assess the impact of delirium on short- and long-term health outcomes. METHODS: A prospective cohort included medically ill patients (≥65 years) admitted to a tertiary healthcare facility. Delirium was screened using the 3-Minute Diagnostic confusion assessment method (3D-CAM). RESULTS: During hospitalization, 53.8% (n = 153/284) had delirium. Patients with delirium had a longer length of hospital stay (LOS) (7 vs. 5 days; p < 0.01) compared to patients without delirium. Delirium caused a higher frequency of high-dependency unit (HDU) or intensive care unit (ICU) admission (p < 0.01) and an increased incidence of hospital-acquired complications, including infections (p = 0.03), pressure injuries (p = 0.01), and upper gastrointestinal bleeding (p < 0.01). Inpatient all-cause mortality was higher in patients with delirium than those without delirium (16.3% vs. 1.5%; p < 0.01). Patients with delirium had higher rates of 90-day all-cause mortality (25.4% vs. 8.4%; p < 0.01) and 1-year all-cause mortality (35.9% vs. 16%; p < 0.01) compared to patients without delirium. Patients with delirium exhibited shorter survival periods at 90 days and 1 year compared to patients without delirium with a hazard ratio (HR) = 3.41, 95% CI: 1.75-6.66, p < 0.01 and HR = 2.64, 95% CI: 1.59-4.37, p < 0.01, respectively. CONCLUSIONS: Delirium is associated with serious short-term and long-term clinical consequences. Early recognition, prevention, and targeted interventions addressing reversible risk factors are crucial. Further research is warranted to explore effective strategies for delirium management in general medical wards.

Prevalence, Recognition, and Risk Factors of Constipation among Medically Hospitalized Patients: A Cohort Prospective Study.

Background and Objective: Constipation is a prevalent gastrointestinal condition that has a substantial impact on individuals and healthcare systems. This condition adversely affects health-related quality of life and leads to escalated healthcare expenses due to an increase in office visits, referrals to specialists, and hospital admission. This study aimed to evaluate the prevalence, recognition, risk factors, and course of constipation among hospitalized patients in medical wards. Materials and Methods: A prospective study was conducted, including all adult patients admitted to the General Medicine Unit between 1 February 2022 and 31 August 2022. Constipation was identified using the Constipation Assessment Scale (CAS), and relevant factors were extracted from the patients' medical records. Results: Among the patients who met the inclusion criteria (n = 556), the prevalence of constipation was determined to be 55.6% (95% CI 52.8-58.4). Patients with constipation were found to be older (p < 0.01) and had higher frailty scores (p < 0.01). Logistic regression analysis revealed that heart failure (Odds ratio (OR) 2.1; 95% CI 1.2-3.7; p = 0.01), frailty score (OR 1.4; 95% CI 1.2-1.5; p < 0.01), and dihydropyridines calcium channel blockers (OR 1.8; 95% CI 1.2-2.8; p < 0.01) were independent risk factors for constipation. Furthermore, the medical team did not identify constipation in 217 patients (64.01%). Conclusions: Constipation is highly prevalent among medically hospitalized patients. To ensure timely recognition and treatment, it is essential to incorporate a daily constipation assessment scale into each patient's medical records.

Delirium in Medically Hospitalized Patients: Prevalence, Recognition and Risk Factors: A Prospective Cohort Study.

BACKGROUND: Delirium is a common neuropsychiatric syndrome in hospitalized elderly patients and is associated with poor clinical outcomes. We aimed to determine the prevalence, recognition, risk factors, and course of delirium among hospitalized elderly (65 years of age or older) patients at Sultan Qaboos University Hospital (SQUH). METHODS: A prospective cohort study included 327 elderly patients (65 years of age or older) admitted to the medical wards at SQUH. Patients were screened for delirium using the 3-Minute Diagnostic Confusion Assessment Method (3D-CAM). Additionally, medical records were reviewed to identify possible associated factors. RESULTS: The prevalence of delirium was 55.4% (95% CI 49.9-60.7), and 35.4% of patients with delirium were not recognized by the treating team. Hypoactive delirium is the most common type of delirium. The logistic regression analyzes demonstrated that pre-existing cognitive impairment (OR = 4.0); poor functional status (OR = 1.9); the use of medications that are known to precipitate delirium (OR = 2.3); polypharmacy (OR = 5.7); urinary catheterization (OR = 2.2); dehydration (OR = 3.1); and electrolytes derangements (OR = 2.0) were independent risk factors for delirium. Furthermore, 56.9% of patients with delirium continued to have delirium upon discharge from the hospital. CONCLUSIONS: Delirium is common among elderly patients hospitalized in general medical wards. Implementing effective preventive strategies for delirium during the hospital stay, including early recognition using standard sensitive and specific screening tools (i.e., 3D-CAM) and developing geriatric wards, is crucial.

