Medication Adjustments Research Articles

Telephone follow-up by nurse practitioners of geriatric patients discharged from the emergency department after traumatic injury

IntroductionGeriatric patients discharged from the emergency department (ED) after an injury are at risk for adverse outcomes. Older patients are at a higher risk for sensory impairments and cognitive problems which can make comprehension of discharge instructions more difficult. Moreover, geriatric patients often have limited skills with or access to alternative sources of information, such as hospital web pages or phone applications, which could put them at a higher risk of undertreatment. Implementing telephone follow-up after discharge presents a potential solution to enhance information transfer and address problems related to the injury. MethodsAn exploratory cohort study was conducted in the ED of an inner-city hospital in the Netherlands between 2019-2020. Patients ≥70 years were included if they presented with an injury and were discharged home from the ED. Telephone follow-up was performed by an ED nurse practitioner within 48 hours after discharge to address any problems or questions relating to the injury. Feasibility was assessed by determining whether the intervention could be performed within the allotted time period during normal work hours (1 h per day). The frequency and type of additional advice given, as well as patient satisfaction with the intervention, were documented. Results635 patients were eligible for inclusion, and 266 completed the intervention (median age 77 years; 32 % male). Nurse practitioners were able to complete the intervention on over 90 % of days. A total of 64 % of patients received additional advice during the telephone call, mostly related to pain medication adjustments and instructions to contact their GP. Patient satisfaction with the intervention was high (median score 8/10). ConclusionTelephone follow-up is a feasible intervention that may be able to enhance older patients' comprehension of discharge instructions and help identify new problems after discharge. During the follow-up call, the majority of patients received additional advice, indicating a potential demand for this intervention. The main limitation was that not all eligible patients were approached or did not want to participate in the intervention. Future studies should investigate whether telephone follow-up can effectively reduce adverse events and improve the quality of life for these patients.

The Rapid Access Memory Program for Addressing Concerns of Incipient Dementia in Academic Primary Care Settings.

Expedient diagnosis of incipient dementia is often hindered by time constraints in primary care visits, shortage of dementia specialists, and extended waitlists for comprehensive neuropsychological evaluations. We developed the Rapid Access Memory Program (RAMP) to improve access of neuropsychological services for older adults presenting to our institutional primary care clinics with concerns of cognitive decline. RAMP provides abbreviated neurocognitive assessment, same-day patient feedback, expedited reporting to referring providers, and is financially self-supported. Here, we describe development of RAMP and clinical outcomes from the first 3 years. Of 160 patients seen, dementia was diagnosed in 30% and Mild Cognitive Impairment in 50%; Alzheimer's disease was the most common suspected etiology. New psychiatric diagnosis was made in about one-third (n = 54). Most frequent recommendations involved medication adjustments (initiating cholinesterase inhibitors, deprescribing anticholinergics), safety (driving, decision-making), and specialist referrals. Additionally, 27 (17%) subsequently enrolled in local research. Results support feasibility and utility of RAMP for connecting older adults in primary care with neuropsychological services.

A Comprehensive electroencephalogram audit in a tertiary care center in Pakistan: demographic distribution, referral indications and findings

Background and Objective:
 Electroencephalography (EEG) is a widely employed non-invasive technique for recording brain electrical activity, pivotal for diagnosing various neurological conditions. The study aims to provide insight into demographic distribution, referral indications, and EEG findings in a tertiary care hospital in Pakistan.
 
 Methods:
 A retrospective cross-sectional analysis was conducted involving 2,924 patients who underwent routine EEG evaluations over a three-year period. Data was collected from the EEG records after approval from the ethical review committee. Demographic variables, referral reasons, and EEG findings were recorded and analyzed using descriptive statistics.
 
 Results:
 The study revealed a gender distribution of 41.35 % females and 58.65 % males, aligning with broader epidemiological trends. Participants were categorized into different age groups and most of the patients in our study belonged to the five to 18 years of age group. Most common indication was a suspected seizure disorder (78.32 %), followed by subclinical seizures (7.38 %) and medication adjustment (6.81 %). Notably, encephalopathy was the most common abnormal EEG finding (31 %), with temporal epilepsies being predominant within the focal seizure category.
 
 Conclusion:
 The descriptive nature of the study contributes novel insights. The study’s contribution provides valuable guidance for healthcare professionals, enhancing their comprehension of neurological conditions and refining diagnostic and treatment strategies.

