Department of Family Medicine

Background: Ethical and professional pharmacy practice is fundamental to supporting patient safety and trust. Despite advances in Good Pharmacy Practice (GPP), evidence from developing systems indicates gaps in ethical performance. This study aimed to assess the ethical dimensions of community pharmacists' practice in Jordan from the public's perspective, focusing on counseling quality, privacy, autonomy, and fairness. Methods: A cross-sectional survey was conducted among 710 community pharmacy clients across Jordan using a validated questionnaire measured five ethical domains and an attitude scale. Composite scores for patient satisfaction, ethical conduct, and pharmacist attitude were calculated. Descriptive statistics and logistic regression were used to identify demographic predictors. Results: Participants were predominantly female (57.9%) and from central Jordan (69.6%). Mean domain scores were: history-taking (51.3 ± 34.3), counseling (60.3 ± 29.6), privacy (67.8 ± 26.1), autonomy (60.2 ± 36.6), and justice (86.5 ± 24.0). Counseling was strongest for medication use and timing but weakest for safety aspects-adverse effects (41.4%), storage (40.1%), and drug interactions (31.7%). Justice and professionalism received the highest perception scores, while privacy and autonomy received moderate ratings. Gender (female) and south region predicted higher satisfaction and ethical perception (p < 0.05). Conclusion: Community pharmacists in Jordan were perceived as demonstrating strong fairness and professionalism, but gaps remain in safety-oriented counseling and privacy assurance. These findings highlight areas where communication practices, privacy infrastructure, and ethics-oriented training may warrant further attention. Strengthening these areas could contribute to supporting patient trust and the ethical quality of community pharmacy services.

Nitrate and nitrite contamination of groundwater and surface water is a global public health concern, often linked to the increasing use of nitrogen-based fertilizers. In Jordan's Ghor region, where agriculture is intensive and fertilizer use is widespread, the issue is particularly relevant. This study aimed to investigate the relationship between serum nitrate and nitrite levels with low birth weight and preterm birth. A total of 659 participants were enrolled, comprising 452 controls (normal birth weight and full-term delivery) and 207 cases (low birth weight/preterm delivery). High maternal serum nitrite levels were significantly associated with increased odds of low birth weight delivery in both the unadjusted model (odds ratio [OR] = 1.43, 95% CI: 1.14-1.80, P = 0.002) and the a priori confounder set adjusted model (OR = 1.33, 95% CI: 1.02-1.74, P = 0.038). Nitrite levels were also significantly associated with the combined outcome of preterm and/or low birth weight delivery in the unadjusted model (OR = 1.26, 95% CI: 1.01-1.57, P = 0.036), and this association remained significant after a priori adjustment in a multiple-imputation sensitivity analysis (OR = 1.29, 95% CI: 1.03-1.63, P = 0.029). In conclusion, although metabolically interrelated, nitrite and nitrate levels in pregnant women may differentially impact pregnancy outcomes in the largely low income agricultural communities in the Ghor region in Jordan.

Introduction

Methods

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Discussion

OBJECTIVE: Strategies are needed for patients with chronic pain who are using opioids to safely and effectively wean opioids without worsening of pain. The objective was to measure associations between medical cannabis authorization (MCA) and opioid milligram equivalents (OME) in patients with chronic non-cancer pain. DESIGN: A longitudinal, retrospective cohort analysis from July 2016 to August 2019. SETTING: Electronic health record data were analyzed. SUBJECTS: Adult patients (≥18 years) seen in a university-based pain clinic. METHODS: Longitudinal multilevel modeling with maximum likelihood estimation. RESULTS: Average overall OME at the final time point was 33.4 mg/day (SE = 1.18) with increase over time of 0.45 mg/day per quarter (not statistically significant). Average OME in those without MCA was 32.60 mg/day (SE = 1.11) versus 38.51 mg/day (SE = 4.81) in those with MCA, not significantly different. Medical cannabis consultation predicted a nonsignificant decrease of 14.25 mg/day OME. Long-term opioid use was a significant predictor with a mean OME of 85.34 mg/day, 63 mg/day higher than the rest of the cohort at the final quarter (t = 5.77, SE = 10.93, P < 0.0001). CONCLUSIONS: In this longitudinal study of electronic health record data, MCA was not associated with a statistically significant decrease in OME over time. However, patients with long-term opioid use diagnostic code demonstrated a significantly higher endpoint OME. Future prospective research is needed to establish whether there are opioid-sparing effects of cannabis in humans.

