Associate Professor Susan Hua

What is known and objective: Unintentional medication discrepancies (UMDs) are common in geriatric patients during care transitions, resulting in frequent undesirable consequences. Medication reconciliation could be a useful practice to prevent or ameliorate UMD. However, this practice in Vietnamese hospitals has not been well established or standardized. This study aims to determine the effect of pharmacist-initiated educational interventions on improving medication reconciliation practice. Methods: This prospective 6-month pre-and post-study was conducted in two internal medicine wards in a Vietnamese 800-bed public hospital. Pharmacists provided training and short-term support to physicians on medication reconciliation. Primary outcome measures were the proportions of patients with at least one UMD at admission. Secondary outcome measures were the proportions of patients with preventable adverse drug events (pADEs) score =0.1 due to these UMDs. Odds ratio and 95% confidence intervals were assessed based on a multivariate logistic regression model. Results and discussion: One hundred fifty-two patients were recruited in the pre-intervention phase, and 146 in the post-intervention phase. Following the intervention, the proportion of geriatric patients with =1 UMD at admission significantly decreased from 55.3 to 25.3¿% (ORadj 0.255, 95% CI: 0.151¿0.431). Similarly, the proportion of patients with a pADE =0.1 at admission reduced from 44.1 to 11.6% [ORadj 0.188, 95% CI: 0.105¿0.340] post-intervention. What is new and conclusion: Our pharmacist-initiated educational interventions have demonstrated the ability to produce substantial improvement in medication reconciliation practice, reducing UMDs and potential harm. Our approach may provide an alternate option to implement medication reconciliation for jurisdictions with limited healthcare resources.

Sarcoptic scabiei is an invasive parasitic mite that negatively impacts wombats, causing sarcoptic mange disease, characterized by alopecia, intense pruritus, hyperkeratosis, and eventual mortality. Evidence suggests that wombats may be unable to recovery from infection without the assistance of treatments. Transdermal drug delivery is considered the most ideal route of administration for in situ treatment in free-ranging wombats, as it is non-invasive and avoids the need to capture affected individuals. Although there are effective antiparasitic drugs available, an essential challenge is adequate administration of drugs and sufficient drug retention and absorption when delivered. This review will describe the implications of sarcoptic mange on the physiology of wombats as well as discuss the most widely used antiparasitic drugs to treat S. scabiei (ivermectin, moxidectin, and fluralaner). The prospects for improved absorption of these drugs will be addressed in the context of pathophysiological and pharmaceutical considerations influencing transdermal drug delivery in wombats with sarcoptic mange.

Background: Elderly patients are at high risk of unintentional medication discrepancies during transition¿of care as they are more likely to have multiple comorbidities and chronic diseases that require multiple medications. Objective: The aim of the study was to assess the frequency of unintentional medication discrepancies and identify the associated risk factors and potential clinical impact of them in elderly inpatients during hospital admission. Patients and Methods: A prospective observational study was conducted from July to December 2018 in an 800-bed geriatric hospital in Hanoi, North Vietnam. Patients over 60 years of age, admitted to one of selected internal medicine wards, taking at least one chronic medication before admission, and staying at least 48 h were eligible for enrollment. Medication discrepancies of chronic medications before and after admission of each participant were identified by a pharmacist using a step-by-step protocol for the medication reconciliation process. The identified discrepancies were then classified as intentional or unintentional by an assessment group comprising a pharmacist and a physician. A logistic regression model was used to identify risk factors of medication discrepancies. Results: Among 192 enrolled patients, 328 medication discrepancies were identified, with 87 (26.5%) identified as unintentional. Nearly a third of enrolled patients (32.3%) had at least one unintentional medication discrepancy. The most common unintentional medication discrepancy was omission of drugs (75.9% of 87 medication discrepancies). The logistic regression analysis revealed a positive association between the number of discrepancies at admission and the type of treatment wards. Conclusions: Medication discrepancies are common at admission among Vietnamese elderly inpatients. This study highlights the importance of obtaining a comprehensive medication history at hospital admission and supports implementing a medication reconciliation program to reduce the negative impact of medication discrepancy, especially for the elderly population.

