Medication Profiles Research Articles

Accuracy of an electronic prescribing system for standard treatments

BackgroundThe prescription system known as RELE is the electronic prescribing and dispensing system that has been used by the Balearic Islands Health Service (IB-SALUT, Spain) since April 2006. This repository...

Efficacy of Treatments Targeting Hypothalamic-Pituitary-Adrenal Systems for Major Depressive Disorder: A Meta-Analysis.

Abnormal hypothalamic-pituitary-adrenal (HPA) axis has been implicated in major depressive disorder (MDD). A number of studies have attempted to use HPA-modulating medications to treat depression. However, their results are inconsistent. The efficacy of these drugs for MDD remains uncertain. The aims of this meta-analysis were to determine the effect and safety profile of HPA-targeting medications for MDD. World of Science and PubMed databases were comprehensively searched up to March 2021. All randomized controlled trials (RCTs) and open-label trials exploring antiglucocorticoid and related medications in patients with depression were included. Standardized mean differences (SMDs) and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for continuous or dichotomous outcomes, respectively. In the meta-analysis, we identified 16 RCTs and seven open-label studies that included 2972 subjects. Pooling the change data that assessed the efficacy across all included HPA-targeting medications for depression showed a significant difference between interventions and controls with very small heterogeneity after influence analysis (SMD = 0.138, 95%CI = 0.052, 0.224, p = 0.002; I2 = 20.7%, p = 0.212). No obvious publication bias was observed (p = 0.127). Effectiveness remained significant in patients with MDD (SMD = 0.136, 95%CI = 0.049, 0.223, p = 0.002). Subgroup analysis showed a significant difference favoring mifepristone and vasopressin 1B (V1B) receptor antagonist treatment. Adverse events were reported by 14 studies and our analysis of high-quality studies showed a significant difference in favor of controls (RR = 1.283, 95%CI = 1.134, 1.452, p = 0). Our study suggested that patients with MDD may benefit from mifepristone and V1B receptor antagonist treatments that have tolerable side effects. HPA-based medications are promising for depression treatment. However, additional high-quality RCTs, including head-to-head trials, are needed.Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/, identifier registration number: CRD42021247279

Post-Market Surveillance of a Blood Glucose Test Strip Demonstrates No Evidence of Interference on Clinical Accuracy in a Large Cohort of People with Type 1 or Type 2 Diabetes.

Regulations and industry guidance relating to testing for interference in blood glucose monitoring (BGM) systems continue to focus on in vitro laboratory bench tests. Post-market surveillance (PMS) in a clinical setting allows for BGM accuracy assessments to evaluate the impact of real-world exposure to polypharmacy in people with diabetes. This study evaluated the OneTouch Select Plus® BGM test-strip accuracy with respect to polypharmacy using a clinical registry dataset. Medication profiles were analysed for 1023 subjects (425 with type 1 (T1D) and 598 with type 2 diabetes (T2D)) attending 3 UK hospitals. Blood samples were analysed to determine clinical accuracy of the BGM test-strip against a laboratory comparator. 538 different medications (48 diabetes and 490 non-diabetes) were recorded across the 1023 subjects. Patients took on average 6.9 (n = 1-36) individual medications and 4.1 (n = 1-13) unique medication classes. Clinical accuracy to EN ISO 15197:2015 criteria were met irrespective of increasing average number of individual medications, categorized from 1-3, 4-6, 7-9, 10-12 and >12 taken per subject (97.7%, 97.7%, 97.8%, 97.8%, and 98.4%, respectively). Clinical accuracy criteria were met across 15 classes of medication using the combined dataset (97.9%; 29784/30433). Surveillance Error Grid (SEG) analysis showed 98.7% (29959/30368) of readings presented no clinical risk. No individual class or combination of medication classes impacted clinical accuracy of the BGM test-strip. Clinical performance for the test strip under assessment demonstrated no evidence of interference from over 500 prescription medications, with clinical accuracy maintained across a range of polypharmacy conditions in people with diabetes.

