Medication Adjustments Research Articles

Abstract 50: The Comparison of Office Blood Pressure with Morning Home Blood Pressure: Self-Automated Measurement

Background: Morning hypertension is associated with poor cardiovascular outcomes. However, office blood pressure (OBP) remains a gold standard in hypertension monitoring and management. Unfortunately, the accuracy in OBP measurement is problematic. Objectives: This study aimed to determine whether routine or unattended OBP could accurately represent home blood pressure (HBP) in patients with hypertension. Methods: We conducted a single-center, cross-sectional study. Hypertensive patients aged between 18 and 80 years, capable of performing self-automated blood pressure measurement, were included in the study. Three self-automated methods of blood pressure measurement were performed: Routine OBP, unattended OBP, and HBP. All participants were instructed to rest for at least 5 minutes prior to measuring blood pressure, and HBP was recorded twice daily, in the morning and at night, for a week after the enrolled visit without antihypertensive medication adjustment. Results: Overall 190 consecutive patients were enrolled, with a mean age of 65.2 ±7.5 years old. Half of the patients had coronary artery disease or type 2 diabetes as comorbidities. Routine OBP was significantly higher than unattended OBP and HBP. Interestingly, Systolic values of unattended OBP were similar to those of morning HBP (mean difference -0.6 ±16.0 mmHg, p=0.641) with moderate correlation (r=0.516, p<0.001). Although diastolic values of unattended OBP were lower than those of morning HBP (mean difference -3.3 ±9.0 mmHg, p<0.001), the values were moderately correlated (r=0.581, p<0.001). Bland-Alman plots between unattended OBP and morning HBP were shown in Figure 1. Both systolic and diastolic values of unattended OBP and average HBP were significantly different (mean difference -3.5 ±14.9 mmHg, p=0.002, and 1.6 ±8.6 mmHg, p=0.013, respectively). Conclusion: Unattended OBP method could effectively represent morning HBP, thus advocating to use in clinical practice.

Abstract MP11: Evaluation of a Remote Patient Monitoring Hypertension Program with Telehealth Pharmacist Management in Nephrology Clinic Patients

Introduction: Remote patient monitoring (RPM) and physician-pharmacist collaborative models have potential in improving hypertension control. Herein, we report the effectiveness of a community based, self-measured blood pressure (SMBP) RPM program on BP control and healthcare utilization in a largely rural health system. Methods: A multidisciplinary team developed a self-measured blood pressure (SMBP) RPM program in central and northeast PA using a virtual platform with bluetooth-connected BP devices targeting patients with BP ≥140/90 mmHg seen in nephrology clinics. From 3/2022 to 9/2022, high BP notifications were transmitted to nephrologists. After 9/2022, BP notifications were transmitted first to pharmacists, who co-managed BP through collaborative practice agreements via telehealth. We captured pharmacist interventions by reviewing electronic health record documentation. Changes in SMBP over time and the effect of pharmacist interventions were analyzed using mixed effects models. All-cause hospitalizations and emergency room (ER) visits were compared in 6-month pre/post-enrollment periods. Results: A total of 205 patients (mean age 62.3y, clinic BP 146/84, 3.1 BP classes, 48% female, 53% CKD) were enrolled into the program and had ≥ 6 months follow-up data. SMBP control <140/90 improved from 30% during week 1 to 67% at 6 months and 74% at 12 months. Overall, systolic SMBP improved over the first 6 months with stronger effect on patients with higher baseline BP (baseline BP ≥150/100 mmHg: -3.3 mmHg/month (95% CI: -3.5, -3.1); baseline 140-149/90-99: -2.4 (95% CI: -2.6, -2.1) mmHg/month; baseline <140/90: -0.6 (-0.9, -0.4) mmHg/month). Pharmacist telehealth encounters were documented in 65% of patients; 46% had a BP medication adjustment; 37% had new BP medication classes, including 9% mineralocorticoid receptor antagonist. Pharmacist medication intervention was associated with greater decline in systolic BP over time (-1.3 mmHg/month; 95% CI: -1.6, -1.1). Comparing the 6 months pre vs. post-enrollment, patients experienced a reduction in hospitalizations (6.0% vs. 0%; Exact Mcnemar p=0.0005) and no difference in ER visits (14.9% vs. 12.9%; p=0.6). Conclusion: Participation in a nephrologist-pharmacist SMBP RPM program was associated with improvement in BP control and reduced hospitalizations. Future efforts are underway to refine delivery of this program for the largest impact on improving BP control.

