Medication Categories Research Articles

Outpatient Pharmacy Prescriptions During the First Year Following Serious Combat Injury: A Retrospective Analysis.

Limited research has analyzed the full range of outpatient medication prescription activity following serious combat injury. The objectives of this study were to describe (1) outpatient medication prescriptions and refills during the first 12months after serious combat injury, (2) longitudinal changes in medication prescriptions during the first-year postinjury, and (3) patient characteristics associated with outpatient prescriptions. This was a retrospective analysis of existing health and pharmacy data for a random sample of U.S. service members who sustained serious combat injuries in the Iraq and Afghanistan conflicts, 2010-2013 (n=381). Serious injury was defined by an Injury Severity Score (ISS) of 9 or greater. These patients typically participate in military rehabilitation programs (eg, amputation care) where prescription medications are essential. Data sources were the Expeditionary Medical Encounter Database for injury-specific data, the Pharmacy Data Transaction Service for outpatient medication prescriptions and refills, and the Military Health System Data Repository for diagnostic codes of pain and psychological disorders. Military trauma nurses reviewed casualty records to identify types of injuries. Using the American Hospital Formulary Service Pharmacologic-Therapeutic Classification system, clinicians identified 13 categories of prescription medications (eg, opioid, psychotherapeutic, immunologic) for analysis. Multivariable negative binomial and logistic regression analyses evaluated significant associations between independent variables (eg, blast injury, traumatic brain injury [TBI], ISS, limb amputation, diagnoses of chronic pain, or psychological disorders) and prescription measures (ie, number or category of medication prescriptions). We also describe longitudinal changes in prescription activity postinjury across consecutive quarterly intervals (91days) during the first-year postinjury. During the first-year postinjury, patients averaged 61 outpatient prescriptions, including all initial prescriptions and refills. They averaged eight different categories of medications, primarily opioid, immunologic, gastrointestinal/genitourinary, central nervous system (CNS), nonopioid analgesic, and psychotherapeutic medications (representing 82% of prescriptions) during the first year. Prescription activity generally declined across quarters. There was still substantial prescription activity during the fourth quarter, as 79% of patients had at least one prescription. From 39 to 49% of patients had fourth-quarter prescriptions for opioid, CNS, or psychotherapeutic medications. Longitudinally, we found that 24-34% of patients had an opioid, CNS, or psychotherapeutic prescription during each of the final three quarters. In multivariable analysis, ISS, limb amputation (particularly bilateral amputation), and diagnoses of chronic pain and post-traumatic stress disorder (PTSD) were associated with significantly higher counts of individual and multiple medication prescriptions. TBI was associated with significantly lower numbers of prescriptions for certain medications. This is one of the first studies to provide a systematic analysis of outpatient medication prescriptions following serious combat injury. The results indicate substantial prescription activity from multiple medication categories throughout the first-year postinjury. Diagnoses of chronic pain, PTSD, and limb amputation and ISS were associated with significantly higher counts of prescriptions overall and more prescription medication categories. This study provides initial evidence to better understand medication prescription activity following serious combat injury. The results inform future research on medication prescription practices and planning for rehabilitation.

Costs Associated with Lower- and Upper-Limb Amputation Over the First 4 Years with a Prosthesis

ABSTRACT Introduction The impact of amputation on health care costs is an understudied topic due to the lack of sufficient population size and data sources. The purpose of this investigation was to leverage a publicly available database on amputations to determine health care–associated costs for individuals with lower- and upper-limb amputation of varying limb loss levels during the first 4 years after receipt of their first prosthesis. Materials and Methods An insurance claims database was obtained via public records request from the Ohio Bureau of Workers' Compensation for persons who suffered a traumatic injury in the workplace that resulted in lower- or upper-limb amputation. Data included information on cost and frequency of prosthetic limbs, equipment, and appointments, as well as information on general hospital care, physical, vocational, and mental health therapies, prescription medication, and additional health care categories. The population was categorized into five limb loss levels: individuals with unilateral transfemoral and transtibial amputation, as well as individuals with hand, below-elbow, and above-elbow amputation. Prosthetic claim codes were examined to determine the types of prostheses prescribed over time based on Medicare guidelines for activity levels (K1–K4) for lower-limb devices and by type (passive [cosmetic], body-powered, hybrid, or externally powered) for upper-limb devices. These data were used to determine short-term costs over the first 4 years, depending on the initial prosthesis prescription. Differences between total costs per year and over all 4 years were explored within each population to determine how initial prosthetic prescription impacts cost. Results In general, the microprocessor-controlled devices (i.e., microprocessor-controlled knee prostheses or externally powered upper-limb prostheses) resulted in higher initial prosthetic and total hospital costs, whereas the simpler mechanical devices (i.e., non–microprocessor-controlled knee prostheses or passive/cosmetic upper-limb prostheses) resulted in lower costs. Costs were highest in prosthetics-related expenses and physical therapy, especially in groups with the more advanced prostheses, during the first year after prosthesis receipt; however, the differences in costs based on prosthesis type minimized as time increased and few cumulative cost differences were seen over 4 years. In addition to determining costs accrued over time, the database provided insight into how frequently individuals with amputation received a new prosthesis and at what level. The average number of devices per person per year averaged 0.62 ± 0.36 for individuals with transfemoral amputation, 0.78 ± 0.40 for individuals with transtibial amputation, 0.24 ± 0.18 for individuals with hand amputation, 0.45 ± 0.39 for individuals with below-elbow amputation, and 0.40 ± 0.32 for individuals with above-elbow amputation. Conclusions The results of this cost investigation provide new information regarding all aspects of health care for individuals with lower-limb amputation and upper-limb amputation, respectively, who suffer from occupation-related traumatic amputation. The results provide new data trends on prosthesis usage and highlight how prosthetic prescription may alter these costs. The results suggest that there are no statistical differences in cost outcomes after 4 years, indicating that paying more initially for a more advanced prosthesis does not result in higher initial costs over time than paying less initially for a simpler prosthesis.

