Concurrent Medication Use Research Articles

PTH-258 Effect of opioid medication use on outcome of sacral neuromodulation in patients with slow transit constipation

Introduction Sacral Nerve Stimulation (SNM) is an accepted treatment in patients with slow transit constipation (STC). Opioid medication use (which is recognised to prolong colonic transit) is often seen in patients with STC. Whether concurrent use of opioids affects the success, or otherwise, of patients undergoing SNM has not been previously investigated. Method All patients with STC undergoing SNM in a 9 year period within a single centre were identified. Patients prescribed two or more opioid drugs at the time of temporary SNM trial were defined as opioid-users. Outcome of the temporary SNM trial and subsequent permanent SNM implantation was determined. Results 32 patients (30 female, 2 male; median age [range] 50 [21–70] years) with STC underwent temporary SNM trial. 12/32 [38%] patients were opioid users and 20/32 (62%) patients non-opioid users. Overall, 20/32 (63%) patients had a successful temporary SNM trial. There was no difference in outcome of temporary SNM trial between opioid- or non-opioid users (successful outcome in 6/12 [50%] opioid-users, 14/20 (70%) non-opioid users; P = 0 .29, Fishers exact test). 15/20 patients who underwent successful temporary SNM trial progressed to permanent SNM implantation, of which 8/15 (53%) had a successful outcome. There was no difference in outcome of permanent SNM between opioid- or non-opioid users (successful outcome in 3/5 [60%] opioid-users, 8/10 (80%) non-opioid users; P = 0.56, Fishers exact test). Conclusion Concurrent use of opioid medication in patients with STC does not affect the success rate of either temporary or permanent SNM. Disclosure of interest None Declared.

Sulfonylurea Prescribing Patterns After the Introduction of DPP-4 Inhibitors and GLP-1 Receptor Agonists

PurposeAlthough newer agents (dipeptidyl peptidase [DPP]-4 inhibitors and glucagon-like peptide [GLP]-1 receptor agonists) are available for the treatment of hyperglycemia in patients with type 2 diabetes mellitus (T2DM), the impact of the availability of these agents on the use of second-generation sulfonylureas (SUs) is unknown. This article presents percentages of patients prescribed SUs, using data from the National Ambulatory Medical Care Survey (NAMCS). The associations between SU prescribing and prespecified variables of interest were also explored. MethodsThe NAMCS database was queried for visits of patients aged ≥18 years with an International Classification of Diseases, Ninth Revision diagnostic code relevant to T2DM. χ2 tests were conducted to assess the associations between SU use and year-group (2003–2004, 2007–2008, or 2009–2010) and other variables of interest. A multivariate logistic regression model was constructed to jointly assess the value of these variables in predicting SU use. All analyses were weighted using procedures recommended by the National Center for Health Statistics. FindingsData from 7042 eligible visits were included, representing an extrapolated national estimate of 280,733,405 patient visits. The percentages of patients who received a prescription for an SU, by study year, were 25.7%, 23.4%, and 23.7% in 2003 to 2004, 2007 to 2008, and 2009 to 2010, respectively (P = 0.57). In the multivariate model, age ≥70 years, male sex, nonwhite race, primary care physician seen, and concurrent DPP-4 inhibitor use were significantly associated with SU use. ImplicationsNo significant decrease in the use of SUs was observed after the introduction of DPP-4 inhibitors and GLP-1 receptor agonists. However, patient-specific factors (eg, select demographic variables, site of care, and concurrent medication use) were associated with SU use.

Use of prescription pain medications among medical cannabis patients: comparisons of pain levels, functioning, and patterns of alcohol and other drug use.

