Pharm D focuses on healthcare - The Hindu

Pharm D focuses on healthcare - The Hindu

PUBLIC & ADR REPORTING

Although pharmacovigilance initiative was launched in the country by Indian Pharmacopoeia Commission in 2010 to build a national data base of adverse drug reactions of drugs marketed in the country, its progress has not been rather satisfactory. Currently, there are only 90 medical colleges, laboratories and hospitals registered under the PvPI programme monitoring ADRs of the drugs marketed in the country. The largest number of ADR centres are located in Karnataka followed by Tamil Nadu. Through this ADR centres, IPC has been able to collect a data base of 54000 ADR reports from different parts of the country. IPC intends to bring in all the medical colleges across the country under the pharmacovigilance programme in the next few years. By the end of March 2014, the target is to increase the number to 150 and by 2015, the ADR centres are expected to be 350 making the pharmacovigilance programme of India the largest in the world. There is no doubt that a country of India’s size requires a massive capacity building for this programme and the number of these centres should have been expanded much faster.

Regular monitoring of clinical data of patients taking both old and newly approved drugs is considered necessary to determine their safety and efficacy as the 3 phase clinical trials usually cover only a few thousands of subjects. Adverse drug reaction of some of the drugs may be only known when the drug is launched in the market and lakhs of people start using them. Therefore, post marketing surveillance and regular monitoring ADRs of drugs is extremely necessary for the health authorities to decide their safety. ADRs of a large number of drugs have been reported in India and other countries in recent years. It has been observed that the patients from across the country have been showing cases of side effects long after they have been under the medication of these drugs. The data from the ADR centres indicate the disturbing fact that some of the drugs considered to  be safe, have been showing signs of adverse reactions on the patients over the years. This is mainly because of the fact that post marketing studies are not undertaken by pharmaceutical companies in India. Pharma companies are required to submit Periodic Safety Update Reports listing side effects, fatalities and injuries of every approved drugs to DCGI every  six months in the first two years and then annually in the following two years. This is not being done by most companies in India although submission of such surveillance data is mandatory. Considering the present status of ADR reporting in the country, there is need for involving pharmacists, patients and general public in this exercise by educating and training them about drug reaction reporting. A public awareness campaign on ADRs by the state health departments and pharmacy councils can be a good initiative.

by

Dr.Akshaya Srikanth B

Pharm.D India

Understanding Issues and Challenges Faced by Many Patients

Now we see how putting the focus on the patient instead of the product has changed the communication. Even in his body language, the pharmacist now shows empathy and active listening, looking at the patient this time instead of at the medicine bottle.

Cultural competence is increasingly important as the diversity of our society increases. A background awareness of the issues facing newcomers to Indians also helps facilitate communication and achieve the healthcare goal. The pharmacist was patient and helpful with the language gap, and sought understanding instead of assuming. The pharmacist was also sensitive to the financial challenges and to the challenges in healthcare access and navigation that can affect Indians.

The key features of cultural competence for organizations include: 

1.Valuing diversity 

2.Conducting cultural self-assessment 

3.Managing the dynamics of difference 

4.Acquiring and institutionalizing cultural knowledge 

5.Adapting to diversity in defining policies and values

When communication barriers arise, whether due to cultural differences or another cause, active listening will help close the gap. Briefly stated, active listening means focusing on what the patient is saying, and then stating it back to them in your own words to allow them to confirm your understanding. Showing empathy in your choice of phrasing will help the patient feel that you have understood both the information – and how they are feeling. 

Embarrassment can often come into play in discussing health issues with patients in the pharmacy. In our next scenario, we see that this is sometimes why the question a patient asks is not the question they really want to know.
Yours 
Dr.B.Akshaya Srikanth
Pharm.D India

Diabetic Peripheral Neuropathy : Nerve damage to diabetes

Peripheral neuropathy is damage to nerves in the peripheral nervous system, the set of connections that link nerve impulses between the central nervous system (brain and spinal cord) and the outlying areas of the body. Although it is not entirely clear why diabetes causes nerve damage, it is thought to be a result of poorly controlled blood sugar over a long period of time.

There are three general types of nerves that can be damaged in peripheral neuropathies—the sensory, autonomic, and motor nerves. Diabetic peripheral neuropathy (DPN) that affects the sensory nerves results in symptoms such as numbness, tingling, increased sensitivity to touch, and burning in the feet, legs, hands, and arms. When autonomic nerves are damaged, symptoms include problems with digestion, breathing, vision, heartbeat, sexual function, and bladder control. Motor nerve damage can be seen in patients with muscle weakness, cramping, or twitching.

The best treatment for DPN is prevention, and tightly controlling glucose levels is the key to success. It is important to maintain a healthy diet, exercise regularly, and limit alcohol. Proper foot care is essential to avoid infections. Nicotine constricts blood flow to peripheral nerves, so smoking cessation is very important to prevent the progression of diabetic nerve damage. Specific treatments are available for individual types of neuropathies, including oral and topical medications that ease pain, regulate blood pressure and heart rate, improve gastric emptying time and digestion, and enhance urinary and sexual function.

Regular Foot Care Is Essential to Prevent Infection

High blood sugar can lead to damage of the sensory, autonomic, and motor nerves that play an important role in health. The risk of nerve damage increases with time, so most of the health consequences of long-term diabetes occur many years after diagnosis. Eventually, more than half of all diabetics will have some degree of peripheral neuropathy, although not everyone will suffer from its symptoms. It is likely that high blood sugar, high cholesterol, hypertension, and obesity contribute to the damage of peripheral nerves.