THE EFFECTS OF PSYCHOTROPIC MEDICATIONS ON GAIT STABILITY OF OLDER ADULTS WITH DEMENTIA

THE EFFECTS OF PSYCHOTROPIC MEDICATIONS ON GAIT STABILITY OF OLDER ADULTS WITH DEMENTIA

Co-detection of isoprenaline and paracetamol in biological and pharmaceutical media by a feather-like La3+/ZnO nano-flowers and N-(ferrocenylmethylidene)fluoren-2-amine-modified carbon paste electrode: analysis of a novel sensor

Belonging to the category of catecholamine-based medications, isoprenaline is excessively beneficial in the heart disease management. Nevertheless, serious adverse consequences can occur following the consumption of high concentrations of this drug. The present study aimed for highly sensitivity co-detection of isoprenaline and paracetamol in aqueous solutions by designing and synthesizing a novel sensor based on feather-like La3+/ZnO nano-flowers and N-(ferrocenylmethylidene)fluoren-2-amine-modified carbon paste electrode (La3+/ZnONFMF2ACPE). To this end, the electrocatalytic oxidation of isoprenaline on the surface of La3+/ZnONFMF2ACPE was evaluated by varied techniques, including chronoamperometry, cyclic voltammetry and differential pulse voltammetry. A linear calibration curve was plotted for different concentrations of isoprenaline (0.1–400.0 μM) with 0.05 μM of detection limit. Finally, acceptable results were obtained after the detection of isoprenaline and paracetamol in human serum, urine and drug real samples using the produced sensor.

A Geriatric Pharmacy Resident's Clinical and Educational Activities During Weekly interprofessional Team Meetings.

OBJECTIVES: To describe and gather further details about the clinical and educational activities that were documented by the geriatric pharmacist resident during both weekly interprofessional Acute Care for the Elderly (ACE) rounds as well as bedside patient counseling. DESIGN: Retrospective chart review (quality improvement project). SETTING: Inpatient geriatric service at University of Pittsburgh Medical Center (UPMC). PATIENTS: Medical learners selected one complex patient from the geriatric service for ACE rounds each week. ACTIVITIES: The geriatric pharmacist resident provided clinical information and medication education to the interprofessional team and to the patient and/or family at their bedside. Activities were documented in a newly developed template. MAIN OUTCOME MEASURES: Patient demographics, medication categories, discrepancies and dosing changes, time-in-rounds, and team members. RESULTS: De-identified data from 18 patients (72.2% female, average age 82.5 ± 9.18 years) over a 6-month period were collected and analyzed. The geriatric pharmacist resident provided most education to the team on antibiotics, antidepressants, over-thecounters (OTCs), and prescription pain medications during ACE rounds. They provided most education to the patient/family on prescription pain medications, antidepressants, OTCs, and anticoagulants. The pharmacist resident identified 38 medication discrepancies (72.2% of patients had ≥ 1 discrepancy, range 0-7) and clinically significant drug-drug interactions in 15 patients. The pharmacist resident recommended dosing changes in 12 patients and therapeutic alternatives in 11 patients. The ACE rounds lasted on average 26.6 [± 6.42] minutes and included medicine, pharmacy, social work, nurse case management, nursing, and nutrition and rehabilitative services when necessary. CONCLUSION: The results provide insight into both the clinical and educational activities of the geriatric pharmacist resident in support of interprofessional rounds.

