Medication Shortages Research Articles

In-depth assessment of Iraqi physicians' adherence to treatment guidelines for different diseases: a qualitative study

Background: In healthcare settings, specialists from different fields may follow the most well-known, reliable, and easy-to-understand medical guidelines. This study aimed to determine Iraqi physicians' adherence to treatment guidelines, to specify which treatment guidelines are utilized for each disease and identify their barriers to follow the guidelines. Methods: This was qualitative study including face-to-face and virtual semi-structured interviews with specialist physicians from different disciplines. The interviews were conducted between December 2021 and May 2022 in Kirkuk province, Iraq. The qualitative data generated through interviews was analyzed using thematic analysis. Result: The study recruited 48 specialists (27 male and 21 female) from seven medical specialties at two large government hospitals. Most physicians (38 /44) revealed that healthcare settings implement treatment guidelines in more than half of cases. American guideline was the most used among the participating physicians. European and British guidelines and textbooks were also used by some specialties. Unfortunately, most (43 out of 47) physicians were unaware of Iraqi treatment guideline. Most seniors often followed the same guidelines for one branch, with little variation in approach based on their experience and flexibility. Almost all participating physicians believed that shortages in treatment (46/47) and investigation/lab materials (45/47) and low patient adherence (44/47) are major barriers to implement the guideline(s). Six out of seven specialties experienced shortage in the essential medications that recommended by the guidelines Conclusions: Most physicians followed well-known international guidelines. Each specialty follows different guidelines relying on the disease. Medication shortage in the public hospitals was the main barrier facing physicians to implement treatment guidelines. Enhancing physician awareness of the Iraqi guidelines should be encouraged. Finally, securing essential medicines in public hospitals is pivotal to adopt evidence-based guidelines effectively.

Impact of the Novel CoronaviruS (COVID-19) on Frontline PharmacIsts Roles and ServicEs: INSPIRE Worldwide Survey.

Pharmacy has been recognized as a vital healthcare profession during the COVID-19 pandemic. The primary objective of the INSPIRE Worldwide survey was to determine the impact of COVID-19 on pharmacy practice and pharmacists' roles around the world. A cross-sectional online questionnaire with pharmacists who provided direct patient care during the pandemic. Participants were recruited through social media, with assistance from national and international pharmacy organizations between March 2021-May 2022. The questionnaire was divided into (1) demographics, (2) pharmacists' roles, (3) communication strategies, and (4) practice challenges. The data were analyzed using SPSS 28, and descriptive statistics were used to report frequencies and percentages. A total of 505 pharmacists practicing in 25 countries participated. The most common role that pharmacists undertook was responding to drug information requests (90%), followed by allaying patients' fears and anxieties about COVID-19 (82.6%), and addressing misinformation about COVID-19 treatments and vaccinations (80.4%). The most common challenges were increased stress levels (84.7%), followed by medication shortages (73.8%), general supply shortages (71.8%), and inadequate staffing (69.2%). Pharmacists within this study were significantly impacted by the COVID-19 pandemic and took on new or adapted roles (e.g., providing COVID-specific information, managing patients' emotions, and educating on public health measures) to meet the needs of their communities. Despite, the significant challenges (e.g., increased stress, supply chain challenges, addressing misinformation, and staffing shortages) faced by pharmacists, they continued to put their patients' needs first and to provide pharmacy services.

When caring breeds contempt: The impact of moral emotions on healthcare professionals' commitment during a pandemic.

The novel coronavirus (COVID-19) pandemic is a major heath crisis that continues to impact healthcare organizations worldwide. As infection rates surged, there was a global shortage of personal protective equipment, critical medications, ventilators, and hospital beds, meaning that healthcare professionals faced increasingly difficult workplace conditions. In this conceptual study, we argue these situations can lead to healthcare professionals experiencing moral emotions - defined as specific emotions which relate, or occur in response, to the interest or welfare of others - towards their organizations. This paper explores the three moral emotions of contempt, anger and disgust, and their potential influence on healthcare professionals' workplace commitment in the context of a pandemic. Drawing from the moral emotions and organizational commitment literature, we develop a process model to demonstrate how healthcare professionals' affective and continuous commitment are likely to decrease while, paradoxically, normative, and professional commitment may become amplified. The possible potential for positive outcomes from negative moral emotions is discussed, followed by theoretical and practical contributions of the model, and finally, directions for future research.