Types of Nerve Damage

Diabetic peripheral neuropathy (DPN) of the sensory nerves signals a problem with the transmission of sensations between the brain and the distant nerves of the arms and legs. A common symptom of sensory nerve damage is numbness. When sensation is lost in the extremities, especially the toes and feet, there is no warning of injury or infection. Without proper foot care, this loss of sensation can result in serious infections that require amputation. Another form of sensory nerve damage involves increased sensitivity to touch, tingling, pins-and-needles sensations, and burning, often beginning in the feet, slowly moving up the legs, or progressing from the fingers to hands to arms.

Autonomic nerve damage can affect a variety of organs and their function. Difficulty swallowing, slowed stomach emptying, constipation, and diarrhea are potential problems with digestion that are controlled by autonomic nerves. The autonomic nerves also control heart rate and blood pressure, so heartbeats may be too fast or irregular, and dizziness can be a problem when standing up from a sitting position. Patients with diabetes have a higher risk of cataracts, glaucoma, and retinopathy, which can cause blindness. Other conditions that result from autonomic nerve damage include problems with bladder emptying and sexual function. Motor nerve damage can be seen in the patients with muscle weakness, cramping, twitching muscles just under the skin, and paralysis. Diagnosis of DPN is based on a thorough review of symptoms, as well as a physical examination and testing to determine the type of nerve damage and its severity.

Treatment and Prevention Options

Treatment of DPN depends on the type and severity of nerve damage. Strict blood sugar control is the most important step toward limiting the progression of nerve damage and preventing future complications. Once blood sugar is in a normal range and diet, exercise (or physical therapy), and medications are adjusted to maintain good control over blood sugar fluctuations, treatment to help relieve symptoms can begin.

Diabetic nerve pain is treated with antidepressant medications, anticonvulsant drugs, and opioid painkillers. Drugs specifically approved to treat the pain of DPN include duloxetine, pregabalin, and tapentadol. Skin creams and transdermal patches are also available. Medications are also used to improve stomach emptying, blood pressure, bladder control, and sexual function.

A serious complication of DPN is infection. Regular foot care is very important in prevention and early treatment of infection, which may be missed due to lack of symptoms and poor peripheral circulation with advancing age. When a soft-tissue infection spreads to the bone, amputation of the toes or foot may be required. Prompt recognition of an infection and timely treatment can prevent many of these surgeries. Patients with diabetes should have a foot examination at least once a year to check for neuropathy. If a sensory neuropathy is detected, more frequent foot examinations should be scheduled to assist in early detection of infections, as well as their prompt treatment.

by

Dr.Akshaya Srikanth, 

Pharm.D India

Artificial gene synthesis

Artificial gene synthesis is the process of synthesizing a gene in vitro without the need for initial template DNA samples. The main method is currently by oligonucleotide synthesis (also used for other applications) from digital genetic sequences and subsequent annealing of the resultant fragments. In contrast, natural DNA replication requires existing DNA templates for synthesizing new DNA.

Synthesis of the first complete gene, a yeast tRNA, was demonstrated by Har Gobind Khorana and coworkers in 1972.Synthesis of the first peptide- and protein-coding genes was performed in the laboratories of Herbert Boyer and Alexander Markham, respectively.

Gene Optimization

While the ability to make increasingly long stretches of DNA efficiently and at lower prices is a technological driver of this field, increasingly attention is being focused on improving the design of genes for specific purposes. Early in the genome sequencing era, gene synthesis was used as an (expensive) source of cDNA's that were predicted by genomic or partial cDNA information but were difficult to clone. As higher quality sources of sequence verified cloned cDNA have become available, this practice has become less urgent.

Producing large amounts of protein from gene sequences (or at least the protein coding regions of genes, the open reading frame) found in nature can sometimes prove difficult and is a problem of sufficient impact that scientific conferences have been devoted to the topic. Many of the most interesting proteins sought by molecular biologist are normally regulated to be expressed in very low amounts in wild type cells. Redesigning these genes offers a means to improve gene expression in many cases. Rewriting the open reading frame is possible because of the degeneracy of the genetic code. Thus it is possible to change up to about a third of the nucleotides in an open reading frame and still produce the same protein. The available number of alternate designs possible for a given protein is astronomical. For a typical protein sequence of 300 amino acids there are over 10150 codon combinations that will encode an identical protein. Using optimization methods such as replacing rarely used codons with more common codons sometimes have a dramatic effects. Further optimizations such as removing RNA secondary structures can also be included. At least in the case of E. coli, protein expression is maximized by predominantly using codons corresponding to tRNA's that retain amino acid charging during starvation.Computer programs are written to perform these, and other simultaneous optimizations are used to handle the enormous complexity of the task.A well optimized gene can improve protein expression 2 to 10 fold, and in some cases more than 100 fold improvements have been reported. Because of the large numbers of nucleotide changes made to the original DNA sequence, the only practical way to create the newly designed genes is to use gene synthesis.

Standard Methods

Chemical synthesis of oligonucleotides

Oligonucleotide synthesis

Oligonucleotides are chemically synthesized using nucleotides, called phosphoramidites, normal nucleotides which have protection groups: preventing amine, hydroxyl groups and phosphate groups interacting incorrectly. One phosphoramidite is added at a time, the product's 5' phosphate is deprotected and a new base is added and so on (backwards), at the end, all the protection groups are removed. Nevertheless, being a chemical process, several incorrect interactions occur leading to some defective products. The longer the oligonucleotide sequence that is being synthesized, the more defects there are, thus this process is only practical for producing short sequences of nucleotides. The current practical limit is about 200 bp for an oligonucleotide with sufficient quality to be used directly for a biological application. HPLC can be used to isolate products with the proper sequence. Meanwhile a large number of oligos can be synthesized in parallel on gene chips. For optimal performance in subsequent gene synthesis procedures they should be prepared individually and in larger scales.

