European journal of hospital pharmacy : science and practice最新文献

Background: The term stratification is increasingly used in pharmaceutical care to guide the allocation of interventions and optimise patient follow-up. However, its conceptual boundaries remain ambiguous and are frequently conflated with related constructs such as triage, clinical scoring or prioritisation, thereby compromising consistency in implementation. This lack of conceptual clarity hinders the development of standardised tools and limits the comparability and transferability of stratified care models in clinical pharmacy practice.

Objective: To clarify the concept of stratification in pharmaceutical care by identifying its defining attributes, antecedents, consequences and empirical referents.

Methods: A structured concept analysis was conducted using the Walker and Avant framework. A comprehensive literature search was performed across major biomedical databases covering the period from January 2000 to May 2025. Empirical studies, theoretical articles, conceptual frameworks and models addressing stratification or patient prioritisation in pharmaceutical care and related health services were included. Relevant publications were screened independently by both authors and analysed thematically.

Results: Eleven publications were included in the concept analysis. Four defining attributes of stratification in pharmaceutical care were identified: patient-centred segmentation, prioritisation of care intensity, resource-sensitive allocation and structured re-stratification over time. Key antecedents included increasing clinical complexity, limited pharmacist availability and the need for value-based care. Consequences and empirical referents were also identified, allowing stratification to be distinguished from related constructs such as triage or risk scoring.

Conclusion: This concept analysis establishes a theory-based conceptual foundation for stratification in pharmaceutical care. Clarifying its meaning may support greater conceptual consistency and inform the development, implementation and evaluation of structured patient prioritisation models across healthcare settings.

Objectives: Transfusion-dependent β-thalassaemia (TDT) requires lifelong blood transfusions, resulting in progressive iron overload and liver injury. Serum ferritin is a practical surrogate for iron burden, while liver function tests (LFTs) may reflect hepatic damage. However, the influence of gender and the chelation regimen on the ferritin-LFT relationship remains underexplored. This study evaluated these associations in a large Iraqi TDT cohort.

Methods: A retrospective cross-sectional study was conducted on 323 patients with TDT at the Center of Hereditary Blood Diseases, Karbala, Iraq. Data on demographics, ferritin, LFTs, transfusion history and chelation regimen were collected. Mann-Whitney U test, Fisher's exact test, Spearman's correlation and multiple linear regression were used to explore predictors of ferritin, including interaction terms. Receiver operating characteristic (ROC) analysis assessed aspartate aminotransferase (AST) and alanine aminotransferase (ALT) cut-offs for predicting ferritin >2500 ng/mL.

Results: Median ferritin was 2214 ng/mL. AST (ρ=0.581) and ALT (ρ=0.516) showed strong positive correlations with ferritin (p<0.001). Gender-stratified analyses revealed consistent AST-ferritin associations, with females demonstrating additional links involving bilirubin and alkaline phosphatase (ALP). Patients on deferasirox (DFX) + deferoxamine (DFO) had higher ferritin, AST and ALT than DFX alone (p<0.001). In regression models, AST and DFX+DFO were independent predictors overall, while subgroup models identified bilirubin and interaction effects in females, and bilirubin-treatment interactions in the DFX+DFO group. ROC analysis showed AST cut-offs were lower in females and combination therapy, though predictive accuracy remained high (AUC >0.79 in all subgroups).

Discussion: Gender and the chelation regimen modify the ferritin-LFT relationship in TDT. AST is a consistent predictor of ferritin across all groups, while bilirubin and interaction terms contribute in specific subgroups. These findings highlight the need for gender- and regimen-specific interpretation of biochemical markers, especially where advanced iron assessment is unavailable.

Objective: Atrial fibrillation in elderly patients increases the risk of thromboembolism, necessitating long-term anticoagulation. While non-vitamin K oral anticoagulants (NOACs) are generally preferred, appropriate dosing in older patients who are frail remains a challenge. This study aimed to evaluate the impact of NOAC underdosing and identify bleeding risk factors using artificial intelligence in a local elderly population.

Methods: A retrospective study was conducted that included 119 patients with atrial fibrillation who were treated with apixaban or rivaroxaban between October 2020 and May 2022. Patients were categorised based on whether NOAC prescriptions were in accordance with dosing recommendations. Bivariate analyses and univariable logistic regression were performed to assess associations with clinical outcomes. To identify bleeding risk factors, a combination of stepwise logistic regression, learning vector quantisation and variable permutation was used. These risk factors were then used to develop supervised machine learning models to predict bleeding risk, for interpretation purposes.

Results: Significant differences in bleeding and thrombotic events were observed between patients with guideline-concordant and underdosed prescriptions. Using univariable logistic regression, underdosing NOACs was associated with a lower risk of bleeding (OR 0.3) but a higher risk of thrombosis (OR 6.7). In the multivariable analysis, guideline adherence, sex and NOAC choice were identified as key predictors of bleeding events. Guideline-concordant prescriptions were independently associated with an increased bleeding risk.

