Changes In Prescribing Research Articles

Impact of an Intervention to Reduce Bronchodilator Use in Bronchiolitis - A Time Series Analysis.

International guidelines recommend against the use of bronchodilators in bronchiolitis. Despite attempts to address low value care practices in pediatrics, the literature is still evolving regarding which interventions are most effective in low value care reduction. We aim to assess the impact of a multifaceted intervention on rates of bronchodilator prescription in bronchiolitis. With electronic medical record (EMR) data over a 76- month period, we evaluated changes in bronchodilator prescription among infants aged 1 to 12 months diagnosed with bronchiolitis, using interrupted time series analysis, controlling for preintervention prescribing trends. The setting was the emergency department of a large teaching pediatric hospital. The intervention included education, clinician audit-feedback, and an EMR alert, implemented February 2019. The main outcome measure was rate of bronchodilator prescription per month. There were 9576 infants, aged 1 to 12 months, diagnosed in the emergency department with bronchiolitis over the study period. Bronchodilator ordering reduced from 6.9% to 3.2% after the intervention. Once underlying trends were accounted for, the multifaceted intervention was associated with a reduction in the rate of prescribing (inter-rater reliability 0.98, 95% confidence interval 0.96 to 0.99, P = .037). We found that the multifaceted intervention, including an EMR alert, may be an effective method of reducing low value care prescribing in bronchiolitis, accelerating the reduction of unnecessary care and supporting sustainable change.

A 6-Year Review of the Electronic Drug Prescription System in the Republic of Türkiye

Pharmacoepidemiological studies are important for the development of health systems. The aim of this study is to examine the seasonal and branch changes of prescriptions written in the light of national data. Drug and prescription information between 01.01.2016 and 31.12.2022 analyzed retrospectively from electronic data. In addition to gender and age distribution, the specialty and hospital level at which the prescription was written were examined in temporal terms. Prescribed drugs have been classified according to Anatomical Therapeutic Chemical (ATC) codes previously created by the World Health Organization. It was determined that 1,452,128,177 prescriptions were written during the study period. These included a total of 4,602,556,489 drugs with the ATC code. The most written ATC code group was A (alimentary tract and metabolism), followed by M (musculo-skeletal system), and R (respiratory system) group drugs. In terms of specialization, the group that wrote the most prescriptions was family physicians, followed by emergency physicians, and internal medicine specialists. Examining prescription software trends is important when creating healthcare policies. Developing strategies to reduce prescription costs will contribute to the efficient use of resources and improving the quality and sustainability of health services delivery.

Effectiveness and Adherence of Dry Eye Patients Who Switched from Short- to Long-Acting Diquafosol Ophthalmic Solution.

Long-acting (lasting extend) diquafosol ophthalmic solution 3% (DQSLX) is administered three times daily versus six times daily for the currently approved diquafosol ophthalmic solution (DQS). We investigated the efficacy and adherence of switching from DQS to DQSLX in patients with dry eye disease. We retrospectively enrolled 54 patients (17 men and 37 women) with eye drop prescription changes from DQS to DQSLX between December 2022 and March 2023. The number of eye drops, subjective symptoms, tear breakup time (TBUT), and fluorescein staining scores from baseline to 4 weeks after starting DQSLX were evaluated. Participants then chose between DQSLX and DQS. Patients administered DQSLX three times per day, as listed on the package insert, 88.9% of the time; significantly higher than the 5.6% of patients who used DQS six times per day, as instructed. The DQSLX group showed significant improvements in symptoms and fluorescein staining scores (23.3 ± 20.1 and 0.8 ± 1.7, respectively) compared with the baseline (37.8 ± 24.1 and 1.1 ± 1.5, p = 0.01 and <0.001, respectively). The TBUT in the DQSLX group (5.0 ± 2.5 s) did not significantly improve compared to the DQS group (4.5 ± 1.7 s) (p = 0.75). Fifty-one (94.4%) patients opted to continue DQSLX because of the pleasant feeling of the eye drops, long-lasting moisture, and less frequent administration. The efficacy and adherence of DQSLX was comparable to DQS.

Prevalence and clinical implications of polypharmacy and potentially inappropriate medication in elderly patients with heart failure: results of six months' follow-up.