Annealing based connection of oligonucleotides

Usually, a set of individually designed oligonucleotides is made on automated solid-phase synthesizers, purified and then connected by specific annealing and standard ligation or polymerase reactions. To improve specificity of oligonucleotide annealing, the synthesis step relies on a set of thermostable DNA ligase and polymerase enzymes. To date, several methods for gene synthesis have been described, such as the ligation of phosphorylated overlapping oligonucleotides, the Fok I method and a modified form of ligase chain reaction for gene synthesis. Additionally, several PCR assembly approaches have been described. They usually employ oligonucleotides of 40-50 nt long that overlap each other. These oligonucleotides are designed to cover most of the sequence of both strands, and the full-length molecule is generated progressively by overlap extension (OE) PCR, thermodynamically balanced inside-out (TBIO) PCR or combined approaches. The most commonly synthesized genes range in size from 600 to 1,200 bp.although much longer genes have been made by connecting previously assembled fragments of under 1,000 bp. In this size range it is necessary test several candidate clones confirming the sequence of the cloned synthetic gene by automated sequencing methods.

Limitations

Moreover, because the assembly of the full-length gene product relies on the efficient and specific alignment of long single stranded oligonucleotides, critical parameters for synthesis success include extended sequence regions comprising secondary structures caused by inverted repeats, extraordinary high or low GC-content, or repetitive structures. Usually these segments of a particular gene can only be synthesized by splitting the procedure into several consecutive steps and a final assembly of shorter sub-sequences, which in turn leads to a significant increase in time and labor needed for its production. The result of a gene synthesis experiment depends strongly on the quality of the oligonucleotides used. For these annealing based gene synthesis protocols, the quality of the product is directly and exponentially dependent on the correctness of the employed oligonucleotides. Alternatively, after performing gene synthesis with oligos of lower quality, more effort must be made in downstream quality assurance during clone analysis, which is usually done by time-consuming standard cloning and sequencing procedures. Another problem associated with all current gene synthesis methods is the high frequency of sequence errors because of the usage of chemically synthesized oligonucleotides. The error frequency increases with longer oligonucleotides, and as a consequence the percentage of correct product decreases dramatically as more oligonucleotides are used. The mutation problem could be solved by shorter oligonucleotides used to assemble the gene. However, all annealing based assembly methods require the primers to be mixed together in one tube. In this case, shorter overlaps do not always allow precise and specific annealing of complementary primers, resulting in the inhibition of full length product formation. Manual design of oligonucleotides is a laborious procedure and does not guarantee the successful synthesis of the desired gene. For optimal performance of almost all annealing based methods, the melting temperatures of the overlapping regions are supposed to be similar for all oligonucleotides. The necessary primer optimization should be performed using specialized oligonucleotide design programs. Several solutions for automated primer design for gene synthesis have been presented so far.

Error correction procedures

To overcome problems associated with oligonucleotide quality several elaborate strategies have been developed, employing either separately prepared fishing oligonucleotides,mismatch binding enzymes of the mutS familyor specific endonucleases from bacteria or phages. Nevertheless, all these strategies increase time and costs for gene synthesis based on the annealing of chemically synthesized oligonucleotides.

Increasingly, genes are ordered in sets including functionally related genes or multiple sequence variants on a single gene. Virtually all of the therapeutic proteins in development, such as monoclonal antibodies, are optimized by testing many gene variants for improved function or expression.

by

Dr.Akshaya Srikanth

Pharm.D India

ANTI-ARRHYTHMIC DRUGS

Antiarrhythmic drugs are a group of pharmaceuticals that are used to suppress fast rhythms of the heart such as atrial fibrillation, atrial flutter, ventricular tachycardia, and ventricular fibrillation.Antiarrhythmic agents may be considered the first-line therapy in the prevention of sudden death in certain forms of structural heart disease, and failure of these agents to suppress arrhythmias may lead to implantation of an implantable cardioverter-defibrillator (ICD).

Vaughn-Williams Classification

The Vaughn-Williams classification of antiarrhythmic therapy takes into account some of this approach. It is a somewhat confusing mechanism of memorizing antiarrhythmics and we will spend little time discussing the classification system itself. It is based on the cellular properties of the normal his-Purkinje cells. Classification of drugs is dependent upon the ion currents responsible for depolarization and repolarization as well as the beta-adrenergic receptors. Its advantages are that it is a physiologically based system and highlights the beneficial and deleterious effects of the specific drugs. Unfortunately, its disadvantages are that all cells are not normal. Therefore in addition to this, all cells in the heart are not his-purkinje in origin and therefore have different dysrhythmia profiles.

The Vaughn-Williams classification as I stated before divides antiarrhythmics based on certain ion channels they affect. Class I antiarrhythmics are sodium channel blockers and have direct membrane action upon the sodium channel. Class II antiarrhythmics are the beta-blockers and affect the heart by sympatholysis (beta blocking). Class III antiarrhythmics prolong repolarization by affecting the potassium channels and Class IV antiarrhythmics are calcium channel blockers. In addition to these classes other antiarrhythmics would include purinergic agonists and the digitalis glycosides, which do not fall in any of the above classifications.

There are five main classes in the Vaughan Williams classification of antiarrhythmic agents:

* Class I agents interfere with the sodium (Na+) channel.

* Class II agents are anti-sympathetic nervous system agents. Most agents in this class are beta blockers.

* Class III agents affect potassium (K+) efflux.

* Class IV agents affect calcium channels and the AV node.

* Class V agents work by other or unknown mechanisms.