Effect of Pilates on Anxiety, Depression, and Anthropometric Indices of Women with Type 2 Diabetes

Background: Type 2 diabetes mellitus (T2DM) is prevalent among overweight or obese women. Due to the chronic nature of diabetes, individuals with this condition often experience psychological complications, such as anxiety and depression. This study aimed to investigate the effects of Pilates exercises on anthropometric indices, anxiety, and depression in women with diabetes attending diabetes clinics in Zahedan, Iran. Methods: This two-group quasi-experimental study with pre-test and post-test assessments included 60 female patients diagnosed with T2DM who attended diabetes clinics in Zahedan within March 2021 and July 2022. The participants were selected using convenience sampling and then randomly assigned to either the Pilates exercise group or the control group using a random allocation method with permutation blocks. Initially, anthropometric indices, including body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR), were measured, and the Hospital Anxiety and Depression Scale was completed by both groups. The intervention group participated in Pilates exercises three times a week for 8 weeks, with each session lasting 60 minutes and supervised by a Pilates exercise expert. The control group received routine care at the diabetes clinic, including diet counseling and medication adjustments. After 8 weeks, the data were collected again and statistically analyzed using SPSS 22 software. The significance level was set at P < 0.05. Results: Significant differences were observed in anxiety scores before and after the intervention (13.33 ± 2.6 and 3.2 ± 5.41, respectively; P = 0.001), depression scores (11.9 ± 2.61 and 2.56 ± 1.85, respectively; P = 0.001), and anthropometric indices (P < 0.05). Waist circumference (96.20 ± 9.86 and 92.25 ± 8.56, respectively; P = 0.001), BMI (27.75 ± 1.99 and 26.67 ± 2.03, respectively; P = 0.001), and WHR (0.97 ± 0.06 and 0.93 ± 0.17, respectively; P = 0.001) all showed significant improvements. Conclusions: Exercise is a crucial non-pharmacological intervention in the management of diabetes. The results of this study demonstrate that Pilates exercises can effectively reduce anxiety and depression while improving anthropometric indices in women with T2DM. Therefore, it is recommended to incorporate Pilates exercises as a method to reduce anxiety and depression and enhance anthropometric indicators in this population.

Creating optimal educational settings for children with rare diseases – a working method

ABSTRACT Rare diseases are usually complex syndromes, which sometimes cause extensive functional impairments affecting everyday life. The number of rare diseases and of people having one is increasing. Children with rare diseases often display special education needs and require support and adapted pedagogical methods to participate and achieve academic goals. The aim of this paper is to present a holistic educational working method for creating optimal settings for children with rare diseases, taking the dynamic interaction of biological and contextual factors into consideration and applicable to most rare diseases. It is based on over 20 years of practical implementation of a strategy for meeting the needs of children with rare diseases and their families. A research review about education for children with rare diseases, published between 2017 and 2021 is also presented. The results show that rare diseases often have educational consequences and that a holistic educational method, applicable to most rare diseases, is needed, but lacking. To contribute to a high-quality inclusive education teachers must understand how the origin of needs, including medical facts, their consequences and appropriate adjustments are closely linked.

Risk Stratification of QTc Prolongation in Critically Ill Patients Receiving Antipsychotics for the Management of Delirium Symptoms.

Patients experiencing significant agitation or perceptual disturbances related to delirium in an intensive care setting may benefit from short-term treatment with an antipsychotic medication. Some antipsychotic medications may prolong the QTc interval, which increases the risk of potentially fatal ventricular arrhythmias. In this targeted review, we describe the evidence regarding the relationships between antipsychotic medications and QTc prolongation and practical methods for monitoring the QTc interval and mitigating arrhythmia risk. Searches of PubMed and Cochrane Library were performed to identify studies, published before February 2023, investigating the relationships between antipsychotic medications and QTc prolongation or arrhythmias. Most antipsychotic medications commonly used for the management of delirium symptoms (eg, intravenous haloperidol, olanzapine, quetiapine) cause a moderate degree of QTc prolongation. Among other antipsychotics, those most likely to cause QTc prolongation are iloperidone and ziprasidone, while aripiprazole and lurasidone appear to have minimal risk for QTc prolongation. Genetic vulnerabilities, female sex, older age, pre-existing cardiovascular disease, electrolyte abnormalities, and non-psychiatric medications also increase the risk of QTc prolongation. For individuals at risk of QTc prolongation, it is essential to measure the QTc interval accurately and consistently and consider medication adjustments if needed. Antipsychotic medications are one of many risk factors for QTc prolongation. When managing agitation related to delirium, it is imperative to assess an individual patient's risk for QTc prolongation and to choose a medication and monitoring strategy commensurate to the risks. In intensive care settings, we recommend regular ECG monitoring, using a linear regression formula to correct for heart rate. If substantial QTc prolongation (eg, QTc > 500 msec) is present, a change in pharmacologic treatment can be considered, though a particular medication may still be warranted if the risks of discontinuation (eg, extreme agitation, removal of invasive monitoring devices) outweigh the risks of arrhythmias. This review aims to summarize the current literature on relationships between antipsychotic medications and QTc prolongation and to make practical clinical recommendations towards the approach of antipsychotic medication use for the management of delirium-related agitation and perceptual disturbances in intensive care settings.