Drug-related problems and pharmacy interventions in non-prescription medication, with a focus on high-risk over-the-counter medications

Background The risks associated with over-the-counter medication are often underestimated by consumers. The incorrect use of certain medications can lead to significant patient harm. Inappropriate use can be prevented by pharmaceutical counselling. Objective To determine the number and nature of drug-related problems in over-the-counter medication with a special emphasis on high-risk over-the-counter medications. Setting Fifty-two community pharmacies in Finland. Method This observational study was conducted as a questionnaire survey. The pharmacists working in participating pharmacies documented the observed drug-related problems and pharmacy interventions in over-the-counter medication during 1 week using an electronic study form based on the Westerlund drug-related problem classification system. Main outcome measure The prevalence of drug-related problems and problem types in different medication categories. Results The 52 community pharmacies documented 339 drug-related problems in 0.6% of over-the-counter customers, the most common problem being “Uncertainty about the indication for the drug” (39.2%). A significant proportion of the documented problems (26.3%) concerned high-risk over-the-counter medications, and the majority of these cases were associated with non-steroidal anti-inflammatory drugs (21.8%). In total, pharmacies made 641 interventions to resolve the drug-related problems. For majority of drug-related problems (87%), pharmacist’s intervention involved counselling. In more than half of the problem cases, the pharmacy intervention was precautionary. Conclusion Pharmacists intervene in and prevent problems related to over-the-counter medications, including high-risk medications like analgesics, in which inappropriate use due to consumers’ lack of knowledge can lead to severe consequences. As the selection and use of over-the-counter medications is continuously increasing, pharmaceutical counselling should be readily available and actively provided for consumers to achieve safer self-medication.

Abstract P3-08-71: Medication use to reduce mammographic breast density in premenopausal women: A systematic review

Abstract Background: Mammographic breast density (MBD) is a strong modifiable risk factor for breast cancer, especially in premenopausal women. It is estimated that up to 39% of breast cancer cases in premenopausal women could potentially be prevented by reducing dense breasts to non-dense breasts. Therefore, reducing breast density through targeted interventions is an excellent opportunity to substantially reduce breast cancer incidence in premenopausal women. We performed a critical evaluation of the literature to determine the associations of chemoprevention agents use with MBD. This will guide the management of premenopausal women at risk for breast cancer. Methods: Eleven databases were searched on July 2019. We included interventional, cross-sectional, longitudinal or observational studies in Englishreporting the associations of medication with mammographic breast density in premenopausal womenwith no history of breast cancer. Two researchers extracted the data and assessed the quality of the studies. Supplements not otherwise specified were excluded. Results: After de-duplication process, 1,464 citations were screened for eligibility. Seven studies met our inclusion criteria: two observational, four randomized controlled, and one non-randomized controlled trials (RCT). There were two categories of medications: dietary supplements (i.e. vitamin D, calcium, isoflavone) and drugs (non-steroidal anti-inflammatory drugs [NSAIDs], selective estrogen receptor modulators (SERMs) goserelin, and GnRHA deslorelin acetate). In observational studies, calcium use was associated with a significant reduction in MBD, while vitamin D and NSAIDs showed no reduction6. Likewise, Isoflavone and vitamin D in doses of 1000, 2000 or 3,000IU/day were not associated with a reduction in MBD in two different RCT. Groselin, GnRHA, deslorein acetate, statins were not associated with MBD reduction in an RCT’s. SERMs (tamoxifene and raloxifene) were the only drugs associated with reductions in MBD in RCTs. Conclusions: Only a very limited number of medications (SERMs) are associated with reductions in MBD. In view of their low uptake and adherence, identifying other medications that can reduce MBD is crucial, as these could have utility in breast cancer prevention. Citation Format: Ana S. Salazar, Malika Rakhmankulova, Laura E. Simmon, Adetunji Toriola. Medication use to reduce mammographic breast density in premenopausal women: A systematic review [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-71.

