Greater Number Of Medications Research Articles

Adrenal insufficiency in pediatric kidney transplantation recipients.

Immunosuppression of pediatric kidney transplant (PKT) recipients often includes corticosteroids. Prolonged corticosteroid exposure has been associated with secondary adrenal insufficiency (AI); however, little is known about its impact on PKT recipients. This was a retrospective cohort review of PKT recipients to evaluate AI prevalence, risk factors, and adverse effects. AI risk was assessed using morning cortisol (MC) and diagnosis confirmed by an ACTH stimulation test. Potential risk factors and adverse effects were tested for associations with MC levels and AI diagnosis. Fifty-one patients (60.8% male, age 7.4 (IQR 3.8, 13.1) years; 1 patient counted twice for repeat transplant) were included. Patients at risk for AI (MC < 240 nmol/L) underwent definitive ACTH stimulation testing, confirming AI in 13/51 (25.5%) patients. Identified risk factors for AI included current prednisone dosage (p = .001), 6-month prednisone exposure (p = .02), daily prednisone administration (p = .002), and rejection episodes since transplant (p = .001). MC level (2.5 years (IQR 1.1, 5.1) post-transplant) was associated with current prednisone dosage (p < .001), 6-month prednisone exposure (p = .001), daily prednisone administration (p = .006), rejection episodes since transplant (p = .003), greater number of medications (β = -16.3, p < .001), 6-month hospitalization days (β = -3.3, p = .013), creatinine variability (β = -2.4, p = .025), and occurrence of acute kidney injury (β = -70.6, p = .01). Greater corticosteroid exposure was associated with a lower MC level and confirmatory diagnosis of AI noted with an ACTH stimulation test. Adverse clinical findings with AI included greater medical complexity and kidney function lability. These data support systematic clinical surveillance for AI in PKT recipients treated with corticosteroids.

Potentially inappropriate medication use among older adults with lower-limb loss

ObjectiveThe aim of this study was to evaluate the prevalence of, and explore factors related to, prescription of potentially inappropriate medications (PIMs) among older adults with lower-limb loss (LLL). MethodsThis was a secondary analysis of a cross-sectional dataset collected through an interdisciplinary limb loss clinic between September 2013 and November 2022. Self-report medication lists were reviewed during in-clinic face-to-face interviews and compared to the American Geriatrics Society Beers Criteria corresponding to the patient's evaluation year. ResultsOf 82 participants (72.9 ± 6.6 years-old; 78.0 % male), n = 41 (50.0 %) reported using one or more PIM. PIM prescription was significantly associated with presence of phantom limb pain, history of upper gastrointestinal issues, and a greater number of medications. DiscussionPolypharmacy and PIM use are common among older adults with LLL. Greater attention should be paid to medications post-amputation, especially pain management medications, to minimize potential adverse side-effects.

Medication error in geriatric population of an urban area and its relation with different factors influencing medication error

Medication errors have been a matter of concern since the time we started using medicines. The frequency of these errors is influenced by a number of factors few of them were pretty obvious and few surprising. Keeping this in mind this research was designed and carried out in geriatric population of an urban area. We tried to evaluate the role of various factors which influence medication error in geriatric population.1-Primary objective was to estimate the frequency of medication error. 2-Secondary objective was to find out relation of different factors related to medication error. This is a cross sectional study which aims to estimate the frequency of medication error in 250 patients of geriatric age group (Age More Than 65 Years) residing in an urban area and factors related to medication error For this a questionnaire was prepared which had questions related to demographic details and few questions focused on knowing the factors that could have an influence on medication error. These factors were taken into consideration as per the previous studies which were done on medication error.It was found that more than 80% of patients thought that medication errors are only those incidents where they use a medication other than what was prescribed to them hence Patients were properly explained what medication error actually is e.g. they were told that even if they take the correct mediation in wrong dose, frequency or duration it accounts for medication error and after this they started recalling incidents when they have faced these errors. There responses were entered into these questionnaire/case record forms which were later analysed.The data was entered in MS excel and analysed using Epi Info software. The quantitative variables were analysed as frequency. Association between variables was analysed using chi square test. P value &amp;#60;0.05 was considered as significant .The incidence of medication error was found to be 53% and its frequency was higher in patients with greater number of medications, increasing number of chronic health conditions , while it was lower in patients with higher educational status ,those belonging to lower age groups and if doctor or pharmacist explained the medications to them. surprisingly its frequency was low in patients who could just identify their medication with their health condition. It was concluded that medication errors are common health related issue in patients of geriatric age group and a number of factors can influence its incidence. If these factors are properly addressed it will have a considerable impact on the morbidity and mortality associated with this problem.