Management of chronic pain is one of the most common reasons given by individuals seeking medical cannabis. However, very little information exists about the concurrent use of cannabis and prescription pain medication (PPM). This study fills this gap in knowledge by systematically comparing medical cannabis users who use or do not use PPM, with an emphasis on understanding whether concurrent use of cannabis and PPM is associated with more serious forms of alcohol and other drug involvement. Data from this study were collected from a medical cannabis clinic in southwestern Michigan (N = 273). Systematic comparisons were made on measures of sociodemographics, reasons for substance use, pain, functioning, and perceptions of PPM and medical cannabis efficacy. PPM users tended to be older and reported higher levels of pain and lower levels of functioning. The overall sample exhibited higher lifetime and past-3-month rates of alcohol and other noncannabis drug use than did the general population. Approximately 40% of subjects reported combining cannabis with alcohol, but no significant difference was observed between PPM users and nonusers. PPM users and nonusers did not exhibit any difference in either lifetime or past-3-month use of other drugs, including cocaine, sedatives, street opioids, and amphetamines. PPM users rated the efficacy of cannabis higher than PPM for pain management and indicated a strong desire to reduce PPM usage. Use of PPM among medical cannabis users was not identified as a correlate for more serious forms of alcohol and other drug involvement. However, longitudinal study designs are needed to better understand the trajectories of alcohol and other drug involvement over time among medical cannabis users.

Naltrexone vs Placebo for the Treatment of Alcohol Dependence: A Randomized Clinical Trial.

Alcohol use disorder is one of the leading causes of disability worldwide. While effective pharmacological treatments exist, they are efficacious only in certain individuals, contributing to their limited use. Secondary analysis of clinical trial data suggests that a functional polymorphism (rs1799971, Asn40Asp) of the µ-opioid receptor gene (OPRM1) is associated with the risk of relapse to heavy drinking following treatment with the opioid antagonist naltrexone. To prospectively examine whether rs1799971 is predictive of naltrexone treatment response. We conducted a 12-week, double-blind, randomized clinical trial of naltrexone vs placebo in individuals with alcohol dependence (intent-to-treat analysis). Participants were randomly assigned to study treatment based on the presence of 1 or 2 copies of the Asp40 allele compared with those homozygous for the Asn40 allele (2 × 2 cell design). Recruitment occurred between January 2009 and September 2013. All participants were seen in an outpatient clinical setting. A convenience sample of participants (n = 221) was recruited from 5 sites. All participants met DSM-IV criteria for alcohol dependence, with no concurrent psychotic or manic symptoms, no use of concurrent psychotropic medications, and no current dependence on illicit substances. The study drug was naltrexone (50 mg) given once daily or corresponding placebo. The primary study outcome measure was relapse to heavy drinking measured using the timeline follow-back method. There was no evidence of a genotype × treatment interaction on the primary outcome of heavy drinking (P = .32). In the Asn40 group, the observed effect of naltrexone was similar to that in previous trials (odds ratio, 0.69; 95% CI, 0.41-1.18; P = .17), with a very small naltrexone effect in the Asp40 group (odds ratio, 1.10; 95% CI, 0.52-2.31; P = .80), contrary to the pattern expected a priori. A significant reduction in heavy drinking occurred across all groups (P = .001). Other drinking outcomes, and all secondary outcomes, demonstrated similar time effects, with no genotype × treatment interaction. The results of this study do not support the hypothesis that the Asp40 allele moderates the response to naltrexone treatment. It is premature to use the Asn40Asp polymorphism as a biomarker to predict the response to naltrexone treatment of alcohol dependence. clinicaltrials.gov Identifier: NCT00831272.

Sleep in Children and Adolescents with Obsessive-Compulsive Disorder.

Sleep problems are not a core feature of obsessive-compulsive disorder (OCD), but emerging empirical data indicate some form of sleep disruption to be highly common. Available research in both adult and child patients is limited in several important ways, including the use of subjective reports (particularly in children), high rates of comorbid depression, and concurrent use of psychotropic medication. The presence of sleep disruption in OCD patients may compound severity and impairment of the disorder. More research is needed to fully understand the nature and consequences of sleep-wake disruption in children with OCD.

