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Objectives Medicines optimization (MO) in patients with chronic kidney disease (CKD) is at high risk at transition points of different ambulatory care levels such as nephrologists in outpatient clinics and general practitioners (GPs). We examined if adding a clinical pharmacist to the therapeutic team promotes implementation of nephrologists’ drug therapy recommendations by GPs’ and reduces drug-related problems (DRPs). Methods A prospective, controlled intervention study was conducted in the nephrology outpatient clinic of the Klinikum Fulda, Germany. The control and intervention phases took place successively. Patients with CKD stage 3–5 and at least one concomitant disease, for example, arterial hypertension or type-2 diabetes were recruited consecutively in three subgroups (naive, 1 contact, ≥2 contacts with nephrologist) from June 2015 to May 2019. GPs’ acceptance and frequency of DRPs without (control group [CG]) and with (intervention group [IG]) pharmacist’s interventions were compared after 6 months. Interventions include educational training events for GPs between control- and intervention phase, medication therapy management and pharmaceutical patient counselling. Key findings In total, 256 patients (CG = 160, IG = 96) were recruited into the study. GPs’ acceptance of nephrologists’ medication recommendations increased significantly among naive patients and those with one prior contact with the nephrologist (CG/IG: naive = 72.8%/95.5%, 1 contact = 81.1%/94.4%; P < 0.001). DRPs per patient were significantly reduced in all subgroups (P < 0.001). Conclusions Interdisciplinary collaboration between the nephrologist, GPs and clinical pharmacist resulted in better MO for patients with CKD.

Objectives Chronic kidney disease (CKD) is a common disorder all over the world. Therapeutic goals are early detection of declining renal function and implementation of adequate pharmacological treatments regarding underlying and secondary diseases. As therapy becomes more complex with increasing stages of CKD, a decision-making tool for healthcare professionals could help to ensure safe drug treatment in patients with CKD in the outpatient setting. Therefore, a list of renally relevant drugs as a decision-making tool was developed to improve medicines optimisation for CKD patients in the outpatient setting long term. Methods A renally relevant drug list (RRD-list) with renally relevant drugs, based on data from a study on medicines optimisation in patients with CKD from June 2015 to March 2018, was developed at the nephrological outpatient clinic at the Klinikum Fulda, Germany. The whole study is published elsewhere. A clinical pharmacist reviewed the patients’ medications, current drug-related problems and all nephrologists’ recommendations, and categorised all detected drugs into renally relevant and non-renally relevant groups. The 10 most frequently detected renally relevant drug groups were summarised in the RRD-list and extended by treatment alternatives and advice. Results The medication of 160 patients, who were receiving overall 1376 drugs, was analysed; 831 drugs were defined as renally relevant. Drug-related problems were caused by 543 renally relevant drugs. The nephrologists made 292 recommendations regarding 28 drug classes. Considering the 10 most frequent drug groups, in total 16 renally relevant drug groups with 36 drug classes were added to the RRD-list. Conclusions The RRD-list could be an essential tool for all healthcare professionals in their daily work, such as general practitioners and community pharmacists, for the treatment of patients with renal insufficiency.

IntroductionAn implementation of process driven work in dietetics requires detailed analysis and specific planning. Therefore, gathering information on structures of the institution is an essential step and prerequisite for the development of an implementation concept. Process driven work in nutrition counseling and therapy, especially the implementation of the new developments into practice becomes more and more important.The aim of the present qualitative study was to assess and analyse structures of the in-patient setting of nutrition counseling and therapy in a German clinical centre. Subsequently, strengths and challenges for the implementation of process driven work were identified.Materials and MethodsBased on a structured literature search, guidelines for interviews with dietitians of a clinical centre were developed. The five interviews were recorded, transcribed with f4® and analysed by using the qualitative content analysis by Mayring. Finally, strengths and challenges for process driven work were identified out of this qualitative research.ResultsThe following strengths and challenges were identified:Strengths: concrete responsibility for indications, flexible duration of patient-consultations, use of standardized patient information, use of a digital documentation system, continuous intra- and interprofessional exchange, participation in education and trainingChallenges: variety of different activities, barriers in the access to the dietitian, often only one-time dietitian-patient-consultation, time dependent problems because of the limited in-patient therapy, deficiency of rooms for a private patient consultation, non-existing data exchange from the in-patient into the outpatient setting, knowledge deficits of dietitians regarding process-driven workDiscussionFor the new developments for process driven work adequate structures of nutrition counseling and therapy in the in-patient setting are very important for patient care. Based on the gathered information on structures and processes, a concept for the implementation of a process model with a target and milestone planning will be helpful. Especially the appropriate access to patients as well as the fact that the dietitian-patient-consultation is mainly one-time have to be considered for the implementation concept. The integration of every process step in the in-patient setting is difficult to realize. Therefore, the prioritization of the considered process steps is necessary. Consequently, an exchange with the outpatient setting is advisable for the implementation of the complete process model.

