Depression and Capacity to Withdraw from Dialysis

A patient with a history of bipolar II disorder and end-stage renal disease who required hemodialysis for five years abruptly wished to withdraw from dialysis on day seven of her hospital admission for a urinary tract infection. She had never discussed wishing to withdraw from dialysis prior to this hospital admission. She had experienced several symptoms of depression during her stay. Her desire to withdraw from dialysis treatment was discordant with her previously expressed desires, and the psychiatry team determined that her judgment was likely altered by her depressive episode. Given her previous positive response to electroconvulsive therapy (ECT), the psychiatry team recommended that she receive ECT before she choose to withdraw from dialysis.

Prescriptions for Potentially Inappropriate Medications from the Beers Criteria Among Older Adults Hospitalized for Heart Failure

BACKGROUND

We sought to better understand patterns of potentially inappropriate medications (PIMs) from the Beers criteria among older adults hospitalized with heart failure (HF). This observational study of hospitalizations was derived from the geographically diverse REasons for Geographic and Racial Differences in Stroke cohort.

METHODS AND RESULTS

We examined participants aged 65 years and older with an expert-adjudicated hospitalization for HF. The Beers criteria medications were abstracted from medical records. The prevalence of PIMs was 61.1% at admission and 64.0% at discharge. Participants were taking a median of 1 PIM (interquartile range [IQR] 0-1 PIM) at hospital admission and a median of 1 PIM (IQR 0-2 PIM) at hospital discharge. Between admission and discharge, 19.1% of patients experienced an increase in the number of PIMs, 15.1% experienced a decrease, and 37% remained on the same number between hospital admission and discharge. The medications with the greatest increase from admission to discharge were proton pump inhibitors (32.6% to 38.6%) and amiodarone (6.2% to 12.2%). The strongest determinant of potentially harmful prescribing patterns was polypharmacy (relative risk 1.34, 95% confidence interval 1.16-1.55, P < .001).

CONCLUSIONS

PIMs are common among older adults hospitalized for HF and may be an important target to improve outcomes in this vulnerable population.

Attitudes toward deprescribing among adults with heart failure with preserved ejection fraction

BACKGROUND/OBJECTIVES

Attitudes toward deprescribing could vary among subpopulations. We sought to understand patient attitudes toward deprescribing among patients with heart failure with preserved ejection fraction (HFpEF).

DESIGN

Retrospective cohort study.

SETTING

Academic medical center in New York City.

PARTICIPANTS

Consecutive patients with HFpEF seen in July 2018-December 2019 at a program dedicated to providing care to older adults with HFpEF.

MEASUREMENTS

We assessed the prevalence of vulnerabilities outlined in the domain management approach for caring for patients with heart failure and examined data on patient attitudes toward having their medicines deprescribed via the revised Patient Attitudes Toward Deprescribing (rPATD).

RESULTS

Among 134 patients with HFpEF, median age was 75 (interquartile range 69-82), 60.4% were women, and 35.8% were nonwhite. Almost all patients had polypharmacy (94.0%) and 56.0% had hyperpolypharmacy; multimorbidity (80.6%) and frailty (78.7%) were also common. Overall, 90.3% reported that they would be willing to have one or more of their medicines deprescribed if told it was possible by their doctors; and 26.9% reported that they would like to try stopping one of their medicines to see how they feel without it. Notably, 91.8% of patients reported that they would like to be involved in decisions about their medicines. In bivariate logistic regression, nonwhite participants were less likely to want to try stopping one of their medicines to see how they feel without it (odds ratio 0.25, 95% confidence interval [0.09-0.62], p = 0.005).

CONCLUSIONS

Patients with HFpEF contend with many vulnerabilities that could prompt consideration for deprescribing. Most patients with HFpEF were amenable to deprescribing. Race may be an important factor that impacts patient attitudes toward deprescribing.

Characterization of staphylococci sampled from diabetic foot ulcer of Jordanian patients

AIMS

The aim of this study was to isolate and characterize staphylococcal isolates from diabetic foot ulcers (DFU) in Jordanian patients.

METHODS AND RESULTS

Selected aerobic pathogens recovered from DFU specimens and patients' nares with a focus on staphylococci were investigated. Antimicrobial susceptibilities and the prevalence of methicillin-resistant staphylococci (MRS) were determined. SCCmec types and toxigenic characteristics were analysed and spa typing was performed for methicillin-resistant Staphylococcus aureus (MRSA) isolates. The relationship between toxigenic characteristics of MRSA and the Wagner ulcer grading system was statistically analysed. A total number of 87 DFU patients were recruited for the study. The DFU cultures were polymicrobial. Members of the genus Staphylococcus were the most common among DFU-associated isolates found in 48·3% (n = 42) of all patients enrolled. Coagulase-negative staphylococci (CoNS) comprised 63·3% of staphylococci isolated from DFUs predominated by Staphylococcus epidermidis in both DFU (7·6%) and nares (39·2%). Staphylococcus aureus was isolated from DFUs and nares in 14·2 and 9·8%, respectively, while 93 and 70% of these isolates were MRSA. Most of MRSA carried SCCmec type IV (76·2%) while SCCmec elements were non-typeable in most methicillin resistant coagulase negative staphylococci (MR-CoNS) (61·9%). The most frequent MRSA spa type was t386 (23·8%). Most MRSA and MR-CoNS exhibited resistance towards aminoglycosides, fluoroquinolones and macrolides and susceptibility towards vancomycin, mupirocin and linezolid. No association was found between the possession of pvl, tst, sea and hlg toxins and Wagner ulcer grading system (P value >0·05).

CONCLUSIONS

This analysis of Jordanian DFU culture demonstrated its polymicrobial nature with predominance of Staphylococcus sp.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study is the first of its type to assess the microbiology of DFU among Jordanian patients. The results will help in the appropriate application of antimicrobial chemotherapy in the management of DFU.

Physicians' knowledge, attitude and practices regarding management of medications in Ramadan

To evaluate knowledge, attitude and practices (KAP) of physicians regarding the management of medications in Ramadan we used a self-administered questionnaire on a target sample of 381 physicians at Jordan University Hospital, King Abdulla University Hospital and a number of private clinics in Amman, during September and October of 2008. A total of 297 questionnaires were returned. Physicians' KAP about management of medications in Ramadan was generally insufficient. The main factors that affected KAP were age, nationality, specialty, and country and year of last qualification (P < 0.05). Female physicians scored better than males, and fellows scored better than other groups for knowledge. Most physicians' attitudes and practices were in line with religious opinion in regard to which routes of drug administration can nullify fasting, indicating that physicians have adequate knowledge in this area.