The class I antiarrhythmic agents interfere with the sodium channel and they are also called Membrane Stabilizing agents.Class II agents are conventional beta blockers. They act by blocking the effects of catecholamines at the β1-adrenergic receptors, thereby decreasing sympathetic activity on the heart.Class III agents predominantly block the potassium channels, thereby prolonging repolarization.Class IV agents are slow calcium channel blockers. They decrease conduction through the AV node, and shorten the plateau phase of the cardiac action potential.

Antiarrhythmic therapy has progressed over the past years from a concept of empiric arrhythmia diagnosis; that is, diagnosis solely of the appearance of the electrograms on the surface ECG with interventions aimed at making the ECG and the patient appear more “normal”, to a more scientific approach to current electrophysiology.

In current pediatric and adult cardiology practices, an attempt is made at understanding the pathophysiologic diagnosis ( the what and how) of the arrhythmia. This allows the cardiologist to evaluate mechanisms and components of the arrhythmia in order to evaluate vulnerable parameters and target the arrhythmia on a subcellular level. Ultimately this intervention leads to, for the most part, making the ECG and the patient appear more “normal”!

A simple example of this would be the diagnosis and treatment of AV node reentry tachycardia. 

The diagnosis of this arrhythmia can be made on a surface electrocardiogram. However, when a Pediatric Cardiologist evaluates this more closely, the AV node reentry circuit that is responsible for this tachycardia is secondary to an anatomic fast and slow pathway within the AV node. The AV node slow conduction pathway provides a retrograde circuit making this much like other types of reentry tachycardia. The vulnerable perimeter in this case would be the AV nodal action potential. On a subcellular level, the L-type calcium channel is prominent within the AV node. Therefore, interventions could be aimed at interfering with this channel either directly with a calcium channel blocker or indirectly with a beta-blocker. In either case, the clinical outcome would be the same and that is returning the patient to sinus rhythm.

by

Dr.Akshaya Srikanth

Pharm.D India

Anti Microbial Resistance

Antimicrobial resistance is a natural biological phenomenon of response of microbes to the selective pressure of an antimicrobial drug. Resistance may be inherent, which explains the phenomenon of opportunistic infection or acquired. Concern about the resistance increased in the late 1990's and since then, many governmental and agency reports have been published regarding the agricultural use of antibacterials, advising less use of antibacterials, appropriate choice of antibacterials and regimens, prevention of cross-infection and development of new antibacterials. The emergence of multidrug resistant strains of Gram-negative bacteria (Pseudomonas, Klebsiella, Enterobacter, Acinetobacter, Salmonella species) and Gram-positve organisms (Staphylococcus, Enterococcus, Streptococcus species) is the more worrisome in the present therapeutic scenario. Multidrug - resistant tuberculosis is another serious public health problems. Resistance to some agents can be overcome by modifying the dosage regimens (e.g., using high-dose therapy) or inhibiting the resistance mechanism (e.g., beta-lactamase inhibitors), whereas other mechanisms of resistance can only be overcome by using an agent from a different class. It is urgently required to ban the sale of antibiotics without prescription, to use antibiotics more judiciously in hospitals by intensive teaching of the principles of the use of antibiotics and to establish better control measures for nosocomial infections. Thus, it is highly recommended that practicing physicians should become aware of the magnitude of existing problem of antibacterial resistance and help in fighting this deadly threat by rational prescribing.

Drug Resistance can be described as a state of insensitivity or of decreased sensitivity to drugs that ordinarily cause growth inhibition or cell death. This phenomenon has been recognized since the latter part of the 19th century in the micro-organisms and more recently in mammalian cells in vitro and in cancer cells in vivo. The discovery of antimicrobial agents by Paul Ehrlich was one of the most remarkable discoveries, that changed the face of medical practice. However, the increased global flow of antimicrobials brought with it the threat of antimicrobial resistance. Concern about the resistance increased in the late 1990's since then, many governmental and agency reports have been published regarding the agricultural use of antibacterials, advising less use of antibacterials, appropriate choice of antibacterials and regimens, prevention of cross-infection and development of new antibacterials. As antimicrobials are frequently misused and overused in many developing countries, thus resistance to antimicrobials, has led to an increase in morbidity, mortality and cost of health care. To maintain the useful life of antimicrobial drugs in developing countries there is need to improve access to diagnostic laboratories, improved surveillance of the emergence of resistance, better regulation of the use of antibiotics, and better education of the public, doctors, and veterinarians in the appropriate use of the drugs.

by 

Dr.Akshaya Srikanth B

Pharm.D India

A Reinvented Condom : Opportunities from Challenges

Yes, it's true. Researchers working to see a reinvented condom. But, Why?

Because the condom has been in use for 400 years and yet has "undergone very little technological improvement in the past 50 years." And it's not just the male condom, either. The foundation wants to improve the female condom also. In fact, we're challenging you to look at the materials, shapes, and designs of condoms to see how any or all of these might contribute to a better experience for men and women, leading to - yes - even more people using them.

But that's only part of the story - because once an improved condom (or, as Mashable calls it, "a futuristic prophylactic") is developed (or for that matter, a new vaccine, new treatment, or any improved contraceptive), we need partners who can actually get it to those who need them; particularly those in the poorest (lowest resource) countries in the world. A spiffy new condom won't do much good sitting in a lab somewhere.

34 million people, around the world, are living with HIV, according to The Global Fund to Fight AIDS, TB, and Malaria. An astounding two-thirds live in sub-Saharan Africa. And though the number of people dying from HIV fell, in 2011, there were still 1.7 million people who lost their lives from the disease. Improved access to treatment to prevent transmission from HIV positive pregnant women to their newborns; HIV testing and counseling sessions and the distributions of condoms has helped save hundreds of thousands of lives.