The Prevalence and Impact of Evidence-Based Medications on Cardiovascular and Cerebrovascular Outcomes in Patients with Acute Coronary Syndrome Post-Revascularization in Oman.

OBJECTIVES: International cardiovascular guidelines recommend prescribing a combination of five evidence-based medications (EBM) for acute coronary syndrome (ACS) patients post-revascularization. This study aims to assess the prevalence and impact of prescribing the full (five medications) versus partial (four medications or fewer) EBM combination on major adverse cardiovascular and cerebrovascular events (MACCE) in patients with ACS post-revascularization. METHODS: Data from patients with ACS who had revascularization between January 2016 and September 2021 were collected retrospectively. Patients were then followed up until March 2022 for MACCE. RESULTS: The full EBM combination was prescribed to 70% of the patients. However, after taking into account the presence of contraindications and clinical factors, the actual adherence to the guidelines was 95%. Patients who received the full EBM combination were younger (58 versus 62 years; p = 0.0 and 3) and had lower rates of chronic kidney disease (11% versus 41%; p < 0.001) and heart failure (9% versus 20%; p = 0.012) when compared to patients who received the partial EBM. Compared to the partial EBM group, the full EBM group was associated with lower MACCE rates (54% versus 37%, p = 0.012). After employing the propensity score technique utilizing the 1:1 nearest neighbor matching method without replacement, the univariate findings were further re-affirmed with those on full EBMs (compared to those on partial EBMs) associated with a significant reduction in the MACCE rate (average treatment effect of -25%; 95% confidence interval: -10--40%; p = 0.001). CONCLUSIONS: The full EBM utilization was significantly high in our setting and in line with international guidelines. The full EBM combination was predominantly prescribed in younger and less comorbid patients and was associated with lower MACCE rates. The findings were further reaffirmed by the propensity score matching method.

Clinical Associations with the differences in rivaroxaban dosing in patients with atrial fibrillation stratified by three renal function formulae.

Background: Clinical trials used Cockcroft-Gault (CG) formula to calculate the estimated glomerular filtration rate (eGFR) in order to dose rivaroxaban for patients with atrial fibrillation (AF). Objectives: The aim of this study is to evaluate rivaroxaban dosing appropriateness in patients with AF with or without renal impairment based on the CG formula and other formulae, including Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and the isotope dilution mass spectrometry (IDMS) traceable Modification of Diet in Renal Disease (MDRD) Study equation and the associated clinical outcomes. Methodology: A retrospective cohort study conducted at Sultan Qaboos University Hospital (SQUH) from 1st January 2016 to 31st December 2020, included all adult patients (≥ 18 years) treated with rivaroxaban for AF and followed up for one year after starting the treatment. Results: Based on the CG formula, the rivaroxaban dose was inappropriately prescribed in 27% of the patients (21% overdosed and 6% underdosed). Higher baseline creatinine (P=0.0014) and concurrent use of antiplatelet therapy (P<0.001) were associated with the tendency to rivaroxaban overdosing. Higher Body Mass Index (BMI) (P=0.002), female sex (P=0.032), and CKD (P=0.003) were associated with rivaroxaban underdosing. The degree of agreement between the renal function tests when comparing MDRD vs CG and CKD-EPI vs CG in terms of estimated glomerular filtration rate/creatine clearance (eGFR/CrCl) calculation was moderate (κ=0.46) and poor (κ=0.00), respectively, while, in terms of rivaroxaban dose appropriateness was almost perfect (κ=0.82) and substantial (κ=0.77). Clinical outcomes measured by stroke and bleeding events were not significantly different according to the appropriateness of the rivaroxaban dose. Conclusion: This study has shown a relatively high consistency with the gold standard in dosing rivaroxaban in AF patients using CG formula. Treatment efficiency and safety were not affected by the proportion of dose inappropriateness found in this cohort.