Conclusions: Underdosing NOAC was associated with a reduced bleeding risk but at the cost of a markedly increased thrombosis risk. Guideline-concordant dosing was also associated with higher bleeding risk in the multivariable model. Overall, the results do not support systematic underdosing of NOACs in elderly patients. These findings were shared with local prescribers to reinforce appropriate dosing practices and to improve follow-up for patients identified as being at increased bleeding risk.

Background: Alcohol-related liver disease (ALD) causes approximately one-fifth of all alcohol-related deaths. Only 4% of patients with alcohol use disorder (AUD) receive medications for AUD, such as acamprosate. Medications for AUD may decrease progression of ALD. Challenges in treating AUD include limited primary care physician familiarity with medications. Gabapentinoids are occasionally used but are not approved for AUD treatment, and primary care physicians are familiar with them. This study aimed to examine the association between both therapies and progression of ALD among patients with AUD.

Methods: This was a retrospective propensity score (PS)-matched cohort study using data from the Veterans Affairs healthcare records. Patients with AUD who were started on acamprosate or gabapentinoids after being diagnosed with AUD were identified. The primary outcome was the composite outcome of ALD progression (alcoholic hepatitis, compensated cirrhosis, decompensated cirrhosis and hepatocellular carcinoma). The secondary outcome was alcohol-related admission. A PS encompassing 80 variables was created and patients who used acamprosate and gabapentinoid were matched into pairs. Another PS-matched cohort was created that was restricted to patients who continued their medications for ≥120 days (persistent cohort).

Results: 24 477 pairs of patients who used acamprosate and gabapentinoid were PS matched. The primary outcome occurred in 15.78% of patients using acamprosate and 13.37% of those using gabapentinoid (OR 1.21; 95% CI 1.15 to 1.27). Alcohol-related admission occurred in 24.73% of patients using acamprosate and 18.01% of those using gabapentinoid (OR 1.50; 95% CI 1.43 to 1.56). Similar outcomes were observed in a PS-matched persistent cohort of 12 258 pairs.

Conclusion: Gabapentinoids were associated with a decreased risk of ALD progression and alcohol-related admission compared with acamprosate. Gabapentinoids may be a viable tool to decrease progression of ALD in AUD. Further studies are needed to examine whether gabapentinoids are associated with less heavy drinking only or with higher abstinence.

Background: Type 2 diabetes mellitus (T2DM) and hypertension are prevalent global health concerns associated with increased morbidity, mortality and healthcare expenditure. This study evaluated the effectiveness of patient-centred care (PCC) and population health management (PHM) strategies in improving clinical outcomes and medication adherence among patients with co-existing T2DM and hypertension in Hounslow, UK.

Study design: Quantitative intervention study.

Methods: A total of 221 patients were selected from 6000 attendees at West Middlesex University Hospital's pre-assessment clinic. Participants were allocated into three groups. Study 1 was a randomised controlled pilot trial with 40 patients assigned to either a PCC intervention group (n=20) or a usual care group (n=20) over 6 months. Study 2 involved 41 patients receiving a pharmacist/nurse-led collaborative PCC intervention for 6 months. Study 3 included 140 patients enrolled in a 6-month community-based PHM lifestyle programme integrated with PCC. Data collection involved patient questionnaires and hospital records, focusing on clinical and behavioural outcomes.

Results: In study 1, the PCC group showed a significant reduction in glycated haemoglobin (HbA1c) (mean decrease 23.2 mmol/mol, 95% CI 4.3 to 42.1) and improved medication adherence compared with controls. The number needed to treat (NNT) was 1.8 (95% CI 1.3 to 7.6). Study 2 participants experienced significant reductions in systolic (27.5 mm Hg) and diastolic (9.1 mm Hg) blood pressure, and HbA1c (23.1 mmol/mol) (all p<0.001). In study 3, 90% of patients with elevated body mass index achieved 5-10% weight loss, and 82% reported an increase in moderate or higher physical activity levels.

Conclusion: PCC and PHM integration led to substantial improvements in glycaemic control, blood pressure, weight management and physical activity. These findings support the adoption of community-based PCC models to manage chronic conditions effectively and improve public health outcomes.

Objective: To determine the prevalence, severity and characteristics of potential drug-drug interactions (DDIs) in a homogeneous cohort of patients with early-stage breast cancer receiving adjuvant or neoadjuvant chemotherapy.

Methods: We performed a retrospective observational study of patients treated with systemic chemotherapy at a tertiary hospital. All medications prescribed during chemotherapy were recorded. Potential DDIs were identified using the Lexicomp database and classified by risk level, clinical severity, quality of evidence and mechanism of action. Associations between patient-related factors and DDIs were analysed.