Impact of Pharmacist-Led Interventions on Hypertension Management in Cancer Patients Undergoing Chemotherapy

Background: Hypertension (HT) is a common cardiovascular condition, particularly prevalent among cancer patients, with approximately 40% exhibiting concurrent diseases. This study aimed to investigate the relationship between hypertension and cancer, focusing on how anticancer treatments contribute to hypertension and its cardiovascular complications. Methods: A retrospective analysis was conducted at a specialized pharmacy involving adults receiving oral chemotherapy. Participants were divided into control (n=50) and intervention (n=29) groups, based on their enrollment in a pharmacist-led hypertension management program. Data were collected on blood pressure (BP) measurements and interventions, with statistical analyses employed to assess differences between groups. Results: The intervention group demonstrated significant improvement in BP management, with 19 out of 29 patients achieving controlled BP by February 2023 (p=0.04), compared to 21 out of 50 in the control group. Continuous monitoring led to a gradual decline in average BP measurements in the intervention group, indicating effective management. Pharmacists made recommendations to physicians, achieving a 100% acceptance rate for medication adjustments. Conclusion: Integrating pharmacist-led interventions in managing hypertension among cancer patients significantly improves BP control and patient outcomes. Given the rising prevalence of hypertension in this population, further research is necessary to explore the long-term effects of such interventions and their broader implementation in clinical practice.

Role of new generation implantable loop recorders in managing undiagnosed pediatric cardiac symptoms

Pediatric cardiac symptoms such as palpitations, syncope, or seizure-like episodes pose diagnostic challenges for general pediatricians. These symptoms, though often benign, may reveal underlying arrhythmias or inherited cardiac conditions (ICCs), affecting the quality of life and limiting activity participation. The purpose of this study is to determine the effectiveness and safety of implantable loop recorders (ILRs) in diagnosing and managing arrhythmias in pediatric patients. A retrospective cohort study conducted over an 8-year period from January 2016 to December 2023 in a single pediatric cardiology center. A cohort of 155 pediatric patients (median age 11.4 years) who underwent ILR implantation were selected based on symptoms such as palpitations, chest pain, or syncope, and those with previously recorded arrhythmias or high-risk ICCs. The primary outcomes were the diagnostic yield of ILRs for arrhythmias and subsequent changes in patient management. Diagnostic yield was defined as the detection of relevant arrhythmias, such as pauses of 3 s or longer, high-degree AV block, sinus node dysfunction, supraventricular tachycardia, ventricular tachycardia, or inappropriate sinus tachycardia. The median follow-up period was 2.3 years (845 days). Diagnostic arrhythmias were recorded in 60% of patients with symptom-activated transmissions and 80% of device-activated transmissions. Sinus pauses (37.5%) and VT (30%) were the most common arrhythmias detected. In patients with syncope (n = 76), 30% had relevant arrhythmias. In the palpitations group (n = 20), 35% had relevant arrhythmias. Approximately 80% of patients with ILR-diagnosed arrhythmias underwent targeted management, including medication changes and additional procedures. No significant complications were observed; minor complications occurred in 2.5% of patients.Conclusions: New generation ILRs are effective and safe for diagnosing and managing pediatric arrhythmias, providing significant reassurance to patients and families. Further studies are needed to evaluate the impact of ILRs on quality of life and sports participation in high-risk young patients.What is Known:• Pediatric Cardiac Symptoms: Symptoms like palpitations, syncope, and seizure-like episodes in pediatric patients pose significant diagnostic challenges.• Diagnostic Tools: Traditional diagnostic tools such as ECG, Holter monitors, and external loop recorders often have low diagnostic yields due to the sporadic nature of symptoms.• Implantable Loop Recorders (ILRs): ILRs have been shown to improve the diagnostic yield for arrhythmias in adults and provide long-term rhythm monitoring.What is New:• Effectiveness in Pediatrics: This study demonstrates that new generation ILRs significantly enhance the diagnostic yield for arrhythmias in pediatric patients with undiagnosed cardiac symptoms.• Safety and Efficacy: The study confirms that ILRs are both safe and effective in the pediatric population, with minimal complications and high diagnostic accuracy.• Targeted Management: Findings show that ILR-diagnosed arrhythmias lead to targeted management changes in approximately 80% of cases, including medication adjustments and additional procedures.• Long-term Monitoring: ILRs provide continuous long-term monitoring, offering reassurance to patients and families, and potentially improving quality of life and participation in activities for high-risk young patients.