In fact, Global Fund programs allowed for the purchase and distribution of 4.2 billion condoms,  by the end of 2012. The U.S. Government’s PEPFAR program not only has procured nearly 67 million female condoms but also works to promote behavior change and an increase in condom use to prevent the spread of HIV.  But here's the thing: In 2011, there were 2.5 million new HIV infections. In order to prevent those from happening we need to pay attention to all links in the chain. If we can help light the fire that sparks an innovative, new condom design that improves the chances that more people will use this critical HIV prevention method, we want to do it.

Innovation has sparked many advances in the work to improve health around the world – from HIV anti-retroviral medications to reinvention of toilets for better sanitation. Technology today allows us to improve upon any and all of our public health "tools"  – even the best ones, like the condom. In this case, for both male and female condoms, we need to make sure any new and exciting "reinvention" actually makes it to those men and women who need it most.

by

Dr.Akshaya Srikanth

Pharm.D India

Changing Trends in Global Pharmacy workforce

INTRODUCTION

Increased demand for health services and increasing expectations to service delivery have a significant effect in shaping work dynamics.Contemporary issues surrounding the global pharmacy workforce identified from the literature's include the importance of working conditions and job satisfaction, wide range of supply and demand factors affecting the workforce and migrations.To support growth in the establishment of pharmacy practice and its aspiration for increased patient focused care, work force needs another trends will need to be factored into pharmaceutical service development plans.

Global Policy Context

The world’s health workforce is facing significant challenges with a shortage of more than FOUR million health workers worldwide. The global health workers crisis is possibly the greatest health system constraint on countries seeking to meet their 2015 millennium development goals (MDGs). Increased demand for health services and increasing expectations for service delivery has changed the health workforce issues have generated huge interest and international action to bring about change. -World health report 2006

In order to meet the MDGs, had laid revolutionary change in every sector of healthcare system in accelerating, delivering and planning the future health care professional not only to national needs but also to global health innovations.

In many countries, pharmacists are the most accessible of all health care workers and a such play a key role in the delivery of health care services, particularly the safe distribution of medicines at all levels. In an era of rapidly accelerating change in health care delivery, the roles of pharmacists are constantly being redefined, as roles, competency, and training requirements change.Thus, understanding the current workforce and the factors that influence it are key components to human resource planning in pharmacy. As the recent report from the Office of The Chief Pharmacist of US, a health system improvement that is well supported by the evidence-base is to maximize the expertise and scope of pharmacists in minimize expansion barriers for an already existing and successful upgrading the health care delivery models in USA, Canada, Australia and Great Britain. There is also a need for countries to model their workforce needs based on predicted future provision of services and care, roles and responsibilities of the pharmacy support workforce, increased use of technology, the advancement of biotechnology and personalized medicine, demographic changes, and future patterns of working all while ensuring there is a sustainable academic workforce to maintain the supply of suitably trained pharmacists. 

Work Condition & Job Satisfaction

The level of job satisfaction among pharmacy personnel is an important indicator of staff turnover and retention. A number of studies found female pharmacists hold high levels of job satisfaction compared with their male counterparts.Other factors identified as increasing pharmacist retention were good remuneration, good relationships with co-workers, and flexible schedules. Factors increasing staff turnover included high stress, insufficient or unqualified staff, and poor salary.Evidence also suggests that pharmacists engaged in shift work might present unique characteristics, which has implications for labour supply and pharmacy services delivery.

Workforce development: Education, training, & leadership

Continuing professional development (CPD) has the potential to be useful in pharmacy workforce revalidation. Pharmacy professionals on the whole agreed with the principle of engaging with CPD, but there was little evidence to suggest widespread and wholehearted acceptance and uptake of CPD, essential for revalidation.Direct experience of effective CPD in the absence of perceived barriers could impact personal and professional development and patient benefit, thus strengthening personal beliefs in the value of CPD.

Supply and demand issues: Current status & future directions Increased demand and limited supply of pharmacists constrains the ability of the workforce to expand. Many different supply and demand factors that influence the pharmacy profession were identified, the majority of which were common to most countries.

Supply and demand issues: Current status & future directions The most common factors increasing demand for pharmacists were increased feminisation, increased clinical governance measures through continually reviewing and improving the quality of patient care, increased numbers of prescriptions, and increased complexity of medication therapy. The most common factors mitigating demand for pharmacists included increased use of technology, expansion in the numbers and roles of pharmacy technicians, and increased numbers of pharmacy graduates. 

Pharmacy workforce migration

There is greater migration from less-developed countries to more-developed countries. The pharmacist workforce from African and Asian countries was disproportionately affected by migration. Significant number of pharmacists from developing countries migrate to the developed world; however, the extent of such migration was not properly captured. Postulated reasons for migration include better remuneration, joining or supporting family, political and social instability, poor living conditions, poor working conditions and management, unsafe environment, further training and qualifications, and job opportunities and satisfaction.

Conclusion

The current challenges affecting the global pharmacy workforce in ensuring equitable access and responsible use of safe, effective and quality medicines. The present status states that there is a huge paradigm shift from the past to current Pharmacy profession leading in the developed countries for more advancement and the developing countries upgrading for the better services with new branches in managing future needs in delivering of the health services.  But still many skillful pharmacists are needed to strengthen the workforce in the Global Pharmacy.

Source: Global workforce Report 2012

by

Dr.Akshaya Srikanth

Pharm.D

Does Chronic Pain Raise Hypertension Risks?

Experienced pain practitioners have noted that unrelieved pain often may be objectively assessed by clinical signs in patients with chronic pain conditions. Results of a recently reported, large-scale research study suggest that these patients may exhibit a greater risk of hypertension and increased sensitivity to acute pain.