Frailty and polypharmacy in the community‐dwelling elderly with multiple chronic diseases

Both multi-morbidity (MM) and polypharmacy (PP) are common in the elderly and pose a challenge for health and social care systems. However, high-quality patient-centred care requires context-bound understanding of the patterns and use of medications in those with MM. Therefore, the aim of this study was to investigate the prevalence of PP in community-dwelling elderly, and the factors associated with MM, PP, excessive polypharmacy (EPP), and the types of drugs used. We analysed data of 164 community-dwelling subjects aged ≥60 years from January to December 2020 at a general hospital in a rural area of Taiwan. MM was defined as >4 diagnoses of chronic health conditions. Non-polypharmacy (NP), PP, and EPP were defined as <5, 5-8, and >8 prescriptions, respectively. Other variables including basic activities of daily living (BADL), severity of frailty, depressive mood, screening for intellectual impairment, and nutritional status were also analysed. Of the 164 participants, 34.8% had >4 diagnoses, 66.5% had PP, and 26.2% had EPP. The patients with >4 diagnoses had worse performance in BADL, higher levels of frailty, and more prescriptions than those with fewer diagnoses. The EPP group had worse performance in BADL, a higher level of frailty, more comorbidities, and higher prevalences of diabetes mellitus and chronic kidney disease compared to the NP and PP groups. After adjusting for covariates, we further found a higher number of medications associated with having more comorbidities, and a higher level of frailty associated with having a greater number of medications. We found relationships between frailty and PP, and between PP and MM, but frailty did not associate with MM. Since frailty, PP, and MM may be viewed as an inevitable trinity of ageing, reducing PP could be a method to both prevent frailty and disentangle this trinity in the elderly.

The Cost of Multimodal vs Opioid Postoperative Pain Regimens for the Foot &amp; Ankle Surgical Patient

Category: Other; Other Introduction/ Purpose: Orthopedic surgeons are one of the highest prescribing specialties of opioids in medicine. To address the ongoing opioid crisis in the United States, many surgeons have adopted multimodal regimens for post-operative pain control to decrease the need for opioids. Recent studies have demonstrated the effectiveness of opioid-sparing multimodal pain management therapies when compared to opioid inclusive therapies. However, to date there are no published studies analyzing the cost of multimodal vs opioid postoperative pain regimens for the elective foot &amp; ankle surgical post-surgical patient. Methods: A secondary analysis of data collected from two studies that evaluated pain control after elective forefoot surgery was analyzed. The index study examined the number of opioid pills consumed post-operatively. A follow-up then examined the clinical utility of the non-opioid pain regimen for pain control post-operatively. Medications in the non-opioid multimodal regimen included cyclobenzaprine, ketorolac, meloxicam, pregabalin, and acetaminophen. Using information collected during these two studies, deidentified patient profiles were constructed using the patient’s insurance carrier and preferred pharmacy to determine the cost of each patient’s post-operative regimen (narcotics vs multimodal). All patients, 40 patients from the multimodal pain pathway study and 59 from the opioid pain control study, were included in this analysis and their prescription costs were totaled and analyzed. Results: A box plot was constructed to visualize data and identify outliers to be removed for data analysis. Prescriptions in the opioid group had an average cost of $8.92 (SD=$5.74) while the multimodal group had an average cost of $25.60 (SD=$10.49), p Conclusion: Patients whose post-operative pain was managed by an opioid-free multimodal regimen had statistically significant higher prescription costs than with opioid monotherapy regardless of health insurance type. However, the difference may not be clinically significant as on average it was $17. As more studies demonstrate the effectiveness of opioid-free post-operative pain management, it may be reassuring to surgeons that despite a greater number of medications with the multimodal protocol the average cost difference was only about $17. This information may allow surgeons to prescribe this regimen to all patients regardless of socioeconomic status and continue to decrease post-operative opioid prescriptions.