Current Perspectives Regarding The Effects of Muscular Exercise on Neurological Disorders: A Literature Review

Abstract Regular physical exercise is a well-known mechanism for preventing and treating several health conditions, from the general improvement of the overall health condition and the prevention of obesity and increasing the arterial collater-alization and blood flow to the upregulation of antiinflamma-tory and antioxidant signaling cascades. The beneficial effects of regular physical exercise are far-reaching and diverse. Chronic neurological disorders are considered a significant public health concern. Given the fact that the available treat-ment modalities in most neurological conditions are not fully curative and aiming primarily at improving the quality of life and the ability to cope, with a wide side effect profile of the available medications to the high cost of other available methods as electric stimulation devices, this highlight the importance of investigating the beneficial roles of regular physical exercise, both as a preventive and a curative tool, indifferent chronic neurological diseases. This short review of the literature highlights the recent research finding and mechanisms of the beneficial effects of exercise in different chronic neurological diseases.

Differential Diagnosis and Treatment of Itching in Children and Adolescents.

Itching is prevalent in children with skin disorders and associated with effects on their mood, quality of life, and social functioning. Surprisingly, there are no data on childhood prevalence of pruritus in the general population. The aim of this article is to explore the epidemiology, clinical manifestation, and treatment for itch (pruritus) in the pediatric population (from infancy to adolescence), and to be helpful to primary care physicians who assess and diagnose pediatric patients with itching. In this study, we searched for specific keywords using PubMed and MEDLINE (Ovid) and, then, refined the retrieved searches for each cause and treatment. As a result of reviewing the literature, atopic dermatitis was shown to be the most common cause of itching, especially during infancy and through preschool. Not only skin disorders but also systemic diseases, drugs, and postburn states can predispose an individual to itching in childhood. There are traditional and newly developed treatment modalities for itching in pediatric patients. However, because the pharmacokinetics and pharmacodynamics of childhood are different from those of adults, the medications for itching have to be applied carefully for these age groups. There are many areas to be elucidated regarding the prevalence and objective assessment of pruritus in pediatric patients. Moreover, the safety profiles of medications in the pediatric population need to be better understood. Further studies to investigate itching in childhood are warranted.

Psychiatric comorbidity and quality of life in patients with epilepsy on anti-epileptic monotherapy and polytherapy.

Objective:The bio-psycho-social factors affecting the quality of life in patients with epilepsy can be numerous but are often overlooked. The behavioral side effects of anti-seizure medications can be one such potential factor. The aim of the study is to address the effect of the number of anti-seizure medications on the development of psychiatric comorbidity and quality of life in patients with adequate seizure control.Materials and Methods:The study recruited 100 participants with generalized tonic-clonic seizures from a tertiary care center in North India, who were seizure-free from the last 1 month. The study participants were divided into two groups based on whether they were on monotherapy or polytherapy. The two groups were matched for their socio-demographic and clinical profile. We assessed for psychiatric comorbidity in each group using Mini International Neuropsychiatric Interview. All the study participants were given Hindi translated version of quality of life in the epilepsy-31 questionnaire for objective assessment of the quality of life.Results:The patients receiving anti-epileptic polytherapy had significantly higher prevalence of psychiatric comorbidity than patients on monotherapy. Furthermore, the patients on polytherapy scored significantly less on the cognitive domain of quality of life as well as the overall quality of life domain in the epilepsy-31 questionnaire.Conclusion:The patients with epilepsy must be evaluated for psychiatric comorbidity and side effect profile of anti-seizure medications to improve the quality of life. This is particularly more important for patients who are on anti-epileptic polytherapy even if the seizure control is adequate.

Severe Hypertension During Pregnancy: Considerations for Preventive Measures by Health Care Providers