Topiramate for Weighht Loss in Children and Adolescents Prescribed Psychotropic Medications

Obesity rates in children and adolescents in the United States has tripled since 1980, with 16.9% falling into this range in a 2007-2008 study. Children are increasingly being prescribed antipsychotic medications for a variety of illnesses. This class of medication can lead to increased weight gain, obesity, and metabolic syndrome. Method We performed a retrospective chart review in our Child Psychiatry outpatient clinic for visits between 7/1/11 and 6/30/13 looking at the effects of concurrent use of topiramate and antipsychotic medications. Exclusion criteria included concurrent treatment wuth other medications known to cause weight loss (e.g. stimulants), a primary diagnosis of eating disorder, a primary medical illness that would have an impact in weight (e.g. thyroid illness), and medications not prescribed through our clinic. Brief Results N = 47 with a mean age of 13.36 years. Mean dosage for topiramate was 121.74 mg. Mean baseline BMI = 31.82. Mean treatment length = 200 days. Mean weight loss = 0.97 BMI points Discussion We will review the United States FDA indications for topiramate, the potential adverse events, and the preliminary data regarding the effectiveness for the treatment of weight gain, for patients prescribed and not prescribed antipsychotic medications.

Pitfalls in the diagnosis and management of Cushing's syndrome.

Despite many recent advances, the management of patients with Cushing's disease continues to be challenging. Cushing's syndrome is a complex metabolic disorder that is a result of excess glucocorticoids. Excluding the exogenous causes, adrenocorticotropic hormone-secreting pituitary adenomas account for nearly 70% of all cases of Cushing's syndrome. The suspicion, diagnosis, and differential diagnosis require a logical systematic approach with attention paid to key details at each investigational step. A diagnosis of endogenous Cushing's syndrome is usually suspected in patients with clinical symptoms and confirmed by using multiple biochemical tests. Each of the biochemical tests used to establish the diagnosis has limitations that need to be considered for proper interpretation. Although some tests determine the total daily urinary excretion of cortisol, many others rely on measurements of serum cortisol at baseline and after stimulation (e.g., after corticotropin-releasing hormone) or suppression (e.g., dexamethasone) with agents that influence the hypothalamic-pituitary-adrenal axis. Other tests (e.g., measurements of late-night salivary cortisol concentration) rely on alterations in the diurnal rhythm of cortisol secretion. Because more than 90% of the cortisol in the circulation is protein bound, any alteration in the binding proteins (transcortin and albumin) will automatically influence the measured level and confound the interpretation of stimulation and suppression data, which are the basis for establishing the diagnosis of Cushing's syndrome. Although measuring late-night salivary cortisol seems to be an excellent initial test for hypercortisolism, it may be confounded by poor sampling methods and contamination. Measurements of 24-hour urinary free-cortisol excretion could be misleading in the presence of some pathological and physiological conditions. Dexamethasone suppression tests can be affected by illnesses that alter the absorption of the drug (e.g., malabsorption, celiac disease) and by the concurrent use of medications that interfere with its metabolism (e.g., inducers and inhibitors of the P450 enzyme system). In this review, the authors aim to review the pitfalls commonly encountered in the workup of patients suspected to have hypercortisolism. The optimal diagnosis and therapy for patients with Cushing's disease require the thorough and close coordination and involvement of all members of the management team.

Active and passive smoking and the incidence of asthma in the Black Women's Health Study.

Evidence linking active or passive smoking to the incidence of adult-onset asthma is inconsistent with both positive and inverse associations being reported. Most previous studies of active smoking have not accounted for passive smoke exposure, which may have introduced bias. To assess the separate associations of active and passive smoking to the incidence of adult-onset asthma in the U.S. Black Women's Health Study, a prospective cohort of African American women followed since 1995 with mailed biennial questionnaires. Active smoking status was reported at baseline and updated on all follow-up questionnaires. Passive smoke exposure during childhood, adolescence, and adulthood was ascertained in 1997. Asthma cases comprised women who reported doctor-diagnosed asthma with concurrent asthma medication use. Cox regression models were used to derive multivariable hazard ratios (HRs) and 95% confidence intervals (CIs) for former and current smoking and for passive smoking among nonsmokers compared with a reference category of never active or passive smokers. Among 46,182 participants followed from 1995 to 2011, 1,523 reported incident asthma. The multivariable HRs for former active smoking, current active smoking, and passive smoking only were, respectively, 1.36 (95% CI, 1.11-1.67), 1.43 (95% CI, 1.15-1.77), and 1.21 (95% CI, 1.00-1.45), compared with never active/passive smoking. In this large population with 16 years of follow-up, active smoking increased the incidence of adult-onset asthma, and passive smoke exposure increased the risk among nonsmokers. Continued efforts to reduce exposure to tobacco smoke may have a beneficial effect on the incidence of adult-onset asthma.