Shortages of antiseizure medications in Australia and the association with patient switching, and adherence in a community setting

PurposeTo quantify sponsor-reported shortages of oral antiseizure medications in Australia, estimate the number of patients impacted, and the association between shortages and brand or formulation switching, and changes in adherence. MethodsA retrospective cohort study of sponsor-reported shortages (defined as where the supply of a medicine will not or will not be likely to meet the demand over a 6-month period) of antiseizure medications reported to the Medicine Shortages Reports Database (Therapeutic Goods Administration, Australia); cross-referencing shortages to the IQVIA-NostraData Dispensing Data (LRx) database, a deidentified, population-level dataset collecting longitudinal dispensation data on individual patients from ∼75% of Australian community pharmacy scripts. ResultsNinety-seven sponsor-reported ASM shortages were identified between 2019 and 2020; of those, 90 (93%) were shortages of generic ASM brands. Of 1,247,787 patients dispensed ≥1 ASMs, 242,947 (19.5%) were impacted by shortages. Sponsor-reported shortages occurred more frequently before the COVID-19 pandemic versus during the pandemic, however, shortages were estimated to affect more patients during the pandemic than before the pandemic. An estimated 330,872 patient-level shortage events were observed, and 98.5% were associated with shortages of generic ASM brands. Shortages occurred at a rate of 41.06 shortages per 100 person-years in patients on generic ASM brands versus 0.83 shortages per 100 person-years in patients on originator ASM brands. In patients taking a formulation of levetiracetam affected by a shortage, 67.6% switched to a different levetiracetam brand or formulation during shortages compared with 46.6% in non-shortage periods. ConclusionsApproximately 20% of patients on ASMs were estimated to have been impacted by an ASM shortage in Australia. The rate of patient-level shortages was approximately 50 times higher for patients on generic ASM brands versus originator brands. Shortages of levetiracetam were associated with formulation and brand switching. Improved supply chain management amongst sponsors of generic ASMs is needed to maintain the continuity of supply in Australia.

Generic drugs use during the COVID-19 pandemic among Lebanese patients using psychotropics: An opportunity for generic drug promotion.

The Coronavirus disease of 2019 (COVID-19) pandemic has imposed several challenges leading to the shortage of medications due to the disruption of their supply chains. Among others, patients using psychotropics encountered difficulties finding their medication despite the efforts of investing in local production. Encouraging patients to use generic drugs can be an effective strategy to ensure sustainable access to medication. This study aimed to describe the consumption of psychotropic medications during the COVID-19 pandemic and the willingness together with the reasons for using generic drugs. It also assessed the association between generic drugs and the general characteristics of the patients. A cross-sectional study was performed over a period of 4months (July-October 2021) targeting 128 patients using psychotropic drugs. The sample included more women than men with a mean age of 38years. Antidepressants were the psychotropic medications mostly consumed followed by anti-anxiety medications. Almost 13% of the patients started using psychotropics either through self-prescription or a friend's advice and 73.4% used generic drugs. Fear of dependence, unavailability of the brand drug, and pharmacist's recommendation were the main reported reasons for using generic drugs. During the COVID-19 pandemic, the consumption of psychotropics increased due to new prescriptions and self-medication. No differences were noted between using generics and the characteristics of the patients in contrast to previous studies which support the implementation of generic prescription and substitution policies.

"What If It Was Your Dog?" Resource Shortages and Decision-Making in Veterinary Medicine-A Vignette Study with German Veterinary Students.

The here presented vignette study was part of a survey on ethical judgement skills among advanced veterinary students at the University of Veterinary Medicine Hannover, Foundation. The vignette describes a fictitious dilemma in veterinary practice due to medication supply shortages. First, the students should make an ethically justified decision: who of the two patients in the waiting room gets the last dosage of a medication. Important factors were the animal patients' characteristics (age, state of health, life expectancy), the patient owners' wellbeing, and context-related criteria. Second, the students were asked for decisional changes if one of the patients was their own dog. They reacted in four different ways: (1) for a professional, this should not make a difference; (2) most likely being "egoistic" and preferring their own dog; (3) giving the medication to the other dog; and (4) avoiding a decision. Finally, the students judged a list of possible solutions to the dilemma on a 9-point scale. They preferred patient-related criteria to patient-owner-related criteria in this task. In the overall results, it became obvious that no "gold standard" or guidelines for situations of medication shortages exist, yet, which presents an important subject for future research and veterinary ethics teaching.