Plasma metabolites of aromatic amino acids associate with clinical severity and gut microbiota of Parkinson’s disease

Gut microbial proteolytic metabolism has been reportedly altered in Parkinson’s disease (PD). However, the circulating aromatic amino acids (AAA) described in PD are inconsistent. Here we aimed to investigate plasma AAA profiles in a large cohort of PD patients, and examine their correlations with clinical severity and gut microbiota changes. We enrolled 500 participants including 250 PD patients and 250 neurologically normal controls. Plasma metabolites were measured using liquid chromatography mass spectrometry. Faecal samples were newly collected from 154 PD patients for microbiota shotgun metagenomic sequencing combined with data derived from 96 PD patients reported before. Data were collected regarding diet, medications, and motor and non-motor symptoms of PD. Compared to controls, PD patients had higher plasma AAA levels, including phenylacetylglutamine (PAGln), p-cresol sulfate (Pcs), p-cresol glucuronide (Pcg), and indoxyl sulfate (IS). Multivariable linear regression analyses, with adjustment for age, sex, and medications, revealed that the plasma levels of PAGln (coefficient 4.49, 95% CI 0.40–8.58, P = 0.032) and Pcg (coefficient 1.79, 95% CI 0.07–3.52, P = 0.042) positively correlated with motor symptom severity but not cognitive function. After correcting for abovementioned potential confounders, these AAA metabolites were also associated with the occurrence of constipation in PD patients (all P < 0.05). Furthermore, plasma levels of AAA metabolites were correlated with the abundance of specific gut microbiota species, including Bacteroides sp. CF01-10NS, Bacteroides vulgatus, and Clostridium sp. AF50-3. In conclusion, elevated plasma AAA metabolite levels correlated with disease characteristics in PD, suggesting that upregulated proteolytic metabolism may contribute to the pathophysiology of PD.

Flexible bronchoscopy findings and management impact in children with oropharyngeal dysphagia.

Flexible bronchoscopy (FB) and bronchoalveolar lavage (BAL) are frequently performed in children with known or suspected aspiration, however, the additive value of FB in conjunction with direct laryngoscopy and rigid bronchoscopy (DLB) has not been previously quantified. This study details the common endoscopic/cytological findings and associated management impact of FB and BAL in pediatric Aerodigestive patients undergoing combined airway evaluation (FB and DLB) for oropharyngeal dysphagia. A retrospective chart review was performed in children <3 years of age followed through a large Aerodigestive center undergoing outpatient, combined airway endoscopy for dysphagia. Patient and procedural characteristics, endoscopic and BAL findings, and management metrics were collected and analyzed. A secondary analysis evaluated the association between endoscopic findings and medication changes. Ninety-one procedures (median patient age, 15 months) were identified. All procedures included both FB and DLB, and just over half (52.7%) included esophagogastroduodenoscopy. Common endoscopic findings included bronchitis (73.6%), adenoidal hypertrophy (31.9%), and tracheomalacia (10.8%). BAL cytology frequently identified neutrophilic inflammation (mean 39.6% neutrophils[interquartile range 6.5%-71%)]. Cultured pathogens commonly included Streptococcus viridans (46.6%), Hemophilus influenzae (36.3%), Moraxella catarrhalis (30.1%), and Streptococcus pneumoniae (25.0%). FB and BAL results contributed to clinical decisions in 65 of 91 (71.4%) patients. Endoscopically-diagnosed bronchitis (odds ratio [OR] 7.27, 95% confidence interval [CI] 2.4-21.99) and tracheomalacia (OR 5.79, 95% CI 1.20-27.85) were significantly associated with increased odds of medication adjustments following FB. In pediatric Aerodigestive patients undergoing combined airway evaluation for oropharyngeal dysphagia, FB and BAL are high-yield and clinically impactful procedures.

INFLUENCE OF A POOR LIFESTYLE ON THE DEVELOPMENT OF CYSTS IN WOMEN

Poor lifestyle choices, such as frequently consuming fatty fast food, consuming sugary beverages, living a sedentary lifestyle, and not getting enough exercise, may hasten the ovarian hyperthecosis progression. A recurrent hormonal disorder that affects women of reproductive age (15-30) known as polycystic ovarian disease (PCOD), where the ovaries contain an abundance of tiny cysts. It might interfere with their menstrual cycles and complicate attempts to conceive. PCOD is a serious health issue since those who have it have a higher risk factors include endometrial hyperplasia, endometrial cancer, obesity, cardiovascular disease, diabetes mellitus, obstructive sleep apnea, depression, and nonalcoholic fatty liver disease. Endometrial cancer may be brought on by aberrant, unopposed endogenous estrogenic stimulation brought on by feminizing ovarian tumors and polycystic ovarian syndrome. Patients with polycystic ovarian disease support the finding that endometrial carcinoma with a concurrent endogenous estrogenic stimulation has a better prognosis (P0.01) than endometrial carcinoma alone. A mature follicle, which is also a cystic structure, develops throughout a typical menstrual cycle with ovulation. The symptoms and potential problems of PCOD appear to be well managed by lifestyle changes. Depending on the condition, medication or lifestyle adjustments may be necessary. Getting regular exercise, losing weight, and increasing your daily activity can all help treat or perhaps prevent insulin resistance and lower testosterone levels. Synthetic medications can be used to treat PCOD. This paper contains the correlation between the poor life style and the occurrence of PCOD in women and its cure