OBJECTIVE: To assess the efficacy of cannabis for the treatment of acute migraine. BACKGROUND: Preclinical and retrospective studies suggest cannabinoids may be effective in migraine treatment. However, there have been no randomized clinical trials examining the efficacy of cannabinoids for acute migraine. METHODS: In this randomized, double-blind, placebo-controlled, crossover trial, adults with migraine treated up to four separate migraine attacks, one each with vaporized (1) 6% Δ9-tetrahydrocannabinol (THC) (THC-dominant), (2) 11% cannabidiol (CBD) (CBD-dominant), (3) 6% THC + 11% CBD, and (4) placebo cannabis flower in a randomized order. Washout period between treated migraine attacks was ≥1 week. The primary endpoint was pain relief, and secondary endpoints were pain freedom and most bothersome symptom freedom, all assessed at 2-h post-vaporization. RESULTS: Ninety-two participants were enrolled and randomized, and 247 migraine attacks were treated. THC + CBD was superior to placebo at achieving pain relief (67.2% vs. 46.6%, odds ratio [95% confidence interval] 2.85 [1.22, 6.65], p = 0.016), pain freedom (34.5% vs. 15.5%, 3.30 [1.24, 8.80], p = 0.017), and most bothersome symptom freedom (60.3% vs. 34.5%, 3.32 [1.45, 7.64], p = 0.005) at 2 h, as well as sustained pain freedom at 24 h and sustained most bothersome symptom freedom at 24 and 48 h. THC-dominant was superior to placebo for pain relief (68.9% vs. 46.6%, 3.14 [1.35, 7.30], p = 0.008) but not pain freedom or most bothersome symptom freedom at 2 h. CBD-dominant was not superior to placebo for pain relief, pain freedom, or most bothersome symptom freedom at 2 h. There were no serious adverse events. CONCLUSION: Acute migraine treatment with 6% THC + 11% CBD was superior to placebo at 2-h post-treatment with sustained benefits at 24 and 48 h.

INTRODUCTION: Despite sepsis having growing awareness nationally, efforts to reduce the public health impact of sepsis have lagged. Although there are known pathophysiologic mechanisms and preventive strategies, sepsis is rarely approached as a predictable or preventable condition. Predicting who will develop sepsis in patients with infection still remains a challenge. This study examined modifiable and nonmodifiable risk factors associated with patients initially discharged home with an infection and had future sepsis-related admissions within 7 days of the index Emergency Department (ED) visit. METHODS: We conducted a multi-center retrospective cohort analysis of adults presenting to two university hospital EDs. The inclusion criteria encompassed adult patients who were discharged from the ED at their index visit with discharge diagnosis (ICD 10-CM code) of pneumonia, urinary tract infection (UTI), and/or cellulitis and who returned for hospital admission within 7 days of the index visit due to sepsis, severe sepsis without septic shock, and/or septic shock. Using multivariate regression, risk factors that predict return sepsis admission within 7 days of ED index visit were evaluated, and a 7-day return sepsis admission model was constructed. The predictive power of the model was measured by c-statistic. RESULTS: Among 10,179 unique ED patients, return sepsis admissions within 7 days occurred in 113 visits (1.11 % of discharged patients). Statistically significant risk factors among patients with infection associated with subsequent sepsis admission in the chosen model were Cardiovascular Disease (OR 2.07 95 % CI 1.26-3.42), Hypertension (OR 2.21 95 % CI 1.37-3.56), Chronic Kidney Disease (OR 1.80 95 % CI 1.11-2.91), Cancer (OR 2.22 95 % CI 1.43-3.45), Male (OR 1.67 95 % CI 1.13-2.45), arriving in an ambulance (vs. walk in OR 2.55 95 % CI 1.46-4.44), higher heart rate (OR 1.29 95 % CI 1.16-1.45), and higher temperature (OR 1.23 95 % CI 1.05-1.45), Hyperlipidemia was protective (OR 0.56 95 %CI 0.34-0.91). The c-statistic of our chosen model was 0.77 (95 % CI 0.73-0.81). The Hosmer-Lemeshow test for our logistic regression model resulted in a chi-square value of 7.23 with 8 degrees of freedom with a p-value of 0.51. This suggests that our model fits the data well. CONCLUSION: Our findings may be used to risk stratify and guide outpatient disposition decisions for ED patients with infection and to determine which patients need to be more closely monitored in the outpatient setting following ED discharge.