Constipation is associated with an increased risk of major adverse cardiac events in a UK population.

Traditional cardiovascular risk factors, including hypertension, only explain part of major adverse cardiac events (MACEs). Understanding what other risk factors contribute to MACE is essential for prevention. Constipation shares common risk factors with hypertension and is associated with an increased risk of several cardiovascular diseases. We hypothesized that constipation is an underappreciated risk factor for MACE. We used the population healthcare and genomic data in the UK Biobank (n = 408,354) to study the contribution of constipation (ICD10 K59.0) to the risk of MACE, defined by any episode of acute coronary syndrome (ACS), ischemic stroke, and heart failure (HF). Analyses were controlled for traditional cardiovascular risk factors. We also assessed genetic correlations (rg) between constipation and MACE. Constipation cases (n = 23,814) exhibited a significantly higher risk of MACE compared with those with normal bowel habits [odds ratio (OR) = 2.15, P < 1.00 × 10-300]. Constipation was also significantly associated with individual MACE subgroups, in order: HF (OR = 2.72, P < 1.00 × 10-300), ischemic stroke (OR = 2.36, P = 2.02 × 10-230), and ACS (OR = 1.62, P = 5.82 × 10-113). In comparison with patients with constipation-free hypertension, patients with hypertension with constipation showed significantly higher odds of MACE (OR = 1.68, P = 1.05 × 10-136) and a 34% increased risk of MACE occurrence (P = 2.3 × 10-50) after adjustment for medications that affect gut motility and other traditional cardiovascular risk factors. Finally, we detected positive genetic correlations between constipation and MACE subgroups ACS (rg = 0.27, P = 2.12 × 10-6), ischemic stroke (rg = 0.23, P = 0.011), and HF (rg = 0.21, P = 0.0062). We identified constipation as a potential risk factor independently associated with higher MACE prevalence. These findings warrant further studies on their causal relationship and identification of pathophysiological mechanisms.NEW & NOTEWORTHY Analyzing 408,354 participants of the UK Biobank, we show that constipation cases exhibited a significantly higher risk of major adverse cardiac events (MACEs) than those with regular bowel habits. In comparison with patients with constipation-free hypertension, patients with hypertension with constipation showed significantly higher odds of MACE and a 34% increased risk of subsequent MACE occurrence. Finally, we detected positive genetic correlations between constipation and MACE. This association holds potential for therapeutic exploitation and prevention based on individuals' risk assessment.

Transition of mild cognitive impairment to Alzheimer's disease: Medications as modifiable risk factors.

Mild cognitive impairment (MCI) is a pre-clinical stage of Alzheimer's disease (AD). Understanding the transition probabilities across the disease continuum of AD, ranging from MCI to AD to Mortality is crucial for the economic modeling of AD and effective planning of future interventions and healthcare resource allocation decisions. This study uses the Multi-state Markov model to quantify the transition probabilities along the disease progression and specifically investigates medications as modifiable risk factors of AD associated with accelerated or decelerated transition times from MCI to AD, MCI to mortality, and AD to mortality. Individuals with MCI were identified from the National Alzheimer's Coordinating Center between September 2005 and May 2021. A three-state Markov model was postulated to model the disease progression among three states: MCI, AD, and mortality with adjustment for demographics, genetic characteristics, comorbidities and medications. Transition probabilities, the total length of stay in each state, and the hazard ratios of the use of medications for diabetes, hypertension, and hypercholesterolemia (the known modifiable risk factors of AD) were evaluated for these transitions. 3,324 individuals with MCI were identified. The probability of developing AD after one year since the initial diagnosis of MCI is 14.9%. After approximately 6 years from the initial diagnosis of MCI, the probability of transitioning to AD increases to nearly 41.7% before experiencing a subsequent decline. The expected total lengths of stay were 5.38 (95% CI: 0.002-6.03) years at MCI state and 7.61 (95%CI: 0.002-8.88) years at AD state. Patients with active use of lipid-lowering agents were associated with significantly lower hazards of transitioning from MCI to AD (HR: 0.83, 95%CI:0.71-0.96), MCI to mortality (HR: 0.51, 95%CI:0.34-0.77), and AD to mortality (HR: 0.81, 95%CI:0.66-0.99). Results suggest that lipid-lowering agents may confer a protective effect, delaying the onset of AD. Additionally, lipid-lowering agents indicate a favorable association with a longer survival time.

