Complex Regimens Research Articles

Assessment of Medication Regimen Complexity of COPD Regimens in Individuals Visiting Community Pharmacies.

Non-adherence is common and linked to poor COPD outcomes. Medication Regimen Complexity Index (MRCI) scores affect other disease outcomes. Little is known about the implications of MRCI scores in COPD. Secondary analysis was done to calculate MRCI scores assessing relationship to symptoms, COPD severity and health literacy (HL) to identify potential interventions to optimize adherence. Secondary analysis was conducted of cross-sectional, non-randomized survey data. Participants with self-reported COPD completed a survey of demographics, exacerbations, symptoms (COPD Assessment Test (CAT)), and self-reported COPD regimens. COPD severity was classified into Global Initiative for Chronic Obstructive Lung Disease (GOLD) ABCD categories using exacerbation history and CAT. CAT scores were categorized as low (<10), high (>10) and very high (>20). A 1-year proportion of days covered (PDC) was calculated. A MRCI calculator scored regimens (primary endpoint). Published cut-off points were used to categorize MRCIs as low (≤4), medium (5-8) and high (>8) and inhaled device polypharmacy (IDP) as ≥3 devices. Risk for low HL was assessed using a Single Item Literacy Screener. Descriptive and Chi-squared statistics were used. Participants' (N = 709) PDC for 1 maintenance medicine averaged 0.43 ± 0.37; 28.7% were adherent (PDC ≥ 80%). CAT scores were very high in 54.6% and high in 35.8%. Distribution of GOLD categories were A (6%), B (35%), C (4%) and D (55%). High, medium and low MRCI were 85%, 14% and 9%, respectively. Mean devices per regimen was 2.05 ± 0.8; IDP was 28%. MRCI and IDP increased with worsening CAT scores and COPD severity per GOLD category (p<0.05), but not low HL. MRCI scores for COPD regimens increased with COPD severity and symptoms. Overall adherence was low despite high symptom scores; high MRCI scores could contribute. All COPD medication classes are available in multiple devices, combinations, and daily formulations; there is potential to simplify regimens. Prospective studies are needed to evaluate if interventions minimizing MRCI scores improve adherence and COPD outcomes.

Translated Article] Disease-modifying treatments for patients with multiple sclerosis in Spain

Multiple sclerosis is a chronic demyelinating disease of the central nervous system and long-term disabling. Different disease-modifying treatments are available. These patients, despite being generally young, have high comorbidity and risk of polymedication due to their complex symptomatology and disability. Objective primaryTo determine the type of disease-modifying treatment in patients seen in Spanish hospital pharmacy departments. Secondary objectives: to determine concomitant treatments, determine the prevalence of polypharmacy, identify the prevalence of interactions and analyze pharmacotherapeutic complexity. MethodObservational, cross-sectional, multicentre study. All patients with a diagnosis of multiple sclerosis and active disease-modifying treatment who were seen in outpatient clinics or day hospitals during the second week of February 2021 were included. Modifying treatment, comorbidities and concomitant treatments were collected to determine multimorbidity pattern, polypharmacy, pharmacotherapeutic complexity (Medication Regimen Complexity Index) and drug–drug interactions. Results1407 patients from 57 centres in 15 autonomous communities were included. The most frequent form of disease presentation was the relapsing remitting form (89.3%). The most prescribed disease-modifying treatment was dimethyl fumarate (19.1%), followed by teriflunomide (14.0%). Of the parenteral disease-modifying treatments, the two most prescribed were glatiramer acetate and natalizumab with 11.1% and 10.8%. 24.7% of the patients had 1 comorbidity and 39.8% had at least 2 comorbidities. 13.3% belonged to at least one of the defined patterns of multimorbidity and 16.5% belonged to 2 or more patterns. The concomitant treatments prescribed were psychotropic drugs (35.5%); antiepileptic drugs (13.9%) and antihypertensive drugs and drugs for cardiovascular pathologies (12.4%). The presence of polypharmacy was 32.7% and extreme polypharmacy 8.1%. The prevalence of interactions was 14.8%. Median pharmacotherapeutic complexity was 8.0 (IQR: 3.3–15.0). ConclusionsWe have described the disease-modifying treatment of patients with multiple sclerosis seen in Spanish pharmacy services and characterized concomitant treatments, the prevalence of polypharmacy, interactions, and their complexity.

Navigating Access and Optimizing Medication Infusions in an Academic Medical Center: A Quality Improvement Study.