Editorial inhaled corticosteroids: the endocrine and metabolic complications.

Inhaled corticosteroids (ICS) form a major part of the available therapeutic armamentarium for treatment of crippling chronic respiratory illnesses such as bronchial asthma (BA) and chronic obstructive pulmonary disease (COPD) over the past few decades. The World Health Organization (WHO) estimates that globally 235 million people suffer from BA and 64 million from COPD [1]. These chronic respiratory illnesses force physicians worldwide to prescribe ICS to their patients in their day to day clinical practice. ICS are claimed to predominantly possess local anti-inflammatory effects in the airways without significant systemic adverse effects, compared to oral or parenteral steroids, making them a favourable choice in managing BA and COPD. Intranasal inhalation of steroid aerosols/ powder is also useful in the management of allergic rhinitis. Although the systemic adverse effects of using ICS are claimed to be minimal in managing these chronic respiratory conditions, they do occur in a significant proportion of users, especially at high doses [2]. Suppression of the hypothalamo-pituitary-adrenal axis, adrenal insufficiency, growth retardation in children, Cushing syndrome, cataracts, thinning and bruising of the skin, infections from immune-suppression, and osteoporosis are some of the reported systemic adverse effects from the long-term use of ICS [2, 3]. The incidence of systemic effects depends on the type and dose of ICS used, the mode of ICS administration and interactions with concurrent use of other medications. The ICS molecules commonly available in the market are beclomethasone dipropionate (BDP), budesonide (BUD), fluticasone propionate (FP), Flunisolide (FLU), mometasone furoate (MF), and ciclesonide (CIC). Glucocorticoids are powerful steroid hormones secreted by the zona fasciculata of adrenal glands. Soon after the

Chronic kidney disease in lithium-treated older adults: a review of epidemiology, mechanisms, and implications for the treatment of late-life mood disorders.

Lithium is an important medication in the treatment of mood disorders. However, clinicians are hesitant to use lithium in older adults for fear of its medical effects, particularly kidney disease. This review describes the current understanding of the epidemiology and mechanisms underlying chronic kidney disease (CKD) in older lithium users, with recommendations for using lithium safely in late life. Prevalence estimates of CKD in older lithium users range from 42-50%, which does not differ greatly from the 37.8% rates seen in community-dwelling non-lithium using, non-psychiatric populations. Clinical and pre-clinical data suggest a variety of synergistic mechanisms contributing to CKD in older lithium users, including aging, cardiovascular factors, oxidative stress, inflammation, nephrogenic diabetes insipidus, acute kidney injury, and medication interactions. With regards to CKD, lithium can be used safely in many older adults with mood disorders. Compared to patients with pre-existing CKD, those with an estimated glomerular filtration rate >60 mL/min/1.73 m(2) are probably not as susceptible to lithium-associated renal decline. Using lithium concentrations <0.8 mmol/L; monitoring lithium concentrations and renal function every 3-6 months; being vigilant about concurrent medication use (e.g., diuretics, anti-inflammatories); as well as preventing/treating acute kidney injury, nephrogenic diabetes insipidus, diabetes mellitus, hypertension, smoking, and coronary artery disease can all help prevent CKD and further renal decline in older lithium users.

Concurrent use of stimulants and second-generation antipsychotics among children with ADHD enrolled in Medicaid.