P855 The impact of the severe financial crisis on drug persistence and disease course in IBD patients in Lebanon

Abstract Background Lebanon is currently going through an unprecedented financial crisis (considered as one of the worst in the world in modern times) that has affected all aspects of everyday life. In particular, the economical crash has significantly crippled the Lebanese healthcare sector, resulting in severe shortages of basic drugs and medications, most of which cannot be produced locally. Patients with chronic diseases including those with Inflammatory Bowel Disease (IBD) have been impacted most given their need for costly and chronic treatment including biologics. Methods We collected data using a 12-question web survey disseminated through social media platforms of the patient organization, I Battle Disease. The questions aimed to explore the patients’ ability to acquire the necessary medications, whether they had to alter or completely stop their treatment, and any resulting complications (forced corticosteroid use, hospitalization, or surgery) it had on the course of their disease. Results 102 patients completed the survey. The patients were nearly evenly split between Crohn’s disease (53%) and ulcerative colitis (47%). Adalimumab was the most commonly used medication before the economic crisis (30%), followed by infliximab (18%), vedolizumab (10%), ustekinumab (8%), and tofacitinib (8%). Azathioprine and 5-ASA monotherapy were used by 8% and 19% of patients respectively. All biologics and small molecules used to be covered fully by third party payors including the National Social Security Fund (38%), the Ministry of Public Health (22%), and private insurance (18%). As a result of the crisis, the majority of patients (69%) declared stopping or interrupting their treatment in the past 3 years, with most (46%) having interrupted treatment for >12 months. 22% of patients reported switching to azathioprine due to issue in access to biologics. Additionally, 69% of patients reported worsening of their condition after stopping treatment, resulting in forced steroid use (36%), switching to another medication (36%), or unscheduled hospital admission (15%). Further, 66% of participants confirmed that they had to purchase their medications from abroad or through a local private vendor using out-of-pocket foreign currencies. Finally, 12% of patients reported that they had to immigrate or seek employment abroad due to difficulty with drug access. Conclusion The recent financial and economic events in Lebanon have imposed significant challenges on patients with IBD, affecting their adherence to therapy and consequently the control of their disease. There is an urgent need for action within the public health context to improve IBD medication availability and accessibility for the Lebanese population.

Global Health System Resilience during Encounters with Stressors – Lessons Learnt from Cancer Services during the COVID-19 Pandemic

AimsThe protracted COVID-19 pandemic has overwhelmed health systems globally, including many aspects of cancer control. This has underscored the multidimensional nature of cancer control, which requires a more comprehensive approach involving taking a wider perspective of health systems. Here, we investigated aspects of health system resilience in maintaining cancer services globally during the COVID-19 pandemic. This will allow for health systems to be resilient to different types of system stressors/shocks in the future, to allow cancer care to be maintained optimally. Materials and methodsUsing the World Health Organization health system framework (capturing aspects of service delivery, health workforce, information, medical products, vaccines and technologies, financing and governance and leadership), we carried out a comparative analysis of the impact of COVID-19 and the synthesis of the findings in responses in cancer care in 10 countries/jurisdictions across four continents comprising a wide diversity of health systems, geographical regions and socioeconomic status (China, Colombia, Egypt, Hong Kong SAR, Indonesia, India, Singapore, Sri Lanka, UK and Zambia). A combination of literature and document reviews and interviews with experts was used. ResultsOur study revealed that: (i) underlying weaknesses of health systems before the pandemic were exacerbated by the pandemic (e.g. economic issues in low- and middle-income countries led to greater shortage of medication and resource constraints compounded by inadequacies of public financing and issues of engagement with stakeholders and leadership/governance); (ii) no universal adaptive strategies were applicable to all the systems, highlighting the need for health systems to design emergency plans based on local context; (iii) despite the many differences between health systems, common issues were identified, such as the lack of contingency plan for pandemics, inadequate financial policies for cancer patients and lack of evidence-based approaches for competing priorities of cancer care/pandemic control. ConclusionWe identified four key points/recommendations to enhance the resilient capacity of cancer care during the COVID-19 pandemic and other system stressors: (i) effective pandemic control approaches in general are essential to maintain the continuity of cancer care during the emergency health crises; (ii) strong health systems (with sufficient cancer care resources, e.g. health workforce, and universal health coverage) are fundamental to maintain quality care; (iii) the ability to develop response strategies and adapt to evolving evidence/circumstances is critical for health system resilience (including introducing systematic, consistent and evidence-based changes, national support and guidance in policy development and implementation); (iv) preparedness and contingency plans for future public health emergencies, engaging the whole of society, to achieve health system resilience for future crises and to transform healthcare delivery beyond the pandemic.