Characteristics of geriatric rehabilitation inpatients based on their frailty severity and change in frailty severity during admission: RESORT

BackgroundFrailty is prevalent amongst geriatric inpatients and worsens clinical outcomes. Determinants of admission frailty and changes in frailty severity are potential targets for intervention. ObjectiveTo identify characteristics associated with frailty severity at admission and change in frailty severity during geriatric rehabilitation. MethodsThe observational, prospective, longitudinal inception cohort REStORing health of acutely unwell adulTs (RESORT) includes geriatric rehabilitation inpatients. Demographic, medical, nutritional, functional, and psychological characteristics were analysed according to admission Clinical Frailty Scale. Linear and multinomial logistic regression prediction models identified admission characteristics predicting change in frailty severity during rehabilitation. ResultsA total 1716 inpatients (median age [IQR] 83.4 [77.7–88.6] years, 56.4 % females) were included. Poorer admission medical, nutritional, functional, and psychological status was associated with more severe frailty. Cardiac admissions, higher Cumulative Illness Rating Scale, greater number of medications, and better Short Physical Performance Battery at admission predicted improved frailty severity. Admission cognitive impairment, delirium, higher Charlson Comorbidity Index, and Hospital Anxiety and Depression Scale anxiety predicted worsened frailty severity. Explained variation was low. ConclusionsFrailer geriatric rehabilitation inpatients have more complicated disease and impaired nutritional, physical, and psychological markers. Admission cognitive impairment, delirium, comorbidity, and anxiety predict worsening frailty during rehabilitation, and require prompt management.

600-P: Examining Beliefs about Type 2 Diabetes Medications: A Multidimensional Approach

Background: Beliefs about type 2 diabetes (T2D) medications predict treatment adherence; yet, factors that influence these beliefs are poorly understood. Further, prior studies reduce the complex interplay between beliefs about treatment necessity and medication-related concerns to a single dimension by using a difference score. This study examined correlates of T2D medication beliefs and modeled the multidimensional associations of beliefs and adherence. Methods: Participants were 812 primarily disadvantaged and ethnic minority adults with T2D (Female = 56.9%; Latino = 86.5%; Mean [SD] Age and A1C = 59.2 [10.8], 9.3 [1.8], respectively) recruited for a self-management trial. Informed by the Common Sense Model and prior research, relations of patient- and illness-related factors with medication beliefs (Horne, Weinman, Hankins, 1999) were examined using linear regression. Confirmatory and exploratory polynomial regression examined associations of medication beliefs and self-reported adherence. Results: Hispanic ethnicity (p &amp;lt; .01) , insulin use (p &amp;lt; .05) , greater number of medications (p &amp;lt; .05) , and lower levels of education (p &amp;lt; .05) were associated with stronger necessity beliefs. Lower income (p &amp;lt; .05) and Hispanic ethnicity (p &amp;lt; .01) were associated with greater concerns. Adherence was lowest among those with strong concerns and weak necessity beliefs. Non-reciprocal effects were also observed, which could not have been assessed using a difference score. Patients with ambivalent beliefs had lower adherence than those with indifferent beliefs. Discussion: Indicators of lower SES were associated with concerns about T2D medications. Increased disease severity and Hispanic ethnicity were associated with stronger necessity beliefs. However, Hispanics also reported more concerns about their medications. Results further support use of polynomial regression to assess medication beliefs and adherence. Addressing concerns, in particular, may enhance T2D medication adherence. Disclosure A.G.Asman: None. L.A.Phillips: None. E.A.Walker: None. L.D.Pappalardo: None. J.S.Gonzalez: Consultant; Virta Health Corp. Funding National Institutes of Health (R18 DK098742) Einstein–Mount Sinai Diabetes Research Center (P30 DK020541) New York Regional Center for Diabetes Translation Research (P30 DK111022) J.S.G. is supported by National Institutes of Health (RDK104845, RDK121298, RDK121896)

Clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus treated judicially

BackgroundThere is a lack of studies that assess the effectiveness of pharmacotherapeutic follow-up in the context of the judicialization of insulin analogues.AimsTo evaluate the clinical and humanistic impact of pharmacotherapeutic follow-up in patients with type 1 diabetes mellitus who receive insulin analogues by judicial decision in a Brazilian municipality.MethodsA quasi-experimental study of the before-and-after type was carried out through pharmacotherapeutic follow-up. Patients who accepted to participate in the study underwent laboratory tests of glycemic and lipid profile before and after the intervention, and underwent five pharmaceutical consultations. In addition, quality of life and health, knowledge, and skills related to insulin application techniques were analyzed.Results28 patients participated in all stages. Of these, most were female (53.6%), with a mean age of 32.8 ± 11.6 years. After the intervention, there was a reduction in blood glucose levels, blood pressure, and increased body mass index. In addition, there was greater knowledge and skills regarding insulin application techniques, improved quality of life, health, greater number of medications used, reduction of pharmacotherapeutic problems, and improvement in eating habits.ConclusionThe pharmacotherapeutic follow-up promoted clinical and humanistic benefits, with improvement in quality of life and health.