This study examined the prevalence of and factors associated with concurrent use of long-acting stimulants (LAS) and second-generation antipsychotic agents among children and adolescents with attention-deficit hyperactivity disorder (ADHD). The study involved retrospective longitudinal analysis of 2003-2007 Medicaid data from four states for children and adolescents between the ages of six and 17 years who were diagnosed as having ADHD and initiated LAS treatment. Concurrent use of LAS and second-generation antipsychotic medications was defined as simultaneous receipt of both medications for at least 14 days. On the basis of the conceptual framework of the Andersen behavioral model, multivariable logistic regression analysis was used to examine predisposing, enabling, and need factors associated with concurrent use. Among the 61,793 children who initiated LAS treatment for ADHD, 11,866 (19.2%) received LAS and second-generation antipsychotics concurrently for at least 14 days. Overall, the average length of concurrent use was 130±98 days. Multivariable logistic regression revealed that concurrent use was higher among boys, blacks, and foster care children compared with their respective counterparts. Comorbid psychiatric conditions, including disorders that are not approved indications for second-generation antipsychotic use, were associated with concurrent use of LAS and second-generation antipsychotics. Almost one in five children and adolescents who initiated LAS also received second-generation antipsychotics concurrently for at least 14 days. Approved and nonapproved indications of second-generation antipsychotics influenced concurrent use in pediatric ADHD.

Proton pump inhibitors: Are we still prescribing them without valid indications?

Evidence from several Western studies has shown an alarmingly high and inappropriate rate of prescription of proton pump inhibitors (PPIs), which may be associated with increased healthcare costs and adverse outcomes. PPI prescribing patterns remain largely unknown in well-developed healthcare systems in Southeast Asia. We aimed to determine the prevalence of inappropriate prescription of PPI among elderly patients without documentation of valid indications, in a tertiary teaching hospital in Singapore. We carried out a retrospective clinical records review of 150 elderly patients aged ≥65 years that had been admitted to two internal medicine wards between 25 May 2011 and 28 June 2011 to determine the appropriateness of indications for PPIs prescribed at hospital discharge. PPI indications were categorised as "valid", "likely invalid", and "probable" based on current clinical literature. Pre-admission and discharge prescriptions were reviewed to determine continuation of pre-admission and new PPI prescriptions at discharge. Data on clinical characteristics and concurrent use of ulcerogenic medications were collected. From a total of 150 patients, 80 (53 per cent) received prescriptions for PPIs. Of these, 65 (81.2 per cent) had no valid documented indications (i.e., the indication was classed as "likely invalid"); 10 (12.5 per cent) had valid indications; and in five cases (6.2 per cent) the indication was "probable". The most common "likely invalid" indication was primary gastrointestinal bleeding prophylaxis (GIP) among low-dose aspirin users in 28 patients (43 per cent) of invalid PPI prescriptions. Inappropriate prescribing of PPIs without documented valid indications was prevalent among elderly patients at our tertiary teaching hospital in Singapore, providing evidence that shows a similar trend to PPI prescribing to data from Western countries.

Medicinal marijuana for epilepsy: a case series study.

To describe the social, clinical and use-patterns characteristics of medicinal marijuana use among patients with epilepsy (PWEs). Eighteen PWEs with prescriptions for medicinal marijuana from a Canadian adult-epilepsy clinic were included in this study. Eighteen patients had a prescription of medicinal marijuana from a total population of 800 PWEs in our center (2.2%). Mean age of patients was 30±7.4 (19-50) years. Twelve (67%) patients were males. Eleven (61%) patients had drug-resistant epilepsy. Eleven (61%) patients suffered a psychiatric comorbidity and reported the use of illicit substances or heavy alcohol or tobacco consumption. Only two (11%) patients were married; the rest of patients (89%) were single or divorced. The drug use pattern was similar among patients. All patients asked for marijuana permission in the epilepsy clinic. Most (83%) had a previous history of marijuana smoking, with a mean of 6.6±3 (1-15) years. The mean consumption dose was 2.05±1.8 (0.5-8) grams per day. Ten (56%) patients reported withdrawal seizure exacerbation when they stopped the marijuana. Only two patients (11%) reported side effects, and all patients found medicinal marijuana very helpful for seizure control and improvement of mood disorder. PWEs using medicinal marijuana have a common profile. They are usually young single men with drug-resistant epilepsy and psychiatric comorbidity. Most used marijuana before formal prescription and all believe the drug was effective on their seizure control. Because of the concurrent use of other antiseizure medications, it is complex to estimate the actual effect of marijuana.