To investigate the prevalence of polypharmacy and potentially inappropriate medication (PIM) in elderly patients with heart failure (HF) and their impact on readmission and mortality. We conducted a study of 274 participants aged 60 years or older with HF. The prevalence of polypharmacy (defined as the use of five or more medications) was calculated, and the 2019 American Geriatrics Society Beers criteria were applied to access PIMs. Medications and PIMs were characterized at admission and discharge, and changes in prescriptions during hospitalization were compared. The impact of polypharmacy and PIM on readmission and mortality were investigated. The median age of this study population was 68 years old. The median number of prescribed drugs was 7 at admission and 10 at discharge. At discharge, 99.27% of all patients were taking five or more drugs. The incidence of composite endpoint and cardiovascular readmission increased with the number of polypharmacy within 6 months. The use of guideline-directed medical therapy reduced the incidence of composite endpoint events and cardiovascular readmission, while the use of non-cardiovascular medications increased the composite endpoint events. The frequency of PIMs was 93.79% at discharge. The incidence of composite endpoint events increased with the number of PIMs. "PIMs in older adults with caution" increased cardiovascular readmission and "PIMs based on kidney function" increased cardiovascular mortality. Several comorbidities were associated with cardiovascular mortality or non-cardiovascular readmission. Polypharmacy and PIM were highly prevalent in elderly patients with HF, and their use was associated with an increased risk of composite endpoint events, readmission and mortality. Non-cardiovascular medications, "PIMs in older adults with caution", "PIMs based on kidney function" and several comorbidities were important factors associated with hospital readmission and mortality. Our findings highlight the importance of medication optimization in the management of HF in elderly patients.

Patient, Caregiver, and Clinician Experience with a Technologically Enabled Pillbox: A Qualitative Study

Abstract Objectives As part of a study to assess whether a technologically enabled pillbox prescribed to patients at hospital discharge can improve medication safety, we sought to assess participant experiences with the intervention. Methods We conducted a series of semi-structured phone interviews with patients, patient caregivers, and inpatient and outpatient clinicians who participated in the Smart Pillbox Transition Study. We developed an interview guide using the Systems Engineering Initiative for Patient Safety (SEIPS) framework, which included the a priori domains of (1) barriers to implementation, (2) facilitators of the intervention, and (3) general feedback regarding experience with the intervention. Within these domains, we employed SEIPS-informed themes of environment and organization, logistics and tasks, personnel and patients, and technology and tools. Interviews were conducted between May 2018 and January 2019. We used content analysis to interpret findings. Results We interviewed 6 patients, 2 caregivers, and 5 inpatient and 2 outpatient clinicians. Patient-endorsed barriers in the theme of technology and tools included signal issues, inappropriate alarms, and portability. Barriers in the theme of logistics and tasks included coordination with pharmacists in the event of a prescription change. Barriers mentioned by clinicians included patients who were poor fits for the intervention (theme: personnel and patients) and competing demands at discharge (theme: logistics and tasks). Facilitators that were frequently mentioned by patients and caregivers in the theme of technology and tools included useful alarms and ease of use. Clinicians stated that communication with pharmacy and study staff helped facilitate the intervention (theme: personnel and patients). Conclusion We identified several key barriers and facilitators from patients, caregivers, and clinicians to successful implementation of this intervention. Reconciling these sometimes contrasting viewpoints will be crucial if the Smart Pillbox or similar health information technology interventions are to be adopted as tools to improve medication safety during care transitions.

Relationship between assertiveness in community pharmacists and pharmacist-initiated prescription changes

BackgroundDespite the usefulness of assertiveness by healthcare professionals in improving patient safety, few studies have evaluated the assertiveness of community pharmacists. Community pharmacists’ assertiveness might be associated with pharmacist-initiated prescribing changes to improve medication safety. ObjectivesOur objective was to examine which types of assertiveness-related self-expression are associated with community pharmacist-initiated prescribing changes while adjusting for possible confounding factors. MethodsWe conducted a cross-sectional survey in Japan between May and October 2022 in 10 prefectures. Community pharmacists belonging to a large pharmacy chain were recruited. The outcome variable was the frequency of community pharmacist-initiated prescription changes over 1 month. Community pharmacists' assertiveness was assessed using the Interprofessional Assertiveness Scale (IAS) and 3 sub-domains (nonassertive, assertive, and aggressive self-expression). Participants were classified into 1 of 2 categories based on medians. Demographic and clinical characteristics were compared by group with univariate analysis. A generalized linear model (GLM) was used to investigate the association between pharmacist-initiated prescription changes as an ordinal variable and pharmacists' assertiveness. ResultsOf 3346 community pharmacists invited, 963 were included in the analysis. Participants with high assertive self-expression scores had a significantly higher frequency of pharmacist-initiated prescription changes. There was no association between nonassertive or aggressive self-expression and pharmacist-initiated prescription changes. After adjustments, high assertive self-expression remained associated with a high frequency of community pharmacist-initiated prescription changes (odds ratio, 1.34; 95% confidence interval, 1.02–1.74; p = 0.032). ConclusionsHigher assertive self-expression among community pharmacists is associated with higher frequency of pharmacist-initiated prescription changes.