Abstract WP237: Facilitators and Barriers to Medication Adherence Among Stroke Survivors in India

Background: Medication nonadherence is a major problem and is an important mediator between the treatment and the outcome. Strict compliance with medication and life style modification are integral to secondary stroke prevention. Methods: Cross sectional survey among 240 stroke survivors within a post-stroke period of three months to one year was conducted. Interview based self-reported medication adherence was defined as consumption at least more than 80% of their medication, based on their last prescription. Medication adherence was calculated for five categories of medication; antiplatelets, antihypertensives, antidiabetics, statin and anticoagulants. Overall adherence was defined as adherence to all the categories of medications prescribed. Structured interview using pretested interview schedule was done to collect sociodemographic data, health care seeking behaviour, life style, facilitators and barriers to medication adherence. Results: Stroke survivors [n=240; mean age 58.64 ±10.96 years); 25.4% females; post-stroke period of 6.65±3.36 months] were interviewed. Patients with diabetes, hypertension and dyslipidaemia constituted 64.2%, 88.8% and 96.7% and optimal control was achieved in 26%, 36.2% and 72.9% respectively. Overall medication adherence was 43.8% (n=240). Adherence to antiplatelet was 62.24% (n=196). Medication adherence was 34.4% (n=134), 52.6% (n=190) and 56.7% (n=224) for antidiabetics, antihypertensives and statins respectively and was associated with risk factor control (Diabetes: Odds Ratio(OR)=4.85;95% Confidence Interval(CI) 2.12-11.08, Hypertension: OR=3.42; 95% CI 1.83-6.4, Dyslipidaemia: OR=3.88;95% CI 1.96-7.69). Having daily routines (OR=2.82;95% CI 1.52-5.25), perceived need of medication (OR= 2.33;95% CI 1.04-5.2) and perceived poor state of health (OR= 3.09; 95% CI 1.44-6.62) as facilitators. Memory problem (OR 0.32; 95% CI 0.51-0.66), experiencing side effects (OR 0.24; 95% CI 0.11-0.53) and belonging to below poverty line (OR 0.46; 95% CI 0.24-0.91) were barriers to medication adherence. Conclusion: Establishing daily routines, periodic reminders, and financial supports to buy medicines and patient education can enhance medication adherence to prevent future strokes.

Comorbidity and polypharmacy in patients with breast cancer.

Cancer sufferers are aged ≥ 65years, but research has focused infrequently on elderly patients with the majority of cancer. We aimed not only to determine the frequency of comorbidity and polypharmacy, but also to present the discrepiancies in elderly versus non-elderly patients with breast cancer. A total of 352 female patients aged over 18years, 252 non-elderly and 100 elderly, followed-up in the oncology department of a tertiary hospital between January 2016 and September 2019 were retrospectively screened. Demographic data, comorbidity and medications of the patients were recorded hospital data processing system. Polypharmacy was defined as the use of ≥ 5 different medications. The most common four chronic diseases in both non-elderly and elderly groups were muscle-joint-bone disease, gastrointestinal diseases, diabetes mellitus and hypertension. The most common four prescribed drugs were NSAID, adjuvant endocrine therapy, PPI, and vitamin D or/and calcium in non-elderly group while those were ACEI-ARB, PPI, NSAID, and diuretics in elderly one. The frequency of polypharmacy was 50% (n = 126) in the non-elderly patients and 74% (n = 74) in the elderly ones. These were considered statistically significant (p < 0.001). The mean number of prescription medication categories reported was 5.02 (SD = 2.90; range 0-14) in non-elderly group whereas those was 6.83 (SD = 3.18; range 0-15) in elderly one (p < 0.001). The mean of ages were 47.9years (without polypharmacy) and 51.3years (with polypharmacy) in non-elderly patients while those are, respectively, 70.9years and 74.7years in elderly ones. These were considered statistically significant (respectively; p = 0.006, p = 0.009). We first gained to raise awareness in the literature of comorbidity and polypharmacy in patients with breast cancer and to compare between the elderly and non-elderly participants. For the effectiveness of cancer treatment, importance in geriatric population, attention to drug-drug interaction, such studies should be considered during clinical practice.

The Efficacy of Normal Saline (N/S 0.9%) Versus Heparin Solution in Maintaining Patency of Peripheral Venous Catheter and Avoiding Complications: a Systematic Review.

Introduction:Heparin is a sulfated polysaccharide belonging to the glycosaminoglycan family with strong anticoagulant activity. It has been widely used to maintain intravascular catheters in patients requiring intravenous medication. It is believed that heparin prevents thrombus formation in the intravascular catheter, but since the 1980s, the necessity of the heparin solution for peripheral intravenous catheter (PIVC) flushing has been questioned in several clinical trials. According to the Institute for Safe Medication Practices (ISMP), there are four special categories of High Alert Medications (HAMs), including heparin.Aim:The aim of this systematic review was to investigate the efficacy of normal saline versus heparin solution in maintaining the patency and functionality of the PIVC and avoiding complications.Methodology:A systematic review using PubMed and Cochrane Library databases was conducted. Original research studies of hospitalized patients with PIVC, regardless of age, published in English, over the last decade (2009-2019) were eligible for inclusion.Results:The review concluded in 10 studies that met the inclusion criteria. From these studies, it appears that it is not fully documented whether the normal saline (N/S 0,9%) is superior to heparin solution (H/S) in the flushing of the PIVC for maintaining its patency and prevent complications. Researchers tend to support the use of N/S 0,9% due to safety, error avoidance, efficiency, ease of use and cost-effectiveness. Concern about the possible complications of the heparin solution was the cause of guidelines development for N/S 0,9% in countries such as Australia.Conclusions:The use of normal saline seems to outweigh the heparin solution in maintaining the patency of PIVC.