According to background information provided in the study report, published in the February 2013 edition of the journal PAIN, systems modulating blood pressure (BP) and influencing pain overlap physiologically and interact functionally, such that blood pressure is usually stabilized in the presence of acute pain [Olsen et al. 2013]. At the same time, relatively higher resting BP levels are generally associated with hypoalgesia, or reduced sensitivity to acute pain.

However, this BP-related hypoalgesia may be diminished or absent in persons with chronic pain conditions. And, although exact mechanisms for the effect are undetermined, changes in the cardiovascular-pain-modulating system also appear to increase hypertension risk in persons with chronic pain. For example, one large epidemiological study indicated that chronic low back pain was associated with a 50% increased risk for hypertension.

To further examine these relationships, a research team in Norway conducted a first of its kind study to evaluate hypertension prevalence and measure the effect of blood pressure (BP) on acute pain sensitivity in a large general population of persons with chronic pain compared with pain-free controls. Subjects — N=10,135; mean age 56 years, range 30–87 years — were part of a large epidemiological and prospective study of health problems, symptoms, and chronic diseases initiated in 1974 — the Norwegian Tromsø Study — and most recently updated during 2007-2008 from which subjects were recruited for the present investigation.

Data on the self-reported presence of chronic pain in any part of the body, history of hypertension, and use of antihypertensive medications were gathered for all subjects:

Nearly a third (32%) of subjects (61% female) reported chronic pain of any sort, while the remainder (47% female) were free of chronic pain. 

Among those with chronic pain the typical intensity was 5.0±1.8 on a 0-to-10 scale and mean duration of pain was 10 years. 

Persons with chronic pain reported significantly more hypertension. Among subjects with chronic pain, 31% had been diagnosed with hypertension and 23% were taking antihypertensive medications, compared with 26% of pain-free subjects with hypertension and 20% taking antihypertensive meds (P<0 .001="" between="" differences="" font="" for="" groups="">

All subjects participated in a standardized cold pressor test, requiring them to immerse their hands in a container of freezing cold water and provide pain ratings at regular intervals. Significant interactions were observed between (a) chronic pain status, (b) resting BP — both systolic and diastolic — and (c) acute-pain tolerance. In pain-free subjects, having higher resting blood pressure allowed significantly greater tolerance of the painful stimulus (cold pressor test); whereas, no such effects were observed overall in those with chronic pain.

COMMENTARY: This present investigation by Olsen and colleagues, and prior epidemiological studies noted by the authors, suggest that chronic pain may be a significant contributor to the onset and persistence of hypertension. Along with that, the ability of cardiovascular mechanisms to modulate acute pain sensitivity were dysfunctional in persons with chronic pain.

It should be noted, however, that data in this observational study are associative in nature and, thereby, do not prove cause-effect relationships or which came first, chronic pain or hypertension. Additionally, subjects in the chronic pain group reported overall typical pain of moderate intensity (5.0 on a 10 point scale), which may suggest that their pain was under some degree of control; although, the researchers do note that higher pain intensity among select subjects was correlated with an increasing likelihood of hypertension.

It also might be suspected that subjects’ use of antihypertensive medications and/or analgesics might have skewed outcomes. However, the researchers conducted a sensitivity analysis controlling for these variables and did not find any significant alterations of results.

A strength of this study was its large and diverse population of patients, albeit from a single Nordic region, and a broad definition of chronic pain; ie, pain of >3 months duration in any part of the body. But a limitation is that chronic pain status, as well as hypertension status and antihypertensive use, were determined solely by self-reports of participants. While inaccuracies of such reports may not have been sufficient to strongly affect outcomes, this is unknown.

While there was a 23% increased likelihood of hypertension associated with chronic pain, in absolute terms there was a 5.5% greater prevalence of hypertension in subjects with chronic pain than in their pain-free counterparts. This is less than reported in other studies of chronic pain and may not seem large, but on a population level it could be of considerable consequence.

For example, in the United States, with an estimated 100+ million persons suffering chronic pain, this could amount to 5.5-million cases of health-threatening hypertension requiring attention in pain-care settings. The prevalence rate of hypertension might expectedly be much greater specifically among patients with severe and/or unrelieved chronic pain.

Decreased tolerance to acute pain stimuli by persons with chronic pain, as evidenced in this study by Olsen et al., also could be of some importance. Such patients may be more sensitive to breakthrough pain during continuous analgesia and/or pain associated with injury or medical procedures than previously imagined. Further research, using prospective, randomized, and controlled designs might better elucidate the interrelationships of blood pressure, chronic pain, and response to acute pain in this population of patients.

Concern about hypertension, or at least elevated blood pressure, prevalence in patients with chronic pain is not a new concept. In a previous paper for Pain Treatment Topics — “Using Objective Signs of Severe Pain to Guide Opioid Prescribing” Link— Forest Tennant, MD, DrPH, notes that uncontrolled chronic pain may be objectively assessed clinically by elevated blood pressure, as well as by increased pulse rate and pupil size, and the many ways in which these patients seek positional or postural relief and sensory avoidance. These signs can be helpful for determining appropriate treatments and measuring patient responses to therapy.

Furthermore, a prior large-scale research investigation observed a profound link between severe chronic pain and a 70% increased risk of all-cause mortality. Hypertension, as a contributor to cardiovascular-related death, could be of special concern in elderly patients with chronic pain and whenever prescribing analgesic therapies that may carry risks of cardiovascular adverse effects in patients of any age.