Medical professionals advocate that getting good health care before, during, and after pregnancy (which occurs when a sperm fertilizes an egg after it is released from the ovary during ovulation) is very important. This practice can help baby grow and develop sound physical and mental health during later stages of their life. Further, it is equally important to ensure that pregnant women are not subjected to hypertension situations. Furthermore, severe hypertension (defined as severely elevated blood pressure) can be risky from reproductive health (RH) point of view. However, pregnancy-induced hypertension (PIH) is common among pregnant women in many countries, especially in regions characterized by acute poverty and resulting malnutrition situations. It has been reported that the PIH, a form of high blood pressure (BP) in pregnancy, occurs, on an average, in about 7–10% of all pregnancies. It has also been found that many women are confronted with another type of high BP: chronic hypertension, a medical condition, wherein high BP prevails before pregnancy begins. These situations make it significant that the issue of severe hypertension during pregnancy is addressed adequately. It is in this context that the present research paper has been authored, wherein attempts have been made to investigate into strategic interventions that health care providers need to envisage, while treating pregnant women with severe hypertension conditions. This forms the specific objective of this research. With regards to general objectives, this review paper will briefly (a) address the important considerations in management of hypertension during pregnancy, and (b) discuss the future directions in this field. In terms of research mythology employed here, the author has collected secondary data from sources, such as books, book chapters, journal articles, government publications, as well as publications (and policy documents) brought out by the inter-governmental organizations. Data sources are quoted under reference section of the research. Data used are largely ‘qualitative’ in nature. Method of data analysis is ‘descriptive’. It involves desk-based research, as various research reports and other documents (including policy review reports) on subject areas related to hypertension during pregnancy have been studied by the author in order to derive conclusions and key findings (in accordance with objectives). This paper concludes that health care providers should ensure that women with chronic hypertension undergo a pre-pregnancy evaluation, with a focus on medication profile.

Systemic medicines taken by adult special care dental patients and implications for the management of their care.

Introduction Significant changes have taken place in the profile of prescription medicines being taken by the adult UK population over the last decade. The aims of this article are to review the literature to understand the overall trends and underlying factors, and then to compare this with the medication profile of a cohort of adult special care dental (SCD) patients. Materials and method Five hundred patient records were examined and retrospective data on systemic medicines being taken were obtained and classified according to the index used in the British National Formulary (BNF).Results The results revealed a high level of polypharmacy with 57% of SCD patients taking three or more medicines compared to 24% of the population in England. Antiepileptic drugs were the most frequently taken group of medicines (42%), followed by antidepressants (39.7%) and antipsychotics (37.6%). Conclusions Our results demonstrate the medical complexity of patients in this cohort and enable clinicians to increase their familiarity with the most commonly taken medicines and the tools available to manage the implications for dental care.

Does Venous Thromboembolism Prophylaxis Policy Have Any Impact on Clot Risk Reduction in Hospitalized Solid Tumor Patients at Princess Margaret Cancer Centre: A Longitudinal Study?

BackgroundWe continued to witness a strong associations between cancer and the development of blood clots in the in-patient hospital setting. Patients are being treated for a venothromboembolism (VTE) event at any given time. The primary objective of this retrospective study is to determine the safety and efficacy impact of VTE prophylaxis (Prx.) by measuring the incidences of VTE before and after implementation of our prophylaxis policy over a span of 9 years, in order to gauge the clinical impact of this policy.MethodDischarged Abstract Database (DAD) was used to extract post admitted PE and DVT events based on patients' primary diagnosis of solid tumor identified by the ICD-10-CA diagnosis codes. DAD identified the number of total patients or visits admitted to the in-patient units during the fiscal years of 2007 to 2016. Post-Admit VTE bleeding and death while on prophylaxis anticoagulant was also documented. From the pharmacy generated reports over the same period, the medication profile for each patient was cross-referenced with the DAD documented VTE events for accuracy. The timing of anticoagulant ordering for a given VTE event was checked against the information documented in the radiology/imaging section of the electronic patient record. Patients who came in with a full anticoagulant treatment regimen were removed from analysis. Similarly, patients who began anticoagulation treatment during the first 48 hours of hospital admission were also removed from analysis. The resulting vetted patient list containing only those who developed VTE 48 hours post-admission during their hospital stay, and receiving prophylaxis was the target population for analysis. The patients then were divided into two groups; pre-policy 2007-2012 and post-policy 2012-2016, policy implementation date was Sept. 2012. Each of these patient groups was analyzed and categorized by VTE risk according to the in-patient Padua risk score. When available, any information on bleeding in the presence of anticoagulation was reported. The proportion of patient population (*) receiving VTE prophylaxis was evolving in an increasing trend over the study period (from 2007 to policy 2012). The rate of Prx. post policy was close to 100%.ResultsTable 1. Comparisons between pre- and post- policy period in those received Prx. vs. no Prx., as well as risk scores and incidences of VTE within the two groups of patients with or without Prx.ConclusionThe VTE Prx. policy in the in-patient setting has demonstrated positive impact in reducing the absolute number of incidence over the study period (p=0.0020). The bleeding incidence was low in the both pre- and post- periods. The documented 3 deaths in the pre- period was attributable to PE and none of these patients received Prx. Although VTE events in both pre- and post- periods were similar (18 and 20 respectively), these patients received routine Prx. The breakthrough VTE cases while on Prx. may be explained by the high Padua risk scores. In addition to cancer, obesity (Ave. wt. 77 kg, med. Wt. 75kg in pre- and Ave. Wt. 75.5kg, med Wt. 71kg in post-period), reduce mobility, acute infection and hormonal treatments (glucocortico-steroid) may have accounted for the significant VTE risks. Standard dose of enoxaparin 40mg once daily provided VTE prevention in the majority of our hospitalized patients, however a weight-based dosing schema may be needed for higher risk patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Profile of Prescription Medication in an Internal Medicine Ward.