Descriptive analysis of TikTok videos posted under the hashtag #Ozempic

Current discourse regarding weight loss on social media includes the discussion of Ozempic, a drug which facilitates weight loss, although approved for enhancing metabolic control among people with diabetes. The surge in public interest and the subsequent increase in demand for Ozempic has led to medication shortages for people with diabetes, as highlighted in news reports and publications. This cross-sectional study aimed to describe the content of the first 100 video results under the hashtag #Ozempic on TikTok. Videos extracted from TikTok were primarily uploaded by consumers and viewed ∼ 70 million times. The coding sheet encompassed basic information (including the URL identifier, date of upload, view count, number of likes, number of shares, and indication of whether the video was uploaded by consumers or professionals), and 19 content categories. Only two of the 19 content characteristics were covered in the majority (>50%) of the videos, “mentions being on/taking Ozempic or others taking/using/planning to use Ozempic” (n = 69), garnering over 43 million views) and “mentions being used for weight loss” (n = 57), garnering over 44 million views). Over one-third (n = 35), garnering over 31 million views, included content that “encourages/entices other people to try Ozempic/presents Ozempic as a coveted drug/portrays Ozempic positively.” Less than 5% of the sample mentioned “off label prescription use” (n = 3), “bariatric surgery for weight loss” (n = 3), or “medication shortage” that may result from off label use (n = 1). Healthcare professionals, regulatory bodies, and social media platforms should collaborate to address the challenges posed by viral trends resulting in medication shortages with potentially consequential outcomes for people with diabetes.

Impact of the COVID-19 pandemic on pharmacy practice and on the provision of pharmaceutical care: A cross-sectional study among community pharmacists.

Community pharmacists played an essential role in the control and management of the COVID-19 pandemic; both pharmaceutical care and community pharmacists were affected, given that, patients' needs and demands increased due to the fear of lockdowns and shortage of medication throughout the pandemic. This study was based in Lebanon and aimed to assess the impact of the COVID-19 pandemic on (1) pharmacists, including infection rates, pay, and working hours, and (2) pharmacy practice, including medicine and personal protective equipment (PPE) shortages. A cross-sectional study involving 120 community pharmacists was carried out between August and November 2021. Data were collected using an online survey filled out by pharmacists working in Lebanon. Most participants (71.7%) reported an increase in their income during the pandemic, and 60% reduced their working hours. A significant association was noted between being previously infected and marital status, level of education, work position, and salary of the participants. Most participants (95.8%) encountered a shortage of medications during the pandemic leading to high home storage of medication, searching for other sources of medicines, and decreased patient/pharmacist interactions. The COVID-19 pandemic imposed new challenges on pharmacists and the provision of pharmaceutical care. It affected pharmacists' daily routines, putting them at risk of infection with limited availability of medicines and PPE. This study suggests that establishing effective crisis management plans to increase community pharmacists' resilience during similar outbreaks.

Clinical practice in prostate PET imaging.

Positron emission tomography (PET) imaging in prostate cancer has advanced significantly in the past decade with prostate cancer targeted radiopharmaceuticals now playing a growing role in diagnosis, staging, and treatment. This narrative review focuses on the most commonly used PET radiopharmaceuticals in the USA: prostate-specific membrane antigen (PSMA), fluciclovine, and choline. 18F-fluorodeoxyglucose (FDG) is used in many other malignancies, but rarely in prostate cancer. Previous literature is discussed regarding each radiopharmaceutical's utility in the settings of screening/diagnosis, initial staging, biochemical recurrence, advanced disease, and evaluation prior to targeted radiopharmaceutical therapy and radiation therapy. PET imaging has demonstrated utility over traditional imaging in various scenarios; however, there are few head-to-head studies comparing PET radiopharmaceuticals. PSMA radiopharmaceuticals are the newest tracers developed and have unique properties and uses, especially at low prostate-specific antigen (PSA) levels. However, each PET radiopharmaceutical has different properties which can affect image interpretation. Choline and fluciclovine have minimal urinary activity, whereas PSMA agents can have high urinary activity which may affect locoregional disease evaluation. Of the three radiopharmaceuticals, only PSMA is approved for both diagnostic and therapeutic indications with 177Lu-PSMA. A variety of diagnostic PET radiotracers for prostate cancer allows for increased flexibility, especially in the setting of supply chain and medication shortages. For the time being, keeping a diverse group of PET radiopharmaceuticals for prostate cancer is justifiable.