OBJECTIVES: To define meropenem plasma concentrations and pharmacodynamic exposure metrics in children with septic shock during the first 3 days of PICU hospitalization. DESIGN: Pharmacokinetic sampling was undertaken in 19 subjects receiving standard meropenem dosing (20 mg/kg/dose, 8 hr) recruited from March 2019 to March 2022. Sampling occurred once each day following meropenem given 24 hours apart, during the first 3 PICU days. Data analysis was completed in 2023 and noncompartmental analysis was performed to assess pharmacodynamic exposure targets for sepsis. Clearance and volume of distribution at 20 mg/kg/dose were used to simulate mean exposures at 40 and 60 mg/kg/dose. SETTING: PICU in a tertiary care center. SUBJECTS: Patients 4 weeks old or older with hypotension requiring fluid resuscitation and vasopressor therapy, receiving meropenem as empiric therapy for sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Augmented renal clearance (ARC) was documented in eight of 19 subjects, previously associated with subtherapeutic plasma concentrations, while three of 19 had acute kidney injury and decreased renal clearance. When assessed by pharmacodynamic exposure targets for sepsis (plasma meropenem concentrations above the minimum inhibitory concentration [MIC] of Pseudomonas aeruginosa for 70% or 100% of the dosing interval), ten of 19 and nine of 19 children, respectively, had subtherapeutic plasma meropenem exposures during PICU day 1, even for pathogens with an MIC considered "susceptible" by U.S. Food and Drug Administration criteria. Therapeutic meropenem pharmacodynamic exposures were associated with a positive 24-hour fluid balance on PICU day 1 and a negative 24-hour fluid balance by day 3, although profound variability was noted in fluid administered and renal output. CONCLUSIONS: Given the variability in meropenem systemic exposure in pediatric septic shock, therapeutic drug monitoring, or monitoring for ARC, is suggested during the first days of hospitalization to allow daily assessments of dosing needs to achieve pharmacodynamic exposure targets for sepsis.

Although most fractures, and about half of hip fractures, occur outdoors among older women, limited research has uncovered neighborhood predictors for fractures among older women. This study assessed the independent associations of neighborhood socioeconomic status (SES), walkability, and green space with incident any and hip fracture among postmenopausal women. The Women's Health Initiative recruited a national sample of postmenopausal women (50-79 yr) across 40 U.S. clinical centers and conducted yearly assessments from 1993 to 2012 (n = 161 808). Women reporting a history of hip fracture or walking limitations were excluded from the analytic sample, yielding a final sample of 157 583 participants. Fracture events were self-reported and adjudicated annually. Walkability was calculated annually using measures of population density, land use mix, and presence/quantity of nearby high-traffic roadways. Neighborhood green space was calculated annually using measures of exposure to trees/vegetation. Neighborhood SES, walkability, and green space were categorized into tertiles: high, intermediate, and low. The time-varying relationship between neighborhood environmental factors and age at first fracture (any; hip) was examined using extended Cox proportional hazards modeling with adjustment. Neighborhood SES (intermediate vs low: hazard ratio = 1.03, 95% CI, 1.01-1.05; high vs low, hazard ratio = 1.01, 95% CI, 0.99-1.03) and green space (intermediate vs low, hazard ratio = 1.15, 95% CI, 1.12-1.18; high vs low hazard ratio = 1.18, 95% CI, 1.15-1.21) were associated with increased any incident fractures, while walkability had a mixed association (intermediate vs low hazard ratio = 1.06, 95% CI, 1.04-1.07; high vs low, hazard ratio = 0.97, 95% CI, 0.95-0.98). Neighborhood SES, walkability, and green space did not have a relationship with hip fracture after adjustment for important covariates. Results indicate that macroscale neighborhood features did not protect against fractures. Additional research is needed to investigate more granual neighborhood features that might influence injury risk and support physical activity among postmenopausal women.