Analysis of neuropathological comorbid conditions in elderly patients with mild cognitive impairment in a tertiary care center in South India.

Introduction:Mild cognitive impairment (MCI) is a transitional stage in the continuum of cognitive decline. Multiple risk factors may be involved apart from neuropathological states such as Alzheimer’s disease, Parkinson’s disease, and vascular dementia. There is scant data in the literature pertaining to our study population in Kerala, South India that provide associations between suggested risk factors and MCI. Most of the elderly present to family and primary care physicians with complaints of some form of memory impairment.Objectives:To find out the significant neuropathological comorbid conditions present in elderly patients with MCI. To assess for other risk factors in the same population- including laboratory parameters, comorbidities, and psychosocial parameters.Methods:This retrospective record-based study included a sample of 93 patients with MCI as quantified by the Mini-Mental Status Examination (MMSE). These subjects were compared with controls (n = 97) without MCI, with respect to neuropathological diagnoses, laboratory parameters and psychosocial parameters.Results:The findings of our study were that female gender, higher depression scores, a greater number of medications taken, benzodiazepine use, higher alkaline phosphatase levels, positive fall history, loss of a spouse, and lower levels of education were associated with MCI. MCI is negatively associated with positive alcohol history. The most commonly seen proven neuropathological diagnosis was Parkinson’s disease.Conclusion:The risk factors that were found in our study should be highlighted in the elderly and preventive measures should be taken to prevent the downward progression through the cognitive continuum. Prospective studies looking into mild cognitive impairment with better screening tools and proper assessment of neuropathological comorbid conditions can further elucidate the findings related to this study.

Evaluation of changes in prescription among Japanese elderly patients before and after transition to home care.

BackgroundMost patients receiving home care have multimorbidity and tend to be prescribed multiple drugs with the complicated regimen. Family physicians (FPs) are responsible for patients' prescriptions after transition to home care. This study aimed to assess changes in medication regimen complexity and potentially inappropriate medications (PIMs) made by FPs before and after transition to home care.MethodsA retrospective cohort study was conducted in six home care clinics in Ibaraki Prefecture, Japan. Data from patients aged 65 years and older taking any medication who initiated home care between April 2018 and March 2019 were collected using medical records. The medication regimen complexity index‐Japanese version (MRCI‐J) score and the presence of PIMs were assessed before and 3 months after transition to home care.ResultsThe mean age of 169 patients was 84.0 years. MRCI‐J score and percentage of PIMs remained unchanged between before and 3 months after home care initiation. However, MRCI‐J score significantly decreased among patients with polypharmacy, but significantly increased among patients with nonpolypharmacy. In multiple regression analysis, a greater number of medications before home care initiation was associated with a decreasing MRCI‐J score, but pharmacist home visit services were not associated with changes in MRCI‐J score.ConclusionsOur results suggest that FPs involved in home care are trying to adjust prescriptions by simplifying the medication regimen of patients with polypharmacy, and adding symptomatic drugs to those with nonpolypharmacy.

Medication Errors Among Hospitalized Adults in Medical Wards of Nekemte Specialized Hospital, West Ethiopia: A Prospective Observational Study.