Use of Medications by Breastfeeding Women in the 2015 Pelotas (Brazil) Birth Cohort Study.

Background: This study describes medication use by women up to 3 months postpartum and evaluates the association between medication use by women who were still breastfeeding at 3 months postpartum and weaning at 6 and 12 months. Methods: Population-based cohort, including women who breastfed (n = 3988). Medications were classified according to Hale’s lactation risk categories and Brazilian Ministry of Health criteria. Duration of breastfeeding was analysed using Cox regression models and Kaplan-Meier curves, including only women who were still breastfeeding at three months postpartum. Results: Medication use with some risk for lactation was frequent (79.6% regarding Hale’s risk categories and 12.3% regarding Brazilian Ministry of Health criteria). We did not find statistically significant differences for weaning at 6 or 12 months between the group who did not use medication or used only compatible medications and the group who used medications with some risk for lactation, according to both criteria. Conclusions: Our study found no association between weaning rates across the different breastfeeding safety categories of medications in women who were still breastfeeding at three months postpartum. Therefore, women who took medications and stopped breastfeeding in the first three months postpartum because of adverse side-effects associated with medications could not be addressed in this analysis.

A brief survey on the advanced brain drug administration by nanoscale carriers: With a particular focus on AChE reactivators

Obviously, delivery of the medications to the brain is more difficult than other tissues due to the existence of a strong obstacle, which is called blood-brain barrier (BBB). Because of the lipophilic nature of this barrier, it would be a complex (and in many cases impossible) process to cross the medications with hydrophilic behavior from BBB and deliver them to the brain. Thus, novel intricate drug-carriers in nano scales have been recently developed and suitably applied for this purpose. One of the most important categories of these hydrophilic medications, are reactivators for acetyl cholinesterase (AChE) enzyme that facilitates the breakdown of acetylcholine (as a neurotransmitter). The AChE function is inhibited by organophosphorus (OP) nerve agents that are extremely used in military conflicts. In this review, the abilities of the nanosized drug delivery systems to perform as suitable vehicles for AChE reactivators are comprehensively discussed.

Hidden Harms of Hypnotics: a population based record linkage study of psychotropic medication and suicide risk

Background/Main Aim Although psychotropic medication is a known risk factor for suicide, studies investigating the relationship between specific types of psychotropic medication and suicide in adults are scarce.&#x0D; Methods A cohort of 1,115,647 individuals (18-75years) was identified from Northern Ireland’s 2011 Census records and linked to prescription records and death registrations until 2015. Individual, household and area-based attributes were derived from census records and selected on the basis of known suicide risk. Five categories of psychotropic medication was identified; none, antidepressants, anxiolytics, hypnotics and antipsychotics. Logistic regression was used to model the association between specific types of psychotropic medication (singularly and in combinations) and death by suicide adjusting for sociodemographic and physical health characteristics.&#x0D; Results About 14% of the cohort (n=153,319) had received ≥2 prescriptions of any psychotropic medication in the five months around Census. Eight hundred and seventy persons (n=870) died by suicide during 2011 to 2015. Suicide was higher in those on psychotropic medication than in those without (0.24% versus 0.05% respectively). In the fully adjusted logistic regression model, association between death by suicide and any psychotropic medication record remained statistically significant (AOR=3.69, 95%CI: 3.13–4.35). However, individuals solely on hypnotics had the highest AOR of those on singular medication (AOR=4.24, 95%CI: 2.96–6.06 compared to AOR=2.22, 95%CI: 1.75–2.82 for those on antidepressant medication only). In terms of medication combinations, hypnotics both with anxiolytics, and in combination with antidepressants and anxiolytics were the strongest predictors of death by suicide (AOR=8.76, 95%CI: 5.93–12.94 and AOR=8.53, 95%CI: 5.62–12.94 respectively).&#x0D; Conclusion Risk of death by suicide varied by medication type with hypnotic medications making an important contribution to death by suicide. Although previous work has focused on antidepressant therapy and suicide risk, those on hypnotic medication are an at-risk group that warrant further attention.