Change of prescription for patients with schizophrenia or major depressive disorder during admission: real-world prescribing surveys from the effectiveness of guidelines for dissemination and education psychiatric treatment project

BackgroundPolypharmacy of additional psychotropics alongside the main treatment drug (antipsychotics in schizophrenia and antidepressants in major depressive disorder) is common in Japan. Our goal is to align psychotropic prescription in Japan with international standards, while reducing the differences between facilities. To achieve this goal, we aimed to compare prescriptions at the time of hospital admission and discharge.MethodsData on prescriptions at admission and discharge from 2016 to 2020 were collected. We divided the patients into four groups: (1) mono_mono group, monotherapy of the main drug at admission and discharge; (2) mono_poly group, monotherapy at admission and polypharmacy at discharge; (3) poly_poly group, polypharmacy at admission and discharge; and (4) poly_mono group, polypharmacy at admission and monotherapy at discharge. We compared the changes in dosage and number of psychotropics among the four groups.ResultsFor both schizophrenia and major depressive disorder, the patients who received monotherapy with the main drug at admission were likely to receive main drug monotherapy at discharge and vice versa. For schizophrenia, the polypharmacy was prescribed more often in the mono_poly group than that in the mono_mono group. The prescription was not changed at all for more than 10% of the patients.ConclusionsIt is critical to avoid a polypharmacy regimen to ensure that guideline-compliant treatment is provided. We expect higher rates of monotherapy with the main drug after the EGUIDE lectures.Trial registrationThe study protocol was registered in the University Hospital Medical Information Network Registry (UMIN000022645).

Management of anticoagulation in atrial fibrillation patients in Italy: insight from the &lt;i&gt;Atrial Fibrillation-Survey on Anticoagulated Patients Register&lt;/i&gt; (AF-START)

The survey on anticoagulated patients register (START-Register) is an independent, prospective, inception-cohort observational study aimed at providing information on patients on vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) in Italy. In this study, we describe the cohort of atrial fibrillation (AF) patients in the START-Register and report outcomes and changes in anticoagulant prescription from 2011 to 2021. The study included 11,078 AF patients, enrolled in 47 Italian centers distributed all over the Country; the median age was 77 years (range 18-99 years); 6029 (54.3%) were men; 5135 (46.4%) were on VKAs, and 5943 (53.6%) were on DOACs. Warfarin was the most prescribed VKA (98.4%), and apixaban was the most prescribed DOAC (31.6%). Among DOAC users, 4022 (67.7%) patients were naive to anticoagulation, and 2562 (43.1%) patients were treated with a reduced dose. DOAC patients were significantly older than VKA patients (median age 79 years vs 76 years respectively, P&lt;0.001), but no gender difference was detected. The mean CHA2DS2VASc score was higher in DOAC users than in VKA users (3.7 vs 3.6; P=0.03). The mean HAS-BLED score was not different between the two groups. During follow-up, 542 bleeding events were recorded [2.44 per 100 patient-years (pt-yrs)]; 240 were major (1.08 per 100 pt-yrs), and 301 were clinically relevant non-major bleedings (1.34 per 100 pt-yrs). 146 thrombotic events were recorded during follow-up (0.66 per 100 pt-yrs). The total mortality rate was 3.5 per 100 pt-yrs; the mortality rate was 4.54 per 100 pt-yrs among patients on VKAs and 2.31 per 100 pt-yrs among patients on DOACs. During the last 10 years, in Italy, AF patient management has changed with the large spread of DOACs all over the Country. DOAC patients are frequently treated with reduced doses and show a lower mortality rate in comparison to patients on VKAs.