The usefulness for indicated prevention of severe mental disorders should play a central part in the further development of CBT.

Schizophrenic, severe major depressive and bipolar disorders often do not respond sufficiently to the usual pharmacotherapy and therefore constitute the world's greatest public health problem (1). Thus, we have every reason to be happy that we can offer cognitive behavior therapy (CBT) as an effective non-pharmacological adjunct to the millions of people who are treated for those conditions worldwide. Obviously there are methodological problems as well as discrepant and negative results in numerous studies and meta-analyses on the effectiveness of complementary CBT in the above disease groups. Overall, however, the evidence speaks much more for than against the assumption that CBT or CBT-oriented strategies may improve the outcome of pharmacological treatment and prophylaxis, especially for treatment-resistant or chronic patients. On the other hand, the “promise of CBT” should not be overestimated in this important area of therapeutics. Taken as a whole, the hitherto achieved effects are only moderate, and data concerning bipolar disorders are not sufficient. Also, the evidence of efficacy for CBT should not mean that other approaches are now excluded from the search for useful psychotherapies for severe mental disorders. The traditional vulnerability-stress-coping models and also the newer salience theory of psychoses (2) offer a good framework for the development and use of psychological treatment strategies. They show, in fact, that different environmental stressors as well as personal and environmental protective factors may be involved in each individual case. CBT programs can target various but obviously not all of these psychosocial factors. Furthermore, important psychosocial influences such as trauma or migration interact with genetic-epigenetic and other biological factors (3). Therefore, even enthusiastic psychotherapists should not ignore that treatment and prophylaxis of severe mental disorders primarily deal with the current correction and future prevention of disorder-specific neuronal network pathologies in the human brain. The more we understand these pathologies, the more it will be possible to correct the network alterations by means of targeted neuromodulation. Research is currently testing new psychotropic drugs, neuroprotective substances and various brain stimulation methods to achieve this goal. The debate on “promise and limitations of CBT” reflects the presently unsatisfactory state of development. To date there are still no really causally effective psychotropic drugs available for the treatment of severe mental disorders, due to the lack of knowledge about etiology. That is why we try to combine substances which only influence the final pathogenetic pathways, and therefore are only partially effective, with complementary psychological interventions. Here, CBT has proven particularly useful, as it has a favorable impact on some of the psychosocial factors which are important for the release of and coping with the clinical symptoms. Nevertheless, the therapeutic problems are far from being solved, and the search for causal treatment approaches must go on. The directions for future research should include further testing of CBT in the initial high-risk states of psychosis or bipolar disorders (4). In persons who have already suffered from long courses of these diseases, with relapses or chronicity, CBT can only be an adjunct and at best produce the effects described in Thase et al's paper (5). Often the primary therapeutic goal of recovery is not at all achievable and what can be obtained is only coping with symptoms or loss of functions in order to reduce the burden of the disease and improve the quality of life. On the contrary, in the high-risk states, which can nowadays be characterized very well for psychoses (6) and increasingly better for severe mood disorders (7), we just observe initial changes of experience which, depending on the individual constellation of stressors and protective factors, can progress or not to the actual disease. The prevention of the outbreak of severe mental disorders is what is meant by the concept of indicated prevention (8). Right from the beginning, CBT was involved in the studies of indicated prevention of schizophrenia and has repeatedly been shown to be effective as the sole therapy without concurrent use of medication (9). It seems to be able to even prevent the transition of early cognitive disorders into attenuated psychotic symptoms and their transition into full schizophrenic symptoms (10). If this approach of indicated prevention is successfully transferred also to severe mood disorders, it promises to be much more useful in the fight against the world's greatest public health problem than the late adjunctive strategy (11).

Concurrent Use of Acid Suppressive Medications in Non-hematemesis GIB Patients Minimizes the Risk of Peptic Ulcers as the Source of Bleed

Concurrent Use of Acid Suppressive Medications in Non-hematemesis GIB Patients Minimizes the Risk of Peptic Ulcers as the Source of Bleed

Treatment-resistant hypertension in the transplant recipient.