(1) Background: The rising prices of medical infusions have resulted in the increased utilization of policies for payors to manage costs. These policies can be disruptive to the continuity of care, and health systems should develop a systematic strategy to address market changes and prevent patient leakage. (2) Methods: A quality improvement study was conducted by an interdisciplinary workstream to assess the current state of infusion services in an academic medical center in the Midwest and to provide recommendations for immediate access improvement and long-term system planning. An organizational assessment of the value stream was completed, which analyzed the available infusion capacity, billing strategy, patient mix/volumes, payor mix, staffing levels, and current policies. The interventions implemented after developing the infusion system strategy were triaging patients to the appropriate site of care to increase infusion capacity and eliminating paper orders in one of the health system's Infusion Centers. (3) Results: Patients receiving medical infusions for oncologic conditions warrant unique considerations in evaluating the Infusion Center's efficiency due to the infusion regimen's length, complexity, and tolerability. The management of the payor site of care also poses a challenge for health systems to triage patients effectively without fragmenting care. (4) Conclusions: An organizational strategy around infusion services must include broad stakeholder representation to address the clinical, operational, and financial challenges to provide timely care to patients.

Drug burden index in people living with HIV over 50 years of age in a real clinical practice cohort

ObjectivesTo determine DBI and its relationship with polypharmacy and pharmacotherapeutic complexity (PC) in a cohort of PLWH over 50 years of age at follow-up of pharmacotherapy in a tertiary hospital. MethodsObservational and retrospective study that included PLWH in active antiretroviral treatment over 50 years of age who have been followed up in outpatient pharmacy services. Pharmacotherapeutic complexity was estimated through Medication Regimen Complexity Index (MRCI). Collected variables included comorbidities, current prescriptions and its classification according to anticholinergic and sedative activity and associated risk of falls. ResultsStudied population included 251 patients (85.7% men; median age: 58 years, interquartile range: 54–61). There was a high prevalence of high DBI scores (49.2%). High DBI was significantly correlated with a high PC, polypharmacy, psychiatric comorbidity and substances abuse (p<0.05). Among sedative drugs, the most prescribed were anxiolytic drugs (N05B) (n=85), antidepressant drugs (N06A) (n=41) and antiepileptic drugs (N03A) (n=29). For anticholinergic drugs, alpha-adrenergic antagonist drugs (G04C) were the most prescribed (n=18). Most frequent drugs associated with risk of falls were anxiolytics (N05B) (n=85), angiotensin-converting enzyme inhibitors (C09A) (n=61) and antidepressants (N06A) (n=41). ConclusionThe DBI score in older PLWH is high and it is related to PC, polypharmacy, mental diseases and substance abuse as is the prevalence of fall-related drugs. Control of these parameters as well as the reduction of the sedative and anticholinergic load should be included in the lines of work in the pharmaceutical care of people living with HIV+.

Antimycobacterial activity of scopoletin from ethanolic extract of Hymenodictyon floribundum (Hochst. & Steud.) B.L.Rob. Stem bark

The available tuberculosis (TB) therapies are taken for long time with complex regimens associated with adverse effects and drug-drug interactions. The emergence of multidrug resistant (MDR) and extensively drug resistant (XDR) strains of Mycobacterium tuberculosis and HIV co-infections necessitates the need for continued search for new effective anti-TB alternative leads with different mechanisms of action and safety profile. The aim of this study was to isolate and characterize antimycobacterial compounds from Hymenodictyon floribundum (Hochst. & Steud.) B.L.Rob. a plant used traditionally in the management of HIV/AIDS-related conditions. Antimycobacterial activity of the plant extracts and its constituents against Mycobacterium indicus pranii (MIP) and Mycobacterium madagascariense (MM) was tested using a twofold broth micro-dilution technique. Bioassay-guided isolation was used to isolate active compounds. Isolated compounds were also tested for activity against clinical isolates of Mycobacterium tuberculosis (Mtb). The crude plant extract had antimycobacterial activity and its ethyl acetate fraction was the most active with minimum inhibitory concentration (MIC) values of 97 µg/ml and 197 µg/ml against MIP and MM respectively. Three compounds were isolated from the ethyl acetate fraction; 7‑hydroxy-6-methoxycoumarin (1), 7,7′-dihydroxy-6,6′-dimethoxy-3,3′-biscoumarin (2) and 7,7′-dihydroxy-6,6′-dimethoxy-8,8′-biscoumarin (3). Compound 1 had growth inhibitory activity against MIP, MM and Mtb with MIC values of 0.2 M against MIP, 0.41 M against MM, 0.78 M against Mtb1 and 1.63 M against Mtb2. In conclusion, 7-Hydroxy-6- methoxycoumarin exhibited moderate antimycobaterial activity. The findings from this study support the use of H. floribundum by traditional health practitioners for treatment of HIV and AIDS-related conditions.