Weighing the Weight of Bedridden Patient by using Strain Gauge (Weighing Scale) - Prototype

In today’s healthcare landscape, weighing beds plays a pivotal role in patient care and management. These specialized beds provide critical data on a patient’s weight, which is integral for monitoring health, tailoring treatment plans, and ensuring accurate medication dosages in bed rest patients, etc. They are particularly crucial in critical care settings, where precise weight measurements are essential for fluid balance and medication adjustments. Weighing beds also has a significant impact on preventive healthcare, enabling timely interventions and lifestyle recommendations based on weight-related health risks. In post-operative care, they assist in assessing factors like fluid retention, and guiding post-surgical interventions. Furthermore, in pediatric healthcare, weighing beds are indispensable for monitoring growth and development. Integration with electronic health records streamlines data management, enhancing efficiency for healthcare providers. Overall, weighing beds are indispensable tool in modern healthcare, contributing to comprehensive patient care and well-being. As the medication requirement of the bedridden patient depends on weight, overdose or underdose of the drug is expected to complicate the problems further. Till now, in the market, there were available detecting devices, but the main problem with them is those devices lift the patient totally or lift the bed totally; For this workforce is more required and also time-consuming and cost-effective. For bedridden patients, it is difficult to measure body weight due to lifting and equipment, as well as the need for a workforce. Some beds have inbuilt measuring sensors, but they are cost-effective for bed purchase. For this, there is a possible way to measure the patient’s weight by using a strain gauge sensor

Prosedur Percutaneous Trans Luminal Angioplasty (PTA) Pada Pasien Dengan Kasus Aneurisma Artery Popliteal (AAP)

Popliteal Artery Aneurysm (AAP) is a pathological dilation of the popliteal artery, and although often asymptomatic, can lead to serious complications such as rupture, thrombosis, or embolism. Aneurysms if ruptured can result in internal bleeding such as, stroke, and can sometimes be fatal. This research method is a literature review study, where literature exploration is carried out in various databases with keywords such as Percutaneous Transluminal Angioplasty (PTA)", Popliteal Artery Aneurysm (AAP) cases. Percutaneous transluminal angioplasty (PTA) in popliteal artery aneurysm (AAP) involves patient preparation, tools, procedure, post-operative care, and outcome evaluation. Patient preparation includes education, renal function evaluation, medication adjustment. Equipment preparation includes catheterization table, fluoroscopy system, various types of catheters, appropriate contrast agent. The PTA process includes insertion of the catheter into the femoral artery, evaluation and delineation of the popliteal artery, and completion of the procedure. PTA examination in AAP requires careful preparation and coordinated medical team collaboration to achieve optimal results. Percutaneous transluminal angioplasty (PTA) has proven to be effective as a primary therapeutic option to treat popliteal artery aneurysms (AAP) and prevent popliteal artery stenosis. Risk factors such as advanced age, male gender, and cardiovascular disease were considered in the literature analysis. Although PTA successfully improves the diameter of the popliteal artery as a minimally invasive method, it is important to recognize that the success of the procedure and the decision to use stents have a significant impact on the final outcome.

Drug Therapies for Diabetes.

The treatment of type 2 diabetes (T2D) necessitates a multifaceted approach that combines behavioral and pharmacological interventions to mitigate complications and sustain a high quality of life. Treatment encompasses the management of glucose levels, weight, cardiovascular risk factors, comorbidities, and associated complications through medication and lifestyle adjustments. Metformin, a standard in diabetes management, continues to serve as the primary, first-line oral treatment across all age groups due to its efficacy, versatility in combination therapy, and cost-effectiveness. Glucagon-like peptide-1 receptor agonists (GLP-1 RA) offer notable benefits for HbA1c and weight reduction, with significant cardiovascular benefits. Sodium-glucose cotransporter inhibitors (SGLT-2i) lower glucose levels independently of insulin while conferring notable benefits for cardiovascular, renal, and heart-failure outcomes. Combined therapies emphasizing early and sustained glycemic control are promising options for diabetes management. As insulin therapy remains pivotal, metformin and non-insulin agents such as GLP-1 RA and SGLT-2i offer compelling options. Notably, exciting novel treatments like the dual GLP-1/ glucose-dependent insulinotropic polypeptide (GIP) agonist show promise for substantially reducing glycated hemoglobin and body weight. This comprehensive review highlights the evolving landscape of pharmacotherapy in diabetes, the drugs currently available for treating diabetes, their effectiveness and efficacy, the impact on target organs, and side effects. This work also provides insights that can support the customization of treatment strategies.

