Prevalence of Subclinical Rheumatic Heart Disease in Eastern Nepal

Rheumatic heart disease is a rheumatic fever complication resulting in the damage of the heart. In certain parts of the world, this condition is still prevalent. Children are at risk for catching rheumatic fever and the symptoms pointing towards rheumatic heart disease won’t be easily detectable. The complications of rheumatic heart disease may appear later in life. Studies have been conducted to research the background and demographics for children in areas where rheumatic heart disease still persists.

A 2012 study in Eastern Nepal examined 5178 children and their demographic and socioeconomic background before undergoing physical examination. These children were randomly selected from government and public schools both in rural and urban locations. They followed the World Heart Federation criteria for defining rheumatic heart disease.

The results showed that the median age of the children is 10 years old and approximately 50% of the children had unemployed or unskilled parent workers. 12.8% of the children had heart murmurs. Rheumatic heart disease incidence increased in children at ages 5 to 15. They found that 36 children had definite rheumatic heart disease, and 17 children had borderline disease.

I think study is interesting to show that the work to eradicate rheumatic heart disease is not over. These children should be examined in longitudinal studies to assess the effectiveness of early discovery of this condition. There is work to be done and pharmacists can play a big role overseas in providing treatment before the complications expand.

Shrestha N, Karki P, Mahto R, et al. Prevalence of Subclinical Rheumatic Heart Disease in Eastern Nepal. JAMA Cardiol. doi:10.1001/jamacardio.2015.0292 (published 2 March 2016).

Heavy Testosterone Use Among Bodybuilders: An Uncommon Cohort of Illicit Substance Users

Anabolic steroids are synthetic substances that can treat hormone problems and conditions that decrease lean muscle mass. However, anabolic steroids are abused and there are significant health problems that arise from misuse. Athletes and bodybuilders ergogenic use of anabolic steroids provide an advantage and improve performance in their respective fields. Studies have been conducted to report the physiological, psychological short and long terms effects from continued use.

A study in 2015 analyzed similarities among use of anabolic-androgenic steroids (AAS) in bodybuilders. A questionnaire was posted on sites where the AAS users were prevalent. There were 231 participants that fit the criteria and the demographic characteristics were obtained.

The results showed that 59.6% of the participants reported using AAS for at least half of the year and 39% have been using it for over 3 years. Men that used AAS for over 5 years were likely to have used higher doses. 52.7% of the participants cited the internet as the source for acquiring AAS. The most common reason reported for use was for increased muscle mass for improving their physical physique.

I think this study is interesting to learn more about the background history and patterns for AAS use. Pharmacists are very much involved in the process especially with dispensing. What do you think pharmacists can do to intervene and prevent misuse from occurring?


Mayo Clin Proc. 2016;91(2):175-182

Effect of Caloric Restriction or Aerobic Exercise Training on Peak Oxygen Consumption and Quality of Life in Obese Older Patients With Heart Failure With Preserved Ejection Fraction

Researchers analyze risk factors associated with development of medical conditions. Acknowledgement of co morbidities is apparent when discussing hypertension. Older patients with heart failure with preserved ejection fraction (HFPEF) are likely to have significant weight issues. The presence of increased adipose tissue has been commonly seen in patients with HFPEF. Without any intervention for weight loss, the longevity of life is reduced.

A  study conducted in 2009 evaluated the impact of diet or exercise in obese older patients with HFPEF. They tested exercise capacity and quality of life outcomes as measurements to be interpreted. There were 100 participants in the study and they were randomized to either exercise, diet, exercise plus diet, or neither exercise nor diet.

The results showed a 7% reduction in body weight for patients that dieted and 3% reduction for patients that exercised. For patients that dieted and exercised, body weight decreased by 10% and the control group decreased by 1%. Both the exercise and diet groups improved aerobic exercise capacity and there was a synergistic effect seen from the diet plus exercise group in for exercise activity.

I think these results support the reoccurring theme of the significance of diet and exercise. As future healthcare providers, we want to encourage patients to take the steps towards well being. Pharmacists are well aware of the educating their patients of drug therapies but should not forget to inform the patients the importance of diet and exercise in conjunction for improving their life.