The problem of Mycobacterium abscessus complex: multi-drug resistance, bacteriophage susceptibility and potential healthcare transmission

ObjectivesMycobacterium abscessus complex is responsible for 2.6–13.0% of all non-tuberculous mycobacterial pulmonary infections and these are notoriously difficult to treat due to the complex regimens required, drug resistance and adverse effects. Hence, bacteriophages have been considered in clinical practice as an additional treatment option. Here, we evaluated antibiotic and phage susceptibility profiles of M. abscessus clinical isolates. Whole-genome sequencing (WGS) revealed the phylogenetic relationships, dominant circulating clones (DCCs), the likelihood of patient-to-patient transmission and the presence of prophages. MethodsAntibiotic susceptibility testing was performed using CLSI breakpoints (n = 95), and plaque assays were used for phage susceptibility testing (subset of n = 88, 35 rough and 53 smooth morphology). WGS was completed using the Illumina platform and analysed using Snippy/snp-dists and Discovery and Extraction of Phages Tool (DEPhT). ResultsAmikacin and Tigecycline were the most active drugs (with 2 strains resistant to amikacin, and one strain with Tigecycline MIC of 4 μg/mL). Most strains were resistant to all other drugs tested, with Linezolid and Imipenem showing the least resistance, at 38% (36/95) and 55% (52/95), respectively. Rough colony morphotype strains were more phage-susceptible than smooth strains (77%—27/35 versus 48%—25/53 in the plaque assays, but smooth strains are not killed efficiently by those phages in liquid infection assay). We have also identified 100 resident prophages, some of which were propagated lytically. DCC1 (20%—18/90) and DCC4 (22%—20/90) were observed to be the major clones and WGS identified 6 events of possible patient-to-patient transmission. DiscussionMany strains of M. abscessus complex are intrinsically resistant to available antibiotics and bacteriophages represent an alternative therapeutic option, but only for strains with rough morphology. Further studies are needed to elucidate the role of hospital-borne M. abscessus transmission.

Retraction: Medication regimen complexity and its association with adherence and blood pressure control among hypertensive patients at selected hospitals of South Gondar Zone: A hospital based cross sectional study.

Retraction: Medication regimen complexity and its association with adherence and blood pressure control among hypertensive patients at selected hospitals of South Gondar Zone: A hospital based cross sectional study.

1217-P: Willingness to Deintensify in Patients with Type 2 Diabetes—The Diabetes and Aging Study

Background: The ADA recommends treatment de-intensification be considered in older patients with poor health, on complex regimens, or experiencing side effects. We examined factors associated with older patients’ willingness to de-intensify treatment. Methods: Cross-sectional analysis of Diabetes Preferences and Self-Care Survey responses and EHR data in adults with type 2 diabetes from Kaiser Permanente Northern California. We calculated proportions of patients who responded to the survey question “I would be willing to take less medication for my diabetes” as willing, neutral, or unwilling. Willingness was contrasted across demographic, clinical, and health status factors. Results: Analysis included 1,337 adults prescribed glucose-lowering medications (age 74.2 ± 6.0 years, 44% women, 54.4% non-Hispanic white). The proportions of willing, neutral, and unwilling to de-intensify treatment were 51.2%, 27.3%, and 21.5%, respectively. Willingness to de-intensify varied by age (p&amp;lt;0.001) with 54.2% of younger adults (age 65-74) willing to de-intensify compared to 38.5% of older adults (age 85+). Willingness varied by duration of diabetes (p&amp;lt;0.001) with 61.0% of adults with diabetes for 0-4 years willing to de-intensify compared to 44.2% of adults with diabetes for longer duration (&amp;gt;15 years). Willingness among those with good, intermediate, or poor health status (as defined by the ADA) was 54.2% vs. 47.5% vs. 55.1%, respectively. Individuals with an A1c greater than 9% were more willing to de-intensify treatment compared to individuals with A1c of 7%-9%, or &amp;lt;7%, (57% vs 51% vs 50%, p&amp;lt;0.001). Willingness to de-intensify decreased as number of medications increased (p&amp;lt;0.001) and little difference was noted in willingness among patients by insulin use or hypoglycemia history. Discussion: Patterns of patient willingness to de-intensify treatment are misaligned with clinical guideline recommendations and highlight the influence of patient experience living with diabetes over time. Disclosure S.Haider: None. M.M.Parker: Research Support; Dexcom, Inc. E.Huang: Advisory Panel; Twin Health, Stock/Shareholder; AbbVie Inc., Cardinal Health, Amgen Inc. R.W.Grant: None. H.H.Moffet: Research Support; Dexcom, Inc. N.Laiteerapong: None. J.Liu: None. K.J.Lipska: Other Relationship; UpToDate. A.J.Karter: None. Funding National Institute on Aging (5R01AG063391)