Summary What is known and objective Good communication between hospital and primary care physicians (PCPs) is important for the continuity of patient care in the transition phase following hospital treatment. Drug-related problems and medication errors may occur at that interface. Discharge letters often lack a structured medication report at the end and therefore may not provide the reasons for medication changes, resulting in low adherence rates. The objectives were to develop a structured medication report as part of the discharge letter, to evaluate the impact of the medication report in ischaemic stroke patients and to identify the most important issues in the transitional care process of stroke patients. Methods First, a structured medication report was developed. Thereafter, the impact of this new medication report on clinical practice was evaluated with an open, prospective, interventional two-phase study conducted at the Klinikum Fulda gAG (Germany), which included patients with ischaemic stroke and >2 drugs in the discharge medication. In the control group (CG), the neurologist included the current medication in the discharge letter. In the intervention group (IG), the clinical pharmacist added the detailed information to a medication report. To evaluate adherence to discharge medication, the PCP was interviewed 3 months after hospital discharge about the medication. Adherence was measured with respect to the entire medication regimen, antithrombotic and cholesterol-lowering drugs and discontinued medication. The most important issues in the transitional care for patients with ischaemic stroke were identified on the basis of the secondary stroke prevention and cardiovascular risk factors. Results and discussion Overall, 312 patients were enrolled in the study with 156 patients in each group. By providing detailed information in the newly developed discharge letter, adherence increased significantly from 83·3% (CG) to 90·9% (IG; P = 0·01). Significant differences between the CG and IG were found with regard to adherence to both antithrombotic drugs [83·8% CG vs. 91·9% IG (P = 0·033)] and statin therapy [69·8% CG vs. 87·7% IG (P

Summary What is known and Objective: Identifying, preventing and resolving drug-related problems (DRP) is an important issue in the pharmaceutical care process. Because DRPs have been detected in a more systematic way, the need for a classification system to document, classify and evaluate the collected data has become necessary. The objective was to develop a classification system for DRPs within the hospital setting, to evaluate the practicality and to assess the inter-rater reliability. Methods: All DRPs defined in PI-Doc and PCNE, which are relevant in the hospital setting, were included. Further relevant DRPs identified in other projects in a hospital setting as well as DRPs from the daily work on the ward were collected, and a short description of each DRP was written. A prospective study was conducted at Klinikum Fulda, Germany, in both a non-surgical and a surgical setting to explore whether the new classification system is suitable to classify DRPs in clinics with different specifications. For assessing the inter-rater reliability, 24 standardized case reports were provided. All participants classified them independently. The inter-rater reliability was analysed using Kappa coefficient. Results and Discussion: A classification system for DRPs in the hospital setting (APS-Doc) was established with 10 main categories and 48 subcategories. Practicality was assessed in 250 patients in a non-surgical ward as well as in 100 patients in a surgical ward. The inter-rater agreement was 0·68 (95% CI, 0·66–0·69) for main categories, which comprises substantial agreement. Moderate agreement (κ = 0·58; 95% CI, 0·58–0·59) was demonstrated for the subcategories. What is new and Conclusion: A new hierarchical classification system for DRPs in the hospital setting has been developed. APS-Doc seems suitable for various parts of the medication process such as medication reconciliation and drug therapy within both non-surgical and surgical wards. Inter-rater reliability was found to be substantial in the main categories and moderate in the subcategories.

The novel oral anticoagulants (NOAC) dabigatran, apixaban, edoxaban and rivaroxaban target either thrombin or factor Xa for the prevention and treatment of thrombosis. A short introduction of the main indications for an oral anticoagulation is followed by the pharmacology of each drug, their effectiveness, selected drug-drug interactions and adverse drug events, especially bleeding. The article represents clinical aspects for the perioperative management, the possibilities for monitoring of each drug, the application in patients with renal impairment as well as different advantages and disadvantages.