Sleep apnea‐related hypoxemia, not sleep fragmentation, is associated with white matter hyperintensities in older adults

AbstractBackgroundSleep apnea is a type of sleep‐disordered breathing that increases risk for Alzheimer’s disease‐related pathology potentially through cerebrovascular pathology, likely exacerbated by two features of sleep apnea: intermittent hypoxia and sleep fragmentation. White matter hyperintensities (WMH), a marker of small vessel cerebrovascular disease, increase in aging and in AD. Here, we tested the hypothesis that apnea‐related hypoxemia severity, and not sleep fragmentation, are associated with WMH volume in older adults.MethodsThirty‐two older adults (73.4±5.3 years, 19 female, AHI = 15.2±18.9) were evaluated with overnight polysomnography (PSG). Apnea severity was quantified using the Apnea‐Hypopnea Index (AHI), Respiratory Disturbance Index (RDI), and blood oxygen desaturation (Oxygen Desaturation Index (ODI), duration, frequency of ≥4% desaturations, and desaturation nadir) stratified by sleep stages. T1‐MPRAGE and T2‐FLAIR scans were acquired using a 3T Siemens scanner. Total WMH volumes were derived using a semi‐automated algorithm. Overnight memory retention was assessed using the change in the lure discrimination index (LDI) for the emotional version of the Mnemonic Discrimination Task.ResultsTraditional measures of apnea severity and sleep fragmentation were not significantly associated with global WMH volume. However, both max duration of oxygen desaturation events (r = 0.44, p = 0.011) and max oxygen desaturation percentage (in rapid‐eye movement (REM) and in total sleep: r = 0.48, p = 0.005, and r = 0.44, p = 0.01), were significantly associated with total WMH volume. Similar relationships were found with time spent below 90% and 80% oxygen saturation (Kendall’s tau = 0.33, p = 0.02 and tau = 0.275, p = 0.03). These relationships survived adjustment for sex, age, and hyperlipidemia and/or hypertension medication at time of PSG. Global WMH volume was also negatively associated with overnight memory retention (r = ‐0.38, p = 0.03).ConclusionsThese findings suggest that hypoxemia severity, compared to sleep fragmentation, are more strongly associated with global WMH volume. As WMH volume was associated with overnight memory retention, this may suggest a pathway in which OSA increases WMH, which is subsequently associated with tau burden, worsening sleep‐dependent memory.

Sleep apnea‐related hypoxemia, not sleep fragmentation, is associated with white matter hyperintensities in older adults

AbstractBackgroundSleep apnea is a type of sleep‐disordered breathing that increases risk for Alzheimer’s disease‐related pathology potentially through cerebrovascular pathology, likely exacerbated by two features of sleep apnea: intermittent hypoxia and sleep fragmentation. White matter hyperintensities (WMH), a marker of small vessel cerebrovascular disease, increase in aging and in AD. Here, we tested the hypothesis that apnea‐related hypoxemia severity, and not sleep fragmentation, are associated with WMH volume in older adults.MethodThirty‐two older adults (73.4±5.3 years, 19 female, AHI = 15.2±18.9) were evaluated with overnight polysomnography (PSG). Apnea severity was quantified using the Apnea‐Hypopnea Index (AHI), Respiratory Disturbance Index (RDI), and blood oxygen desaturation (Oxygen Desaturation Index (ODI), duration, frequency of = 4% desaturations, and desaturation nadir) stratified by sleep stages. T1‐MPRAGE and T2‐FLAIR scans were acquired using a 3T Siemens scanner. Total WMH volumes were derived using a semi‐automated algorithm. Overnight memory retention was assessed using the change in the lure discrimination index (LDI) for the emotional version of the Mnemonic Discrimination Task.ResultTraditional measures of apnea severity and sleep fragmentation were not significantly associated with global WMH volume. However, both max duration of oxygen desaturation events (r = 0.44, p = 0.011) and max oxygen desaturation percentage (in rapid‐eye movement (REM) and in total sleep: r = 0.48, p = 0.005, and r = 0.44, p = 0.01), were significantly associated with total WMH volume. Similar relationships were found with time spent below 90% and 80% oxygen saturation (Kendall’s tau = 0.33, p = 0.02 and tau = 0.275, p = 0.03). These relationships survived adjustment for sex, age, and hyperlipidemia and/or hypertension medication at time of PSG. Global WMH volume was also negatively associated with overnight memory retention (r = ‐0.38, p = 0.03).ConclusionThese findings suggest that hypoxemia severity, compared to sleep fragmentation, are more strongly associated with global WMH volume. As WMH volume was associated with overnight memory retention, this may suggest a pathway in which OSA increases WMH, which is subsequently associated with tau burden, worsening sleep‐dependent memory.