Digital Twin in Managing Hypertension Among People With Type 2 Diabetes: 1-Year Randomized Controlled Trial

BackgroundDigital twin (DT)-guided lifestyle changes induce type 2 diabetes (T2D) remission but effects on hypertension (HTN) in this population are unknown. ObjectivesThe purpose of this study was to assess effects of DT vs standard of care (SC) on blood pressure (BP), anti-HTN medication, HTN remission, and microalbuminuria in participants with T2D. MethodsThis is a secondary analysis of a randomized controlled trial in India of 319 participants with T2D. Participants were randomized to DT group (N = 233), which used artificial intelligence-enabled DT technology, or SC group (N = 86). A Home Blood Pressure Monitoring system guided anti-HTN medication adjustments. BP, anti-HTN medications, HTN remission rates, and microalbuminuria were compared between groups. ResultsAmong the 319 participants, 44 in DT and 15 in SC group were on anti-HTN medications, totaling 59 (18.4%) participants. DT group achieved significant reductions in systolic blood pressure (−7.6 vs −3.2 mm Hg; P < 0.007) and diastolic blood pressure (−4.3 vs −2.2 mm Hg; P = 0.046) after 1 year compared with SC group. 68.2% of DT group remained off anti-HTN medications compared to none in SC group. Among participants with HTN, DT subgroup achieved higher rates of normotension (40.9% vs 6.7%; P = 0.0009) and HTN remission (50% vs 0%; P < 0.0001) than SC subgroup. DT group had a higher rate of achieving normoalbuminuria (92.4% vs 83.1%; P = 0.018) at 1 year compared with SC group. ConclusionsArtificial intelligence -enabled DT technology is more effective than SC in reducing BP and anti-HTN medications and inducing HTN remission and normoalbuminuria in participants with HTN and T2D. (A Novel WholeBody Digital Twin Enabled Precision Treatment for Reversing Diabetes; CTRI/2020/08/027072)

The reduction of LEDD leads to visual dysfunction in patients with PD after STN-DBS: a randomized clinical trial

Background: Medication adjustment after deep brain stimulation (DBS) of the subthalamic nucleus (STN) in patients with Parkinson’s disease (PD) may influence visual function. However, no clinical trials have been designed specifically to investigate this effect. Objectives: To compare the effects of levodopa equivalent daily dose (LEDD) reduction and non-reduction on visual function in patients with Parkinson’s disease (PD) following STN-DBS. Methods: This was a multi-center, prospective, randomized, double-blinded clinical trial. A total of 208 patients with Parkinson’s disease were referred for DBS between June 2019 and July 2021 and analyzed between June 2023 and July 2023. STN-DBS was performed, and the LEDD was reduced in one study arm but not in the other. The primary outcome measure was visual impairment in Parkinson’s disease questionnaire (VIPD-Q) with or without LEDD reduction 12 months postoperatively, and the secondary outcomes included retinal nerve fiber layer (RNFL) thickness, vessel density, eye-tracking system results, contrast sensitivity and visual field. Results: During the short-term follow-up, DBS implantation and stimulation did not significantly affect visual function (VIPD-Q, baseline vs. 1 month, 9.269±8.385 vs. 8.938±7.666, Mann–Whitney U tests; P=0.6746). In the long-term follow-up, the reduction group demonstrated a significant decline in visual function, RNFL thickness, and vessel density after STN-DBS compared with the control group without STN-DBS (P&lt;0.001). Conclusions: Visual dysfunction, particularly a thinner RNFL and lower vessel density, is related to LEDD reduction after STN-DBS. Prolonged administration of dopamine-mimetic drugs prevents visual symptoms. Thus, physicians should consider LEDD adjustment when patients report visual dysfunction before surgery or severe visual symptoms after STN-DBS.

Decision Support and Behavioral Health for Reducing High-Dose Opioids in Comorbid Chronic Pain, Depression and Anxiety: Stepped-Wedge Cluster Randomized Trial.