Treatment-resistant hypertension (TRH) is defined as follows: (1) the failure to achieve optimal blood pressure control to levels less than 140/90 mm Hg despite the concomitant use of 3 or more different classes of antihypertensive agents, one of which is a diuretic, or (2) the simultaneous use of 4 or more different classes of antihypertensive agents in a patient irrespective of blood pressure control and the exclusion of pseudoresistance. Patients with TRH constitute only a subset of patients with poorly controlled hypertension, which also includes other subsets of patients who are treated inadequately or who are noncompliant with prescribed pharmacologic and nonpharmacologic therapy. TRH does occur in kidney-transplant recipients. This may be related to a variety of factors including reduced renal function, renal artery stenosis, concurrent use of medications that increase blood pressure, lack of use or insufficient use of diuretics, noncompliance related to complex medication regimens, or activated neurohormonal pathways, especially aldosterone or the sympathetic nervous system. After kidney transplantation, normalization of blood pressure occurs only in a minority of patients, and it is estimated that 67% to 90% of kidney transplant patients have arterial hypertension and the improvement in glomerular filtration rate and fluid management offered by the kidney transplant may be offset by a wide array of factors. Epidemiologic studies that describe the prevalence of TRH in kidney transplant recipients are lacking.

Pseudohyperphosphatemia in children treated with liposomal amphotericin B.

The results of a study to determine the frequency of pseudohyperphosphatemia in a sample of pediatric patients treated with i.v. liposomal amphotericin B are reported. A single-site retrospective study was conducted to identify evidence of pseudohyperphosphatemia in the medical records of patients 18 years of age or younger who received at least five doses of amphotericin B liposome; the maximum dose was calculated for each regimen and categorized as either ≤5 or >5 mg/kg/day. The primary objective was to ascertain the rate of pseudohyperphosphatemia (i.e., abnormally high serum phosphate without elevated serum calcium). The secondary objective was to compare rates of pseudohyperphosphatemia at the higher and lower amphotericin B dosage levels. A multivariate generalized estimating equation (GEE) regression model was used to identify potential predictors of pseudohyperphosphatemia. Data were collected on 72 courses of amphotericin B liposome administered during a 13-month period to 47 patients; based on a review of chart notations and clinical data, it was determined that 36 regimens (50%) involved pseudohyperphosphatemia. The GEE model revealed no significant association between pseudohyperphosphatemia and any evaluated variable, including age, weight, duration of therapy, and concurrent use of medications known to alter serum phosphorus. In children receiving amphotericin B liposome, half of the regimens were associated with pseudohyperphosphatemia. Although no factors were found to predict pseudohyperphosphatemia, on average, patients who developed the abnormality were significantly older and heavier and received a significantly higher absolute initial dosage of amphotericin B liposome than those who did not develop the condition.

Comorbidities among the HIV-infected patients aged 40 years or older in Taiwan.

BackgroundWith the widespread use of combination antiretroviral therapy (cART), life expectancy of HIV-infected patients has significantly prolonged. An increasing number of HIV-infected patients are aging and concurrent use of medications are not uncommon for management of metabolic complications and cardiovascular diseases related to aging and prolonged exposure to cART.MethodsWe reviewed medical records of all HIV-infected patients aged 40 years or older who had been followed at a university hospital for HIV care in Taiwan between January and December 2013. A standardized case record form was used to collect information on demographics and clinical characteristics, comorbidity, cART, and concurrent medications.ResultsDuring the study period, 610 patients aged 40 to 49 years (mean, 44.1) and 310 aged 50 years or older (mean, 58.8) sought HIV care at this hospital. Compared with patients aged 40 to 49 years, those aged 50 years or older were significantly more likely to be female (15.9% vs 3.8%); to have received cART (97.7% vs 94.8%) and a lower plasma HIV RNA load (1.6 vs 1.7 log10 copies/ml); and to have diabetes mellitus (18.4% vs 4.6%), hypertension (31.0% vs 10.8%), hyperlipidemia (29.4% vs 11.6%), coronary artery disease (6.8% vs 0.5%), and an estimated glomerular filtration rate <60 ml/min/1.73 m2 (11.5% vs 2.7%); and were significantly less likely to have syphilis. Other than HIV infection, patients aged 50 years or older were more likely to have been receiving two or more concurrent medications than those aged 40 to 49 years (22.9% vs 6.4%).ConclusionsOur findings show a significant proportion of the HIV-infected patients aged 50 years or older have multiple comorbidities that may increase the risk for cardiovascular and renal complications. Issues of poly-pharmacy among the HIV-infected patients who are aging should be addressed to ensure adherence and minimize drug-drug interactions.