Clinical impact of therapeutic drug monitoring for newer anti-seizure medications in patients with epilepsy: A real-world observation study

BackgroundThe clinical value of therapeutic drug monitoring (TDM) for newer anti-seizure medications (ASMs) remains uncertain. This study aimed to assess the impact of newer ASM TDM on clinical decision making in patients with epilepsy. MethodsWe retrospectively identified all plasma requests for newer ASM level measurement as part of routine clinical management in the outpatient departments of seven medical institutes across Taiwan between September 2016 and May 2019. Data collected from reviewed medical records included clinical and medication details, indications for TDM requests, test results, interpretation, and impact on patient management. ResultsA total of 682 visits with 1051 plasma samples were included. The most frequently analyzed ASMs were levetiracetam (36.1%), oxcarbazepine (18.4%), and lamotrigine (12.0%). Reasons for TDM included poorly controlled seizures (55.3%), concerns about drug-drug interactions (12.3%), and suspicion of drug overdose (10.6%). 68.8% of samples were within the orienting therapeutic range, even for patients with poorly controlled seizures. TDM for non-adherence concerns showed 54.3% below the orienting therapeutic range, while ASM-related adverse events assessment only 8.9% showed levels exceeding the orienting therapeutic range. Following TDM results, 64.2% of cases had medication adjustments, mainly dosage increases. Overall, 55.9% of newer ASM TDM visits showed improved outcomes, including reduced seizures (47.5%) and fewer ASM-related side effects (8.4%). ConclusionsThese findings suggest that appropriate utilization of TDM for newer ASMs provides clinical benefits in adjunct to complement clinical decision making in the management of epilepsy patients in a real-world clinical setting.

Ritelatur Review: Prosedur Pemeriksaan Coronary Angiogrhpy (Cag) Pada Kasus Acute Trasmular Myocardial Infraction

Literature review: coronary angiography examination procedure in cases of acute trasmular myocardial infarction. Background: Acute transmural myocardial infarction (ATMI) is a critical condition that describes heart damage involving the entire thickness of the ventricular wall due to total blockage of the coronary arteries. This situation can cause serious complications such as heart failure, arrhythmia, and sudden death if not treated quickly. Coronary angiography has become an important diagnostic tool in the management of STEMI. This process allows the doctor to directly view the coronary arteries and determine the location and severity of the blockage. This knowledge is critical because it guides medical or surgical interventions that may be necessary to open blocked arteries and restore blood flow to the heart. Prompt use of coronary angiography, followed by interventions such as angioplasty and stent placement (percutaneous coronary intervention, PCI), has been shown to reduce heart damage, increase survival, and improve long-term outcomes for patients with STEMI. Method: This research is a literature review, where literature exploration is carried out in various databases with keywords such as Coronary Angiograhy, Cases of Acute Transmular Myocardial Infarction, etc. Reference sources used in preparing this article include Google Scholar, as well as articles in English and Indonesian scientific journals. Results: Coronary Angiography (CAG) examination in Acute Trasmular Myocardial Infarction (ATMI) cases involves patient preparation, equipment preparation, medical team, examination procedures, post-operative care, description of examination results, and its role in the management of AMTI. Patient preparation involves patient education about procedures, fasting before examination, renal function checks, medication adjustments, vascular access preparation, discussion of contrast agents, and vital monitoring. ATMI patients require special attention in this preparation. Equipment preparation includes a stable catheterization table, fluoroscopic imaging system, various types of catheters, appropriate contrast agents, resuscitation equipment, pre-procedure medication, and hemostasis equipment. The medical team involved in ATMI examination in ATMI patients involve interventional cardiologists, radiological technologists, catheterization nurses, catheterization technicians, and additional support personnel such as the anesthesia team and resuscitation team. The examination procedure includes patient preparation, vascular access, catheter insertion into the coronary arteries, evaluation and imaging of the coronary arteries, and completion of the procedure .Post-operative care includes hemodynamic monitoring, examination of the access site, gradual mobilization, hydration, monitoring reaction to contrast agent, patient education, and follow-up with a cardiologist. Examination results may show normal coronary arteries, narrowing of the arteries, complete blockage, formation of arteries collaterals, and left ventricular dysfunction. CAG examination has an important role in detecting coronary artery disease, pre-operative assessment, determining therapy, evaluating collaterals, and assessing left ventricular dysfunction in ATMI patients. CAG examination in ATMI patients requires careful preparation and involves collaboration a well-coordinated medical team to provide optimal results and a significant contribution in ATMI management. Conclusion: In the context of treating Acute Transmural Myocardial Infarction (MI), the Coronary Angiography (CAG) examination procedure has a central role in determining the diagnosis, evaluating the level of coronary artery damage, and guiding decision making regarding coronary intervention. CAG allows rapid and accurate diagnosis of MI by directly viewing the condition of the coronary arteries and assessing the degree of obstruction that could lead to myocardial infarction. CAG provides a detailed visual image of coronary artery damage, infarct size and the area of ??myocardial tissue affected, which is essential for planning optimal treatment strategy. CAG results assist the medical team in identifying coronary lesions that require immediate intervention, such as coronary angioplasty and stent placement, with the aim of restoring normal blood flow to the myocardial tissue. In addition to focusing on the affected coronary arteries, CAG also provides a comprehensive view on overall heart function and condition, helping to evaluate damage and risk of complications.