Complete article available at : Pain Journal

by

Dr.Akshaya Srikanth B

Pharm.D India

Osteoporosis - Not Just a Woman’s Disease

Osteoporosis or "porous bone" is a disease of the skeletal system characterized by low bone mass and deterioration of bone tissue. Osteoporosis leads to an increased risk of bone fractures typically in the wrist, hip, and spine. Because so much of the focus surrounding osteoporosis tends to focus on women, it’s easy to forget that men get this condition too. Osteoporosis is more common in women—affecting an estimated 30 percent of postmenopausal women. But one in five men over the age of 50 will at some point suffer a bone fracture as a result of osteoporosis. After the age of 75, men become even more vulnerable to bone loss and breaks than their younger peers. And, by some estimates, the number of hip fractures in men worldwide will double by 2025.

What’s to Blame?

As with women, osteoporosis in men is caused, in part, by declining estrogen levels. (Just as women have small amounts of testosterone in their bodies, men have small amounts estrogen.) Estrogen has various roles—it reduces the amount of calcium drawn from the bones, and it boosts the levels of bone-enhancing hormones like calcitonin, which stimulates bone growth.

While very little can be done to stop this natural decline in estrogen, new research has found that it is possible for older men to lessen the risk of developing osteoporosis by making a few lifestyle adjustments.

In this study, researchers followed 1,122 men aged 70 to 97 for two years who were part of the Concord Health and Ageing in Men Project (CHAMP). They collected data on these men’s mobility, muscle strength, balance, medication use, cognition, medical history, lifestyle factors and serum vitamin D levels. They each also had baseline and follow-up measurements of total hip bone mineral density.

At the conclusion of the study, researchers found that annual loss of bone mineral density accelerated with increasing age - 0.4 percent in men 70 to 75 years of age, to 1.2 percent in men older than 85. They also learned that these men lost bone density faster with increasing age; with the use of thiazolidinedione or loop-diuretic medications; if they had kidney disease, poor balance or larger hip bone area; or if they had lower serum vitamin D levels.

On the other hand, older men who used walking as a form of exercise and who worked on achieving better balance were able to slow the progression of osteoporosis. Interestingly, the use of beta-blocker medication (used to treat hypertension and heart problems) also appeared to reduce bone loss. Previous studies have found a link between the use of this particular medication and reduced fracture risk, as well as higher bone mineral density.

The jury is still out on how exactly beta-blockers prevent osteoporosis, but some research indicates that it has to do with the hunger-regulating hormone leptin, which also has been shown to control bone formation and resorption (destruction). The resorption characteristic associated with leptin is controlled by the sympathetic nervous system via a specific receptor present on bone cells. Without this receptor, people would make more bone and destroy less bone, leading to fewer osteoporotic fractures.

Beta-blockers come into play because they inhibit the sympathetic nervous system, thereby reducing the bone-destructive characteristics of leptin.

Recommendations for Preventing Osteoporosis

Despite the results of this study, don’t be too quick to resort to beta-blockers to prevent your risk of osteoporosis. Like all drugs, beta-blockers have some unpleasant side effects and should only be used for their intended purpose and under the supervision of a doctor. Side effects include fatigue, cold hands, digestive troubles, dizziness and headache.

In addition, beta-blockers deplete levels of the hormone melatonin, which is important for many aspects of health, including sleep, immunity and heart health. Ironically, researchers also have linked low melatonin levels to high blood pressure.

Realistically, the two best ways to build strong bones and reduce the risk of osteoporosis are to take bone-supportive supplements and to exercise regularly. Walking is good, but strength training or weight-bearing exercise is even better.

As for supplements, be sure you’re taking a combination of calcium, vitamin D, magnesium, vitamin K, zinc, copper, silicon, vitamin C and phosphorus every day to protect your bones.

by

Dr.Akshaya Srikanth

Pharm.D India

Suicidal Risk of Antiepileptic drugs for Pain

Antiepileptic drugs (AEDs, also known as anticonvulsant medications) have a prominent role in the treatment of several types of chronic pain, particularly relating to neuropathy and fibromyalgia. Yet, there have been strong concerns about suicide risks associated with these medications and a new review article examines the relatively weak evidence behind this apprehension.

The recent research on suicidality and AEDs and discuss implications for the treatment of neuropathic pain and fibromyalgia. According to background information in their article, gabapentin and pregabalin are recommended as first-line treatments for various neuropathic conditions, while carbamazepine and oxcarbazepine are commonly used in trigeminal neuralgia, and other AEDs are considered second- or third-line treatments for neuropathic pain. Additionally, pregabalin is recommended for fibromyalgia, and topiramate and valproic acid are considered first-line treatments for migraine prophylaxis.

Given the major role of AEDs in pain management, it is important to consider findings regarding these medications and suicidality, which includes both suicidal ideation and actual suicidal behavior. Furthermore, the researchers note that chronic pain it is also associated with suicidality, and as many as 50% of patients with chronic pain have comorbid depression, which is a well-established risk factor for suicide.

Three articles were discovered as demonstrating increased suicidality risks of AEDs:

• The first article was a large meta-analysis conducted by the FDA that focused on 199 placebo-controlled trials of 11 AEDs and included a total of nearly 44,000 patients. Approximately half of the patients had epilepsy or psychiatric disorders (52%), and the remainder were classified as having “other” conditions, including obesity, insomnia, migraine, and various pain disorders.  Based on adjusted risk estimates, 0.43% of patients in the AED groups had suicidal ideation or behavior vs. 0.24% in the placebo groups. The FDA concluded that AEDs appeared to increase the risk of suicidality regardless of treatment indication, specific AED, or mechanism of action, and that increased risk was observed as early as one week after treatment initiation and continued for at least 24 weeks.  The odds ratio for increased suicidality risk in the “other” group in the FDA meta-analysis, which included patients with various pain conditions, was a moderate 1.87 (95% Confidence Interval, 0.81-4.76), but this was not statistically significant. Patients in this group were taking divalproex, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, topiramate, or zonisamide. 
• A Danish study assessed 6,780 suicides compared with a cohort of 169,725 treatments-naïve patients. The cohort population consisted of patients with epilepsy, psychiatric disorders, and those taking opioids, presumably for chronic pain. The authors concluded that valproate, lamotrigine, clonazepam, and phenobarbital may increase the risk of suicide shortly after treatment initiation.
• A third investigation, using a medical claims database, was an observational study of 297,620 patients treated for various neurologic and psychiatric conditions. Suicidal acts and violent death were compared in patients beginning AEDs and those taking topiramate, the reference AED. Various statistical analyses demonstrated that several AEDs, including gabapentin, increased the risk of suicidal acts. Of particular interest, nearly 17% of the gabapentin group were being treated for neuropathic pain; whereas, less than 1% were treated for epilepsy. 

Several other studies evaluated the association between AEDs and suicidality but did not examine pain patients. Based on their findings, and despite limitations in the data, Pereira et al. conclude that that “the risk of suicidality ─ although small in absolute terms ─ should be considered carefully in the treatment of patients with neuropathic pain, fibromyalgia, and other chronic pain conditions for which treatment with an AED is being considered.”

The risk of suicidality can be evaluated in patients initiating AED therapy for pain and periodically thereafter, the authors suggest. This would be especially appropriate in those with evidence of past or current suicidality, past or present mood disorders, and other risk factors for suicidality, including treatment with antidepressant medications in individuals under the age of 25.

Article: Suicides associated with Antiepileptic Drugs

by

Dr.Akshaya Srikanth, 

Pharm.D India

WORLD TOP 15 MEDICAL UNIVERSITIES 2012

The future need for increased numbers of physicians has been clearly demonstrated and the gap between demand and supply is growing. This gap is the largest, and is growing the fastest, in primary care specialties and in rural communities. To meet the need for physician workforce in our region we need to begin producing more physicians locally.

The medical education pipeline is a minimum of seven years long (up to 12 or 13 for some specialties). This lead time adds to the urgency of the medical education expansion effort. Attaining the medical education from the best universities will add more turbo to the personal and profession growth of the individual. In contrast of all these medical profession is always a Hallmark of the quality of education and patient care. 

Let me explain a short summary about medicine.

Medicine is a profession that has an established history of teaching its own trainees in the practice setting. Considering the entire medical education pipeline, all but the first two years of that education occurs in a practice setting. Thus, in places where much medicine is practiced, much teaching could and, I would argue, should occur. Should occur because when physicians teach, and the clinic or hospital becomes a teaching environment, the quality of care tends to improve. For many physicians, job satisfaction also improves when teaching is part of the practice environment. Spokane has a very large clinical practice community and a relatively small medical education enterprise. This is a natural place for medical education to grow.

In the field of medicine, the ranking of the universities by the following indicators: the number of alumni and staff winning Nobel Prizes and Fields Medals; number of highly cited researchers selected by Thomson Scientific; number of articles published in journals of Nature and Science; number of articles indexed in Science Citation Index - Expanded and Social Sciences Citation Index; and per capita performance with respect to the size of an institution. So, selection of Best universities is always a important from Under graduation to Post Doctor Fellowship (PDF). Here,I am listing the TOP 15 medical universities in the world.

15. University College London

Country: United Kingdom

Total Score: 61.4

Total Enrollment: 19,673

International Students: 7,203 (37%)

14. Mayo Medical School

Country: United States

Total Score: 61.8

Total Enrollment: 57,000

International Students: N/A

13. University of Minnesota, Twin Cities

Country: United States

Total Score: 62.3

Total Enrollment: 40,909

International Students: 3,424 (8%)

12. University of Michigan – Ann Arbor

Country: United States

Total Score: 64

Total Enrollment: 39,694

International Students: 4,666 (12%)

11. Karolinska Institute

Country: Sweden

Total Score: 64.1

Total Enrollment: 7,051

International Students: N/A

10. University of Pittsburgh

Country: United States

Total Score: 64.7

Total Enrollment: 25,359

International Students: 1,957 (8%)

9. Stanford University

Country: United States

Total Score: 65.4

Total Enrollment: 15,861

International Students: 3,581 (23%)

8. University of Cambridge

Country: United Kingdom

Total Score: 68.6

Total Enrollment: 17,868

International Students: 5,526 (31%)

7. University of California, Los Angeles

Country: United States

Total Score: 69.1

Total Enrollment: 37,633

International Students: 3,169 (8%)

6. The University of Texas Southwestern Medical Center at Dallas

Country: United States

Total Score: 69.6

Total Enrollment: 2,004

International Students: 142 (7%)

5. Columbia University

Country: United States

Total Score: 71

Total Enrollment: 21,817

International Students: 5,280 (24%)

4. The Johns Hopkins University

Country: United States

Total Score: 76.9

Total Enrollment: 15,116

International Students: 2,484 (16%)

3. University of Washington

Country: United States

Total Score: 78.9

Total Enrollment: 40,280

International Students: 3,270 (8%)

2. University of California, San Francisco

Country: United States

Total Score: 87.5

Total Enrollment: 3,119

International Students: 133 (4%)

1. Harvard University

Country: United States of America

Total Score: 100

Total Enrollment: 21,260

International Students: 4,526 (21%)

Harvard University is ranked number one since 2003 in not just the clinical medicine and pharmacy field, but also natural sciences and mathematics, life and agriculture sciences and social sciences. The only field in which Harvard has not taken the top spot is engineering/technology and computer sciences — over the last six years its average ranking is around 38.

Source-ARWU

by

Akshaya Srikanth

Pharm.D India