The impact of Three-Dimensional Gait Analysis in adults with pathological gait on management recommendations

BackgroundThree-Dimensional Gait Analysis (3DGA) is a gold standard tool that can help identify pathological components of walking patterns. It has been well established that this tool influences the treatment decision making of clinicians treating paediatric patients with Cerebral Palsy, but it has not been established whether this tool changes decision making of clinicians treating adults with complex pathological gait. Research questionTo investigate the impact of pre-treatment 3DGA on treatment plans and management of adults with complex pathological gait. MethodThis retrospective audit examined the medical records of 87 patients undergoing pre-treatment 3DGA between 2014 and 2019. The review collected treatment plans from the initial referral, the post-gait analysis multidisciplinary report, and post-intervention progress notes with consistencies and differences noted throughout the care pathway. ResultsTreatment plans of patients were altered in 80 % (N = 32) of patients following 3DGA assessment and recommendations. These treatment plan alterations included a change in surgery or avoidance of surgery, changes in orthosis prescriptions, casting or rehabilitation; and administration or changes in administration of Botulinum Neurotoxin (BoNT-A). In 47 % (N = 15) of cases the change in plans represented a de-escalation in intervention requirements (e.g. BoNT-A in lieu of surgical intervention), and in 31 % (N = 10) the change in plans represented an escalation in intervention requirements (e.g. requirement for surgery). These changes in treatment plans were either fully or partly enacted by the referring consultant in 86 % of cases. SignificancePre-treatment 3DGA impacts the management of adult patients with complex pathological gait and facilitates patients potentially avoiding unnecessary interventions. Further investigation is needed to determine the cost effectiveness of 3DGA in this population and the impact of pre-treatment 3DGA on management outcomes.

646-P: Improved Metabolic Outcomes in Individuals with Type 2 Diabetes and Nonalcoholic Fatty Liver Disease after a Digital Intervention

Nonalcoholic fatty liver disease (NAFLD) is a common comorbidity among individuals with type 2 diabetes mellitus (T2DM). The aim of this study was to test the feasibility and efficacy of a digital intervention to improve metabolic outcomes for patients with T2DM and NAFLD. A single-arm study was conducted in Iceland. Participants were provided with a 12-week digital behavioral intervention via the Sidekick app, focused on health education and lifestyle coaching, reducing carbohydrate intake, increasing physical activity, and improving mental health. Individuals with NAFLD and either BMI&amp;gt;30, metabolic syndrome, or T2DM were recruited; here we present a sub-analysis of participants with T2DM. The primary outcome was feasibility, as measured by user retention and engagement; secondary outcomes were changes in anthropometric and clinical measures from baseline to post-program. Out of 38 recruited participants, 19 (50%) had T2DM (mean age 61.1 (SD 10.8) years, 10 (53%) female) and 18/19 (95%) completed the program. The 19 participants were active for a median of 7 days/week (IQR 4.76-7.0). Mean weight reduction was 3.9 kg (SD 4.1, p&amp;lt;0.001) and the average fat mass reduced by 2.4 kg (SD 2.9, p=0.002); a 4.9% relative change (SD 6.3). The median decrease in HbA1c levels was 4.0 mmol/mol (IQR -0.5, 5.0, p=0.05), fasting insulin decreased by 4.8 µU/ml (SD 9.2, p=0.03), and HOMA-IR by 2 mmol/L (SD 3.7, p=0.03). Mean systolic blood pressure reduced by 9.1 mmHg (SD 16.6, p=0.03), and relative liver fat by 18.6% (SD 25.3, p&amp;lt;0.01). These changes were not explained by changes in prescriptions or dosages, nor by self-reported medication adherence, and were not different between patients with or without T2DM. At the end of the 12-week digital intervention, participants with T2DM had improved glucose metabolism, liver fat values and body composition, suggesting that this digital intervention can help individuals with T2DM and NAFLD achieve better metabolic outcomes. Disclosure S. Bjornsdottir: Research Support; Sidekick Health, Reykjavik, Iceland. H. Úlfsdóttir: Employee; Sidekick Health. B. Dobies: Employee; Sidekick Health. E.F. Gudmundsson: Employee; Sidekick Health. K. Sveinsdottir: Employee; Sidekick Health. A.P. Isberg: Employee; Sidekick Health. G. Bjornsdottir: None. S. Sigurdsson: None. V. Gudnason: None.

1032-P: A System-Based Approach to Advancing Care Delivery in High-Risk Patients with T2D—Findings from a Quality Improvement Educational Intervention (QIEi)