Aging-related loss of resilience associated with the lack of evidence regarding the therapeutic efficacy of medicines can prompt a lack of efficacy of treatments and multiple prescriptions. This work aims to characterize the medication profile of Portuguese older adult inpatients and explore the relationship between hospitalization days and the consumption of medicines. A retrospective data analysis study in older patients who were admitted to a medical internal medicine ward during 2019. The median age of the 616 patients included was 85 years. During the hospitalized period, patients took on average 18.08 medicines. The most prescribed drugs belong to the subgroup of (a) anti-thrombotic agents (6.7%), with enoxaparin being the most prescribed, (b) other analgesics and antipyretics (6.6%), paracetamol being the most frequent, and (c) the Angiotensin Conversion Enzyme Inhibitor (ACE) (6.5%), captopril being the most frequent. The high number of prescriptions in older adults during their hospitalization suggests the need of changing therapeutics to achieve a better efficacy of treatment, which corroborates the hypothesis that the lack of scientific evidence concerning the risk/benefits of many medical therapies in older adults can make it difficult to achieve good clinical outcomes and promote the wastage of health resources.

Impact of Interferons and Biological Drug Inhibitors of IL-2 and IL-6 on Small-Molecule Drug Metabolism Through the Cytochrome P450 System.

Assess the impact of interferons and interleukin (IL)-2 and IL-6 inhibitors on cytochrome P450 (CYP) drug metabolism in human subjects. PubMed search from 1980 to March 31, 2021, limited to human subjects and English language via search strategy: (biological drug names) [AND] (cytochrome [OR] CYP metabolism). Narrative review of human studies assessing biological drugs in select classes that affect CYP drug metabolism. Exogenous interferons suppress CYP1A2 (theophylline, caffeine, antipyrone) clearance by 20% to 49% in patients; have minimal impact on CYP3A4 (midazolam and dapsone), CYP2C9 (tolbutamide), or CYP2C19 (mephenytoin) metabolism; and increase CYP2D6 (debrisoquine, dextromethorphan) metabolism. Biological IL-2 inhibitors (basiliximab, daclizumab) have no effect on metabolism via CYP1A2 (caffeine), CYP2C9 (s-warfarin), CYP2C19 (omeprazole), CYP2D6 (dextromethorphan), and CYP3A4 (midazolam, tacrolimus) but may enhance CYP3A4 (cyclosporin) metabolism over time. IL-6 inhibitors (sirukumab, tocilizumab, sarilumab) significantly enhance metabolism via CYP2C9 (s-warfarin), CYP2C19 (omeprazole), and CYP3A4 (simvastatin, midazolam) and reduce metabolism via CYP1A2 (caffeine). Patients using interferons, IL-2, or IL-6 blocking drugs at steady state with CYP substrates could have altered drug metabolism and experience adverse events. With interferons and biological anti-inflammatory drugs, some isoenzymes will be inhibited, whereas others will be enhanced, and the magnitude of the effect can sometimes be significant. In clinical practice, clinicians may consider these metabolic changes as an additive effect to a patient's entire disease and medication profile when determining risk/benefit of treatment. Interferon therapy or inflammatory suppression via IL-2 or IL-6 can alter steady-state concentrations of CYP-metabolized small-molecule drugs.