Atrial fibrillation is one of the most important indications for oral anticoagulation. Besides vitamin K antagonists, the novel oral anticoagulants dabigatran, apixaban, edoxaban and rivaroxaban are one therapy option in patients with atrial fibrillation. The following case report describes an 83-year-old female patient treated with dabigatran for secondary stroke prevention. Due to different factors, the renal function of the patient decreases significantly (acute on chronic renal failure), resulting in a re-evaluation of the current treatment. This case report is an example of decision-making 'for and against' novel oral anticoagulants versus vitamin K antagonists.

Background and Purpose— Communication between hospitals and primary care physicians is essential for the continuity of care for patients being transferred from hospital to ambulatory care. Patients are often discharged from hospital on medication regimes different from those used before hospital admission. The aim of the study was to evaluate the adherence to hospital discharge medication in patients with ischemic stroke before and after implementing a systematic approach provided by a clinical pharmacist. Methods— Patients with transient ischemic attack/ischemic stroke taking ≥ 2 drugs during hospital stay and at discharge were prospectively recruited. In the control group, the neurologist included the medication list in the discharge letter as before. In the intervention group, the clinical pharmacist listed the medication on admission and at discharge next to each other and gave detailed information for all medication changes during hospital stay. Results— Overall, 312 patients were enrolled in the study with 156 patients in each group. Significant differences between the control group and intervention group were ascertained with regard to adherence to both antithrombotic drugs (83.8% control group versus 91.9% intervention group [ P =0.033]) and to statin therapy (69.8% control group versus 87.7% intervention group [ P Conclusions— Providing detailed information on medication changes can lead to substantially improved adherence to discharge medication, probably resulting in better secondary stroke prevention.

Surgical site infections (SSIs) are associated with a high morbidity, mortality and healthcare costs. The prevention of SSIs is based on a combination of preoperative preparation, surgical techniques, perioperative antibiotic prophylaxis (PAP) and postoperative wound care. Despite an abundance of evidence demonstrating the effectiveness of antimicrobials to prevent SSIs, the use of antimicrobial prophylaxis in this clinical setting is associated with inappropriate timing and selection and excessive duration of administration. To date, pharmacy interns (PIs) have not been involved in this process. The aim of this study was to evaluate feasibility of involving PIs in monitoring adherence to the guidelines for antibiotic prophylaxis in surgery patients.The study was conducted in seven hospitals in Germany within the framework of the project "Pharmacy interns on the ward" (P-STAT2). Twenty-seven PIs participated, either from either May to October 2008 or from November 2008 to April 2009. Each patient admitted to the participating wards was consecutively monitored. PIs documented the antibiotic prophylaxis and checked the adherence with the hospital ward's PAP guidelines taking both the choice of antibiotic drug and the duration of PAP into account. The costs of antibiotics, personnel and material were calculated in cases of non-adherence with guidelines.This is the first time that PIs were involved in monitoring antibiotic prophylaxis guidelines. A total of 6,167 patients were enrolled (mean age 58.3 ± 19.6 years; 47.1% male); of these, 5,064 patients underwent surgery and were ultimately available for evaluation. Guidelines for antibiotic prophylaxis were followed in 70.7% of the cases.The study revealed that many patients do not receive the appropriate antibiotic prophylaxis despite the fact that guidelines are in place. Based on these results, we conclude that PIs may play an important role in antibiotic prophylaxis management.

Objectives To improve patients health-related quality of life (HQL) after transient ischemic attack (TIA) or ischemic stroke; to guarantee an effective secondary prevention; to increase the patient’s satisfaction with recommendations regarding their medication by pharmacists. Setting Stroke Unit, neurological ward at the Klinikum Fulda, rehabilitation hospitals and community-based pharmacies in the region of Fulda, Germany. Method Patients with TIA or ischemic stroke were included. The patients were assigned to an intervention group (IG) or a control group (CG). The individual assignment of patients to IG or CG was based on the type of the local pharmacy to which patients belong. Community-based pharmacies either delivered standard care (CG) or provided additional intensified pharmaceutical care (PC; IG). Pharmacies delivering PC belong to a pre-existing “Quality Assurance Working Group” (QAWG). To evaluate the patient’s HQL, the Short Form-36 (SF-36) was used at study entry in hospital and at 12 months. The secondary prevention was documented at study entry in hospital and at 12 months. The patients’ satisfaction was measured by a questionnaire at the end of the study. Main outcome measures Patients’ HQL; secondary prevention; patients’ satisfaction with recommendations of the pharmacists with regards to their medication. Results Out of 1316 patients screened for participation in this study, 255 were recruited with 90/255 patients assigned to the IG and 165/255 patients assigned to the CG. During the study, the HQL of the patients in the IG did not change significantly. A significant decrease in the HQL was observed for the CG in 7/8 subscales and in both summary measures of the SF-36. After 12 months, 85.3% of the patients in the IG and 86.3% of the patients in the CG were treated with antiplatelet drugs or oral anticoagulants in accordance to treatment guidelines. Patients in the IG were significantly more satisfied with the individualized recommendations of the pharmacists than patients in the CG. Conclusion Our findings indicate that an intensified PC of patients after ischemic stroke by dedicated pharmacists may have a positive impact on HQL and patients’ satisfaction. PC in this study had no impact on adherence to secondary prevention medication.

