Comparison of polypharmacy and potentially inappropriate medication use in older adults with and without dementia receiving residential medication management reviews

OBJECTIVES

Among residents who had a residential medication management review (RMMR), there is a lack of studies assessing exposure to polypharmacy and potentially inappropriate medications (PIMs) in people with dementia. This study compared the exposure to polypharmacy and PIMs in residents with dementia and without dementia receiving RMMR.

METHODS

A retrospective analysis was performed using data of 16,261 residents living in 343 Australian residential aged care facilities who had an RMMR in 2019. Medication use was assessed as polypharmacy (defined as ≥9 medications) and use of ≥1 PIMs using the 2019 updated Beers criteria. Dementia diagnosis was determined with ICD-10 coding from medical records. Descriptive analyses reported resident demographics and patterns of medication use. Pearson's χ2 tests and logistic regression analysis were conducted to compare medication exposure between residents with and without dementia.

RESULTS

Among 16,261 residents, 6781 (42%) had dementia. Residents with dementia were significantly more likely to be exposed to polypharmacy and PIMs, compared to those without dementia (74% vs. 70% and 83% vs. 73%, p < .001 respectively). Residents with dementia had 1.31 times the odds of exposure to polypharmacy (adjusted OR: 1.31, 95% CI: 1.22-1.41, p < .001) and 1.88 times the odds of being prescribed ≥1 PIMs than people without dementia (adjusted OR: 1.88, 95% CI: 1.73-2.04, p < .001).

CONCLUSIONS

In a study of residents receiving RMMR, polypharmacy and PIMs were highly common, and those with dementia were more likely to be exposed to inappropriate polypharmacy. There is a need for targeted deprescribing strategies to immediately address inappropriate prescribing in residents, particularly those living with dementia.

Dispensing error rates in pharmacy: A systematic review and meta-analysis

BACKGROUND/OBJECTIVES

Dispensing errors can cause preventable patient harm such as adverse drug events, hospitalisation, or death. The aim of this study was to systematically review the literature and quantify the global prevalence of dispensing errors across pharmacy settings.

METHODS

Electronic databases including EMBASE, MEDLINE, and CINAHL were searched between January 2010 and September 2023. Studies published in English, from all pharmacy settings, with data that could be used to calculate the prevalence of dispensing errors were included. Studies were excluded if they did not report true dispensing errors. Data including study characteristics and dispensing error characteristics were extracted. The quality of the studies was assessed using 10 criteria. Random-effects meta-analysis was employed to estimate pooled prevalences and heterogeneity was quantified using the I2 statistic. Subgroup analyses were performed according to sample size, study design, setting, error identification method, location, and study quality.

PROSPERO

CRD42020197860.

RESULTS

Of the 4216 articles, 62 studies were included. Hospital was the most common pharmacy setting (n = 44, 71.0%) and 15 studies were based in the community. The type of denominator used to report dispensing errors varied between studies, such as dispensed items (n = 45, 72.6%), doses (n = 7, 11.3%), or patients (n = 5, 8.1%). The prevalence of dispensing errors ranged from 0 to 33.3% (n = 62 studies with 64 prevalence estimates). The pooled prevalence for dispensing errors across all studies was 1.6% (95% CI 1.2%-2.1%, I2 = 100%). A majority of studies were of moderate methodological quality (n = 36, 58.1%) and interrater reliability was applied in eight studies.

CONCLUSIONS

The worldwide prevalence of dispensing errors was 1.6% across community, hospital and other pharmacy settings. This varied depending on the type of denominator used, study design and how the error was identified. This review highlights the need for consistent definitions and standardised classifications of dispensing errors worldwide to reduce heterogeneity.

The Carer Assessment of MedicaTion Management GuidanCe for People With Dementia at Hospital Discharge (CATCH) Tool: Exploratory Factor Analysis

PURPOSE

The Carer Assessment of medicaTion management guidanCe for people with dementia at Hospital discharge (CATCH) tool was developed to examine the carer's experiences of medication management guidance delivery at discharge. This study explored its factor structure, characterized carers' experiences at discharge, and identified predictors of carer preparedness to manage medications at discharge.

METHODS

A cross-sectional survey of carers across Australia was distributed. Survey responses were analyzed descriptively, and exploratory factor and regression analyses were performed.