156-LB: Nursing Burden Administering/Monitoring Complex Insulin Regimens vs. Basal Insulin/GLP-1 RA Fixed-Ratio Combinations (FRCs) for People with Type 2 Diabetes (PWT2D) in Long-Term Care (LTC)

Aim: Management of older PWT2D in LTC is challenging due to comorbidity, functional dependence, and hypoglycemia risk, and is further complicated by nurse shortages. This cross-sectional survey emailed to LTC nurses assessed perceived nursing burden associated with complex insulin regimens (basal-bolus [BB], sliding scale insulin [SSI]) vs FRCs. Methods: The survey comprised 3 hypothetical cases of PWT2D receiving BB, SSI, or FRC. Perceived burden was assessed using the unweighted NASA-Task Load Index (TLX). Responses for the 6 TLX subscales (mental, physical, and temporal demand; effort, frustration, performance) and perceived frequency of fingerstick use were summarized descriptively. Results: 10,982 nurses received the survey. Of the 250 who qualified (administered BB/SSI/FRC in past 90 days), 87% were female, 51% were ≥45 y, 49% had ≥11 y experience in LTC. TLX scores (max 20 higher = worse) were lower for FRCs vs BB or SSI (Table). Nurses perceived FRCs to require fewer fingersticks vs BB or SSI (Table). Conclusions: FRCs were perceived to reduce nursing burden and fingerstick use compared with complex insulin regimens. These findings, coupled with the lower hypoglycemia risk for FRCs vs complex insulin regimens reported in clinical trials suggest that use of FRCs in LTC has potential to reduce nursing workload. Disclosure H. E. Davidson: Research Support; Sanofi-Aventis U. S. A. Nelson: Research Support; Sanofi-Aventis U. S. L. F. Han: Research Support; Sanofi-Aventis U. S. M. Lamantia: Research Support; Sanofi-Aventis U. S. K. Desai: Employee; Sanofi. X. Li: Employee; Sanofi-Aventis U. S. T. A. Dex: Employee; Sanofi-Aventis U. S., Stock/Shareholder; Pfizer Inc., Viatris Inc., Teva Pharmaceutical Industries Ltd. J. F. Vance: None. K. Overbeck: None. Funding Sanofi

83-LB: Simplifying Insulin Treatment in Persons with T2 DM over 65 Years—Interim Report of the STOP Study

This is an interim evaluation of the STOP study, a proof-of-concept observation, whose aim is to test effectiveness and safety of IDegLira in deintensifying diabetes therapy in insulin-treated persons with T2DM aged &amp;gt;65 years. The study, retrospective observational, gathered so far data related to 93 consecutive persons with T2 DM, in whom IDegLira was introduced in therapy, and for whom clinical data were available for at least 6 months after the switch. The 93 persons (42 F, age 76±8 yrs, diabetes duration 20±10 yrs, duration of insulin treatment 13±12 yrs, BMI 28.6±4.9 kg/m2, A1C 7.4±0.9), were for the 75% in basal/bolus insulin therapy. Sixteen % of them, needed caregiver, whereas 53% were in follow up at the Geriatric Clinic for mild/severe cognitive impairment. After 3 months, fasting plasma glucose (PG) decreased (from 138±38 to 117±24 mg/dl, p=0.000036 vs baseline), similarly A1C (from 7.4±0.9 to 7.0±0.6%, p=0.000126). All results showed additional improvement at 6 month (p&amp;lt; 0.005 vs baseline). Rates of hypoglycemia at any time of day (PG &amp;lt;70 mg/dl) were lower after 3 months (0.35±0.94 vs 1.15±2.61, episodes/pt/month, p=0.0057). Episodes with PG &amp;lt;54 mg/dl decreased from 0.56±1.71 to 0.03±0.25, p=0.0093). Accordingly, the proportion of patients with at least one episode of PG &amp;lt;70 mg and 54 mg/dl, felt down from baseline to 3 month (23.7 to 14%;16.1 to 11%, respectively), being zero at 6 months. Rapid acting insulin dose decreased by 80 % at 3, up to 95% at 6 months (from 0.18±0.13 to 0.04±0.06 at 3, and 0.01±0.04 U/kg at 6 months, p&amp;lt; 0.0001). Nearly all patients interrupted it. IDegLira was initiated at a mean dose of 17±5.4 U/die to further increase to 23±9.6 after 6 months. BMI did not change significantly (p=ns). According to our preliminary results, IDegLira seems to offer a relevant option, to more complex insulin regimens, in terms of effectiveness and safety, in a population in whom preventing hypoglycemia and improving quality of life are mandatory and clinical inertia is often present. Disclosure A. Mazzieri: None. M. De fano: None. F. Mancinetti: None. D. Xenos: None. V. Boccardi: None. C. G. Fanelli: None. F. Porcellati: Board Member; Lilly Diabetes, Sanofi, Consultant; Novo Nordisk.