Purpose: Geriatric inpatients generally have a high risk of drug-related problems (DRP) in prescribing following hospital admission, which are likely to cause negative clinical consequences. This is particularly evident in developing countries such as Vietnam. Therefore, clinical pharmacy service (CPS) aims to identify and resolve these DRPs to improve the quality use of medicines in the older population following hospital admission. Patients and Methods: The study was conducted as a prospective, single-center study implemented at a general public hospital in Hanoi. Patients aged =60 years with at least three chronic diseases admitted to the Internal Medicine Department between August 2020 and December 2020 were eligible to be enrolled. A well-trained clinical pharmacist provided a structured CPS to identify any DRP in prescribing for each patient in the study. Clinical pharmacist interventions were then proposed to the attending physicians and documented in the DRP reporting system. Results: A total of 255 DRP were identified in 185 patients during the study period. The most frequent types of DRP were underuse (21.2%), dose too high (12.2%), and contraindication (11.8%). There was a very high rate of approval and uptake by the physicians regarding the interventions proposed by the clinical pharmacist (82.4% fully accepted and 12.5% partially accepted). Of the interventions, 73.4% were clinically relevant (pADE score =0.1). In general, 9 out of 10 physicians agreed that CPS has significant benefits for both patients and physicians. Conclusion: Improving clinical pharmacy services can potentially have a positive impact on the quality of prescribing in elderly inpatients. These services should officially be implemented to optimize the quality use of medicines in this population group in Vietnam.

Targeted delivery of therapeutics to the uterus is an important goal in the treatment of obstetric complications, such as preterm labour, postpartum hemorrhage, and dysfunctional labour. Current treatment for these obstetric complications is challenging, as there are limited effective and safe therapeutic options available. We have developed a targeted drug delivery system for the uterus by conjugating anti-oxytocin receptor (OTR) antibodies to the surface of PEGylated liposomes (OTR-PEG-ILs). The functionality of the OTR-PEG-ILs has previously been evaluated on human and murine myometrial tissues as well as in vivo in a murine model of preterm labour. The aim of this study was to report the pharmaceutical synthesis and characterization of the OTR-PEG-ILs and investigate their specific cellular interaction with OTR-expressing myometrial cells in vitro. Immunoliposomes composed of 1,2-distearoyl-sn-glycero-2-phosphocholine (DSPC) and cholesterol were prepared using an optimized method for the coupling of low concentrations of antibody to liposomes. The liposomes were characterized for particle size, antibody conjugation, drug encapsulation, liposome stability, specificity of binding, cellular internalization, mechanistic pathway of cellular uptake, and cellular toxicity. Cellular association studies demonstrated specific binding of OTR-PEG-ILs to OTRs and significant cellular uptake following binding. Evaluation of the mechanistic pathway of cellular uptake indicated that they undergo internalization through both clathrin- and caveolin-mediated mechanisms. Furthermore, cellular toxicity studies have shown no significant effect of OTR-PEG-ILs or the endocytotic inhibitors on cell viability. This study further supports oxytocin receptors as a novel pharmaceutical target for drug delivery to the uterus.