Background: A Quality Improvement Educational Intervention (QIEi) was developed to improve disease management for T2D patients with CVD/CKD who may benefit from SGLT-2i/GLP-1RA. An aim was to assess the change in the number of prescriptions of these two medication classes. Methods: The QIEi was deployed at two practice sites of a large Integrated Health Care System. A team was formed comprising of endocrinologists and 3 PCPs at each site. EHR data review confirmed the gaps and guided QI project discussions. Process improvements and communication strategies were implemented. All the PCPs at the practice sites (N=18 each) received education on these two medication classes. Cased-based and didactic CME accredited webinars designed to help improve knowledge, decision-making and implement best practices were made available for on-demand participation across the health care system. Results: Prescription rates of SGLT-2i and GLP-1RA at the intervention (N=4247 baseline, 4033 follow up) and non-intervention sites (N=98637 baseline, 91923 follow up) were obtained pre- and 6 months post QIEi. Odds of GLP-1RA prescription dropped by 2% (p=0.75) at the intervention sites and by 6% (p&amp;lt;0.001) at the non-intervention sites. The decrease was not significantly different across sites (p=0.41). There was a small increase in SGLT2i prescription at the intervention sites (p=0.90), while the odds of use decreased by 3% (p=0.017) at non-intervention sites. This was not significantly different across sites (p=0.54). Conclusion: No meaningful change in prescriptions post-QIEi at the two intervention sites was observed. While it did improve knowledge and engagement, it did not translate into prescription increases. Perhaps more time is needed to observe system-wide changes and/or other factors need to be considered to increase prescriptions for this patient population. Further studies investigating prescribing barriers are warranted. Disclosure P.Rao: None. V.Makin: Speaker's Bureau; Bayer Inc. S.Kawczak: None. P.Lazure: None. J.F.Bena: None. P.Mcfadden: None. G.Jacobs: None. K.M.Pantalone: Consultant; AstraZeneca, Bayer Inc., Corcept Therapeutics, Diasome, Eli Lilly and Company, Merck &amp; Co., Inc., Novo Nordisk, Sanofi, Research Support; Bayer Inc., Merck &amp; Co., Inc., Novo Nordisk, Twin Health, Speaker's Bureau; AstraZeneca, Corcept Therapeutics, Merck &amp; Co., Inc., Novo Nordisk. Funding Eli Lilly and Company; Merck &amp; Co., Inc.

16-LB: Teneligliptin Observational Retrospective Real-World Study to Evaluate Its Effect on Renal Parameters and Safety in Indian Type 2 Diabetes Mellitus Patients with Chronic Kidney Disease (TOP RENAL)

Background and Aim: Teneliglitpin, approved in India since 2015, is the most commonly prescribed DPP4i in India. Due to lack of evidence, this study was planned in real world setting to evaluate effects of teneligliptin on renal parameters and safety in Indian T2DM patients with CKD. Methodology: TOP RENAL real world study enrolled T2DM patients with eGFR ≤60 to ≥15 ml/min/1.73m2 and were started on teneligliptin (20/40 mg OD) and continued it for next six months. Those patients prescribed any antidiabetic medication along with teneligliptin or those with change in antidiabetic prescription in the following six months were excluded. Results: 377 patients data was collected during August'22-October'22 and grouped according to baseline eGFR (ml/min/1.73m2): G3a: 45-59 (n=102); G3b: 30-44 (n=124); G4: 15-29 (n=151). The mean age was 59.86±9.58 years and 47% were females. Renal parameters: eGFR, Sr creatinine and BUN were assessed at baseline, 3 months and 6 months. Results showed non-significant changes in eGFR (Table1), Sr. creatinine and BUN at 3 and 6 months in all three groups. No safety concerns or hypoglycemia were reported during the study. Conclusion: Teneligliptin initiation in Indian T2DM patients with mild-severe renal impairment did not show any safety concerns and was well tolerated. Disclosure S. Suryawanshi: Employee; Glenmark Pharmaceuticals. V. Jadhao: Employee; Glenmark Pharmaceuticals. M. Brid: Employee; Glenmark Pharmaceuticals. S. Bhushan: None. H. V. Barkate: None. Funding Glenmark Pharmaceuticals Limited

443-P: Two-Year Results from a Novel, Patient-Centered, Team-Based Intervention for Patients with Type 2 Diabetes at High Cardiovascular Risk