Ethical Approaches to Public Policy for Health: A Focus on Principles and Working Together

News about the healthcare crisis, including strikes in multiple countries, workforce shortages, ambulance diversion and delays on entry to emergency rooms, closing floors while demand for beds increases, long waits for appointments in primary and specialty care, and shortages of supplies and medications all lead to proposed solutions for each issue. The point must be noted that these also point to some basic questions. This Commentary calls for a “back to basics” approach that requires dialogue (not just talking but listening) and a focus on some of our primary principles.

Second ADHD medication shortage leaves patients in 'very difficult position', pharmacists warn

Second ADHD medication shortage leaves patients in 'very difficult position', pharmacists warn

Reasons for Avoiding their Local Clinics among Non-emergency Patients at Accident and Emergency Department, Pretoria, South Africa

Background: An accident and emergency department (AED) is designated for patients who need to be seen urgently. However, at Jubilee Hospital, a large number of patients regularly presented directly to the AED with minor ailments. This resulted in long queues in the already overcrowded waiting room. Methods: A cross-sectional study design with a sample of 289 participants. Results: Those aged 21-40 years accounted for 44.6% of the participants. Patients mainly arrived on Fridays (72%), and medical-related complaints (128; 44.3%) were the most prevalent. In addition, patients primarily relied on public transportation to get there (180; 62.1%). In most cases, patients had previously visited clinics more than twice (141; 58.8%). Majority of patients were aware of the community health centres’ services. Only 33.6% of the clinics that were bypassed provided services 24 hours a day. Almost 80% of bypassed clinics were within 10 km of the District Hospital. Patients’ main reasons were long queues (89.6%) and medication shortages (67.6%). In 51.2% of cases, patients were aware of the referral system, but 14.5% did not think it made sense, and 11% did not understand it well. Conclusion: Proper strict application of the triage system and education of patients will decrease emergency department overcrowding. This will improve patient safety, clinical outcomes and the efficiency of the health system. In addition, changing local clinics’ operating hours will assist in reducing the high number of patients seen at Jubilee Hospital.

1005. Financial and clinical impact of ceftolozane/tazobactam global recall on the treatment of multi-drug resistant Pseudomonas in a large health system

Abstract Background In December 2020, ceftolozane/tazobactam (CT) was voluntarily recalled due to failed sterility tests. With this recall, clinicians were forced to utilize alternatives for multi-drug resistant (MDR) Pseudomonas (PSA) infections until CT returned in late December, 2021. While many studies have examined the impact of medication shortages, few have evaluated the impact of antimicrobial shortages. We evaluated the impact of the CT recall by assessing cost, clinical outcomes, and utilization of novel alternative agents. Methods This multi-site retrospective cohort study compared patients treated for MDR PSA prior to the CT recall (Jan-Jul 2020) to patients treated during the CT recall (Jan-Jul 2021) across seven AdventHealth Central Florida (AHCF) adult hospitals. The primary outcome was percentage of patients treated with novel therapies (CT, ceftazidime/avibactam, or cefiderocol). Secondary outcomes included length of therapy (LOT), inpatient mortality, 30-day readmissions, length of say (LOS), pharmacy expenditures, and average cost per case. Results A total of 203 patients with MDR PSA were evaluated: 100 in the pre-recall cohort and 103 in the post-recall cohort. The majority (58%) of patients were male with an average age of 64 years. The most common source of infection in both cohorts was pneumonia, followed by complicated urinary tract infection. Significantly more patients were treated with novel agents as definitive therapy in the post-recall cohort (65% vs. 29%, p< 0.0001). Average LOT for all anti-PSA therapy was 12 days in the pre-recall cohort compared to 14 days in the post-recall cohort (p=0.1753). Inpatient mortality and 30-day readmissions were not statistically different between groups. Hospital LOS was significantly different between the two groups (18 days vs. 25 days, p=0.006). Significantly higher pharmacy expenditures were found in the post recall cohort (Figure 1) and the average cost per case was significantly higher in the post-recall cohort ($125,254 vs. $62,249). Figure 1:Pharmacy Expenditures for Novel Agents Novel agents: cefiderocol, ceftazidime/avibactam, ceftolozane/tazobactam Conclusion The CT recall had a significant impact on both economic and clinical outcomes, particularly increased length of stay, length of therapy, and cost to both the patient and health system. Higher utilization of novel agents is concerning given rising rates of PSA resistance. Disclosures Amy L. Carr, PharmD, BCIDP, Shionogi: Advisory Board.