Factors influencing concentrations of risperidone and 9-hydroxyrisperidone in psychiatric outpatients taking immediate-release formulations of risperidone.

To analyze the factors affecting the concentrations of the active moiety of risperidone (RIS) and its active metabolite 9-hydroxyrisperidone (9-OH-RIS) in psychiatric outpatients taking immediate-release formulations. This is a retrospective study on the therapeutic drug monitoring (TDM) data regarding RIS and 9-OH-RIS in adult psychiatric outpatients. TDM data with simultaneous RIS and 9-OH-RIS monitoring from March 2018 to February 2020 and relevant medical records (including dosage, dosage form, sex, age, diagnosis, combined medication, and comorbid disease) from 399 adult psychiatric outpatients (223 males and 176 females) were included in this study. The daily dose of RIS was 5.56±2.05mg, the concentration of total active moiety was 42.35±25.46ng/mL, and the dose-adjusted plasma concentration (C/D) of active moiety was 7.83±3.87 (ng/ml)/(mg/day). Dose, sex, and age were identified as important factors influencing concentrations of RIS and 9-OH-RIS in adult psychiatric outpatients. Individualized medication adjustments should be made according to the specific conditions of psychiatric outpatients. The findings strongly support the use of TDM to guide dosing decisions in psychiatric outpatients taking RIS.

The impact of outpatient pharmacological optimization on echocardiographic parameters in heart failure with reduced ejection fraction

Abstract Background The 2022 landmark STRONG-HF study demonstrated that aggressive uptitration of guideline directed medical therapy (GDMT) in patients recently hospitalized for heart failure leads to a reduction in the composite endpoint of heart failure hospitalization and mortality. However, the impact of optimization of GDMT on echocardiographic parameters in heart failure with reduced ejection fraction (HFrEF) is unknown. Purpose This goal of this study was to determine the impact of a virtual HFrEF optimization program for achieving GDMT uptake and its impacts of echocardiographic parameters. Methods We conducted a single center study at a Canadian community cardiovascular centre using a prospective pre-post design. NYHA class II/III HFrEF patients referred from inpatient and outpatient settings were enrolled in our virtual 3-month HFrEF optimization program. All participants underwent an initial consult with a nurse and cardiologist. After this, all patients were seen remotely by a nurse every two weeks for adjustment of HFrEF medications with the goal of maximally tolerated GDMT dosing within 3 months was. Transthoracic echocardiograms were performed prior to participation in the program &amp; after completion. Results Over 9 months, 284 NYHA class II/III HFrEF patients enrolled in the virtual HFrEF optimization program. Mean age was 67 and 70% were male. Mean ejection fraction was 34% and 54% had New York Heart Association Class II symptoms. At intake, the proportion of patients prescribed each class of GDMT was: 69% for Beta-blockers, 23% for Mineralocorticoid Receptor Inhibitors (MRA), 16% for Valsartan-Sacubitril and 7% for SGLT2 inhibitors. At 3-month follow-up, rates of GDMT prescription were improved: 90% for beta-blockers (p&amp;lt;0.01), 71% for MRA (p&amp;lt;0.01), 95% for ARNI (p&amp;lt;0.01) and 79% for SGLT2i (p&amp;lt;0.01). From baseline to follow-up echocardiogram, mean Left Ventricular End Diastolic Diameter improved from 5.51 to 5.13 cm (p&amp;lt;0.01). Mean Left Ventricular End Systolic Diameter improved from 4.33 to 3.75 cm (p&amp;lt;0.01). Mean Left Ventricular Mass Index was improved from 112.5 to 102.5 g/m2 (p&amp;lt;0.01). Mean Left Ventricular Ejection Fraction improved 34.4% to 49.8% (p&amp;lt;0.01). No hospitalizations due to medication-related adverse events were reported and 18 patients were hospitalized for HF exacerbation during study follow-up. Mean serum creatinine increased from 97.4 to 104.5 µmol/L (p&amp;lt;0.01); mean serum potassium increased from 4.48 to 4.58 (p&amp;lt;0.01). Conclusions This study demonstrates that a virtual program for GDMT optimization can safely and rapidly promote uptake of therapy in HFrEF patients. Furthermore, medical optimization was associated with significant reductions in left ventricular size, mass and ejection fraction. This provides a structural explanation for reductions in morbidity and mortality seen in STRONG-HF. Future studies should examine the effect of similar interventions on patient outcomes in a randomized setting.

Quadruple therapy for heart failure before and after electronic cardiac device implantation - are we hitting our targets?