THE PREVALENCE OF ORTHOSTATIC HYPOTENSION AMONG HOSPITALIZED OLDER ADULTS AT RISK FOR FALLING

Orthostatic hypotension (OH) may cause falls in hospitalized older adults. OH is a sustained drop of at least 20 mm Hg for systolic blood pressure or at least 10 mm Hg for diastolic blood pressure when changing position from supine to sitting, sitting to standing, or supine to standing. A recent systematic review revealed an inconsistent relationship between OH and falls. Orthostatic vital signs (OVS) measurement is often included in fall prevention initiatives. Some experts suggest that the time required to collect OVS and the possibility of measurement inaccuracy by nurses make this bedside screening unnecessary. The study aims were to determine: 1) the prevalence of OH, 2) if those older adults with documented OH experienced falls, and 3) the influence of medications known to be associated with OH and falls. Medication categories included antihypertensives, dopamine agonists, antipsychotics and antidepressants. A retrospective chart review was conducted on a convenience sample of 8,474 older adults on two Acute Care of the Elderly units at a large health system in the mid-Atlantic between 2015 and 2018. Results were determined using contingency tables and Chi-square analysis. More complex relationships were pursued using log linear models. The overall OH prevalence was 46.9% at some point during their hospital stay. Over the three years, 68 patients of whom 62% were hypotensive (p=.034). There was no statistical association of OH with medications or co-morbidities. The results demonstrate that although prevalent in almost half of this sample, orthostatic hypotension did not lead to falls.

Treatment of migraine in patients with CADASIL: A systematic review and meta-analysis.

Migraine is a common and often refractory feature for individuals with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) without consensus guidelines for treatment. Migraine treatment poses a theoretical risk within this unique population with precarious cerebrovascular autoregulation, given the vasomodulatory influence of many antimigraine medications. In this systematic review and meta-analysis, we evaluate the frequency and efficacy of treatments for migraine in individuals with CADASIL. A search protocol was designed to include all available publications reporting antimigraine therapies for CADASIL. Individual responses to medications were categorized as unfavorable, neutral, or favorable. Responses across medication classes were compared using the Mann-Whitney U test. Thirteen studies were included, yielding a cohort of 123 individuals with a median age of 53 years (range: 23-83 years), with 61% (75/123) being women. No controlled trials were identified. Simple analgesics (35.8%, 44/123) and beta-blockers (22.0%, 27/123) were the most common abortive and prophylactic strategies, respectively. Over half (54.4%) of all patients had used more than 1 medication sequentially or concomitantly. Beta-blockers were significantly associated with a neutral or unfavorable response (13.5%, 22/163, p = 0.004). We found no significant associations among other medication categories. Migraine in CADASIL remains a formidable therapeutic challenge, with patients often tried on several medications. Antimigraine prophylaxis with beta-blockers may be contraindicated relative to other common therapies in CADASIL. Controlled studies are needed to rigorously evaluate the safety and efficacy of antimigraine therapies in this population.

Characteristics of falls and recurrent falls in residents of an aging in place community: A case-control study

BackgroundFalls and fall-related injuries remain an ongoing and serious health problem in older adults. Many clinical and environmental factors have been implicated in falls and recurrent falls, including sleep disturbances, sensory deficits, balance problems, incontinence, comorbid conditions, and certain categories of medications. We undertook this study to determine if there was an association between these factors and falls or recurrent falls in older adult residents of an aging in place community. MethodsOur retrospective case-control study compared residents who did and did not fall in an aging in place community, as well as those who experienced recurrent versus single falls in a single year. ResultsA total of 50 residents met the criteria for inclusion in this study, with 30 participants (60%) having experienced one or more falls during the observation period. Of the 30 participants who fell, 21 (70%) experienced more than one fall in a single year. Variables associated with falls included marital status and bowel incontinence; variables associated with recurrent falls included self-reported sleep difficulty, balance with sitting to standing and surface-to-surface transfer, use of a walker, and use of antidepressant medications. DiscussionOur study supports the existing nursing research that falls, and recurrent falls are the result of multiple, interrelated factors. Further research is needed into preventative measures for both falls and recurrent falls, particularly in the context of aging in place.