Implications of the medication regimen complexity index score on hospital readmissions in elderly patients with heart failure: a retrospective cohort study

BackgroundThe likelihood of elderly patients with heart failure (HF) being readmitted to the hospital is higher if they have a higher medication regimen complexity index (MRCI) compared to those with a lower MRCI. The objective of this study was to investigate whether there is a correlation between the MRCI score and the frequency of hospital readmissions (30-day, 90-day, and 1-year) among elderly patients with HF.MethodsIn this single-center retrospective cohort study, MRCI scores were calculated using a well-established tool. Patients were categorized into high (≥ 15) or low (< 15) MRCI score groups. The primary outcome examined the association between MRCI scores and 30-day hospital readmission rates. Secondary outcomes included the relationships between MRCI scores and 90-day readmission, one-year readmission, and mortality rates. Multivariate logistic regression was employed to assess the 30- and 90-day readmission rates, while Kaplan-Meier analysis was utilized to plot mortality.ResultsA total of 150 patients were included. The mean MRCI score for all patients was 33.43. 90% of patients had a high score. There was no link between a high MCRI score and a high 30-day readmission rate (OR 1.02; 95% CI 0.99–1.05; p < 0.13). A high MCRI score was associated with an initial significant increase in the 90-day readmission rate (odd ratio, 1.03; 95% CI, 1.00-1.07; p < 0.022), but not after adjusting for independent factors (odd ratio, 0.99; 95% CI, 0.95–1.03; p < 0.487). There was no significant difference between high and low MRCI scores in their one-year readmission rate.ConclusionThe study’s results indicate that there is no correlation between a higher MRCI score and the rates of hospital readmission or mortality among elderly patients with HF. Therefore, it can be concluded that the medication regimen complexity index does not appear to be a significant predictor of hospital readmission or mortality in this population.