The Clinical Associations With The Differences in Rivaroxaban Dosing in Patients with Atrial Fibrillation Stratified by three Renal Function Formulae

Background: Clinical trials used Cockcroft-Gault (CG) formula to calculate the estimated glomerular filtration rate (eGFR) in order to dose rivaroxaban for patients with atrial fibrillation (AF). Objectives: The aim of this study is to evaluate rivaroxaban dosing appropriateness in patients with AF with or without renal impairment based on the CG formula and other formulae, including Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and the isotope dilution mass spectrometry (IDMS) traceable Modification of Diet in Renal Disease (MDRD) Study equation and the associated clinical outcomes. Methodology: A retrospective cohort study conducted at Sultan Qaboos University Hospital (SQUH) from 1st January 2016 to 31st December 2020, included all adult patients (≥ 18 years) treated with rivaroxaban for AF and followed up for one year after starting the treatment. Results: Based on the CG formula, the rivaroxaban dose was inappropriately prescribed in 27% of the patients (21% overdosed and 6% underdosed). Higher baseline creatinine (P=0.0014) and concurrent use of antiplatelet therapy (P<0.001) were associated with the tendency to rivaroxaban overdosing. Higher Body Mass Index (BMI) (P=0.002), female sex (P=0.032), and CKD (P=0.003) were associated with rivaroxaban underdosing. The degree of agreement between the renal function tests when comparing MDRD vs CG and CKD-EPI vs CG in terms of estimated glomerular filtration rate/creatine clearance (eGFR/CrCl) calculation was moderate (κ=0.46) and poor (κ=0.00), respectively, while, in terms of rivaroxaban dose appropriateness was almost perfect (κ=0.82) and substantial (κ=0.77). Clinical outcomes measured by stroke and bleeding events were not significantly different according to the appropriateness of the rivaroxaban dose. (AU)

Symptoms-triggered approach versus fixed-scheduled approach of benzodiazepines for management of alcohol withdrawal syndrome: Non-randomized controlled trial.

BACKGROUND: Alcohol withdrawal syndrome, if untreated, can lead to potentially life-threatening complications. Benzodiazepines are the drugs of choice for the treatment of alcohol withdrawal syndrome. We aimed to compare the symptoms-triggered approach and fixed-dose approach of benzodiazepine administration for treatment of alcohol withdrawal syndrome in regard to the health care utilization measured by the total dose of benzodiazepines, length of hospital stays, and 90-day readmissions rate. METHODS: A single-center prospective non-randomized controlled trial included all patients diagnosed with alcohol withdrawal syndrome. The group of patients admitted between October 1, 2019, and September 30, 2020, were treated with the fixed-scheduled approach (n = 150), while all patients admitted between November 1, 2020, to October 31, 2021, were treated with the symptoms-trigger approach (n = 50). RESULTS: The fixed-dose approach group showed a significant higher 90-day readmissions rate (HR: 2.61; 95% CI = 1.18, 6.84; p = 0.01). Kaplan-Meier survival analysis showed a significantly shorter duration to the first readmission in the fixed-scheduled approach group (HR: 2.3; 95% CI = 5.6, 1.16; p = 0.02). The symptoms-triggered approach group required a significantly lower dose of diazepam (40 mg vs. 10 mg; p < 0.01) and a higher dose of thiamine (800 mg vs. 600 mg; p < 0.01). Length of hospital stay was significantly increased in the symptoms-triggered approach group (3.9 vs. 2.2 days; p < 0.01). DISCUSSION: The use of a symptoms-triggered approach to treat alcohol withdrawal syndrome was associated with a lower 90-day readmission rate, prolonged period to the first readmission, and reduced total dose of benzodiazepines, but longer length of hospital stays. CONCLUSION: The symptoms-triggered approach is safe, cost-effective, and associated with reduced alcohol dependence relapse.

Impact of Clinical Pharmacists-driven Bundled Activities from Admission to Discharge on 90-day Hospital Readmissions and Emergency Department Visits.