JAMA. 2016;315(1):36-46.

Parent-Reported Errors and Adverse Events in Hospitalized Children

Parents play a large role in monitoring the condition of their children. They are consistently observing and playing an active part in their children’s hospital care. They are able to notice things that health providers might not see. Having different personnel and systems make the efforts to provide the best care to the children complicated. Medical errors unnoticed can lead to preventable adverse side effects. Parents can be a vital resource in identifying errors that can be prevented in the future.

In 2013, a study was conducted to evaluate parent reports of safety incidents their children experienced. These reports that met stated definitions were labeled medical errors or potential adverse events. Parents of randomly selected inpatient children were given surveys to report any safety incidents throughout their stay at the hospital. Reviewers would categorize the safety incidents as either harmful or non-harmful. Finally, they reviewed clinical/demographic data and analyzed medical records obtained from the hospital.

The results showed 37 safety concerns had been reported from 34 of the 383 parents surveyed. 62% of the safety incidents were found to be physician review medical errors. 43% of the medical errors reported by parents did not show up on the medical record review. 30.4% of the medical errors were defined as harmful. They also found that the length of stay was correlated with parental reporting a medical error. This makes sense because the risk increases with greater exposure.

One of the issues that was brought up in this study was excluding non-English speaking families. They should be included in further studies and I think their input will be valuable in further identifying medical errors and potential adverse events. Researchers can utilize language interpreters to translate their surveys to the families.

Khan A, Furtak SL, Melvin P, et al. Parent-Reported Errors and Adverse Events in Hospitalized Children. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.4608 (published 29 February 2016).


Effectiveness of Short Message Service Text-Based Smoking Cessation Intervention Among University Students

Smoking cessation interventions can improve the probability of smokers to successfully quit. Tobacco use is a preventable cause of illness and death and progress is being made for those who want to quit. The tobacco cessation brochures and medications are one of the few methods of intervention. However, there are teenagers and young adults, in which these interventions do not appeal to them. Tobacco cessation programs incorporating technology aims to change that.

A four month study conducted in Sweden examined the use of SMS text-based messaging as a smoking cessation program in young adults. Participants were allowed to pick a stop date within four weeks as a part of the motivational phase. For 12 weeks, they received text messages of advice from experts and smoking cessation manuals. The results showed that 25.9% of the participants stated an eight week prolonged abstinence and 20.6% of complete cessation four weeks after the intervention phase.

I think this study was fascinating because I believe this program has the capability to reach to more adults and those who are afraid to seek outsider help. This study should examine the long term effects of the intervention and determine if this can appeal to younger adults. The participants were mainly 21 to 30 and I think incorporating teenagers should be considered. There are certain countries, such as Austria, where the legal age to purchase or smoke tobacco is 16.


What do you think about SMS text-based messaging intervention? What could this program do to improve the cessation rates?


Müssener U, Bendtsen M, Karlsson N, et al. Effectiveness of Short Message Service Text-Based Smoking Cessation Intervention Among University Students. JAMA Intern Med. doi:10.1001/jamainternmed.2015.8260. (published 22 February 2016).

Participation in Physical Activity and Risk for Amyotrophic Lateral Sclerosis Mortality Among Postmenopausal Women

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative fatal disease that attacks neurons in the brain and spinal cord. It is also known as Lou Gehrig’s disease, after the famous baseball player was diagnosed. ALS disables the voluntary control of muscles and weakens functional movements requiring muscle. This is a major concern because there are no known causes for this disease. However, studies are being done to correlate risk factors associated it.

A study conducted examined a potential association between exercise and risk of ALS for postmenopausal women. 161,809 postmenopausal women were recruited to participate in the study ranging from age 50 to 79. The women were frequently evaluated with a self-administered questionnaire to determine the intensity level and extent of exercise performed in their life. Over the course of the study 165 of the 161,809 women died of ALS. The median age of these women was 66 years.