The identity of cancer stem cells (CSCs) remains an enigma, with the question outstanding of whether CSCs are fixed entities or plastic cell states in response to microenvironmental cues. Recent evidence highlights the power of the tumor microenvironment to dictate CSC functionality and spatiotemporal regulation that gives rise to tumor heterogeneity. This microenvironmental regulation of CSCs parallels that of normal tissues, whereby resident stem cells reside within specialized microenvironments or ¿niches¿, which provide the cellular and molecular signals that wire every aspect of stem cell behavior and fate. The extracellular matrix (ECM), along with its sequestered growth factors, is a fundamental component of the stem cell niche. Pathological ECM remodeling is an established hallmark of cancer, with the ECM a key mediator of metastasis and drug resistance. In this review, we discuss the controversial identity of CSCs and new understanding of the impact of tumor microenvironment on CSC function and phenotype. We outline parallels between development, wound repair and cancer to discuss how changes in ECM dynamics influence stem cell function during normal physiological processes and pathological states, as well as the transition between the two in the form of precancerous lesions. We then explore examples illustrating the molecular circuits partnering cancer cells with stromal cells and how this communication involving ECM imparts a CSC phenotype and promotes chemoresistance. Understanding the mechanisms underlying CSC functionality and chemoresistance, along with mathematical modeling approaches and advancing technologies for targeting the undruggable proteome, should open opportunities for cancer breakthroughs in the future.

Background: Medication adherence is an important factor in the management of chronic obstructive pulmonary disease (COPD). However, the rate of non-adherence to medications is high in COPD and is associated with worsened clinical outcomes and health-related quality of life for patients. Objectives: Our study aimed to evaluate the impact of a pharmaceutical care program led by pharmacists in the improvement of medication adherence and quality of life for COPD patients in Vietnam. Methods: A pre- and post-intervention study was conducted over 12 months. Pharmacists provided brief counselling which focused on the role of COPD medications and the importance of adherence. Morisky Medication Adherence Scale was used to evaluate patients¿ adherence. Quality of life was assessed using the EQ-5D-5L questionnaire and clinical outcomes were evaluated by symptom scores. These outcomes were reassessed at baseline (T0), after 3 months (T1), 6 months (T2) and 12 months (T3). Results: Study participants consisted of 211 COPD patients (mean age: 66.6 ± 8.2 years). The percentage of patients with good adherence significantly increased from 37.4% to 53.2% (p < 0.001) after the program. Mean medication adherence scores improved from 6.7 (T0) to 7.4 (T2) and 7.4 (T3) (p < 0.001). EQ-5D-5L index values also increased from 0.47 (T0) to 0.59 (T3) (p < 0.001). There was no significant change in symptom scores across the duration of the study. Conclusions: Medication adherence and quality of life of COPD patients improved considerably after implementation of a pharmaceutical care program, thus supporting a vital role for pharmacists alongside physicians in the management of COPD.

Background: Incorrect use of inhalers is very common and subsequently leads to poor control of COPD. Among health care providers, pharmacists are in the best position to educate patients about the correct use of inhaler devices. Objective: The objective of this study was to evaluate the impact of pharmacist-led training on the improvement of inhaler technique for COPD patients in Vietnam. Patients and methods: For this pre-and post-intervention study, standardized checklists of correct use of metered-dose inhalers (MDIs) and dry powder inhalers (DPIs) were used to evaluate the inhaler technique. A scoring system (maximum score =8) was applied before and after training to guarantee assessment uniformity among pharmacists. Three methods including ¿face-to-face training¿, ¿teach-back¿ and ¿technique reminder label¿ were used. After the baseline evaluation (T0), the inhaler technique was reassessed after 1 month (T1), 3 months (T2), 6 months (T3) and 12 months (T4). Results: A total of 211 COPD patients participated in the study. Before the training, a high rate of errors was recorded. After the training, the percentage of patients using MDIs and DPIs perfectly increased significantly (p,0.05). The mean technique score for MDIs and DPIs improved from 6.0 (T0) to 7.5 (T3) and 6.9 (T4) and 6.7 (T0) to 7.6 (T3) and 7.2 (T4), respectively (p,0.05). The average training time was 6 minutes (T0) and 3 minutes (T3), respectively. Conclusion: Pharmacist-led comprehensive inhaler technique intervention program using an unbiased and simple scoring system can significantly improve the inhaler techniques in COPD patients. Our results indicated a 3-month period as the optimal time period between training and retraining for maintaining the correct inhaler technique. The training would be highly feasible and suitable for implementing in the clinical setting. Our model of pharmacist-led training should be considered as an effective solution for managing COPD patients and better utilization of health care human resources, especially in a developing country like Vietnam.