RESULTS

A total of 185 survey responses were completed. Exploratory factor analysis revealed 2 factors in the CATCH tool: (1) shared and supported decision-making in medication management (16 items loading 0.47 to 0.93); 2) provision of medication management guidance that is easy to understand (4 items loading (0.48 to 0.82). Internal consistency was acceptable (Cronbach alpha >0.8). Almost 18% of participants stated that they were not included in decisions about medications for people with dementia. The carer reported that the measure of how guidance is provided was positively related to their confidence in the management of medications postdischarge and satisfaction ( P < 0.05 for both).

CONCLUSIONS

The CATCH tool can give the patient and carer an opportunity to provide feedback on key elements of medication management guidance delivered at discharge.

A novel use for routine CBCT imaging during radiotherapy to detect COVID-19

INTRODUCTION

Thoracic CT is a useful tool in the early diagnosis of patients with COVID-19. Typical appearances include patchy ground glass shadowing. Thoracic radiotherapy uses daily cone beam CT imaging (CBCT) to check for changes in patient positioning and anatomy prior to treatment through a qualitative assessment of lung appearance by radiographers. Observation of changes related to COVID-19 infection during this process may facilitate earlier testing improving patient management and staff protection.

METHODS

A tool was developed to create overview reports for all CBCTs for each patient throughout their treatment. Reports contain coronal maximum intensity projection (MIP's) of all CBCTs and plots of lung density over time. A single therapeutic radiographer undertook a blinded off-line audit that reviewed 150 patient datasets for tool optimisation in which medical notes were compared to image findings. This cohort included 75 patients treated during the pandemic and 75 patients treated between 2014 and 2017. The process was repeated retrospectively on a subset of the 285 thoracic radiotherapy patients treated between January-June 2020 to assess the efficiency of the tool and process.

RESULTS

Three patients in the n = 150 optimisation cohort had confirmed COVID-19 infections during their radiotherapy. Two of these were detected by the reported image assessment process. The third case was not detected on CBCT due to minimal density changes in the visible part of the lungs. Within the retrospective cohort four patients had confirmed COVID-19 based on RT-PCR tests, three of which were retrospectively detected by the reported process.

CONCLUSION

The preliminary results indicate that the presence of COVID-19 can be detected on CBCT by therapeutic radiographers.

IMPLICATIONS FOR PRACTICE

This process has now been extended to clinical service with daily assessments of all thoracic CBCTs. Changes noted are referred for oncologist review.

Evaluating the communities care program: best practice for rigorous research to evaluate gender based violence prevention and response programs in humanitarian settings

Background

Gender-based violence (GBV) is a significant issue for women and girls in humanitarian settings. Innovative primary prevention programs are being developed and implemented with existing response programs to change harmful social norms that sustain GBV in humanitarian settings. Social norms are expectations of how women, men, girls and boys should behave, who should have power and control over behavior, and how families and communities value women and girls and support their rights and opportunities.

Methods

The United Nations Children’s Fund (UNICEF) led Communities Care program is a primary prevention and response program designed from the understanding that within the context of conflict and displacement, there is an opportunity for positive change in social norms that support gender equity, and decrease GBV. The goal is to support communities in humanitarian settings to create healthy, safe and peaceful environments with quality response services for women and girls by transforming harmful social norms that uphold violence into norms that promote dignity, equity, and non-violence.

Conclusion

This manuscript will highlight the use of best practices in GBV research to rigorously evaluate the Communities Care program in two diverse in humanitarian settings, Somalia and South Sudan.

The evolving role of saline infusion sonography (SIS) in infertility

Saline infusion sonography (SIS) has become a valuable diagnostic modality in gynaecology over the last three decades. SIS is now commonly employed for detailed evaluation of the uterine cavity as part of pre-treatment assessment in infertile women. The objective of this paper is review the scientific literature on SIS in infertility. Medline, Ovid and Cochrane databases were searched for relevant articles. The indications, technical aspects and the potential advantages of SIS are discussed. The efficacy and sensitivity of SIS are compared to hysteroscopy in the evaluation of uterine polyps, fibroids, intrauterine adhesions and uterine anomalies. Increasing evidence suggests the use of SIS prior to an in-vitro fertilization (IVF) cycle as it has increased sensitivity in the detection of intrauterine pathology. SIS is cost-effective and results in better patient satisfaction scores than hysteroscopy.

Endovenous laser ablation for major varicose tributaries

OBJECTIVE

The purpose was to determine whether endovenous laser ablation (EVLA) could be used to treat major varicose tributaries as well as saphenous veins.