Blood Lead Concentration and Prescription Medication Use Among US Children and Adolescents

TPS 636: Metals and health 2, Johan Friso Foyer, Floor 1, August 28, 2019, 3:00 PM - 4:30 PM Background: Lead is a toxicant to many organ systems, and it is especially harmful to children during developmental stages. Prescription medication use prevalence in children and adolescent indicates shifting disease burdens, as well as over-prescription of inappropriate or ineffective treatments. There may be relationships between environmental pollutants and prescription medication but it has not been explored. Methods: We used serial cross-sectional data of children and adolescents aged 1 to 19 years in the US National Health and Nutrition Examination Survey (NHANES), from 1999 to 2014. A total of 17 categories of prescription medications commonly used by children and adolescents were involved. We used multivariate linear and logistic regression to explore the relationship of blood lead concentration (independent variable) and prescription medication use (dependent variable), adjusted for age, gender, race, income, education, insurance and health condition. Results: In this serial cross-sectional study that included 24412 subjects, the mean blood lead concentration decreased from 1.61 µg/dL to 0.76 µg/dL. Blood lead concentration was not correlated with overall use of prescription medications in the last 30 days. Each µg/dL increase in blood lead concentration was associated with lower odds ratio of asthma medications (OR=0.88, 95%CI: 0.82 to 0.94) (p<0.005) and higher odds ratio of antibiotics amoxicillin/clavulanate (OR=1.10, 95%CI: 1.05 to 1.14) (p<0.005). Higher blood lead level was also associated with more use of overall antibiotics, narcotic-containing analgesics and ADHD medications (amphetamines), and less use of tetracyclines, antidiabetic agents, antipsychotics, contraceptives, proton pump inhibitors and dermatological agents (p<0.05). Conclusions: Blood lead concentration is related to prescription medication usage use among children and adolescents in the US.

88 Most Adverse Events in the Emergency Department are Present on Arrival: Burden and Types of Events Identified

Relatively little is known about adverse events (AEs) - physical injury to a patient due to health care that requires some intervention - and the characterization of patient harm in the ED. Even less is known about the nature of AEs occurring in the ED vs. those occurring prior to arrival, ie, how often ED visits result from AEs occurring elsewhere in the health system. This is a secondary evaluation of data from a retrospective observational study testing the ED Trigger Tool at an urban, academic medical center (data from 10/1/2014 - 10/31/2015; 92,860 eligible visits). Patients aged ≥18 completing a visit were eligible for inclusion. We performed dual independent level 1 nurse review of 4,772 visits sampled from records with ≥1 of 97 candidate triggers (findings that increase the likelihood of an AE), followed by a confirmatory level 2 physician review of records with putative AEs. AE severity was characterized with the MERP index. AEs were categorized using the ED Taxonomy of Adverse Events and Near Misses, which includes categories, subcategories and modifier terms. Reviewers indicated whether AEs occurred in the ED or were present on arrival (POA). We present descriptive data, bivariate associations between patient sociodemographics, triggers and POA AEs detected and multivariable modeling identifying POA AEs. Analyses were conducted using SAS 9.4 and R. We identified 965 AEs, of which 614 were POA and 351 occurred in the ED. Patients with POA AEs were more often white (51% vs 40%) and older (median age 62 vs 55 ) compared to patients with AEs in the ED, with no difference in distribution by sex (53% female overall). Medication and Patient Care categories account for over 70% of both ED and POA AEs. POA AEs included more health care Associated Infections and Surgical/Procedural AEs, and fewer Device-related AEs than those occurring in the ED. Key differences are visible at the subcategory level. Medication-related hypotension is a common AE in the ED (23%) but is rarely POA (3%). Medication-related bleeding is a common POA AE (21%) but is rarely an ED AE (3%). Medication-related Allergic Reaction is common to both (∼10-13%). Eight EDTT triggers are associated with POA AEs. The joint presence of any two of these triggers occurs in 9.4% of all visits in the population, has a positive predictive value of 39.6% for POA AEs, and identifies POA AEs similar to those described in Table 1. The ED trigger tool is a promising new approach to quality and safety review and identifies a broad scope of event types. The majority (64%) of AEs detected in the ED are present on arrival. This underscores the role of the ED not only as a safety net for patients but also for patient harm that occurs elsewhere in the health system. This also demonstrates that it may be important for surveillance methods to distinguish between POA and ED events for internal quality improvement.Tabled 1ED (N=351 AEs)POA (N=614 AEs)CategorySubcategory% of AEsCategorySubcategory% of AEsMedication63.20%Medication58%Hypotension23.40%Bleeding21.20%Allergic Reaction10.30%Allergic Reaction13.80%Hypoxia9.40%Fall5.90%Other4.30%Other4.20%Nausea/Vomiting4.30%Hypotension3.40%Glycemic Event3.70%Delirium2.60%Bleeding3.40%Dizziness2.40%Delirium2.00%Patient Care14.30%Device13.40%Failure Monitor7.70%Infiltration/Extravasation13.10%Fall5.90%Other2.80%Patient Care17.10%Delayed Treatment2.00%Failure Monitor6.60%Delayed Treat.5.40%HCAI11.10%Other4.80%Pneumonia4.70%Fall3.10%Surgical Site Infection*2.80%Delayed Dx2.30%Glycemic Event2.00%Surgical/ Procedural11.10%Hypoxia2.00%Other3.70%Wound Complication**2.80%Surgical/ Procedural5.10%Ileus/Obstruction2.00%Bleeding2.00%Device5.00%HCAI<1%Infection2.00%Frequencies of AE categories/subcategories for POA and ED events. Rare subcategories are omitted for clarity; and an event may have more than one subcategory.HCAI - Healthcare Associated Infection*< 30 Days Post-Op; Up To 1 Year If Implanted Hardware Present**Non-infectious Open table in a new tab