Objective: Community pharmacists can make significant contributions and be an indispensable member in the asthma therapy chain. The present study aimed to investigate the current knowledge level of Vietnamese community pharmacists in asthma counselling and the impact of a short training program on asthma knowledge and practice. Method: 300 community pharmacists participated in the study. A knowledge questionnaire about asthma medications and a standardized inhaler checklist were designed to evaluate their knowledge before and after a 4-h training program. Six to eight weeks later, 10 simulated patients were sent to the community pharmacies to evaluate the pharmacists¿ knowledge and practice. Results: The training program significantly improved the asthma knowledge score of pharmacists from 5.3 to 17.2 out of a maximum score of 20 (p < 0.001). After the training, the percentage of pharmacists performing correctly inhaler devices increased significantly (0% vs.~50%, p < 0.001). In the simulated patient study, pharmacists who attended the training demonstrated better asthma knowledge with higher scores (5.4 vs 1.7 out of a maximum score of 7.0, p < 0.001), as well as much better inhaler technique scores (6.1 vs 4.3, out of a maximum score of 8, p < 0.001). These pharmacists achieved higher scores in all aspects encompassing distinguishing controllers and relievers, counselling correctly about adherence, and common side effects. Conclusion: Our results revealed significant knowledge deficiency about asthma among Vietnamese community pharmacists. However, a short training program was effective in upskilling the pharmacists to effectively counsel asthmatic patients about the management of their condition and medications.

Background International and interprofessional collaborations are increasingly becoming a core requirement for health professionals in our globalized world. Aim The aim of this study was to evaluate the effectiveness of the Asia Pacific Alliance of Health Leaders (APAHL) Forum to enhance the development of international perspectives and leadership among students and faculty in the discipline of health. Methods This pilot study used a student-designed questionnaire to evaluate the views of students and faculty members about the effectiveness of APAHL in meeting its goals. Quantitative data from the scaled items on the questionnaire were analyzed by aggregating the data. Qualitative data were analyzed using a qualitative descriptive approach. Results Study participants comprised of 22 health science (nursing and laboratory science) students and 15 faculty members. Both faculty and students agreed that APAHL was effective in leadership development of students, as well as in advancing internationalization, interprofessional collaboration, and cultural awareness among students. A clear theme among the students was acknowledgement of the importance of communication, in particular being proficient in English. Difficulties in communication were an issue for both students and faculty members. Conclusion This pilot study has shown the benefits of a student-focused international forum in developing cross-cultural awareness, and will provide the groundwork for evaluating the effectiveness of cross-cultural and interprofessional leadership forums aimed particularly at students of health.

Introduction: Eosinophilic gastrointestinal disorders (EGIDs) are increasingly prevalent chronic inflammatory diseases characterized by eosinophilic infiltration of the gastrointestinal (GI) tract, in the absence of other known causes of eosinophilia. Areas covered: Clinical management of EGIDs is challenging, as there are currently limited therapeutic options available. The most common EGID is eosinophilic esophagitis (EoE), and rarer forms are eosinophilic gastritis, eosinophilic gastroenteritis, and eosinophilic colitis. Clinical presentation depends on the affected GI site. Recently duodenal eosinophilia has been recognized to commonly be present in patients with functional dyspepsia. This review will provide an overview of the pathogenesis and therapeutic management of EGIDs, with particular focus on the pharmacological strategies for these conditions. Expert commentary: Despite the considerable progress made in understanding the pathogenesis of EGIDs, there is still an urgent need for the development of specific and effective therapeutic approaches. Therapeutic management protocols are required that are based on rigorous clinical investigation in large prospective controlled trials to better understand the risks, benefits and limitations of each therapy. More well-defined and consistent end-points are also required to assess treatment outcomes, as there has been variability between patient reported outcomes, clinical outcomes, and histological outcomes in the studies to date.