METHODS

From 173 major venous systems in 95 patients treated by EVLA over a 12-month period, 108 had major varicose tributaries, of which 78 (70%) were treated by attempted EVLA of the saphenous veins and associated tributaries.

RESULTS

Treatment was successful in 71 venous segments (83%). The lengths of saphenous veins treated were 3-46 (median 18) cm. and the lengths of tributaries treated were 3-38 (median 14) cm. The diameters of treated saphenous veins were 4-10 (median 6) mm, and the estimated mean diameters of treated tributaries were 3-8 (median 5) mm, as measured prior to operation with the patient in 45° reverse Trendelenburg on a tilt table. There were no early or delayed complications.

CONCLUSIONS

Major varicose tributaries as well as the saphenous veins can be treated by EVLA in approximately two-thirds of cases, with success in the majority selected and with no significant complications.

Dijet azimuthal decorrelations in pp collisions at √s=7 TeV

Measurements of dijet azimuthal decorrelations in pp collisions at √s=7 TeV using the CMS detector at the CERN LHC are presented. The analysis is based on an inclusive dijet event sample corresponding to an integrated luminosity of 2.9 pb⁻¹. The results are compared to predictions from perturbative QCD calculations and various Monte Carlo event generators. The dijet azimuthal distributions are found to be sensitive to initial-state gluon radiation.

Measurement of the B(+) production cross section in pp collisions at sqrt[s]=7 TeV

Measurements of the total and differential cross sections dσ/dp(T)(B) and dσ/dy(B) for B(+) mesons produced in pp collisions at sqrt[s]=7  TeV are presented. The data correspond to an integrated luminosity of 5.8  pb(-1) collected by the CMS experiment operating at the LHC. The exclusive decay B(+)→J/ψK(+), with J/ψ→μ(+)μ(-), is used to detect B(+) mesons and to measure the production cross section as a function of p(T)(B) and y(B). The total cross section for p(T)(B)>5  GeV and |y(B)|<2.4 is measured to be 28.1±2.4±2.0±3.1  μb, where the first uncertainty is statistical, the second is systematic, and the last is from the luminosity measurement.

Measurement of the isolated prompt photon production cross section in pp collisions at √s=7 TeV

The differential cross section for the inclusive production of isolated prompt photons has been measured as a function of the photon transverse energy E(T)(γ) in pp collisions at √s=7  TeV using data recorded by the CMS detector at the LHC. The data sample corresponds to an integrated luminosity of 2.9  pb(-1). Photons are required to have a pseudorapidity |η(γ)|<1.45 and E(T)(γ)>21  GeV, covering the kinematic region 0.006<x(T)<0.086. The measured cross section is found to be in agreement with next-to-leading-order perturbative QCD calculations.

Search for stopped Gluinos in pp collisions at square root s=7 TeV

The results of the first search for long-lived gluinos produced in 7 TeV pp collisions at the CERN Large Hadron Collider are presented. The search looks for evidence of long-lived particles that stop in the CMS detector and decay in the quiescent periods between beam crossings. In a dataset with a peak instantaneous luminosity of 1×10(32) cm-2 s-1, an integrated luminosity of 10 pb-1, and a search interval corresponding to 62 hours of LHC operation, no significant excess above background was observed. Limits at the 95% confidence level on gluino pair production over 13 orders of magnitude of gluino lifetime are set. For a mass difference mg - mχ1(0) >100 GeV/c2, and assuming BR(g→gχ1(0))=100%, mg < 370 GeV/c2 are excluded for lifetimes from 10 μs to 1000 s.

Search for quark compositeness with the dijet centrality ratio in pp collisions at √s=7 TeV

A search for quark compositeness in the form of quark contact interactions, based on hadronic jet pairs (dijets) produced in proton-proton collisions at √s=7 TeV, is described. The data sample of the study corresponds to an integrated luminosity of 2.9 pb(-1) collected with the CMS detector at the LHC. The dijet centrality ratio, which quantifies the angular distribution of the dijets, is measured as a function of the invariant mass of the dijet system and is found to agree with the predictions of the standard model. A statistical analysis of the data provides a lower limit on the energy scale of quark contact interactions. The sensitivity of the analysis is such that the expected limit is 2.9 TeV; because the observed value of the centrality ratio at high invariant mass is below the expectation, the observed limit is 4.0 TeV at the 95% confidence level.