Background: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of death in patients with type 2 diabetes (T2D). CINEMA is a novel, patient-centered, team-based intervention for patients with T2D/prediabetes with high risk for ASCVD. We present the outcomes from the first 2 years of the CINEMA program. Methods: Patients with T2D or prediabetes at high risk for CV events (established ASCVD, coronary artery calcium &amp;gt;100 AU, chronic heart failure, chronic kidney disease, and/or metabolic syndrome) were included. Linear mixed effects and generalized linear mixed models were used to assess changes in ASCVD risk factors and guideline-based medication prescriptions over time, respectively. Results: From May 2020 to September 2022, 426 patients were enrolled in CINEMA; 47% were women and 37% Black, with mean age 60 yrs, mean BMI 36kg/m2, and 48% with established ASCVD. 54% had ≥ 1 follow up visit with median follow up time of 3 months. There were significant reductions in risk factors including HbA1c (-12.1%), LDL-C (-14.2%), BP (-1.8%), and BMI (-2.2%) (P&amp;lt;0.001 for all). SGLT2 inhibitor and GLP-1 RA prescriptions increased from during follow up (20% to 56% and 17% to 66%, respectively). Conclusion: A multidisciplinary approach to treating patient with type 2 diabetes with the CINEMA program improves ASCVD risk factors and guideline-based medication adherence. Disclosure A.Arafah: None. I.Neeland: Consultant; Nestlé Health Science, Speaker's Bureau; Boehringer Ingelheim and Eli Lilly Alliance, Bayer Inc. B.M.Bourges-sevenier: None. Z.Albar: None. C.Sullivan: None. S.G.Al-kindi: None. S.Rajagopalan: Advisory Panel; Novartis, Novo Nordisk, Speaker's Bureau; Novo Nordisk.

#2858 EXERCISE AND PREDIABETES AFTER RENAL TRANSPLANTATION: THE EXPRED I STUDY

Abstract Background and Aims Post-Transplant Diabetes Mellitus (PTDM) is a severe disease that may affect about 30% of renal transplant patients. PTDM beyond 12 months (late PTDM) mostly develops in subjects with prediabetes. Although exercise may have a potential role in preventing late PTDM, there is scarce evidence on the effect of exercise in renal transplantation. We designed a 12-month exploratory study to test the capacity of therapeutic exercise in reverting prediabetes to prevent the development of late-PTDM. Method This is a pilot study in which renal transplant patients with prediabetes were treated with exercise for 12 months. To detect prediabetes and to evaluate the reversibility, relapse, or persistence of prediabetes, the oral glucose tolerance test (OGTT) was performed at baseline and every 3 months to the end of the study. Prediabetes was defined by the presence of Impaired Fasting Glucose (IFG) in 100-125 mg/dl and/or Impaired Glucose Tolerance (IGT) between 140-199 mg/dL after the OGTT. The protocol included a stepped incremental plan of aerobic and/or strength training. The frequency, intensity, and duration of aerobic exercise, as well as the addition of strength training depended on the recovery, persistence, or recurrence of prediabetes. All patients started with moderate aerobic exercise (brisk walking), 30 min/day and 5 times per week and, based on that, changes in prescription were considered every 3 months. Additionally, we evaluated: (a) an active plan for promoting adherence to exercise (telephone calls, digital technology, and visits) and (b) improvements in metabolic risk factors: obesity, dyslipidaemia, and blood pressure. Since prediabetes may spontaneously revert to normal glucose metabolism in 25-30% [1], we assume that in 60 cases, the spontaneous reversibility could be of 30% (n = 18) and the reversibility induced by exercise may account for another 30% (n = 18), so the total reversibility will be 60%. Considering an expected drop out of 20%, the number of cases necessary to include was 72 patients. Results The study was early interrupted due to efficacy after the evaluation of 27 patients that reach 12 months of follow-up. Mean age was 54.2 ± 9.6 and 67% were men. Half of the patients were obese and most had overweight. At baseline IGT or IFG alone were found, respectively, in 13 (48%) and 5 (19%) patients, and the combination of both in 9 (33%). All patients were on prednisone and tacrolimus with the addition of mycophenolate on 20 subjects and 7 on everolimus. Of the group, 16 (60%) reverted to normal glucose levels (fasting and 120 min after an OGTT): this was two time higher than the 30% reversibility rate shown in a previous publication [1], p &amp;lt;0.05, assuming a potency of 85%. In parallel, 11 (40%) subjects had prediabetes (9) or developed PTDM (2). No significant changes were found in weight during follow-up in all groups whereas triglycerides diminished in patients on whom prediabetes reverted (154 mg/dL ± 61 to 96 ± 27; p = 0.016). At the end of follow up, adherence to exercise was good (≥70%) in 13 patients (∼50%), moderate (40-70%) in 9 (∼30%) and bad (≤40%) in 5 (∼20%). Finally, all patients with good adherence reverted to normoglycaemia, 3 out of 9 (33%) cases with moderate reverted to normal glucose metabolism and no cases with bad adherence improved on follow-up. No relevant injuries attributed to exercise were observed during the study. Conclusion Therapeutic exercise is safe and effective to improve glucose metabolism in renal transplant patients with prediabetes. Adherence is a crucial aspect to consider in the planification of exercise treatment.