High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors. Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions. Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA. Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls. EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management. Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation. Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants. Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain. ClinicalTrials.gov ID NCT03889418.

Evaluation of Patient Outcomes after Pharmacological Intervention in Home Health Care Utilizing Pharmaceutical Care Records

The purpose of this study was to identify patient outcomes after pharmacist interventions in the home health care context using pharmaceutical care records accumulated during daily operations. We focused on 591 cases at Nakajima Pharmacy from April 2020 to December 2021, where dispensing fees were charged to prevent duplication of medication and unnecessary interactions of home patients (excluding those related to adjustment of ongoing medications). The study investigated the content and background of prescription changes, the follow-up rate, and patient outcomes. The most common circumstances that led to pharmacist intervention for homebound patients were symptom occurrence (uncontrolled symptom, new symptom, drug adverse event). Of the patients for whom pharmacist intervention was provided for symptoms, 72.8% received follow-up according to the pharmaceutical care records. Furthermore, 59.2% of patients with follow-up showed an improvement of their symptoms. In addition, many patients had their medications discontinued or the dosage reduced by the pharmacist despite stable symptoms. More than 90% of these patients showed no change in symptoms. Besides interventions associated with the occurrence of symptoms, many interventions related to medication adherence were found to result from the patient's physical condition, such as poor swallowing function. The results suggest that tracking pharmacy drug histories may help pharmacists to better understand the need for follow-up implementation and the changes in patient outcomes after interventions.

Effects of an Intervention to Improve Evidence-Based Care for People With Diabetes and Cardiovascular Disease Across Sex, Race, and Ethnicity Subgroups: Insights From the COORDINATE-Diabetes Trial.

Results from the COORDINATE-Diabetes trial (Coordinating Cardiology Clinics Randomized Trial of Interventions to Improve Outcomes - Diabetes) demonstrated that a multifaceted, clinic-based intervention increased prescription of evidence-based medical therapies to participants with type 2 diabetes and atherosclerotic cardiovascular disease. This secondary analysis assessed whether intervention success was consistent across sex, race, and ethnicity. COORDINATE-Diabetes, a cluster randomized trial, recruited participants from 43 US cardiology clinics (20 randomized to intervention and 23 randomized to usual care). The primary outcome was the proportion of participants prescribed all 3 groups of evidence-based therapy (high-intensity statin, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and sodium-glucose cotransporter-2 inhibitor or glucagon-like peptide 1 receptor agonist) at last trial assessment (6 to 12 months). In this prespecified analysis, mixed-effects logistic regression models were used to assess the outcome by self-reported sex, race, and ethnicity in the intervention and usual care groups, with adjustment for baseline characteristics, medications, comorbidities, and site location. Among 1045 participants with type 2 diabetes and atherosclerotic cardiovascular disease, the median age was 70 years, 32% were female, 16% were Black, and 9% were Hispanic. At the last trial assessment, there was an absolute increase in the proportion of participants prescribed all 3 groups of evidence-based therapy in women (36% versus 15%), Black participants (41% versus 18%), and Hispanic participants (46% versus 18%) with the intervention compared with usual care, with consistent benefit across sex (male versus female; Pinteraction=0.44), race (Black versus White; Pinteraction=0.59), and ethnicity (Hispanic versus Non-Hispanic; Pinteraction= 0.78). The COORDINATE-Diabetes intervention successfully improved delivery of evidence-based care, regardless of sex, race, or ethnicity. Widespread dissemination of this intervention could improve equitable health care quality, particularly among women and minority communities who are frequently underrepresented in clinical trials. URL: https://www.clinicaltrials.gov. Unique identifier: NCT03936660.

Evaluating the benefit of medical adjustment on the predictive accuracy of the revised trauma index

In the early 1970s, data from emergency trauma units was used to develop the trauma index (TI) as a triage tool for non-physicians. Over the next two decades several modifications were made to the TI, and in 1990 a revised trauma index (RTI) was published. Throughout the 1990s, modifications to the RTI concerning pre-existing medical conditions (PEC) have been studied. Our study incorporated a PEC scoring system into the RTI, and evaluated its performance against using the RTI alone. The addition of PECs to the trauma index improved its accuracy in predicting overall outcome as shown by the increase in the kappa score from 0.42 to 0.73. Based on this finding, we suggest incorporating a PEC scoring system into the revised trauma index to better predict patient outcomes.