Drug Prescription Profiles in Patients with Polypharmacy in Spain: A Large-Scale Pharmacoepidemiologic Study Using Real-World Data.

We aimed to identify and compare medication profiles in populations with polypharmacy between 2005 and 2015. We conducted a cross-sectional study using information from the Computerized Database for Pharmacoepidemiologic Studies in Primary Care (BIFAP, Spain). We estimated the prevalence of therapeutic subgroups in all individuals 15 years of age and older with polypharmacy (≥5 drugs during ≥6 months) using the Anatomical Therapeutic Chemical classification system level 4, by sex and age group, for both calendar years. The most prescribed drugs were proton-pump inhibitors (PPIs), statins, antiplatelet agents, benzodiazepine derivatives, and angiotensin-converting enzyme inhibitors. The greatest increases between 2005 and 2015 were observed in PPIs, statins, other antidepressants, and β-blockers, while the prevalence of antiepileptics was almost tripled. We observed increases in psychotropic drugs in women and cardiovascular medications in men. By patient´s age groups, there were notable increases in antipsychotics, antidepressants, and antiepileptics (15–44 years); antidepressants, PPIs, and selective β-blockers (45–64 years); selective β-blockers, biguanides, PPIs, and statins (65–79 years); and in statins, selective β-blockers, and PPIs (80 years and older). Our results revealed important increases in the use of specific therapeutic subgroups, like PPIs, statins, and psychotropic drugs, highlighting opportunities to design and implement strategies to analyze such prescriptions’ appropriateness.

A multidimensional measure of polypharmacy for older adults using the Health and Retirement Study

Polypharmacy is commonly defined based on the number of medications taken concurrently using standard cut-offs, but several studies have highlighted the need for a multidimensional assessment. We developed a multidimensional measure of polypharmacy and compared with standard cut-offs. Data were extracted for 2141 respondents of the 2007 Prescription Drug Survey, a sub-study of the Health Retirement Study. Latent classes were identified based on multiple indicators of polypharmacy, including quantity, temporality and risk profile. A four-class model was selected based on fit statistics and clinical interpretability: ‘High risk, long-term’ (Class 1), ‘Low risk, long-term’ (Class 2), ‘High risk, short-term’ (Class 3), and ‘High risk for drug interactions, medium-term, regular’ (Class 4). Classes differed regarding sex, cohabitation, disability and multimorbidity. Participants in the ‘low risk’ class tended to be male, cohabitating, and reported fewer health conditions, compared to ‘high risk’ classes. Polypharmacy classes were compared to standard cut-offs (5+ or 9+ medications) in terms of overlap and mortality risk. The three ‘high risk’ classes overlapped with the groups concurrently taking 5+ and 9+ medications per month. However, the multidimensional measure further differentiated individuals in terms of risk profile and temporality of medication taking, thus offering a richer assessment of polypharmacy.

Appropriate and Potentially Inappropriate Medication Use in Decompensated Cirrhosis.

Patients with decompensated cirrhosis are prescribed numerous medications. Data are limited as to whether patients are receiving medications they need and avoiding those they do not. We examined a large national claims database (2010-2015) to characterize the complete medication profile as well as the factors associated with appropriate and potentially inappropriate medication use in 12,621 patients with decompensated cirrhosis. Clinical guidelines and existing literature were used to determine appropriate and potentially inappropriate medications in decompensated cirrhosis. The total medication days' supply was calculated from pharmacy data and divided by the follow-up period for each decompensation. Ascites was the most common (86.5%), followed by hepatic encephalopathy (HE; 37.8%), variceal bleeding (VB; 17.5%), hepatorenal syndrome (6.3%), and spontaneous bacterial peritonitis (SBP; 6.1%). For patients with ascites, 55.8% filled a diuretic. For patients with HE, 32.4% and 63.3% filled rifaximin and lactulose, respectively. After VB, 60.3% of patients filled a nonselective beta blocker, and after an episode of SBP, 48.0% of patients filled an antibiotic for prophylaxis. The minority (4.5%-17.3%) had enough medication to cover >50% follow-up days. Potentially inappropriate medication use was common: 53.2% filled an opiate, 46.0% proton pump inhibitors, 14.2% benzodiazepines, and 10.1% nonsteroidal anti-inflammatory drugs. Disease severity markers were associated with more appropriate mediation use but not consistently associated with less inappropriate medication use. Patients with decompensated cirrhosis are not filling indicated medications as often or as long as is recommended and are also filling medications that are potentially harmful. Future steps include integrating pharmacy records with medical records to obtain a complete medication list and counseling on medication use with patients at each visit.