P01 Antibiotic efficacy treatment of community-acquired pneumonia among CMV-infected individuals

Abstract Background The investigation is devoted to possible antibiotic resistance formation and its adverse event prognostic influence among young patients with community-acquired pneumonia (CAP) with cytomegalovirus (CMV) persistence and absence of other comorbid pathology. Subjects and methods The observation included 105 patients (average age 34.1 ± 0.8 years), which had been examined by epidemiological, clinical (including PORT prognostic scale) according to European Respiratory Society requirements, serological test for CMV IgM, IgG detection and antibiotic usage questionnaire for a 3-month period prior CAP. Results 76.2% (n = 80) CAP patients had positive CMV IgG. CMV-positive patients were characterized by higher severity outcome risk in the nearest future versus CMV-negative ones (P &amp;lt; 0.0001): third risk class—14.9 times higher, fourth risk class—10.5 times higher. CMV IgG–positive results correlated with the CAP severity level (r (Spearman) = 0.472). In total, 51.4% (n = 54, among them 47 CMV-positive patients) mentioned antibiotic use during the last 3 months prior to CAP. During the CAP treatment, 75.0% (n = 60) of CMV-positive patients and 20.0% (n = 5) of CMV-negative ones did not respond to antibiotic treatment by cephalosporin and quinolone lines and needed changes in aetiology prescription according to antibiotic susceptibility microbial test. 61.3% (n = 47) of CAP patients (everybody was after medication replacement) got adverse events like antibiotic-associated diarrhoea (16 cases), QT prolongation in ECG (17 cases), creatinine, urea elevation (11 cases) and alanine/aminotransferase elevation (5 cases). Conclusions CMV persistence is associated with higher risk of severe CAP among young patients without comorbid pathologies and contributes to the antibiotic resistance creation as well as related side effects.

Referrals for Recurrent Acute Otitis Media With and Without Spontaneous Tympanic Membrane Perforation Through COVID-19: A Cross-Sectional Comparative Study.

To the Editors: Most children experience at least one episode of acute otitis media (AOM) and approximately one-third of them suffer from recurrent episodes (rAOM) with or without spontaneous tympanic membrane perforation (STMP).1 Data on the epidemiology of rAOM and STMP during the COVID-19 pandemic are scarce. The aim of this report is to evaluate the number and characteristics of children presenting with rAOM with and without STMP before and during the pandemic. This study was conducted at the otitis media pediatric outpatient clinic of the Ospedale Maggiore Policlinico, Milan (Italy), from 2019 to 2022. All consecutive children referring to the outpatient clinic for a first-time visit for rAOM2 were eligible and the following information was extracted: sex, age (≤2 and >2 years), date of first visit and history of STMP. Data were obtained from patient’s online medical records. Four periods were considered for the analysis: the year preceding the pandemic (2019), the 2 years with the strictest measures to limit the spread of COVID-19 (2020 and 2021) and the year in which these measures were progressively relaxed (2022). The Fisher exact test or the χ2 test were used for the analysis, as appropriate. A P value <0.05 was assumed as significant. The study was approved by the Ethical Committee of the Ca’ Granda Ospedale Maggiore, Milan (Comitato Etico Area2). A total of 786 children (53% >2 years of age and 45% females) were included (Table 1). A decreasing trend in the number of children with rAOM was observed in the first 3 years of the study. Furthermore, the percentage of children <2 years of age increased in 2021 and 2022. Similar data were observed for children with rAOM without STMP. No age difference (P = 0.319) was found for children with rAOM and STMP. TABLE 1. - Total Number of Patients and Number of First-Time Visits for rAOM With and Without STMP All 2019 2020 2021 2022 P Value rAOM N 786 300 141 108 237 Male 437 165 71 54 147 0.072 Age ≤2 yr 367 (47%) 120 (40%) 61 (43%) 59 (55%) 127 (53%) 0.004 >2 yr 419 (53%) 180 (60%) 80 (57%) 49 (45%) 110 (47%) rAOM without STMP N 441 143 59 72 167 Male 248 79 30 36 103 0.273 Age ≤2 yr 190 (43%) 44 (31%) 21 (36%) 41 (57%) 84 (50%) 0.0002 >2 yr 251 (57%) 99 (69%) 38 (64%) 31 (43%) 83 (50%) rAOM with STMP N 344 157 81 36 70 Male 189 87 41 18 43 0.544 Age ≤2 yr 177 (51%) 77 (40%) 39 (48%) 18 (51%) 43 (62%) 0.319 >2 yr 167 (49%) 80 (60%) 42 (52%) 18 (49%) 27 (38%) rAOM indicates recurrent acute otitis media; STMP, spontaneous tympanic membrane perforation P values <0.05 are in bold. The changes in rAOM frequency during the study period is consistent with prior research indicating a reduction in AOM cases.3,4 However, the main finding of this investigation pertains to a notable shift in the age distribution of children affected by rAOM. This age bracket presumably comprises children born during the peak of the stringent control measures. As such, the infection control protocols might have limited their exposure to pathogens, creating a cohort of immunologically naive children more susceptible to rAOM once the restrictions were lifted. Contrary to initial expectations, a significant rise in rAOM with STMP cases in 2022 and the decrease in the age of affected children were not observed. Recent data point out a change in antibiotic prescription in children after 2020.5 The early and widespread use of broad-spectrum antibiotics for respiratory infections and AOM may have decreased the incidence of common complications such as STMP. The main limitation of this study relies on its retrospective, monocentric design. In conclusion, this investigation reveals a rise in rAOM cases in 2022 with a noticeable increase in the younger age groups. These data underscore the possible medium to long-term repercussions of infection control measures.