PurposeA high prevalence of medication errors in older adults are due to a combination of different factors such as polypharmacy, polymorbidity, enrolment in several disease-management programs, and fragmentation of care that causes medication errors in all age groups. This study aims to assess the incidence and determinants of medication errors among hospitalized adults in medical wards of Nekemte Specialized Hospital (NSH), West Ethiopia.Patients and MethodsA prospective observational study design was conducted at Nekemte Specialized Hospital among hospitalized adults from October 30, 2018 to January 30, 2019. Data were collected by using checklist-guided observation and review of medication order sheets, medication administration records, and patient charts. To identify the independent predictors of medication errors, logistic regression analysis was used. Statistical significance was considered at a p-value <0.05.ResultsA total of 351 patients were included in the present study. The mean age of the patients was 40.67+15.78 years. A total of 813 medication errors were recorded. The most common stage for medication errors was physician ordering 263 (32.4%). In the multivariable analysis, age ≥65 years (AOR: 2.54, 95%CI: 1.12–5.75, p=0.025), hospital stay ≥7 days (AOR: 2.16, 95%CI: 1.17–3.98, p=0.014), number of medication taken (AOR: 1.75, 95%CI: 1.13–2.73, p=0.013) and presence of comorbidity (AOR: 1.57, 95%CI: 1.01–2.46, p=0.049) had shown statistical significance in predicting medication errors.ConclusionMedication errors are common at Nekemte Specialized Hospital with an incidence of 48.3 per 100 orders, 231.6 per 100 admissions, and 433.4 per 1000 patient days. In particular, adults with older age, increased hospital stay, a greater number of medications, and presence of comorbidities were at greater risk for medication errors.

DIVE/DPV registries: benefits and risks of analog insulin use in individuals 75 years and older with type 2 diabetes mellitus

IntroductionThe aims of this study were to characterize insulin-treated individuals aged ≥75 years with type 2 diabetes using basal insulin analogs (BIA) or regular insulins (human insulin (HI)/neutral protamine Hagedorn...

Self-Reported Nonadherence to Medication Is Not Associated with Health-Related Quality of Life in Parkinson's Disease.

Nonadherence is a growing issue in the treatment of Parkinson’s disease (PD). Many factors are known to influence nonadherence, but little is known about the influence of quality of life (QoL). Detailed clinical data were obtained from 164 patients with PD using the Parkinson’s Disease Questionnaire-39 (PDQ-39) and the German Stendal Adherence with Medication Score (SAMS). Descriptive statistics were used to identify reasons for nonadherence, and multivariable linear models were used to study associations between QoL and clinical parameters as well as nonadherence. Multivariate analysis of variance (MANOVA) and multivariate analysis of covariance (MANCOVA) were used to study the effect of the SAMS on PDQ domains and other medical covariates. The results showed that 10.4% (n = 17) of patients were fully adherent, 66.4% (n = 109) were moderately nonadherent, and 23.2% (n = 38) were nonadherent. Nonadherence was associated with male gender, lower Montreal Cognitive Assessment (MoCA) score, higher non-motor symptoms questionnaire (NMS-Quest) score, greater number of medications per day (an indicator of comorbidity), and higher Beck Depression Inventory (BDI) score. QoL was correlated with male gender, lower MoCA score, higher NMS-Quest score, more comorbidities, and higher BDI score, but was not correlated with nonadherence.

Potentially inappropriate medications at discharge among elderly patients at a single tertiary emergency medical institution in Japan: a retrospective cross-sectional observational study.

AimPotentially inappropriate medications (PIMs) are associated with a lower medication adherence and a higher incidence of adverse events and medical costs among elderly patients. The current study aimed to examine the prescription status of elderly patients transported to tertiary emergency medical institutions to compare the proportion of elderly patients using PIMs at admission and discharge and to investigate the characteristics of PIMs at discharge and their associated factors.MethodsIn total, 264 patients aged 75 years or older who were transferred to and discharged from the emergency room at Tokyo Medical University Hospital, a tertiary care hospital, from September 2018 to August 2019 were included in this study. We quantified the number of PIMs at admission and discharge based on the Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions (STOPP) criteria version 2. The primary outcomes were the proportion of elderly patients taking at least one PIM at admission and discharge.ResultsThe proportions of patients taking PIMs at admission and discharge were 55% (n = 175) and 28% (n = 74), respectively. Old age, greater number of PIMs at admission, and greater number of medications at discharge were directly associated with PIMs at discharge.ConclusionsAdmission to tertiary care hospitals resulted in a lower number of prescribed PIMs. Elderly patients with a higher number of PIMs at admission and higher number of medications at discharge might have been prescribed with PIMs.