Abstract Background Quadruple therapy is currently recommended pharmacological treatment for heart failure with reduced ejection fraction (HFrEF). It consists of beta-blockers, mineralocorticoid receptor antagonists (MRA), angiotensin converting enzyme inhibitors (ACE-I) – recently suggested to be replaced with angiotensin receptor/neprilysin inhibitor (ARNI), and sodium-glucose cotransporter-2 inhibitors (SGLT2-I). Patients eligible for implantable cardioverter-defibrillator (ICD) or cardiac resynchronization therapy (CRT) implantation should have therapy titrated to evidence-based target doses prior to the procedure, whenever tolerable. Compliance with guidelines as well as distinction in prescription practice before and after device implantation in the era of quadruple HFrEF therapy has not yet been fully researched. Purpose The purpose of this study is to evaluate the use of disease-modifying drugs in corresponding target doses in patients with HFrEF eligible for ICD or CRT implantation, prior to and after the procedure. Methods This is a retrospective observational study which included patients with HFrEF hospitalized for ICD or CRT implantation in a single tertiary centre from January 2021 to January 2023. Data was collected through patients' medical history and phone calls. Results We collected data on a total of 107 patients with HFrEF and ICD or CRT implantation. Most patients received all four classes of guideline-directed therapy before ICD or CRT implantation: beta-blockers (91,6%), MRA (86,0%), ACE-I (31,8%) or ARNI (59,8%) and SGLT2-I (59,8%). Evidence-based target doses were reached for 10,2%, 52,2%, 11,8%, 32,8% and 100% patients receiving beta-blockers, MRA, ACE-I, ARNI and SGLT2i respectively. After hospitalization for device implantation, results pointed to an increase in prescription of beta-blockers (99,1%), MRA (97,2%), and most notably SGLT2-I (87,9%), while more ACE-I (19,6%) were replaced with ARNI (75,7%). Target doses were reached for 19,8%, 72,1%, 28,6%, 37,0%, and 100% patients receiving beta-blockers, MRA, ACE-I, ARNI, and SGLT2-I respectively. Conclusions Most of the examined patients have been receiving all four drug classes prior to device implantation. We noticed a rising trend in recruiting novel heart failure drugs, ARNI and SGLT2-I, after the procedure. However, drug titration was non-compliant with guidelines. There was a slight improvement in up-titration of therapy after the procedure, which could be explained by more common medication adjustments by electrophysiologists during device control sessions as well as better drug tolerability after device implantation. Regardless, a minority of patients received ACE-I, ARNI and beta blockers in target doses. Despite several objective obstacles to adequate administration of disease-modifying drugs, including intolerability and patients’ non-adherence, further effort in up-titrating guideline-directed medical therapy should be applied.Therapy administration practice

Cost-Effectiveness of Pharmacist Prescribing for Managing Hypertension in the United States

Pharmacist-led interventions can significantly improve blood pressure (BP) control. The long-term cost-effectiveness of pharmacist-prescribing interventions implemented on a large scale in the US remains unclear. To estimate the cost-effectiveness of implementing a pharmacist-prescribing intervention to improve BP control in the US. This economic evaluation included a 5-state Markov model based on the pharmacist-prescribing intervention used in The Alberta Clinical Trial in Optimizing Hypertension (or RxACTION) (2009 to 2013). In the trial, control group patients received an active intervention, including a BP wallet card, education, and usual care. Data were analyzed from January to June 2023. Cardiovascular (CV) events, end-stage kidney disease events, life years, quality-adjusted life years (QALYs), lifetime costs, and lifetime incremental cost-effectiveness ratio (ICER). CV risk was calculated using Framingham risk equations. Costs were based on the reimbursement rate for level 1 encounters, medication costs from published literature, and event costs from national surveys and pricing data sets. Quality of life was determined using a published catalog of EQ-5D utility values. One-way sensitivity analyses were used to assess alternative reimbursement values, a reduced time horizon of 5 years, alternative assumptions for BP reduction, and the assumption of no benefit to the intervention after 10 years. The model was expanded to the US population to estimate population-level cost and health impacts. Assumed demographics were mean (SD) age, 64 (12.5) years, 121 (49%) male, and a mean (SD) baseline BP of 150/84 (13.9/11.5) mm Hg. Over a 30-year time horizon, the pharmacist-prescribing intervention yielded 2100 fewer cases of CV disease and 8 fewer cases of kidney disease per 10 000 patients. The intervention was also associated with 0.34 (2.5th-97.5th percentiles, 0.23-0.45) additional life years and 0.62 (2.5th-97.5th percentiles, 0.53-0.73) additional QALYs. The cost savings were $10 162 (2.5th-97.5th percentiles, $6636-$13 581) per person due to fewer CV events with the pharmacist-prescribing intervention, even after the cost of the visits and medication adjustments. The intervention continued to produce benefits in more conservative analyses despite increased costs as the ICER ranged from $2093 to $24 076. At the population level, a 50% intervention uptake was associated with a $1.137 trillion in cost savings and would save an estimated 30.2 million life years over 30 years. These findings suggest that a pharmacist-prescribing intervention to improve BP control may provide high economic value. The necessary tools and resources are readily available to implement pharmacist-prescribing interventions across the US; however, reimbursement limitations remain a barrier.