A 61-year-old patient with a sudden numbness of the right arm and hand and signs of amnestic aphasia is admitted to the stroke unit with the diagnosis of an acute ischemic stroke for systemic thrombolysis. Based on a case-report, drug-related problems are discussed according to the SOAP scheme. Aspects of pharmaceutical care such as counselling by a pharmacist about secondary prevention, discharge information and a pharmaceutical care plan in the community pharmacy are described.

Background Health-related quality of life (HRQoL) after stroke is an important healthcare measure. Pharmaceutical Care (PC) is an evolving concept to optimize drug-therapy, minimize drug-related problems, and improve HRQoL of patients. The purpose of this study was to evaluate the impact of PC on HRQoL, as determined by Short Form 36 (SF-36) among patients after TIA or ischemic stroke one-year following their initial entry in hospital. Methods Patients were assigned to either an intervention (IG) or a control group (CG). The individual assignment of the patient to IG or CG depended on the community pharmacy to which the patients were assigned for care. Community pharmacies either delivered standard care (CG) or provided intensified PC (IG). Pharmacists who are members of the "Quality Assurance Working Group" (QAWG) provided PC for patients in IG. Results 255 patients were recruited (IG: n = 90; CG: n = 165) between 06/2004 to 01/2007. During the study, the HRQoL of the patients in IG did not change significantly. In the CG, a significant decrease in the HRQoL was observed in 7/8 subscales and in both summary measures of SF-36. Conclusions This is the first follow-up study in Germany involving a major community hospital, rehabilitation hospitals, community pharmacies and general practitioners investigating the impact of PC on HRQoL of patients after ischemic stroke. Our findings indicate that an intensified education and care of patients after ischemic stroke by dedicated pharmacists based on a concept of PC may maintain the HRQoL of IG patients.

Isolated hepatocytes were prepared from rat liver by collagenase perfusion and density gradient centrifugation. The hepatocyte preparation released angiotensinogen at a basal rate of 50-120 pmol/g wet weight per h. Release was linear with time for at least 4 h. Angiotensinogen secretion was reduced in the presence of actinomycin D, and inhibited by cycloheximide, puromycin, colchicine and vinblastine. In the presence of tunicamycin, an inhibitor of N-glycosylation, the secretion of angiotensinogen as well as total protein and albumin secretion were diminished. Hepatocytes from nephrectomized rats exhibit an increased secretion rate of angiotensinogen, whereas total protein secretion was unaltered. Preincubation of hepatocytes with hydrocortisone (0.1 mM) or angiotensin II (10 nM) induced an increase of angiotensinogen release. There was no concomitant increase of total protein or albumin secretion, indicating that these effects are not the expression of a general stimulation of protein synthesis and secretion.

Chronic treatment with converting enzyme inhibitors induces a fall of plasma angiotensinogen concentration, which is thought to result from increased consumption by renin. As this explanation cannot account for all the observations, we reexamined this effect. Rats received captopril (50 mg/kg per day), enalapril (10 mg/kg per day) or Hoe 498 (1 mg/kg per day) for 7 days. Plasma angiotensinogen (by indirect assay) fell to 34, 37 and 43% of its initial values, respectively. Total immunoreactive angiotensinogen (by direct radioimmunoassay, which also measures des-AI-angiotensinogen) was 76, 70 and 95% of the initial values, respectively. This suggests that a major part of the fall of intact angiotensinogen can be attributed to increased cleavage by renin, but an additional factor is likely to be involved. Experiments with isolated hepatocytes indicated that converting enzyme inhibitors in high concentrations may have a direct effect on angiotensinogen secretion. Whether this can account for the fall in total immunoreactive angiotensinogen in vivo remain unclear.