The results showed that the mortality rates of women with no physical activity at 7.4 per 100,000 person years and that increased to 10.6 per 100,000 for women engaged in strenuous exercise 3 days a week. The ALS death odds ratio for women that exercise frequently to women who didn’t was 1.56. Women with a BMI of 30.0 or greater had the lowest incidence of ALS and there was a possible pathophysiological connection between physical activity and ALS by abnormal mitochondrial activity from greater oxidative stress. They state that despite these findings, strenuous exercise provides overall benefit to general well being, total mortality, and cardiovascular health.

I think this study highlights the challenges researchers and health care providers face with ALS. There isn’t a cure nor treatment but progress is being made in understanding this disease. Genetic predispositions and environmental factors may play a significant role in the development. In the future, we should expect to see more studies on risk factors beyond physical activity and clinical trials with patients having ALS utilizing gene and drug therapies.

Eaglehouse YL, Talbott EO, Chang Y, et al. Participation in Physical Activity and Risk for Amyotrophic Lateral Sclerosis Mortality Among Postmenopausal Women. JAMA Neurol. doi:10.1001/jamaneurol.2015.4487 (published 19 January 2016).

Association of Fitness in Young Adulthood With Survival and Cardiovascular Risk

Evidence has shown the benefits of exercise to be prognostic factor for overall health and developmental changes to cardiovascular system for adults. Specifically, cardiorespiratory fitness (CRF) is one predictive indicator for older adults with cardiovascular disease but a study was conducted to examine the risk factor of CRF of young adults linked to cardiovascular disease (CVD). Patients underwent a treadmill exercise test at the beginning of the study and repeated the test 7 years later. They assessed obesity, left ventricular mass and strain, coronary artery calcification, and vital status, and incident CVD at different time points to grasp the progression of their cardiovascular health.

The results showed that individuals with longer exercise duration had lower risks of mortality (15%) and cardiovascular disease (12%). There was an association between cardiorespiratory fitness and myocardial phenotypes. Those with a higher CRF levels had a lower left ventricular mass index and a better global longitudinal strain. They did not find a correlation between fitness level and coronary artery calcification. This shows early detection of cardiovascular disease through cardiorespiratory fitness as a biomarker can be beneficial in young adults and can be an influential factor in changing the fitness lifestyle.

I believe this assessment reminds us that preventative measures can be taken at an early stage in adulthood that will lead to better health outcomes. Genetics will be anticipated but there are manageable variables that people can control. In the future, we could see applications of CRF to other health complications, such as diabetes and obesity.

Question: Could the cardiorespiratory fitness of teenagers prior to adulthood be an indicator for potential cardiovascular diseases later in life?


JAMA Intern Med. 2016;176(1):87-95.

Estimating the cost of unclaimed electronic prescriptions at an independent pharmacy

Electronic prescribing continues to expand across the health care system in the United States. A study was conducted in a Midwestern state independent pharmacy which estimated the cost of unclaimed electronic prescriptions towards the operational pharmacy practice. The study was organized in an area with a population of 6,000 over a six-month period. Researchers had to analyze the incurring costs to prepare, fill, and return the unclaimed prescription after 14 days In addition, the cost of personnel and contacting the patient were incorporated in the total expenditure.

The results showed that the unclaimed electronic prescriptions consisted of 0.44% of total prescriptions and 0.82% of the total electronic prescriptions. There were 147 unclaimed e-prescriptions and the cost ranged from 18.54 to 25.02 per unclaimed e-prescription depending on the cost of dispensing and staff.

I think that this study brought attention to the importance of medication adherence and obstacles the independent pharmacies face as they continue to operate on slim margins. Geographical location, patient population, and number of local competition factor into the success of the independent pharmacies. However, they do not have the capital of corporate community pharmacies to remain afloat from the decreasing reimbursement rates. Inflation of AWP contributes to the problem with single-source medications, drug manufacture mergers, and tighter regulations from FDA that increases the cost from inception to market. Areas with larger populations face potentially more unclaimed e-prescriptions leading to a greater cost without compensation.

Question: What can be done to curb this problem and maximize efficiency as electronic prescribing rises?

J Am Pharm Assoc. 2016;56(1):58-61.