Adherence to antimicrobial agent recommendations and utilization during drug shortages.

Antimicrobial shortages occur frequently, but the impact on antimicrobial use is not well defined. The study objectives were to characterize utilization of antimicrobial agents with established restrictions during a medication shortage, assess utilization of shortage antimicrobials following shortage resolution, and examine use of recommended alternative antimicrobials during the shortage period. Five antimicrobials were restricted due to shortages from 2015 through 2020. Chart review of inpatients receiving a shortage medication during each restriction period was performed to determine factors influencing adherence to established restriction criteria. To assess antimicrobial utilization during shortages and following shortage resolution, days of therapy per 1,000 patient days were analyzed for each shortage and alternative antimicrobial. Across 266 patients receiving shortage antimicrobials, antimicrobial use was adherent to restriction criteria for 151 patients (57%). Meropenem, ampicillin/sulbactam, and piperacillin/tazobactam had the greatest adherence. Median duration of therapy was shorter in the nonadherent group than in the adherent group (4 vs 2 days, P < 0.0001). Shortage antimicrobial use was more likely to be nonadherent for indications such as sepsis rule out, surgical prophylaxis, and urinary tract infection. Adherence increased with use of visual cues in the chart (99% vs 94%, P = 0.03). Utilization of shortage agents decreased during shortage and restriction periods. After shortage resolution, utilization exceeded baseline usage for all agents except meropenem and metronidazole, for which usage returned to baseline. Utilization of 1 to 2 recommended alternative agents for each shortage agent significantly increased during the shortage and restriction periods. Current strategies for restriction significantly decreased utilization of shortage antimicrobials, but additional opportunities exist. Identifying alternative agents and providing visual cues increased adherence.

A pilot assessment of the career and job satisfaction of the pharmaceutical workforce in Lebanon

BackgroundLebanon has been recognized as a center for high-quality healthcare services in the Middle East because of its prestigious facilities certified by international bodies, competent health workers, and credible pharmaceutical sector. This study assessed the professional situation of the Lebanese pharmaceutical workforce upon graduation and entry to the job market. It also evaluated the satisfaction of pharmacists with the financial, physical, and psychological aspects of their job and the effect of the current socioeconomic crisis on their profession.MethodsA cross-sectional study was performed between January and May 2021 among 114 Lebanese pharmacists from all pharmaceutical sectors across Lebanon. A self-administered questionnaire was elaborated to assess the pharmaceutical workforce in Lebanon. The online questionnaire was built using Google Forms and disseminated via emails and social platforms.ResultsFresh graduates seemed more oriented toward community pharmacies, and 78.1% of the participants worked at least once in their lifetime in a community pharmacy. Pharmacists from the public university worked predominantly in the community pharmacy sector, while those who graduated from private universities worked mainly as medical representatives. Hospital pharmacy comprised significantly more PharmD graduates than other sectors; medical representatives had mainly a BS pharmacy, while those working as industrial pharmacists had a Master’s degree. A low percentage (31.6%) of participants found it easy to get hold of a job across different pharmaceutical sectors while 64.0% considered the internships experience insufficient to get employed. Nearly half (48.2%) of the respondents were poorly satisfied with their job, and 54.0% of community pharmacists reported not working in their preferred field compared to 39.1% of pharmacists from other sectors. Also, 65.79% felt that the economic crisis and the consequent medication shortages affected their credibility and how society perceived them. About half (45.61%) of the participants reported that their employment status was not affected by the crisis; the rest got a second job to cover their expenses (15.79%) or changed jobs (14.91%).ConclusionOur study findings revealed that most Lebanese fresh graduates worked as community pharmacists, which does not correspond to their preference, the available job market, and the modern pharmacy wingspan. Most pharmacists were also financially, physically, and emotionally dissatisfied due to the Lebanese economic crisis that added heavy workloads and responsibilities without any financial raise.

