Enhancing medication management in hemodialysis patients: Exploring the impact of patient-centered pharmacist care and motivational interviewing.

BACKGROUND: Patients on hemodialysis (HD) often uses several medications, making them highly susceptible to medication-related problems (MRP) thereby leading to medication nonadherence. Therefore, an innovative pharmaceutical care strategy incorporating drug therapy optimization (DTO) and motivational interviewing (MI) can mitigate medication-related problems and optimize patient care. AIMS AND OBJECTIVE: The objective of this study is to assess the efficacy of pharmacist led interventions in utilizing DTO and MI techniques in managing medication related problems among patients undergoing hemodialysis. METHOD AND DESIGN: A12-months, cross sectional prospective study was conducted among 63 End Stage Renal Disease (ESRD) patients on HD. DTO was conducted by the pharmacist to identify the MRP by reviewing complete medication list gathered from patient interview and medical records. All MRPs was classified using the PCNE classification version 9.00 and medication issues, that require patient involvement were categorized as patient-related, while those that necessitate physician intervention were classified as physician-related. The DTO was performed at the baseline, 6-month and at the final month of the study. Identified medication issues were communicated to the site nephrologist and was tracked during next follow up. Whereas MI was conducted physically at Month-3 and via telephone on month-6 and month-9 to address patient related medication issues. RESULTS: Mean age of the study population was 48.5±14 years. While the mean number of prescribed medications was 8.1±2 with 57% of the patients taking more than 5 types of medication. After 12 months of pharmacist intervention using DTO and MI, a mean reduction in MRP was observed for both patient-related and physician-related MRPs across three time series. However, further analysis using repeated measure ANOVA revealed that the reduction in patient-related MRPs was statistically significant [F(1.491, 92.412) = 60.921, p < 0.05], while no statistically significant difference was detected in physician-related MRPs [F(2, 124) = 2.216, P = 0.113]. CONCLUSION: Pharmaceutical care service through DTO and MI can effectively reduce and prevent drug-related issues to optimize medication therapy among HD patients.

Study protocol: Effectiveness of patient centered pharmacist care in improving medication adherence, clinical parameters and quality of life among hemodialysis patients.

BACKGROUND: Patients requiring hemodialysis (HD) often have several chronic comorbidities, which necessitate the use of several medications and hence put them at high risk of polypharmacy. Medication-related problems (MRPs) among HD patients are a serious issue as they can increase morbidity and nonadherence with medications. To overcome this issue, a unique pharmacy practice model including medication review (MR) and motivational interviewing (MI) is needed to improve medication adherence, by reducing MRPs and optimizing therapeutic outcomes. The present study aims to assess the effectiveness of MR and MI in improving medication adherence, quality of life (QOL) and clinical outcomes among end-stage renal disease (ESRD) patients who are on dialysis. METHOD AND DESIGN: This pre-post study will be conducted prospectively among patients with ESRD who have been on dialysis at the Hemodialysis Unit, Hospital Kuala Lumpur and the Hemodialysis Affiliated Centers of the University Malaya Medical Centre, from August 2020 till August 2021. Medication adherence will be assessed using the General Medication Adherence Scale (GMAS), whilst patients' HRQOL will be assessed using the Kidney Disease Quality of Life Short Form 36 (KDQOL-36). Clinical parameters such as blood glucose level, calcium, phosphate, hemoglobin and serum low-density lipoprotein (LDL) levels will be obtained from medical records. A total of 70 patients will be recruited. DISCUSSION: We hypothesize that the implementation of pharmacy-based MR and MI may expect an increase in medication adherence scores and increase in HRQOL scores from baseline as well as achieving the clinical lab parameters within the desired range. This would indicate a need for a pharmacist to be involved in the multidisciplinary team to achieve a positive impact on medication adherence among hemodialysis patients. TRIAL REGISTRATION: Ethical approval has been obtained from the National Medical Research and Ethics Committee NMRR: 20-1135-54435 and Medical Research Ethics Committee, University Malaya Medical Centre MREC ID NO: 202127-9811.

Effects of short-term exercise in the heat on thermoregulation, blood parameters, sweat secretion and sweat composition of tropic-dwelling subjects.

This study investigates the effects of a short-term aerobic training program in a hot environment on thermoregulation, blood parameters, sweat secretion and composition in tropic-dwellers who have been exposed to passive heat. Sixteen healthy Malaysian-Malay male volunteers underwent heat acclimation (HA) by exercising on a bicycle ergometer at 60% of VO2max for 60 min each day in a hot environment (Ta: 31.1+/-0.1 degrees C, rh: 70.0+/-4.4%) for 14 days. All parameters mentioned above were recorded on Day 1 and at the end of HA (Day 16). On these two days, subjects rested for 10 min, then cycled at 60% of VO2max for 60 min and rested again for 20 min (recovery) in an improvised heat chamber. Rectal temperature (Tre), mean skin temperature (Tsk) heart rate (HR), ratings of perceived exertion (RPE), thermal sensation (TS), local sweat rate and percent dehydration were recorded during the test. Sweat concentration was analysed for sodium [Na+]sweat and potassium. Blood samples were analysed for biochemical changes, electrolytes and hematologic indices. Urine samples were collected before and after each test and analysed for electrolytes.After the period of acclimation the percent dehydration during exercise significantly increased from 1.77+/-0.09% (Day 1) to 2.14+/-0.07% (Day 16). Resting levels of hemoglobin, hematocrit and red blood cells decreased significantly while [Na+]sweat increased significantly. For Tre and Tsk there were no differences at rest. Tre, HR, RPE, TS, plasma lactate concentration, hemoglobin and hematocrit at the 40th min of exercise were significantly lower after the period of acclimation but mean corpuscular hemoglobin and serum osmolality were significantly higher while no difference was seen in [Na+]sweat and Tsk. It can be concluded that tropic-dwelling subjects, although exposed to prolonged passive heat exposure, were not fully heat acclimatized. To achieve further HA, they should gradually expose themselves to exercise-heat stress in a hot environment.