Results: A total of 273 patients were included (median age 52 years) and 56% had at least one comorbidity. Overall, 2842 drugs were prescribed (median 10 per patient), resulting in 2287 potential DDIs. All patients presented at least one DDI; 89% had at least one type D interaction and 14.6% at least one type X interaction. Most DDIs were classified as type C (75.3%), followed by type D (21.7%) and type X (3.0%). The total number of DDIs was significantly associated with age, comorbidity burden and number of prescribed drugs.

Conclusions: Potential DDIs are highly prevalent in patients with early-stage breast cancer receiving chemotherapy, with a substantial proportion involving clinically significant or contraindicated combinations. Polypharmacy, age and comorbidities are key risk factors, highlighting the importance of systematic medication review and interdisciplinary collaboration to improve treatment safety.

Objectives: Clinical pharmacy care in German hospitals has recently evolved, driven by digitalisation and legal reforms. The only comprehensive overview of clinical pharmacy care in Germany was published in 2019. The current survey aims to update and describe the status quo of clinical pharmacy services in Germany, highlighting developments in this field since the previous publication.

Methods: In 2024, an online survey with 45 questions was carried out among chief pharmacists, organised within the German Federal Association of Hospital Pharmacists (ADKA) e.V. (n=328). The survey collected structural data (eg, beds and workforce), as well as information on the extent and range of clinical pharmacy services.

Results: The survey received 135 responses, resulting in a response rate of 41%. The provision of clinical pharmacy services (CPS) was already well established in 114 pharmacies (85.7%), meaning at least 32.4% of all German hospital pharmacies offer CPS. The average number of full-time equivalents dedicated to these services per hospital pharmacy is 4.3, which is an increase of1.9 full-time equivalents compared with the first survey. Regular visits (at least once a week) are reported in the range of 80% for most surgical disciplines, haematology/oncology and critical care/anaesthesia. The regular patient-centred services were offered daily or 2-3 times weekly, respectively.

Conclusions: This follow-up survey provides a comprehensive overview of the developments since the initial survey, offering a detailed analysis of the current status of CPS in German hospitals. A general improvement has been observed regarding the range of services offered, utilisation of workforce resources and frequency of service delivery. Despite this positive development, further measures are necessary to ensure the enhancement and improvement of CPS in all hospitals.

Objectives: Drug shortages, particularly in anaesthesia, pose a risk to patient care. Propofol, a widely used anaesthetic, is formulated as an emulsion requiring a complex industrial manufacturing and pharmaceutical supply chain, making propofol vulnerable. Cyclodextrins can enhance the aqueous solubility of lipophilic drugs and may provide an alternative approach. The objective of this study was to develop and evaluate a ready-to-use cyclodextrin-based propofol formulation that could be prepared in a hospital pharmacy using standard equipment.

Methods: A 1% (w/v) propofol solution was prepared using hydroxypropyl-β-cyclodextrin (HP-β-CD). The association constant (Ka) was calculated using the Higuchi and Connors method. The solution was sterilised by 0.22 µm filtration or by autoclaving at 121°C for 15 min. Stability was assessed over 90 days at 2-8°C and 20-25°C. A validated HPLC-UV method was used to quantify propofol and detect degradation products. Additional quality controls included pH, osmolality, subvisible particles, sterility and endotoxin levels.

Results: The Ka was 1288±32 M⁻¹. A clear 1% (w/v) solution was obtained with 17% (w/v) HP-β-CD and 0.35% (w/v) sodium chloride, without pH adjustment. Both sterilisation methods preserved drug integrity. The formulation remained stable for 3 months under refrigeration. At room temperature, degradation occurred after 14 days.

Conclusion: This study demonstrates the feasibility of a hospital-based preparation of a sterile injectable propofol solution using cyclodextrins. These results support the role of hospital pharmacies in addressing drug shortages by enabling locally controlled and resilient production capacity.

Posterior reversible encephalopathy syndrome (PRES) is a neurological condition associated with seizures, visual disturbances and altered mental status. It is commonly linked to immunosuppressive therapies such as ciclosporin, widely used in recipients of a haematopoietic stem cell transplant (HSCT). Neuroimaging, especially MRI, is the most important diagnostic tool for PRES, as it typically shows bilateral and symmetrical involvement of the occipital and parietal regions with white matter oedema.Electroencephalography may be useful for the detection of (non-convulsive) epileptic seizures, status epilepticus and may play a role in the evaluation of encephalopathy. We present the case of a 12-year-old boy who developed PRES during ciclosporin treatment for graft versus host disease prophylaxis following allogeneic HSCT. After early recognition, discontinuation of ciclosporin and appropriate management, full clinical recovery was achieved. This case highlights the importance of early detection and multidisciplinary management to prevent permanent neurological damage in paediatric recipients of a transplant.