Objectives: Patient-centered clinical pharmacists' activities play a major role in improving clinical outcomes by optimizing the efficacy of drug therapies and minimizing associated toxicities during hospitalization, at the transition of care, and upon discharge. We aimed to compare the impact of comprehensive versus partial clinical pharmacists-driven bundled of care services on the rate of 90-day hospital readmissions and emergency department (ED) visits. Methods: This retrospective study included all admitted patients who received a comprehensive or partial bundle of clinical pharmacy services (medication history, interventions, counseling, and discharge prescription review) from 1 January 2021 to 30 June 2021 at Sultan Qaboos University Hospital. The comprehensive bundle of care included the four services, while the partial bundle of care included one, two, or three services only. Analyses were performed using univariate and multivariate statistical techniques. Results: The study included 430 patients with a mean age of 56.021.0 years, and 43.7% (n = 188) were male. Of the patients, 12.1% (n = 52) received a comprehensive bundle of care. Compared with the partial bundle of care group, the comprehensive bundle of care group had significantly more patients with diabetes (65.4% vs. 42.9%; p =0.002), % 3 comorbidities (50.0% vs. 29.4%; p =0.003), and polypharmacy (% 5 medications) (73.1% vs. 46.0%; p < 0.001). The comprehensive bundle of care group was significantly associated with a lower 90-day readmission rate (adjusted odds ratio (aOR) = 0.27, 95% CI: 0.90?"0.82; p =0.021) but not with ED visits (aOR = 0.57, 95% CI: 0.13?"2.57; p =0.461). Conclusions: This study demonstrated a significant reduction in the 90-day readmission rate for patients on a comprehensive bundle of care but not ED visits. These findings emphasize the importance of the comprehensive services provided by clinical pharmacists on the healthcare resources use and clinical outcomes.

Incidence and Risk Factors for 28 Days Hospital Readmission: A Retrospective Study from Oman.

Objectives: We sought to evaluate the incidence of 28-day hospital readmission in a tertiary hospital in Oman and identify potential factors associated with increased risk of hospital readmission. Methods: We conducted a retrospective study of all adult patients (≥ 18 years) admitted under the care of the General Internal Medicine unit from 1 June to 31 December 2020 at Sultan Qaboos University Hospital. Elective admissions and COVID-19 infection-related admission were excluded from the study. Results: There were 200 patients admitted during the study period. The mean age was 58.6±19.3 years, and 106 (53.0%) patients were males. Forty-eight (24.0%) patients had unplanned readmission within 28-days after discharge from the hospital. Patients with 28 days unplanned readmission were older (66.6 vs. 56.0 years, p < 0.001) and had a longer length of hospital stay (6.0 vs. 4.0 days, p < 0.001). Also, hypertension (77.1% vs. 55.3%, p =0.007), diabetes mellitus (64.6% vs. 48.0%, p =0.045), and comorbidity (≥ 3 comorbidities, [43.8% vs. 23.8%, p =0.005]) were more prevalent in the unplanned readmission group. Patients with poor functional status (43.7% vs. 26.3%, p < 0.001), requiring feeding tube (25.0% vs. 5.3%, p < 0.001), and with polypharmacy (75.0% vs. 50.0%, p =0.003) were at increased risk of readmission. Conclusions: 28-day hospital readmission is prevalent in our health care setting. Old age, polypharmacy, comorbidities, and poor functional status were associated with an increased risk of hospital readmission. Therefore, evidence-based interventions must be implemented in our health care system to minimize the risk of hospital readmission.

The Impacts of Clinical Pharmacists' Interventions on Clinical Significance and Cost Avoidance in a Tertiary Care University Hospital in Oman: A Retrospective Analysis.

OBJECTIVES: Pharmaceutical interventions are implicit components of the enhanced role that clinical pharmacists provide in clinical settings. We aimed to study the clinical significance and analyze the presumed cost avoidance achieved by clinical pharmacists' interventions. METHODS: A retrospective study of documented clinical pharmacists' interventions at a tertiary care hospital in Oman was conducted between January and March 2022. The interventions were electronically recorded in the patients' medical records as routine practice by clinical pharmacists. Data on clinical outcomes were extracted and analyzed. Cost implications were cross checked by another clinical pharmacist, and then, cost avoidance was calculated using the Rx Medi-Trend system values. RESULTS: A total of 2032 interventions were analyzed, and 97% of them were accepted by the treating physicians. Around 30% of the accepted interventions were for antimicrobials, and the most common type was dosage adjustment (30%). Treatment efficacy was enhanced in 60% and toxicity was avoided in 22% of the interventions. The presumed cost avoided during the study period was USD 110,000 with a projected annual cost avoidance of approximately USD 440,000. CONCLUSION: There was an overall positive clinical and financial impact of clinical pharmacists' interventions. Most interventions have prevented moderate or major harm with a high physician acceptance rate. Optimal documentation of the interventions is crucial for emphasizing clinical pharmacists' value in multi-specialty hospitals.

Guideline-directed medical therapy in heart failure patients with reduced ejection fraction in Oman: utilization, reasons behind non-prescribing, and dose optimization.