313 Potentially Inappropriate Medications Do Not Clinically Impact Trauma Recidivism in the Elderly

The study evaluated the association between potentially inappropriate medications (PIM) as defined by Beers’ Criteria and the risk of trauma recidivism in the elderly. The American Geriatric Society (AGS) modified the list of PIMs in 2012 to include 19 categories of medications with limited effectiveness in the elderly but with a positive association with complications such as delirium, bleeding, fracture and falls, a major cause of elderly trauma. We hypothesized that the presence of PIM increases the risk of trauma recidivism. This case-control study reviewed patients over age 65 evaluated at a single Level 1 Trauma center from February 1, 2013 through August 1, 2018. We performed a 1:1 propensity score matched analysis using age and sex between injured patients with one trauma evaluation at any level of trauma activation and those with more than one trauma evaluation during the study period. We used a receiver operating characteristic (ROC) curve to determine the number of PIM with a maximum predictive value for recidivism. Area under the curve (AUC) with 95% confidence intervals (CI) were calculated. We also evaluated if there were specific categories of PIM that were associated with recidivism using Chi square analysis. A p value of <0.05 was deemed significant. During the study period, there were 11,089 trauma evaluations meeting study criteria. 8252 patients had one trauma evaluation only and 2837 patients had more than one trauma evaluation for a 26.2% recidivism rate. Propensity matching resulted in 2324 patients in each group. Patients with one trauma evaluation and recidivists had similar mean number of total medications (12.34, standard deviation (SD) 6.71 vs 12.67, SD 6.83, p = 0.09) but those with one trauma evaluation had a lower mean number of PIM (11.09, SD 6.74 vs 11.88, SD 6.99, p =0.001). ROC curve analysis showed that the maximum predictive threshold was 11 PIM (AUC = 0.545, 95% CI=0.529-0.560). In addition, analgesics, antidepressants, antiplatelets, antipsychotics, anxiolytics, central nervous system medication and stimulants were each significantly associated with recidivism (p <0.001 for all categories). Recidivists were on a greater mean number of medications in these seven categories than non-recidivists (6.45, SD 3.034 vs 6.15, SD 3.038, p = 0.001) PIM are statistically associated with trauma recidivism in the elderly. However, of the 19 categories of PIM identified by the AGS, only seven were associated with recidivism. Moreover, as the mean number of PIMs differed by less than one between the two groups, the clinical significance of our findings is doubtful. We conclude that PIMs do not clinically influence trauma recidivism in the elderly.

A Pharmaceutical Dispensing-based Index of Mortality Risk From Long-term Conditions Performed as well as Hospital Record-based Indices.

The objective of this study was to develop and validate a mortality risk index from multimorbidity using pharmaceutical dispensing data. The P3 (Pharmaceutical Prescribing Profile) mortality risk index was created (development n=2,331,645) using pharmaceutical dispensing records for the last 12 months for long-term conditions. β coefficients from a Cox proportional hazards model for mortality provided component scores for 30 medication categories. Index validity was tested (validation n=1,000,166) for risk of mortality and overnight hospitalization over 1 year, and predictive ability calculated for the P3 index relative to the hospital admission-based Charlson and M3 indices (all models adjusted for age/sex). This study was carried out in the setting of routine health data sources for the New Zealand adult general population, for an index date of January 1, 2012. The P3 index performed equivalently to Charlson for 1-year mortality risk [c-statistics=0.920 and 0.921, respectively; difference=-0.001; 95% confidence interval (CI): -0.004, 0.001]; P3 outperformed Charlson for overnight hospitalization risk (c-statistics=0.712 and 0.682; difference=0.029; 95% CI: 0.028, 0.031). Adding P3 to a model already containing the M3 index led to only marginal improvement for mortality (difference in c-statistics=0.004; 95% CI: 0.002, 0.005) but some improvement for hospitalization risk (difference in c-statistics=0.020; 95% CI: 0.018, 0.021). The P3 index provides an appropriate alternative to measures like the Charlson and M3 index when analysts only have access to pharmaceutical dispensing data for determining multimorbidity. The P3 index had a performance advantage over Charlson when analyzing risk for overnight hospital admissions.