Comparative Efficacy of Hypertension Management Strategies.

Hypertension (HTN) is a major cardiovascular risk factor and a significant contributor to disease burden in the United States. Despite therapeutic advances, gaps remain between clinical trials and practice. This study aims to bridge those gaps by evaluating antihypertensive strategies. This was a retrospective analysis of HTN patients seen at a hospital clinic from 2016 to 2022 with 3- and 12-month follow-up appointments. Demographics, history, blood pressure (BP), and medication regimen were recorded. Treatment strategies were categorized as follows: adding medication (AM), increasing dosage (ID), switching medications (SM), dropped medications (DrM), or no change (NC). Changes in systolic blood pressure (SBP) were compared using linear regressions to assess the efficacy of HTN management. Of 873 patient charts reviewed, 332 patients were included. The AM group had an adjusted ∆SBP of -11 mm Hg at 3 months ( p < 0.001) and -9 mm Hg at 12 months ( p = 0.006). The ID group had an ∆SBP of -8.5 mm Hg at 3 months ( p = 0.074) and -7 mm Hg at 12 months ( p = 0.3). ∆SBP between the AM and ID groups was not statistically significant ( p = 0.8). SM was associated with an ∆SBP of -3 mm Hg at 3 months ( p = 0.6) and -3 mm Hg at 12 months ( p = 0.7). There are meaningful differences in SBP reduction between antihypertensive medication adjustment strategies. AM had the greatest effect on lowering SBP, with ID having a slightly lesser effect. The difference in ∆SBP between the AM versus ID groups was not significant. While further study with a larger dataset is warranted, our findings highlight trends in the efficacy of HTN management strategies to help guide therapeutic regimens.

A cross-sectional study on the potential drug-drug interaction risk ofCOVID-19 patients in hospital.

To investigate the incidence of and risk factors for potential drug-drug interactions (DDIs) among elderly patients with corona virus disease 2019 (-COVID-19) in hospital and to explore management strategies to reduce the occurrence of potential DDIs and ensure patient medication safety. This was a descriptive, retrospective cross-sectional study among patients aged 65 years and older who were hospitalized with COVID-19. Potential DDIs associated with prescriptions containing two or more medicines were analyzed with Lexicomp software, the incidence of DDIs was calculated, recommendations for medication adjustment were formulated, and the χ2-test and binary logistic regression were used to analyze related risk factors. A total of 772 prescriptions were analyzed, 527 (68.26) of which involved 5,732 potential DDIs. The results of this study showed that a total of 152 (28.84%) prescriptions had 270 X risk class potential DDIs (i.e., avoid combining), 313 (59.39%) prescriptions had 1,161 D risk class potential DDIs (i.e., consider therapy modification), and 476 (90.32%) prescriptions had 4,301 C risk class potential DDIs (i.e., monitor therapy). The study findings showed that the total number of drugs (p<0.001), the length of hospital stay (p<0.001), and the number of comorbidities (p<0.001) were risk factors affecting the occurrence of potential DDIs. This study identified factors associated with potential DDIs, which can assist in changing medication strategies, preventing adverse drug reactions, and improving clinical efficacy.

IMPACT OF CREATING MENTAL HEALTH HELPLINE AT A TERTIARY CARE PSYCHIATRIC SET-UP IN PAKISTAN DURING THE COVID -19 PANDEMIC