“Older people tend to be invisible”: a qualitative study exploring the needs and inclusion of older Syrian refugees in the context of compounding crises in host country, Lebanon

BackgroundOlder Syrian refugees in Lebanon are a marginalized population with under-recognized health needs. The inclusivity of this population within the humanitarian response is poorly understood. This study aims to identify the unique needs of older Syrian refugees in the context of recent concurrent crises in Lebanon, and explore the extent to which they are being met and prioritized by local and international aid agencies.MethodsWe conducted in-depth interviews with a snowball sample of 26 stakeholders from 11 organizations operating in the health, nutrition, and water, sanitation, and hygiene sectors. Data analysis followed principles of thematic analysis.ResultsConcurrent political, economic, and public health crises in host country promoted income insecurity among older refugees and increased dependency on younger relatives, leading to food insecurity, neglect, and poor health outcomes, including the sequelae of untreated non-communicable diseases. Mental illness was perceived to be exacerbated by Covid-19 related challenges, including social isolation, uncertainty about the future, and additionally due to feelings of guilt related to economic dependence and fundamental exclusion from labor force participation. Despite their vulnerability, older refugees are overlooked by the humanitarian response, which may be related to a lack of data. Pervasive medication shortages in the setting of the economic collapse, as well as inaccessible physical environments and competing interests were all identified as major barriers to care.ConclusionsOlder Syrian refugees in Lebanon experience dual vulnerability that is acutely exacerbated in the setting of concurrent crises. Sociopolitical, economic, and cultural barriers promote social exclusion and may confer an increased risk of income and food insecurity in this population, with significant implications for health. Humanitarian aid agencies operating in the context of fragmented, under-resourced health systems are currently unable to sufficiently address multi-faceted needs of this community. We recommend moving away from a donor-dependent model of aid by allocating resources toward strengthening inclusive national health systems that emphasize preventative care. We further call for age-disaggregation of routine data and normalization of data sharing among stakeholders in the academic and public health sectors in order to develop evidence-based initiatives that can meet the needs of this under-served community.

Estimating Optimal Infinite Horizon Dynamic Treatment Regimes via pT-Learning

Recent advances in mobile health (mHealth) technology provide an effective way to monitor individuals’ health statuses and deliver just-in-time personalized interventions. However, the practical use of mHealth technology raises unique challenges to existing methodologies on learning an optimal dynamic treatment regime. Many mHealth applications involve decision-making with large numbers of intervention options and under an infinite time horizon setting where the number of decision stages diverges to infinity. In addition, temporary medication shortages may cause optimal treatments to be unavailable, while it is unclear what alternatives can be used. To address these challenges, we propose a Proximal Temporal consistency Learning (pT-Learning) framework to estimate an optimal regime that is adaptively adjusted between deterministic and stochastic sparse policy models. The resulting minimax estimator avoids the double sampling issue in the existing algorithms. It can be further simplified and can easily incorporate off-policy data without mismatched distribution corrections. We study theoretical properties of the sparse policy and establish finite-sample bounds on the excess risk and performance error. The proposed method is provided in our proximalDTR package and is evaluated through extensive simulation studies and the OhioT1DM mHealth dataset. Supplementary materials for this article are available online.

Recommendations for treatment strategies in people with epilepsy during times of shortage of antiseizure medications

In times of severe antiseizure medication (ASM) shortage due to emergency situations (e.g., disasters, conflicts, sudden disruption to international supply chains), management of people with epilepsy with available ASMs can be difficult. A group of experts was brought together by the International League Against Epilepsy (ILAE) to formulate recommendations for such circumstances. Every effort was made to base these recommendations on direct published literature or extrapolations from basic information available about ASMs. Actual published literature in this area is, however, limited, and at times, assumptions were made by the experts to generate these recommendations. During times of shortage of ASMs, switching between different ASMs (e.g., oxcarbazepine and carbamazepine) can occasionally be considered as a mitigation procedure. However, for many ASMs, the option of an overnight switch to another drug does not exist. Switching from brand to generic or between generic products has often been shown to be safe, if required. Finally, when supplies of benzodiazepines or equipment to administer medications intravenously are not available, rectal administration of some ASMs may be an emergency alternative route for treating serial seizures and status epilepticus. Decision-making with regard to treatment and possible options should be driven by what is best for the patient.