Search for dijet resonances in 7 TeV pp collisions at CMS

A search for narrow resonances in the dijet mass spectrum is performed using data corresponding to an integrated luminosity of 2.9 pb⁻¹ collected by the CMS experiment at the Large Hadron Collider. Upper limits at the 95% confidence level are presented on the product of the resonance cross section, branching fraction into dijets, and acceptance, separately for decays into quark-quark, quark-gluon, or gluon-gluon pairs. The data exclude new particles predicted in the following models at the 95% confidence level: string resonances, with mass less than 2.50 TeV, excited quarks, with mass less than 1.58 TeV, and axigluons, colorons, and E6 diquarks, in specific mass intervals. This extends previously published limits on these models.

First measurement of Bose-Einstein correlations in proton-proton collisions at √s=0.9 and 2.36 TeV at the LHC

Bose-Einstein correlations have been measured using samples of proton-proton collisions at 0.9 and 2.36 TeV center-of-mass energies, recorded by the CMS experiment at the CERN Large Hadron Collider. The signal is observed in the form of an enhancement of pairs of same-sign charged particles with small relative four-momentum. The size of the correlated particle emission region is seen to increase significantly with the particle multiplicity of the event.

Transverse-momentum and pseudorapidity distributions of charged hadrons in pp collisions at square root of s = 7 TeV

Charged-hadron transverse-momentum and pseudorapidity distributions in proton-proton collisions at square root of s = 7  TeV are measured with the inner tracking system of the CMS detector at the LHC. The charged-hadron yield is obtained by counting the number of reconstructed hits, hit pairs, and fully reconstructed charged-particle tracks. The combination of the three methods gives a charged-particle multiplicity per unit of pseudorapidity dN(ch)/dη|(|η|<0.5) = 5.78 ± 0.01(stat) ± 0.23(syst) for non-single-diffractive events, higher than predicted by commonly used models. The relative increase in charged-particle multiplicity from square root of s = 0.9 to 7 TeV is [66.1 ± 1.0(stat) ± 4.2(syst)]%. The mean transverse momentum is measured to be 0.545 ± 0.005(stat) ± 0.015(syst)  GeV/c. The results are compared with similar measurements at lower energies.

Managing confidentiality in illicit drugs research: ethical and legal lessons from studies in remote Aboriginal communities

Assuring participant confidentiality in illicit drugs research has raised legal questions and challenges both for researchers and ethics committees. There are similar challenges for clinicians. To study cannabis use in Aboriginal people in Arnhem Land (Northern Territory), a risk-management approach was successful. Aboriginal participants were informed in their own language that confidentiality could not be assured if they disclosed information about illegal behaviours. Researchers avoided questions of intrinsic interest to law enforcement. Relationships between researchers and study participants and the integrity of the study were preserved. These considerations have relevance for clinicians as well as researchers dealing with the influence of illicit behaviours on health.

Outcome of Ultrasound-guided Sclerotherapy for Varicose Veins: Medium-term Results Assessed by Ultrasound Surveillance

OBJECTIVE

To estimate medium-term success after a technique for ultrasound-guided sclerotherapy for superficial chronic venous disease.

DESIGN

A prospective study in a single unit with ultrasound surveillance after treatment.

MATERIALS

Results after 1189 treatment sessions for 807 venous saphenous veins and related tributaries or non-saphenous tributaries in 489 patients.

METHODS

Univariate life table analysis determined primary and secondary success rates. Multivariate Cox regression analysis detected covariates that affected outcome.

RESULTS

Primary and secondary success rates at 36 months for all veins were 52.4% (95%CI 46-58%) and 76.8% (95%CI 71-82%). Cox regression analysis for primary success for all veins showed significantly worse results for saphenous veins compared to tributaries (HR 3.72 - 95%CI 1.9 to 7.3). Cox regression for all saphenous veins showed independently worse results for patients less than 40 years age (HR 2.16 - 95%CI 1.27-3.66), small compared to great saphenous veins (HR 1.58 - 95%CI 1.11-2.24), veins greater than 6mm diameter compared to smaller veins (HR 2.22 - 95%CI 1.40-3.50), liquid compared to foam sclerotherapy (HR 2.20 - 95%CI 1.28-3.78), lower volumes of sclerosant compared to volumes greater than 12 ml (HR 0.51 - 95%CI 0.33-0.81) and highly diluted compared to concentrated sclerosant (HR 2.05 - 95%CI 1.21-3.46) with worse results using highly diluted or undiluted 3% sclerosant compared to a 1.5% concentration. There were no significant differences for primary success for saphenous veins for date of procedure, sex, side, primary or recurrent varicose veins, or commercial type of sclerosant.

