BACKGROUND: Patients who make 5 or more visits per year to hospital emergency departments (EDs) are usually considered ED frequent users (FUs). This study aims to better characterize the influence of alcohol and other drug use-related disorders in this phenomenon in a European Mediterranean country with public, universal, tax-financed healthcare system.
METHODS: Matched case-control study. Cases were adults between 18 and 65 years old who consulted 5 or more times the ED of a tertiary hospital in Spain between December 2018 and November 2019. Each case was assigned a control of the same age and gender, who appeared to the ED on the same day, but who made 4 visits or less to the service during the study period. The electronic record of the first ED visit during this period was used to extract the variables of interest: emergency care received, clinical and social characteristics. Predictors of frequent ED use were identified with conditional logistic regression.
RESULTS: 609 case-control pairs (total n = 1,218) were selected. History of alcohol-related conditions (adjusted odds ratio [AOR] = 1.82 [95% CI: 1.26-2.64] p = 0.001) and also other drug use-related disorders (AOR = 1.50 [95% CI: 1.11-2.03] p = 0.009) significantly increased the probability of frequent use of emergency services.
CONCLUSIONS: Alcohol-related conditions and other drug use-related disorders must be evaluated in all ED FUs. Specific action protocols to concurrently address repeated attendance and addictions in the emergency room could be a good tool to reduce frequent ED use.

BACKGROUND: Pharmacists working in general practice are a relatively new phenomenon in many European countries. Providing insight into what pharmacists do in general practice may support further implementation of general practice-based pharmacist roles and enhance their contribution to health care.
OBJECTIVE: To explore the tasks performed by pharmacists in general practice in Sweden.
METHODS: A case study was conducted in 7 general practices in Uppsala County, Sweden, where pharmacists were employed. Activities performed by pharmacists were self-reported during March 2021. Participant observations and semi-structured interviews with pharmacists were conducted between October and November 2021. Self-reported activities were categorised and analysed using descriptive statistics. Qualitative data were analysed using conventional content analysis.
RESULTS: In total, 174 activities were self-reported by 8 pharmacists. Two pharmacists were observed for 2 days each, and 6 pharmacists were interviewed. Their main task was conducting medication reviews in older patients with polypharmacy. In addition, they handled a broad variety of drug-related questions and treatment follow-up. Pharmacists described working in a more efficient and needs-based manner over time. They stressed that working at the practice increased their accessibility to and their collaborative work with other healthcare professionals, and enabled them to meet patients face-to-face. Future challenges include defining tasks more clearly, assuming greater responsibility for patient care, and meeting the growing demand for pharmacists in general practice.
CONCLUSIONS: Pharmacists in general practice in Sweden perform a broad variety of tasks related to identifying, resolving and preventing drug-related problems, mainly in older patients with polypharmacy.

Objective: To report the development of neuroleptic malignant syndrome (NMS) after donepezil was added to maintenance haloperidol. Case Summary: An East Asian female in her mid-50s with a 25-year history of schizophrenia was prescribed fluvoxamine 150 mg daily, haloperidol decanoate 200 mg intramuscularly every 4 weeks, and benztropine 0.5 mg twice daily. Donepezil 5 mg daily was initiated for the treatment of possible dementia and 2 days later she appeared pale, displayed malaise, reported emesis, but was afebrile. The following day she was notably changed in behavior, withdrawn with a blunted affect. Decreased appetite, hyperthermia (temperatures 99.2-101°F), tachycardia, drooling, and slow, stiff movements with a creatine phosphokinase level of 1413 units/L (normal 26-192 units/L) were noted, and the patient was transferred to a medical hospital for treatment of suspected NMS. Symptoms improved with antipsychotic discontinuation, intravenous fluids, bromocriptine, and dantrolene. Five days after the adverse reaction the creatine phosphokinase significantly improved and she was noted to be more alert and responsive. Discussion: A literature search revealed 9 case reports of cholinesterase inhibitors causing NMS reactions either alone or, more commonly, when used in combination with antipsychotics. In this case, it was probable (Drug Interaction Probability Scale Score 6) the interaction between donepezil and haloperidol decanoate contributed to NMS. Conclusions: Use of cholinesterase inhibitors with antipsychotic medications may create an imbalance in acetylcholine and dopamine, which can precipitate the onset of NMS in susceptible individuals. These agents should be used cautiously in combination with careful monitoring for NMS.

OBJECTIVE: Heart failure (HF) patients are at high risk of having drug-related problems (DRPs). We aim to describe the frequency, types, and temporal occurrence of DRPs in Taiwanese HF outpatients receiving case management.
METHODS: In this study, we included 141 patients from HF clinics in three hospitals in Taiwan from October 2008 to December 2010. Nurse case managers at each of the participating sites registered case report forms (CRFs) for patients during clinic visits. DRPs were classified using the Pharmaceutical Care Network Europe Foundation (PCNE) classification system and documented by pharmacists after reviewing CRFs and participating in multidisciplinary team discussions.
RESULTS: For 141 clinic participants, the average duration of medication use was 17 months, and 796 DRPs were reported. The DRPs most frequently recorded were the need for laboratory tests (32.7% of total DRPs), followed by potential interaction (29.6%), nonallergic side effects (13.3%), and insufficient awareness of health and disease (9.5%). The drugs most frequently causing a DRP were angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, diuretics, warfarin, spironolactone, and β-blockers. The incidence rates of total DRPs was maximal during the initial 3 months of medication treatment, whereas the incidence rates of each category of DRPs showed multiform changes over time among various drug classes.
CONCLUSIONS: In Taiwan where the clinical pharmacist system is not well organized, HF outpatients still had a high prevalence of DRPs despite intensive monitoring by nurse case managers. Clinical pharmacists play critical roles in detecting potential DRPs during long-term medication treatment for this population.