Objectives The objectives of this study were to analyze the calls received at a 24-hour helpline service set up at the Institute of Psychiatry during the first wave of the COVID-19 pandemic for the demographics of the service users, the reasons for calling the helpline phone, and the guidance provided. Design Descriptive retrospective clinical audit Place and Duration of Study The Institute of Psychiatry, from June 2020 and February 2021 Patients and Methods The entries made detailing the call records by psychiatry residents managing the helpline were analyzed. Data was extracted regarding age, area of residence, and reasons for calling by the service users of the helpline, as well as the advice given by the resident on call. The statistical analysis was performed using SPSS version 26, and findings were evaluated in terms of age, geographical distribution, reasons for seeking assistance, and the type of guidance provided thereof. Results Of the 102 calls analyzed, most of the callers were between 30 to 39 years of age (33.3%), and hailed from Rawalpindi (78.4%), followed by Kashmir (5.9%), Chakwal (4.9%) and Murree (3.9%). The most frequently stated reasons for calling were to ask about availability of out-patient services (36.3%), to have medication revised (23.5%), and to enquire about the side effects of medication (11.8%). Other reasons included recurrence of symptoms or lack of improvement in patients already taking treatment (15.7%) and to seek help regarding new psychiatric symptoms (12.7%). The responses given to the callers were invitation to come to the hospital (44.1%), provision of relevant information about the particular questions asked (for example, relating to hospital timings) (36.3%), adjustment of medications (11.8%), and prescribing medication with advice of physical follow-up (7.8%). Conclusion Despite psychiatric out-patient department being temporarily closed down during the initial waves of the COVID 19 pandemic, efforts were made to continue service provision through innovative means, like the 24-hour helpline service. There is a need to further incorporate the use of technology in the delivery of psychiatric services.

Preconception counseling impact in pregnancy outcomes in patients with spondyloarthritis

Introduction: Spondyloarthritis (SpA) is a group of chronic inflammatory diseases, often affecting women in reproductive age, which can have a significant impact on the reproductive health of women. Preconception counselling and medication adjustments have shown to reduce flares and improve pregnancy outcomes in women with rheumatoid arthritis. However, in women with SpA, data of the impact of preconception counselling on pregnancy outcomes is scarce. The aim of this study is to evaluate its impact. Methods: In this retrospective multicentric study, data was collected from medical records of women who gave birth from 2020 to 2022. The study included 45 pregnancies, which were divided into two categories - whether they received preconception consultation or not. Data was collected on patient characteristics, disease duration, medications used, and preconception counselling. Maternal and foetal outcomes were studied. Results: In this study involving 45 patients, radiographic axial spondyloarthritis was the most prevalent type (16 cases), with psoriatic arthritis showing the highest preconception consultation rate (80.0%), with an average of 33.90 years. Lower rates of contraindicated medication were used during pregnancy (0.0%) in counselled patients versus those without counselling (20.0%). Sulfasalazine usage was higher in non-counselled patients (77.8%), while certolizumab pegol use was higher in counselled patients (33.3%). Pregnancy outcomes showed no significant difference in successful pregnancies, but counselled patients experienced significantly fewer postpartum flares (6.4% vs 36.6%). Gestational age at delivery and newborn weight did not significantly differ between groups. Foetal malformation occurred in 2.6% of the population, with no significant difference based on counselling status. Conclusion: Preconception counselling in women with SpA can increase the likelihood of medication adjustments before pregnancy and decrease the occurrence of flares postpartum. These findings suggest that preconception counselling should be implemented in the management of pregnant women with SpA to improve pregnancy outcomes. Further studies are needed to confirm the effectiveness of preconception counselling and to determine the optimal approach.

Overdosing of direct oral anticoagulants

Direct oral anticoagulants (DOAC) are increasingly used for prophylaxis and treatment of thromboembolic events. Incorrectly dosed DOAC treatment is associated with excess mortality. This article aims at raising awareness of DOAC overdosing and its causes as well as presenting adiagnostic and therapeutic work-up. Based on acase presentation, astructured review of the current literature on DOAC overdosing was performed and treatment recommendations were extracted. In addition to wittingly or unwittingly increased DOAC intake, common causes of overdose are inadequate dose adjustment for concomitant medication or comorbidities. Global coagulation testing should be supplemented with DOAC-specific testing. Severe bleeding and the need for invasive diagnostics or urgent surgery represent indications for treating DOAC overdoses. Based on the cause of an DOAC overdose, active charcoal, endoscopic pill rescue, antagonization with idarucizumab or andexanet alfa and the targeted substitution of coagulation factors represent treatment options. The sensitization of clinicians is important to ensure atimely diagnosis and adequate treatment of DOAC overdosing. This report provides an overview of current knowledge on diagnostics and treatment; however, further studies are necessary to improve the existing algorithms.

Cognitive and physical fatigue: the experience and consequences of 'brain fog' after Spontaneous Coronary Artery Dissection (SCAD), a qualitative study.