Background Objective: To determine the reasons behind guideline-directed medical therapy (GDMT) non-prescribing, drug utilization before and after excluding those intolerable to GDMT, as well as dose optimization in heart failure (HF) patients with reduced ejection fraction (<40%) (HFrEF) in Oman. Methods: The study included HF patients seen at the medical outpatient clinics at Sultan Qaboos University Hospital, Muscat, Oman, between January 2016 and December 2019 and followed up until the end of June 2021. The use of renin-angiotensin-system (RAS) blockers (angiotensin-converting-enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) or angiotensin receptor-neprilysin inhibitors (ARNIs)), beta blockers and mineralocorticoid receptor antagonists (MRAs) were evaluated as per the European, American, and Canadian HF guidelines. Analyses were performed using univariate statistics. Results: A total of 171 HFrEF patients were enrolled for this study, the overall mean age of the cohort was 63 ± 15 years old and 59% were male. Over 65% of the patients had chronic kidney disease. Almost 55% of the patients were intolerable to GDMT. The proportion of patients on beta blockers, RAS blockers/ hydralazine-isosorbide dinitrate combination, and MRAs, before and after excluding those intolerable to GDMT, were 89%, 97%, and 77%, and, 94%, 47% and 85%, respectively, while the proportion of patients on the GDMT combination concomitantly was 41% and 83%, respectively. A total of 61%, 44% and 100% of the patients were prescribed ≥50% of the target dose for beta blockers, RAS blockers/ HYD-ISDN combination and MRAs respectively, while 19%, 8.2% and 94% of the patients attained 100% of the target dose for beta blockers, RAS blockers/ HYD-ISDN combination and MRAs respectively. Conclusions: Reasons behind GDMT non-prescribing were frequent and not clearly obvious in patients' medical notes. The majority of the patients were prescribed GDMT. However, dose optimization, specifically for beta blockers and RAS blockers/ HYD-ISDN combination, was still suboptimal. The findings should be interpreted in the context of low study power and that future studies, with larger sample sizes, are warranted to minimize this limitation.

Incidence, patterns, risk factors and clinical outcomes of intravenous acyclovir induced nephrotoxicity.

Objectives: Acyclovir is approved to treat herpes simplex virus (HSV) type 1, type 2 and varicella-zoster virus. It is mainly eliminated via the kidneys, for which drug crystals accumulation might lead to nephrotoxicity. This study aimed to determine the incidence, risk factors, preventive measures, and clinical outcomes of acyclovir induced-nephrotoxicity. Methods: This is a retrospective cohort study of patients >12 years of age at Sultan Qaboos University Hospital (SQUH) receiving IV acyclovir therapy between January 2016 and December 2020. Results: Out of 191 included patients, 40 (20.1%) developed acyclovir induced-nephrotoxicity. Age (per year older: OR 1.04, 95 %CI 1.01-1.07), total duration of treatment (per day OR1.19, 95 %CI 1.06-1.33), and concomitant use of vancomycin (OR 5.96, 95 %CI 1.87-19.01) were significant independent risk factors for acyclovir induced-nephrotoxicity development. Nine patients (4.5%) died during the same hospitalization, including those three patients who required renal replacement therapy (1.5%). Conclusion: Frequent monitoring of kidney function for older patients with concurrent use of vancomycin and IV hydration is essential to prevent IV acyclovir induced-nephrotoxicity. Antimicrobial stewardship is a crucial method to reduce the duration of treatment with IV acyclovir as appropriate.

Levels of agreement among clinical pharmacists on the impact of pharmaceutical interventions in Oman: A retrospective analysis

Objectives: Disagreement between health care providers on medication-related interventions can affect clinical outcomes. We aimed to study the outcomes and significance of clinical pharmacists’ interventions and evaluate the levels of agreement between different clinical pharmacists on the impact of pharmaceutical interventions. Methodology: A retrospective study was conducted at a tertiary care hospital in Oman. The study included all documented interventions by clinical pharmacists for all categories of admitted patients that met the inclusion criteria. Results: The originator clinical pharmacists interjected to improve the efficacy of treatment in (58%, n=1740) of the interventions, followed by toxicity reduction (24%). The level of agreement in the clinical significance resulted in substantial Scotts’ kappa (k) between the originator and the first reviewer, the first and second reviewers, and the second reviewer and supervisor (86%; k=0.77; P<.001), (77%; k=0.63; P<.001), (84%; k=0.77; P<.001), respectively. In terms of grading of clinical significance, the originator clinical pharmacists recorded moderate significance in 50% of the interventions, followed by major (30%), not applicable (8.4%), and minor (7.3%). The level of agreement in the clinical significance resulted in substantial Scotts’ k between the originator and the first reviewer, and between the second reviewer and supervisor (82%; k=0.72; P<.001), (84%; k=0.77; P<.001), respectively. The level of agreement between the first and second reviewer was fair (55%; k=0.28; p<0.001). Conclusion: Clinical pharmacists’ interventions have a crucial impact on patient safety, improving efficacy and reducing toxicities. Overall, there was a substantial agreement among clinical pharmacists on the clinical significance and grading of the interventions. (AU)