BACKGROUND: Overweight and obesity is a global epidemic. Forecasting future trajectories of the epidemic is crucial for providing an evidence base for policy change. In this study, we examine the historical trends of the global, regional, and national prevalence of adult overweight and obesity from 1990 to 2021 and forecast the future trajectories to 2050. METHODS: Leveraging established methodology from the Global Burden of Diseases, Injuries, and Risk Factors Study, we estimated the prevalence of overweight and obesity among individuals aged 25 years and older by age and sex for 204 countries and territories from 1990 to 2050. Retrospective and current prevalence trends were derived based on both self-reported and measured anthropometric data extracted from 1350 unique sources, which include survey microdata and reports, as well as published literature. Specific adjustment was applied to correct for self-report bias. Spatiotemporal Gaussian process regression models were used to synthesise data, leveraging both spatial and temporal correlation in epidemiological trends, to optimise the comparability of results across time and geographies. To generate forecast estimates, we used forecasts of the Socio-demographic Index and temporal correlation patterns presented as annualised rate of change to inform future trajectories. We considered a reference scenario assuming the continuation of historical trends. FINDINGS: Rates of overweight and obesity increased at the global and regional levels, and in all nations, between 1990 and 2021. In 2021, an estimated 1·00 billion (95% uncertainty interval [UI] 0·989-1·01) adult males and 1·11 billion (1·10-1·12) adult females had overweight and obesity. China had the largest population of adults with overweight and obesity (402 million [397-407] individuals), followed by India (180 million [167-194]) and the USA (172 million [169-174]). The highest age-standardised prevalence of overweight and obesity was observed in countries in Oceania and north Africa and the Middle East, with many of these countries reporting prevalence of more than 80% in adults. Compared with 1990, the global prevalence of obesity had increased by 155·1% (149·8-160·3) in males and 104·9% (95% UI 100·9-108·8) in females. The most rapid rise in obesity prevalence was observed in the north Africa and the Middle East super-region, where age-standardised prevalence rates in males more than tripled and in females more than doubled. Assuming the continuation of historical trends, by 2050, we forecast that the total number of adults living with overweight and obesity will reach 3·80 billion (95% UI 3·39-4·04), over half of the likely global adult population at that time. While China, India, and the USA will continue to constitute a large proportion of the global population with overweight and obesity, the number in the sub-Saharan Africa super-region is forecasted to increase by 254·8% (234·4-269·5). In Nigeria specifically, the number of adults with overweight and obesity is forecasted to rise to 141 million (121-162) by 2050, making it the country with the fourth-largest population with overweight and obesity. INTERPRETATION: No country to date has successfully curbed the rising rates of adult overweight and obesity. Without immediate and effective intervention, overweight and obesity will continue to increase globally. Particularly in Asia and Africa, driven by growing populations, the number of individuals with overweight and obesity is forecast to rise substantially. These regions will face a considerable increase in obesity-related disease burden. Merely acknowledging obesity as a global health issue would be negligent on the part of global health and public health practitioners; more aggressive and targeted measures are required to address this crisis, as obesity is one of the foremost avertible risks to health now and in the future and poses an unparalleled threat of premature disease and death at local, national, and global levels. FUNDING: Bill & Melinda Gates Foundation.