Surgical Outcomes of Superotemporal Versus Inferonasal Placement of Aurolab Aqueous Drainage Implant in Refractory Pediatric Glaucoma

We sought to describe the outcomes of the Aurolab aqueous drainage implant (AADI) placed in the superotemporal (ST) versus the inferonasal (IN) quadrant in pediatric eyes with refractory glaucoma. Retrospective comparative interventional case series. This was a retrospective study of patients ≤18 years of age who underwent AADI implantation and completed a minimum of 2-year follow-up. The choice of the quadrant depended upon the amount of scarring and conjunctival mobility. Cumulative success at 2 years was defined as intraocular pressure (IOP) ≤21mm Hg or reduced by ≥20% below baseline on 2 consecutive follow-up visits after 3months, IOP ≤5mm Hg on 2 consecutive follow-up visits after 3months, reoperation for glaucoma or a complication, or loss of light perception vision. A total of 144 patients (144 eyes) underwent AADI placement, including 48 eyes (33%) in the IN and 96 eyes (67%) in the ST quadrants. The IOP was significantly higher in the IN group (17.5 ± 7.4mm Hg vs 13.7 ± 6.2mm Hg, P= .005) with a greater number of medications (1.5 ± 1.0 vs 0.8 ± 0.9, P= .001) after 2 years of follow-up. Cumulative success rates at 2 years were 50.7% (95% confidence interval 35.4%-63.9%) in the IN group and 65.6% (95% confidence interval 56.5%-75.7%) in the ST group (P= .15). Complications occurred more frequently in the IN group, with significantly more tube exposure (12% vs 0%, P= .05). Placement of the AADI in the ST quadrant has better IOP-related outcomes and is a safer surgical option in pediatric eyes compared with the IN quadrant. It may be prudent to avoid AADI in the IN quadrant in children unless the ST location is not a viable option.

Abstract 13178: Attainment of LDL-C Goals is Associated With Measures of Patient Engagement With Their Healthcare Providers

Introduction: Achieving optimal levels of low density lipoprotein cholesterol (LDL-C) reduces risk of cardiovascular events. We have found substantial gaps in LDL-C goal attainment in employees and spouses with an employer-sponsored medical plan. Understanding how patients’ engagement with healthcare providers affects LDL-C goal attainment may inform gap-closure programs. Methods: The study was drawn from 35,276 participants in an annual health assessment program offered by nation-wide clinical diagnostic provider to employees and spouses between September 2017 and June 2018. We excluded those with &lt;1 consecutive year of employer- sponsored health plan and those younger than 40 or older than 75. The analysis was further limited to 7,363 participants who would benefit from LDL-C management according to the AHA/ACC definition of patient-management groups. The association between attaining LDL-C goal and education, socioeconomic status, and self-reported measures of engagement with healthcare providers was assessed in age, sex, and ethnicity adjusted logistic regression models. Results: Attaining LDL-C goal was more likely in those with a personal physician than in those without (OR =2.25, 95%CI, 1.70 to 2.99, P &lt;0.0001). Similarly, greater confidence in selecting a physician, talking with a physician, or understanding medical benefits, as well as a more recent physical exam and a greater number of medications were associated with greater odds of attaining LDL-C goal ( Figure, all P values &lt;0.0001). Socioeconomic status and education levels were not associated with attaining LDL-C goals ( P &gt;0.05). Conclusion: Confidence in interaction with healthcare providers (understanding benefits, selecting a physician, and talking with a physician) was associated with LDL-C goal attainment in those with an employer-sponsored health plan. Improving patients’ confidence in their ability to interact with healthcare providers may improve LDL-C goal attainment.

Understanding the Dual Dilemma of Dry Eye and Glaucoma: An International Review.

Glaucoma-related ocular surface disease (G-OSD) is a significant, yet often underdiagnosed, ocular co-morbidity affecting 40% to 59% of glaucoma patients worldwide. Although the use of topical glaucoma medications represents a proven strategy to control the untoward effects of high intraocular pressure, this treatment can profoundly disrupt the homeostasis of the tear film. The cumulative effect of medications, preservatives, and excipients alter underlying cellular structures which results in tear film abnormalities and instability of the ocular surface. Furthermore, these chronic inflammatory changes have been shown to impact efficacy of glaucoma treatment, patient compliance with therapy and overall quality of life. The pathogenesis of G-OSD is multifactorial and involves a vicious self-perpetuating cycle of inflammatory cytokines and proteins. The diagnosis of such disease is based on similar tests used in assessing traditional dry eye, taking into consideration findings specific to this patient population. The hallmark of treatment for these patients is to minimize the ocular surface inflammatory response by choosing glaucoma therapies that spare the ocular surface such as preservative free formulations and initiating dry eye treatment early in the course of care. In summary, glaucoma affects millions of patients around the world and chronic use of topical glaucoma medications may negatively impact the patient's ocular surface, symptoms, and vision. Understanding the pathogenesis of G-OSD, recognizing its risk factors and incorporating diagnostic and therapeutic strategies that restore and maintain ocular surface homeostasis will result in improved care for our patients.

Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life.

Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention. Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims. VA NHs, known as community living centers (CLCs). Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110). Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission. Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation. Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.

Symptomatic Hypercalcemia in Patients with Primary Hyperparathyroidism Is Associated with Severity of Disease, Polypharmacy, and Comorbidity.

Current primary hyperparathyroidism (PHPT) clinical presentation is asymptomatic in more than 90% of patients, while symptoms concern osteoporosis and rarely kidney stones. Here, we retrospectively investigated the prevalence of PHPT patients presenting with hypercalcemic-related symptoms (HS-PHPT) as cognitive impairment, changes in sensorium, proximal muscle weakness, nausea and vomiting, constipation, and severe dehydration, in a single center equipped with an emergency department and described their clinical features and outcome in comparison with a series of asymptomatic PHPT out-patients (A-PHPT). From 2006 to 2016, 112 PHPT patients were consecutively diagnosed: 16% (n = 18, 3M/15F) presented with hypercalcemic-related symptoms. Gastrointestinal symptoms occurred in 66% of HS-PHPT patients and cognitive impairment in 44%; one woman experienced hypertensive heart failure. Two-thirds of HS-PHPT patients were hospitalized due to the severity of symptoms. Comparing the clinical features of HS-PHPT patients with A-PHPT patients, no gender differences were detected in the two groups, while HS-PHPT patients were older at diagnosis (71 (61–81) vs. 64 (56–74) years, P=0.04; median (IQR)). HS-PHPT patients presented higher albumin-corrected calcium levels (12.3 (11.3–13.7) vs. 10.6 (10.3–11.3) mg/dl, P < 0.001); 4 HS-PHPT presented corrected calcium levels >14 mg/dl. Serum PTH levels and total alkaline phosphatase activity were higher in HS-PHPT. Reduced kidney function (eGFR < 45 ml/min) was prevalent in HS-PHPT patients (42% vs. 5%, P=0.05). No differences in kidney stones and osteoporosis were detected, as well as in the rates of cardiovascular comorbidities and main cardiovascular risk factors. HS-PHPT patients had an age-adjusted Charlson Comorbidity Index higher than that of the A-PHPT patients and were on chronic therapy with a greater number of medications than A-PHPT patients. In conclusion, hypercalcemic-related symptoms occurred in 16% of PHPT patients. Risk factors were severity of the parathyroid tumor function, multimorbidity, and polypharmacy.

PREDICTORS OF MEDICAL, SOCIAL SERVICE, AND MENTAL HEALTH USE AMONG PEOPLE WITH DEMENTIA AND THEIR CAREGIVERS

People with Alzheimer’s disease use more medical services (Eaker et al., 2002) and are admitted to inpatient facilities at higher rates (Zhu et al., 2015) than normal controls. In addition, social services provide support for caregivers and are associated with positive outcomes for care-recipients and their caregivers (Neville, Beattle, Fielding, & MacAndrew, 2014). Despite high level of need, utilization of mental health services and social agencies for caregiver support remains low (Goodarzi, Mele, Roberts & Holroyd-Leduc, 2017; Weber, Pirraglia & Kunik, 2011). Following the Andersen and Newman model (1973), we examined whether predisposing factors (i.e., age of the caregiver and type of PWD-caregiver relationship), needs (i.e., memory impairment, disruptive behaviors, depression, anxiety, pain, functional impairment, caregiver burden, total number of prescribed medications), and enabling factors (i.e., PWD and caregiver income, quality of the PWD-caregiver relationship) differentially predicted the presence of medical, social, and mental health service use. A total of 228 dyads (PWD and the caregiver) were included. We examined each PWD and caregiver characteristic individually (univariate models) and then as a unique predictor of each of the three service use outcomes (multivariate models). A greater number of medications uniquely predicted higher medical service use, greater pain severity and PWD income were uniquely associated with higher social service use, and a greater number of medications and increased memory impairment predicted more mental health service use. These results show that distinct factors predict use of different types of service use among PWD and their caregivers.