A Bayesian Spatio-temporal Model to Optimize Allocation of Buprenorphine in North Carolina

The opioid epidemic is an ongoing public health crisis. In North Carolina, overdose deaths due to illicit opioid overdose have sharply increased over the last 5–7 years. Buprenorphine is a U.S. Food and Drug Administration approved medication for treatment of opioid use disorder and is obtained by prescription. Prior to January 2023, providers had to obtain a waiver and were limited in the number of patients that they could prescribe buprenorphine. Thus, identifying counties where increasing buprenorphine would yield the greatest overall reduction in overdose death can help policymakers target certain geographical regions to inform an effective public health response. We propose a Bayesian spatio-temporal model that relates yearly, county-level changes in illicit opioid overdose death rates to changes in buprenorphine prescriptions. We use our model to forecast the statewide count and rate of illicit opioid overdose deaths in future years, and we use nonlinear constrained optimization to identify the optimal buprenorphine increase in each county under a set of constraints on available resources. Our model estimates a negative relationship between death rate and increasing buprenorphine after accounting for other covariates, and our identified optimal single-year allocation strategy is estimated to reduce opioid overdose deaths by over 5%. Supplementary materials for this article are available online.

MRIの原理学習および操作習得のための簡易MRI学習システムの開発［大会長賞記録］

A simple software simulator was developed for MRI operation training and physics education. Users can learn slice prescription, image contrast, and SNR change on personal laptops or computers. The software helps users with elementary knowledge of MRI understand MR operation even with limited access to MRI scanners.

What Changes Have Occurred in Opioid Prescriptions and the Prescribers of Opioids Before TKA and THA? A Large National Registry Study.

What Changes Have Occurred in Opioid Prescriptions and the Prescribers of Opioids Before TKA and THA? A Large National Registry Study.

Impact of European Union Label Changes for Fluoroquinolone-Containing Medicinal Products for Systemic and Inhalation Use: Post-Referral Prescribing Trends.

Concerns of the persistence and severity of the adverse effects of fluoroquinolones, mainly involving the nervous system, muscles and joints, resulted in the 2018 referral procedure led by the European Medicines Agency (EMA). They advised to stop prescribing fluoroquinolones for infections of mild severity or of a presumed self-limiting course and for prevention of infections, plus to restrict prescriptions in cases of milder infections where other treatment options are available, and restrict in at-risk populations. We aimed to examine whether the impact of EMA regulatory interventions implemented throughout 2018-2019 had an impact on fluoroquinolone prescribing rates. A retrospective population-based cohort study was conducted using electronic health care records from six European countries between 2016 and 2021. We analysed monthly incident fluoroquinolone use rates overall and for each fluoroquinolone active substance through flexible modelling via segmented regression to detect time points of trend changes, in monthly percentage change (MPC). The incidence of fluoroquinolone use ranged from 0.7 to 8.0/1000 persons per month over all calendar years. While changes in fluoroquinolone prescriptions were observed over time across countries, these were inconsistent and did not seem to be temporally related to EMA interventions (e.g., Belgium: February/May 2018, MPC - 33.3%, 95% confidence interval [CI] - 35.9 to - 30.7; Germany: February/May 2019, MPC - 12.6%, 95% CI - 13.7 to - 11.6]; UK: January/April 2016, MPC - 4.9%, 95% CI - 6.2 to - 3.6). The regulatory action associated with the 2018 referral did not seem to have relevant effects on fluoroquinolone prescribing in primary care.