The application of liposomes to assist drug delivery has already had a major impact on many biomedical areas. They have been shown to be beneficial for stabilizing therapeutic compounds, overcoming obstacles to cellular and tissue uptake, and improving biodistribution of compounds to target sites in vivo. This enables effective delivery of encapsulated compounds to target sites while minimizing systemic toxicity. Liposomes present as an attractive delivery system due to their flexible physicochemical and biophysical properties, which allow easy manipulation to address different delivery considerations. Despite considerable research in the last 50 years and the plethora of positive results in preclinical studies, the clinical translation of liposome assisted drug delivery platforms has progressed incrementally. In this review, we will discuss the advances in liposome assisted drug delivery, biological challenges that still remain, and current clinical and experimental use of liposomes for biomedical applications. The translational obstacles of liposomal technology will also be presented.

Pain from the female reproductive tract (FRT) is a significant clinical problem for which there are few effective therapies. The complex neuroanatomy of pelvic organs not only makes diagnosis of pelvic pain disorders difficult but represents a challenge to development of targeted therapies. A number of potential therapeutic targets have been identified on sensory neurons supplying the FRT but our knowledge on the basic neurophysiology of these neurons is limited compared with other viscera. Until this is addressed we can only guess if the new experimental therapies proposed for somatic, gastrointestinal, or bladder pain will translate to the FRT. Once suitable therapeutic targets become clear, the next challenge is drug delivery. The FRT represents a promising system for topical drug delivery that could be tailored to act locally or systemically depending on formulation. Development of these therapies and their delivery systems will need to be done in concert with more robust in vivo and in vitro models of FRT pain. © 2014 Jobling, O'Hara and Hua.

Background: The purpose of this study was to determine the most appropriate dialysis equilibrium method to assess liposomal gel formulations containing hydrophobic drugs, to give the most accurate indication of drug release. Methods: Loperamide hydrochloride-encapsulated liposomes, composed of L-a-phosphatidylcholine and cholesterol (molar ratio of 2:1), were prepared according to the method of dried lipid film hydration. The liposomes were incorporated into a carbopol gel (0.5%, weight/weight). The release of the drug from the nanoparticles was assessed using a number of variations of the dialysis technique, taking into account solubility parameters and formulation. Method 1 (below saturation point) and Method 2 (above saturation point) used a dilution method to evaluate how drug concentration and solubility affects the in vitro drug-release profile of loperamide hydrochloride, while Methods 3 (below saturation point) and 4 (above saturation point) evaluated how drug concentration and the gel base affect the release profile. Results: In Method 1, the liposomes showed a rapid release of just over 60% in the first 3 hours and then a slower, sustained release to just over 70% at 24 hours. Method 2 showed a gradual, sustained release profile with the liposomes with 55% release at 24 hours. In Method 3, the liposomes showed a rapid burst release of 98% at 2 hours. In Method 4, the liposomal gel had a rapid release of 60% within 3 hours and then a more gradual, sustained release with 86% release at 24 hours. The free drug suspension in Methods 2 and 4 showed a limited release across the dialysis membrane, in comparison to Methods 1 and 3, which showed a complete release in a timely manner. Conclusion: This study has demonstrated that the actual method used for equilibrium dialysis plays a significant role in determining the true characteristics of a topical nanoformulation, with Method 3 providing the most accurate indication of the release of a hydrophobic drug from a topical liposomal formulation. © 2014 Hua.

Background: Peripheral opioid receptor targeting has been well established as a novel target in clinical pain management for acute and chronic peripheral inflammatory pain. The physiochemical properties of the peripheral mu-opioid receptor agonist, loperamide HCl, limit the use of the free drug as an analgesic or anti-inflammatory agent, particularly for dermal delivery across intact skin.