Vancomycin Therapeutic Drug Monitoring (TDM) and Its Association with Clinical Outcomes: A Retrospective Cohort.

BACKGROUND: Therapeutic drug monitoring (TDM) has proven effectiveness in maintaining efficacy and reducing toxicities associated with vancomycin. A trough level of (15-20 mg/L) for MRSA serious infections is recommended. Therapeutic failure is of concern due to suboptimal routine vancomycin utilization in clinical practice. This study aims to identify factors of vancomycin TDM practice potentially associated with vancomycin-induced nephrotoxicity and therapeutic failure measured by the need to restart vancomycin therapy within 28-days and all-cause mortality in a tertiary hospital in Oman. METHODS: A single-center retrospective cohort was conducted in a tertiary care hospital that included all adult patients aged ≥ 18 years treated with IV vancomycin for> 72 h. RESULTS: Vancomycin therapeutic level was not achieved in 16.8% of the patients, and 47.5% had high levels (>20 mg/L). Vancomycin-induced nephrotoxicity occurred in 31.7% of the patients, it was restarted within 28-days in 18.8% of the patient, and 25.2% of the patients died during the same hospitalization. Univariate analysis showed old age (p < 0.01), higher baseline creatinine reading (p = 0.03), high vancomycin level (p = 0.03), and vancomycin-induced nephrotoxicity (p < 0.01) were associated with increased all-cause mortality. Multivariate analysis identified overweight and vancomycin-induced nephrotoxicity were independent factors associated with increased all-cause mortality (OR:1.04; p = 0.043; 95% CI 1.00-1.08) and (OR:1.96; p = 0.049; 95% CI 1.00-21.61) respectively. CONCLUSION: Failure to achieve the recommended therapeutic vancomycin level (15-20 mg/L) is common in clinical practice and associated with poor health outcomes; hence, appropriate TDM practice is an essential exercise to improve efficacy, prevent failure and reduce serious toxicities associated with vancomycin therapy.

Guideline-directed medical therapy in heart failure patients with reduced ejection fraction in Oman: utilization, reasons behind non-prescribing, and dose optimization

Background: Objective: To determine the reasons behind guideline-directed medical therapy (GDMT) non-prescribing, drug utilization before and after excluding those intolerable to GDMT, as well as dose optimization in heart failure (HF) patients with reduced ejection fraction (<40%) (HFrEF) in Oman. Methods: The study included HF patients seen at the medical outpatient clinics at Sultan Qaboos University Hospital, Muscat, Oman, between January 2016 and December 2019 and followed up until the end of June 2021. The use of renin-angiotensin-system (RAS) blockers (angiotensin-converting-enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) or angiotensin receptor-neprilysin inhibitors (ARNIs)), beta blockers and mineralocorticoid receptor antagonists (MRAs) were evaluated as per the European, American, and Canadian HF guidelines. Analyses were performed using univariate statistics. Results: A total of 171 HFrEF patients were enrolled for this study, the overall mean age of the cohort was 63 ± 15 years old and 59% were male. Over 65% of the patients had chronic kidney disease. Almost 55% of the patients were intolerable to GDMT. The proportion of patients on beta blockers, RAS blockers/ hydralazine-isosorbide dinitrate combination, and MRAs, before and after excluding those intolerable to GDMT, were 89%, 97%, and 77%, and, 94%, 47% and 85%, respectively, while the proportion of patients on the GDMT combination concomitantly was 41% and 83%, respectively. A total of 61%, 44% and 100% of the patients were prescribed ≥50% of the target dose for beta blockers, RAS blockers/ HYD-ISDN combination and MRAs respectively, while 19%, 8.2% and 94% of the patients attained 100% of the target dose for beta blockers, RAS blockers/ HYD-ISDN combination and MRAs respectively. (AU)