Safety comparison of therapies used in inflammatory bowel disease.

Safety comparison of therapies used in inflammatory bowel disease.

Profiles of polypharmacy in older adults and medication associations with signs of aspiration

ABSTRACT Background Polypharmacy and specific medication classes are prevalent in older adults. Their relationships with swallowing disorders are not well explored, which would best be managed holistically, with consideration of medication profiles. This study aimed to establish profiles of polypharmacy in older adults and investigate the associations of polypharmacy and medication class with signs of aspiration during swallowing. Methods This was a secondary retrospective analysis of data from 291 adults aged 60 years and older. Polypharmacy was profiled numerically and described. Multivariate logistic regression was used to identify associations between medication classes with signs of aspiration, while controlling for independent variables of demographics, functional status, and medical history. Results Three distinct profiles of polypharmacy were described. Higher numbers of medications were associated with higher age, lower functional status, nursing home residency, multimorbidity, and showing signs of aspiration. Thirty-four classes of medications were found in this study, benzodiazepines were the only class independently associated with signs of aspiration. Conclusions Different profiles of polypharmacy can be observed in older adults, but none were independently associated with signs of aspiration. In addition to known demographic and functional status variables, benzodiazepine-use was found to be independently associated with signs of aspiration (p = .005, B = 7.94).

Myocardial Ischemia-Reperfusion and Diabetes: Lessons Learned From Bedside to Bench.

In front of the failure to translate from bench to bedside cardioprotective drugs against myocardial ischemia-reperfusion, research scientists are currently revising their animal models. Owing to its growing incidence nowadays, type 2 diabetes (T2D) represents one of the main risk factors of co-morbidities in myocardial infarction. However, discrepancies exist between reported animal and human studies. Our aim was here to compare the impact of diabetes on cell death after cardiac ischemia-reperfusion in a human cohort of ST-elevation myocardial infarction (STEMI) patients with a diet-induced mouse model of T2D, using a high-fat high-sucrose diet for 16 weeks (HFHSD). Interestingly, a small fraction (<14%) of patients undergoing a myocardial infarct were diabetic, but treated, and did not show a bigger infarct size when compared to non-diabetic patients. On the contrary, HFHSD mice displayed an increased infarct size after an in vivo cardiac ischemia-reperfusion, together with an increased cell death after an in vitro hypoxia-reoxygenation on isolated cardiomyocytes. To mimic the diabetic patients' medication profile, 6 weeks of oral gavage with Metformin was performed in the HFHSD mouse group. Metformin treatment of the HFHSD mice led to a similar extent of lower cell death after hypoxia-reoxygenation as in the standard diet group, compared to the HFHSD cardiomyocytes. Altogether, our data highlight that due to their potential protective effect, anti-diabetic medications should be included in pre-clinical study of cardioprotective approaches. Moreover, since diabetic patients represent only a minor fraction of the STEMI patients, diabetic animal models may not be the most suitable translatable model to humans, unlike aging that appears as a common feature of all infarcted patients.