Effects of exercise in the heat on thermoregulation of Japanese and Malaysian males.

The effect of low-intensity exercise in the heat on thermoregulation and certain biochemical changes in temperate and tropical subjects under poorly and well-hydrated states was examined. Two VO2max matched groups of subjects consisting of 8 Japanese (JS) and 8 Malaysians (MS) participated in this study under two conditions: poorly-hydrated (no water was given) and well-hydrated (3 mL x Kg(-1) body weight of water was provided at onset of exercise, and the 15th, 35th and 55th min of exercise). The experimental room in both countries was adjusted to a constant level (Ta: 31.6+/-0.03 degrees C, rh: 72.3+/-0.13%). Subjects spent an initial 10 min rest, 60 min of cycling at 40% VO2max and then 40 min recovery in the experimental room. Rectal temperatures (Tre) skin temperatures (Tsk), heart rate (HR), heat-activated sweat glands density (HASG), local sweat rate (M sw-back) and percent dehydration were recorded during the test. Blood samples were analysed for plasma glucose and lactate levels.The extent of dehydration was significantly higher in the combined groups of JS (1.43+/-0.08%) compared to MS (1.15+/-0.05%). During exercise M sw-back was significantly higher in JS compared to MS in the well-hydrated condition. The HASG was significantly more in JS compared to MS at rest and recovery. Tre was higher in MS during the test. Tsk was significantly higher starting at the 5th min of exercise until the end of the recovery period in MS compared to JS. In conclusion, tropical natives have lower M sw-back associated with higher Tsk and Tre during the rest, exercise and recovery periods. However, temperate natives have higher M sw-back and lower Tsk and Tre during experiments in a hot environment. This phenomenon occurs in both poorly-hydrated and well-hydrated states with low intensity exercise. The differences in M sw-back, Tsk and Tre are probably due to a setting of the core temperature at a higher level and enhancement of dry heat loss, which occurred during passive heat exposure.

Rehydration after exercise with fresh young coconut water, carbohydrate-electrolyte beverage and plain water.

This is to cross-over study to assess the effectiveness of fresh young coconut water (CW), and carbohydrate-electrolyte beverage (CEB) compared with plain water (PW) for whole body rehydration and blood volume (BV) restoration during a 2 h rehydration period following exercise-induced dehydration. Eight healthy male volunteers (mean age and VO2max of 22.4 +/- 3.3 years and 45.8 +/- 1.5 ml min kg-1 respectively) exercised at 60% of VO2max in the heat (31.1 +/- 0.03 degrees C, 51.4 +/- 0.1% rh) until 2.78 +/- 0.06% (1.6 +/- 0.1 kg) of their body weight (BW) was lost. After exercise, the subjects sat for 2 h in a thermoneutral environment (22.5 +/- 0.1 degrees C; 67.0 +/- 1.0% rh) and drank a volume of PW, CW and CEB on different occasions representing 120% of the fluid loss. A blood and urine sample, and the body weight of each subject was taken before and after exercise and at 30 min intervals throughout a rehydration period. Each subject remained fasted throughout rehydration. Each fluid was consumed in three portions in separate trials representing 50% (781 +/- 47 ml), 40% (625 +/- 33 ml) and 30% (469 +/- 28 ml) of the 120% fluid loss at 0, 30 and 60 min of the 2 h rehydration period, respectively. The drinks given were randomised. In all the trials the subjects were somewhat hypohydrated (range 0.08-0.18 kg BW below euhydrated BW; p > 0.05) after a 2 h rehydration period since additional water and BW were lost as a result of urine formation, respiration, sweat and metabolism. The percent of body weight loss that was regained (used as index of percent rehydration) during CW, PW, and CEB trials was 75 +/- 5%, 73 +/- 5% and 80 +/- 4% respectively, but was not statistically different between trials. The rehydration index, which provided an indication of how much of what was actually ingested was used for body weight restoration, was again not different statistically between trials (1.56 +/- 0.14, 1.36 +/- 0.13 and 1.71 +/- 0.21 for CW, CEB and PW respectively). Although BV restoration was better with CW, it was not statistically different from CEB and PW. Cumulative urine output was similar in all trials. There were no difference at any time in serum Na+ and Cl-, serum osmolality, and net fluid balance between the three trials. Urine osmolality decreased after 1 h during the rehydration period and it was lowest in the PW trial. Plasma glucose concentrations were significantly higher compared with PW ingestion when CW and CEB were ingested during the rehydration period. CW was significantly sweeter, caused less nausea, fullness and no stomach upset and was also easier to consume in a larger amount compared with CEB and PW ingestion. In conclusion, ingestion of fresh young coconut water, a natural refreshing beverage, could be used for whole body rehydration after exercise.