Brain fog and fatigue are common issues after acute coronary syndrome. However, little is known about the nature and impact of these experiences in spontaneous coronary artery dissection (SCAD) survivors. The aims of this study were to understand the experiences of brain fog and the coping strategies used after SCAD. Participants were recruited from the Victor Chang Cardiac Research Institute Genetics Study database and were considered eligible if their event occurred within 12-months. Seven semi-structured online focus groups were conducted between December to January 2021-2022, with this study reporting findings related to brain fog and fatigue. Interviews were transcribed and thematically analysed using an iterative approach. Participants (N=30) were a mean age of 52.2 ((9.5) and mostly female (n=27, 90%). The overarching theme of brain fog after SCAD included four main themes: how brain fog is experienced, perceived causes, impacts, and how people cope. Experiences included memory lapses, difficulty concentrating and impaired judgement, and perceived causes included medication, fatigue and tiredness, and menopause and hormonal changes. Impacts of brain fog included rumination, changes in self-perception, disruption to hobbies/pastimes, and limitations at work. Coping mechanisms included setting reminders and expectations, being one's own advocate, lifestyle and self-determined medication adjustments, and support from peers. Brain fog is experienced by SCAD survivors and the impacts are varied and numerous, including capacity to work. SCAD survivors reported difficulty understanding causes and found their own path to coping. Recommendations for clinicians are provided.

Early symptom improvement and other clinical predictors of response to repetitive transcranial magnetic stimulation for depression

BackgroundRepetitive transcranial magnetic stimulation (rTMS) is a rapidly emerging treatment for depression, but outcome prediction is still a challenge. This study aimed to identify predictors of response to rTMS among baseline clinical factors and early symptomatic improvements. MethodsThis cohort study comprised 136 patients with a unipolar or bipolar depressive episode referred for clinical intermittent theta-burst stimulation or right-sided 1 Hz rTMS at the Uppsala Brain Stimulation Unit. The co-primary outcomes used for logistic regression were response, defined as ≥50 % reduction of Montgomery and Åsberg Depression Rating Scale Self-assessment (MADRS-S) total score, and 1–2 points on the Clinical Global Impression Improvement (CGI-I) scale. Early improvement was defined as ≥20 % reduction in the MADRS-S total score, or ≥ 1 point reduction in each MADRS-S item, after two weeks of treatment. ResultsThe response rates were 21 % for MADRS-S and 45 % for CGI-I. A depressive episode >24 months had lower odds for MADRS-S response compared to ≤12 months. Early improvement of the MADRS-S total score predicted CGI-I response (95 % CI = 1.35–9.47, p = 0.011), Initiative6 predicted MADRS-S response (95 % CI = 1.08–9.05, p = 0.035), and Emotional involvement7 predicted CGI-I response (95 % CI = 1.03–8.66, p = 0.044). LimitationsNo adjustment for concurrent medication. ConclusionsA depressive episode ≤12 months and early improvement in overall depressive symptoms, as well as the individual items, Initiative6 and Emotional involvement7, predicted subsequent rTMS response in a naturalistic sample of depressed patients. This could facilitate the early identification of patients who will benefit from further rTMS sessions.

Paradigm shift in Parkinson's disease: using continuous telemonitoring to improve symptoms control. Results from a 2-years journey.

Conventional care in Parkinson's disease (PD) faces limitations due to the significant time and location commitments needed for regular assessments, lacking quantitative measurements. Telemonitoring offers clinicians an opportunity to evaluate patient symptomatology throughout the day during activities of daily living. The progression of PD symptoms over a two-year period was investigated in patients undergoing traditional evaluation, supplemented by insights from ambulatory measurements. Physicians integrated a telemonitoring device, the PDMonitor®, into daily practice, using it for informed medication adjustments. Statistical analyses examining intra-subject changes for 17 subjects revealed a significant relative decrease of -43.9% in the device-reported percentage of time spent in "OFF" state (from 36.2 to 20.3%). Following the 24-month period, the majority of the subjects improved or exhibited stable symptom manifestation. In addition to positively impacting motor symptom control, telemonitoring was found to enhance patient satisfaction about their condition, medication effectiveness, and communication with physicians. Considering that motor function is significantly worsened over time in patients with PD, these findings suggest a positive impact of objective telemonitoring on symptoms control. Patient satisfaction regarding disease management through telemonitoring can potentially improve adherence to treatment plans. In conclusion, remote continuous monitoring paves the way for a paradigm shift in PD, focusing on actively managing and potentially improve symptoms control.