The Use of Intrapleural Thrombolytic or Fibrinolytic Therapy, or Both, via Indwelling Tunneled Pleural Catheters With or Without Concurrent Anticoagulation Use

Indwelling tunneled pleural catheters are commonly used for recurrent pleural effusion management. Catheter obstruction is not uncommon, often requiring intrapleural medications instillation (i.e., alteplase) to restore flow. The safety profile of intrapleural medications has been previously published, however most studies exclude anticoagulated patients. What is the safety profile of intrapleural alteplase and/or dornase alfa when utilized in indwelling tunneled pleural catheters, including patients that may be undergoing active anticoagulation? Retrospective review of previously placed indwelling tunneled pleural catheters from January 2009 - February 2020 undergoing intrapleural alteplase. Basic demographics, laboratory studies, anticoagulation medication usage, and complications were collected. Descriptive statistics were used to report demographics and outcomes. Univariate Firth's logistic regression analyses were used to identify factors associated with complications, followed by multivariable regression analyses. A total of 94 patients underwent indwelling tunneled pleural catheter placement and intrapleural instillation. The median age of patients was 66.1 (IQR - 57.6-74.9) years. Intrapleural medications were administered 71 times in 30 anticoagulated patients and 172 times in 64 not anticoagulated patients. A total of 20 complications were identified in 18 patients, and one experiencing more than one complication. There were 5 bleeding complications with no significant increased risk with anticoagulation usage (2 anticoagulated, 3 not anticoagulated; p=0.092). Multivariable Firth's logistic regression demonstrated that alteplase dose (p=0.04) and anticoagulation usage (p=0.05) were associated with any complication, but not associated with bleeding complications. We report a relatively low incidence of complications and in particular, bleeding complications in patients receiving intrapleural alteplase for non-draining IPCs. Bleeding episodes occurred in 5/94 (5.3%) patients with no apparent increased risk of bleeding complication, whether receiving anticoagulation or not. Additional study is warranted to identify risk factors for complications, in particular bleeding complications in this patient population.

Pharmacological Management of Spontaneous Intracerebral Hemorrhage in Older Adults

Pharmacological management of intracerebral hemorrhage in adult patients over 65 years of age requires special considerations due to differing clinical presentations, underlying organ dysfunction, and more complex medical histories and medication profiles. A literature review of articles focusing on the age-specific pharmacological management of intracerebral hemorrhage was conducted. Treatment approaches and clinical outcomes specific to older adults were evaluated and therapeutic considerations for this population are summarized. Older adults were commonly included in trials regarding reversal of anticoagulants and antiplatelet agents and these results are generalizable to older adults. Underlying organ dysfunction should frequently be considered throughout the treatment of intracerebral hemorrhage in older adults. Older adults with intracerebral hemorrhage should be managed similarly to younger adult patients; however, consideration of age-related comorbidities and physiological differences is critically important for optimizing patient care.

The Risk of Falling and Consequences of Falling in Patients with Atrial Fibrillation Receiving Different Types of Anticoagulant.

Our objective was to investigate the predictors of falls requiring a visit to the emergency department in patients with nonvalvular atrial fibrillation (AF) receiving different types of anticoagulants and to investigate the clinical consequences of falling in the same population. A total of 1217 patients with nonvalvular AF from two institutions were retrospectively evaluated. Each patient underwent a physical examination, and clinical histories and medication profiles were taken from each patient at baseline. The median age of our cohort was 71 years; 52.3% were males, and 86.1% of patients were receiving anticoagulation at study baseline. The 5-year freedom-from-falling rate was 81.6%. The use and type of anticoagulation was not significantly associated with the risk of falling (P = 0.222), whereas higher Morse Fall Scale (MFS), CHA2DS2-VASC (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category), and HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly [> 65 years], drugs/alcohol concomitantly) scores were significantly associated with a higher hazard of the first fall in univariate analyses. In the multivariate Cox regression model, MFS, older age, osteoporosis, higher levels of high-density lipoprotein cholesterol, higher diastolic blood pressure, and use of amiodarone, diuretics, or short- and medium-acting benzodiazepines were mutually independent predictors of the first fall. Of 163 patients, 93 (57%) had a bone fracture during the fall. Type of anticoagulation significantly affected survival after the first fall (P < 0.001): patients inadequately anticoagulated with warfarin had worse survival rates, and patients receiving apixaban and dabigatran had the best survival rates after the first fall. Older patients who had comorbidities and were taking amiodarone, diuretics, or short- or medium-acting benzodiazepines had the highest risk of falls. The type and quality of anticoagulation did not seem to affect the risk of falling but did significantly affect survival after the first fall.