CONCLUSIONS

Ultrasound-guided sclerotherapy gives satisfactory results if it is accepted that treatment may need to be repeated to achieve secondary success. Results provide a basis for further research to explore factors that might affect outcome. Younger patients with larger diameter saphenous veins may warrant alternative forms of treatment, particularly for small saphenous reflux.

WESTCOP: a disease management approach to coronary artery disease

Disease management is a systematic approach to improving care of populations of patients with specific clinical conditions. Critical to success are the formation of collaborative teams of health care stakeholders, development and promulgation of clinical practice guidelines, and performance measurement and feedback to providers as a process of continuous practice improvement. This article describes a disease management program for patients with coronary artery disease in a provincial health district with a population of 180,000. It discusses the rationale and methods behind the operationalisation of the main program elements, benefits achieved to date and challenges confronted.

The development of an academic rated induction programme in a high dependency unit

The commissioning of a new high dependency unit in a large district general hospital prompted the need to develop a comprehensive structured induction programme. A simple training needs analysis (TNA) tool was developed and used to assess the training requirements of 12 nurses who would make up the team. The results of the TNA gave an indication of where to channel resources into a month-long induction programme. The programme was linked to the outcomes of a diploma module to ease the processes of accreditation of prior learning (APL) for those who chose to access higher education programmes beyond the duration of the induction. The programme was evaluated positively and is seen as a way forward for the future of flexible, accessible, practice-based, continuing professional development opportunities.

Collaborating with the consortium: the development of a foundation in critical care skills programme

This paper outlines the role and function of NHS education and training consortia and how one consortium is addressing the issues of supporting practitioner-led, practice-based training initiatives in critical care. In late 1997 the consortium sought to identify current problems with recruitment and retention of competent critical care nurses, access to training and development and to examine the quality and appropriateness of current pre- and postregistration training related to the critical care areas. A number of issues were identified, with the need for a Foundation in Critical Care Skills Programme' for junior nurses as the principle short term priority. A programme supported by the local consortium, in collaboration with seven NHS trusts' critical care areas (totalling 27 different departments/units), has been developed, incorporating skills workshops, completion of open learning materials, assessments of core competencies and the submission of a portfolio of evidence in support of a professional award (ENB Certificate). The importance and value of collaboration in the development of this practitioner-led consortium-supported venture is highlighted.

Increased absorption of aluminium from a normal dietary intake in dementia

Serum aluminium was significantly raised (p < 0.01) up to 2-3-fold, in patients with dementia including Alzheimers Disease (AD) 0.66 +/- 0.2 (mumol/l mean +/- 1 s.d.) and patients on regular aluminium hydroxide therapy 0.54 +/- 0.17, compared with healthy volunteers 0.21 +/- 0.13, although not as high as in patients with end stage renal failure on regular dialysis 0.88 +/- 0.42. The urine outputs (mumol/l mean +/- 1 s.d.) of aluminium and silicon, respectively, were also significantly increased up to 5-fold in dementia 2.89 +/- 1.78 (n = 23) and 1587 +/- 645 (n = 22) and patients on regular aluminium hydroxide therapy 5.03 +/- 2.08 (n = 8) and 998 +/- 364 (n = 21) compared with healthy volunteers 0.95 +/- 0.82 (n = 84) and 471 +/- 332 (n = 114). The increase in urine aluminium was thus associated with a similarly marked increase in the output of silicon. The increased absorption of aluminium in dementia patients is equivalent to the intestinal loading in Aludrox therapy. Also silicon appears to be important in the renal excretion of the absorbed aluminium. Whether this is a phenomenon related to the elderly or the process of dementia warrants further study.

Ribosomal RNA genes and the B chromosome of Brachycome dichromosomatica

Fluorescence in situ hybridization (FISH) with biotinylated rDNA revealed the presence of an rRNA gene cluster on both the A and B chromosomes of Brachycome dichromosomatica, an Australian native ephemeral plant of the arid regions of south-eastern Australia. This species contains only two pairs of A chromosomes and up to three B chromosomes. The regular attachment of the B chromosome to a nucleolus suggests that these ribosomal RNA genes are transcribed. Southern hybridization of DNA from 0B and +B plants digested with a variety of restriction enzymes indicates that the rRNA genes on the A and B chromosomes are the same in sequence and methylation status.