Predictors of local adverse effects caused by topical tretinoin cream 0·1% in the Veterans Affairs Topical Tretinoin Chemoprevention trial

Topical tretinoin is commonly prescribed, but its frequent adverse effects are barriers to use. Predictors of resistance or susceptibility to retinoid irritation are not known. To identify baseline patient characteristics associated with adverse effects of topical tretinoin. This cohort study used data collected from 324 participants in the Veterans Affairs Topical Tretinoin Chemoprevention trial who were randomized to apply tretinoin cream on the face and ears. Univariate and multivariate logistic regression models were used to examine the associations between baseline characteristics and local adverse effects. One hundred and ninety-seven patients (61% of those randomized to tretinoin) reported local adverse effects within 6 months. Clinical signs of severe photodamage at baseline [odds ratio (OR) 0·15, 95% confidence interval (CI) 0·04-0·54] and history of acne (OR 0·46, 95% CI 0·27-0·77) were associated with a decreased risk of adverse effects to tretinoin. The use of other topical medications at enrolment (OR 1·88, 95% CI 1·15-3·08) predicted an increase in adverse effects. In this study population, the common indications of topical tretinoin treatment were associated with lower risks of adverse effects. The concurrent use of other topical medications may worsen irritation caused by tretinoin.

Risk Analysis for Second Hip Fracture in Patients After Hip Fracture Surgery: A Nationwide Population-Based Study

ObjectivesThe current treatment program for fragility hip fractures (HFx) emphasizes a combination of early surgery, rehabilitation, and tertiary prevention strategy for osteoporosis; however, the effect is unclear and little information is available on the risk factors predicting the occurrence of a second hip fracture (SHFx). The aim of this study was to explore the incidence, risk factors, and subsequent mortality of SHFx in patients after their first hip fracture surgery (HFxS). Design, Setting, and ParticipantsWe performed a nationwide population-based longitudinal observational study using the National Health Insurance Research Database (NHIRD) of Taiwan with a logistic regression model analysis. Of 87,415 patients undergoing HFxS during the period 2004 to 2007, we identified 8027 patients who had sustained an SHFx for analyses. MeasurementsData collected included patient characteristics (demographics, comorbidities, and concurrent medication use), incidence and hazard ratios of SHFx after HFxS, and subsequent age-specific mortality. ResultsThe overall incidence of SHFx was 9.18% and the age-specific mortality was increased 1.6- to 2.2-fold in patients with SHFx compared with those without after HFxS in this 7-year longitudinal study. The identified risk factors included age (AOR = 1.84, 95% CI: 1.24–2.89), female gender (AOR = 1.12, 95% CI: 1.03–2.30), obesity (AOR = 2.89, 95% CI: 1.81–3.01), diabetes (AOR = 3.85, 95% CI: 2.54–4.05), arterial hypertension (AOR = 2.45, 95% CI: 1.83–2.62), hyperlipidemia (AOR = 2.77, 95% CI: 1.27–3.19), stroke/TIA (AOR = 2.85, 95% CI: 2.20–3.23), blindness/low vision (AOR = 3.09, 95% CI: 2.54–3.73), and prolonged use of analgesics and anti-inflammatory medications (all AOR ≥ 3.05, all P values ≤.012). Bisphosphonate therapy after HFxS had a significant negative risk association with the development of an SHFx (20.8% vs 32.3%, P = .023; AOR = 2.24, 95% CI: 1.38–2.90). ConclusionWe concluded that the occurrence of an SHFx and subsequent mortality in patients after HFxS is rather high. An understanding of the risk factors predicting the occurrence of an SHFx provides a valuable basis to improve health care for geriatric populations.