#2976 CHRONIC KIDNEY DISEASE WITH COMORBIDITY IN PRIMARY CARE: CARDIORENAL TREATMENT, QUALITY OF CARE AND PROGNOSIS

Abstract Background and Aims Diabetes, heart failure, hypertension and cardiovascular disease are common in primary care, and frequently coexist with impaired kidney function (CKD), further increasing risk of cardiovascular- and renal events as well as premature death. These comorbidities therefore call for more complex treatment regimens and monitoring. Our aim was to describe the prevalence, management, and prognosis of individuals with CKD and additional comorbidity in a large primary care cohort. Method Individuals were included from the Copenhagen Primary Care Laboratory (CopLab) Database, which contains 112 million biochemistry results from persons followed in primary care between 2000 and 2015 and divided into three groups based on (CKD-EPI) eGFR (&amp;gt;60 ml/min, 30-59 ml/min and &amp;lt;30 ml/min) with or without comorbidity in the form of diabetes or heart failure. We included all individuals with at least two measurements of creatinine. The date of the second measurement of creatinine was considered index date (baseline). The database has been combined with pharmacological data (The Danish National Prescription Registry), outpatient clinic visits and hospitalizations (The Danish National Patient Registry - NPR), and mortality information (The Danish Civil Registration System). Heart Failure was defined by ICD-codes in NPR from outpatient clinic visits and hospitalizations and we calculated crude event rates for a range of outcomes according to comorbidity. Diabetes was defined as at least one measurement of plasma or serum glucose ≥11 mmol/l or HbA1c ≥48 mmol/mol in CopLab. We evaluated monitoring of eGFR, albuminuria (UACR) and use of guideline-recommended pharmacological therapy (i.e. RAS-blockers and statins) in each group. Results In the total primary care population of 171,134 individuals of which 63.8% were female, 8.3% had impaired kidney function (eGFR&amp;lt;60ml/min). The median follow-up for the three eGFR groups was 8.4, 4.7 and 2.0 years, respectively. Overall, event rates were higher in individuals with impaired kidney function and comorbidity, i.e. mortality in the group with eGFR&amp;lt;30 ml/min with concurrent heart failure; 42.8 per 100 patient-years (PY). Event rates for ESKD were low in general (0.03 to 0.51 per 100 PY) except for individuals with eGFR&amp;lt;30 ml/min (2.1 to 3.5 per 100 PY). Annual monitoring of eGFR was high in all groups (&amp;gt;90%) with increasing frequency in individuals with impaired kidney function, and measurement of UACR was low in groups with non-diabetic CKD (10-30%). Antihypertensive treatment was frequently prescribed in eGFR &amp;lt;30 ml/min; overall 87.6% and 94.8% with coexisting diabetes and 92.8% with coexisting heart failure. The use of RAS inhibition was more used in diabetes and in heart failure (&amp;gt;50%) but less with low eGFR. Statin therapy was used in approximately 50% of individuals with diabetes, regardless of CKD group, but was used to a much less extent in non-diabetic CKD (20-24%). Conclusion Our data from a large primary care cohort demonstrate a high prevalence of coexisting diabetes and/or heart failure with CKD, increasing the risk for adverse outcomes. The quality of CKD care in general practice may be improved, especially in the non-diabetic population.

Drug burden index in people living with HIV over 50 years of age in a real clinical practice cohort

ObjectivesTo determine DBI and its relationship with polypharmacy and pharmacotherapeutic complexity (PC) in a cohort of PLWH over 50 years of age at follow-up of pharmacotherapy in a tertiary hospital. MethodsObservational and retrospective study that included PLWH in active antiretroviral treatment over 50 years of age who have been followed up in outpatient pharmacy services. Pharmacotherapeutic complexity was estimated through Medication Regimen Complexity Index (MRCI). Collected variables included comorbidities, current prescriptions and its classification according to anticholinergic and sedative activity and associated risk of falls. ResultsStudied population included 251 patients (85.7% men; median age: 58 years, interquartile range: 54–61). There was a high prevalence of high DBI scores (49.2%). High DBI was significantly correlated with a high PC, polypharmacy, psychiatric comorbidity and substances abuse (p<0.05). Among sedative drugs, the most prescribed were anxiolytic drugs (N05B) (n=85), antidepressant drugs (N06A) (n=41) and antiepileptic drugs (N03A) (n=29). For anticholinergic drugs, alpha-adrenergic antagonist drugs (G04C) were the most prescribed (n=18). Most frequent drugs associated with risk of falls were anxiolytics (N05B) (n=85), angiotensin-converting enzyme inhibitors (C09A) (n=61) and antidepressants (N06A) (n=41). ConclusionThe DBI score in older PLWH is high and it is related to PC, polypharmacy, mental diseases and substance abuse as is the prevalence of fall-related drugs. Control of these parameters as well as the reduction of the sedative and anticholinergic load should be included in the lines of work in the pharmaceutical care of people living with HIV+.

Supporting the Health and Well-Being of Caregivers of Persons with Pain.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Factors Associated With Receipt of Diabetes Self-Management Education and Support for Type 2 Diabetes: Potential for a Population Health Management Approach.

Population health management approaches can help target diabetes resources like Diabetes Self-Management Education and Support (DSMES) to individuals at the highest risk of complications and poor outcomes. Little is known about patient characteristics associated with DSMES receipt since widespread uptake of telemedicine for diabetes care in 2020. In this retrospective cohort study, we used electronic medical record (EMR) data to assess patterns of DSMES delivery from May 2020 to May 2022 among adults who used telemedicine for type 2 diabetes (T2D) endocrinology care in a large integrated health system. Multilevel regression models were used to evaluate the association of key patient characteristics with DSMES receipt. Of 3530 patients in the overall cohort, 401 patients (11%) received DSMES. In adjusted multivariable logistic regression, higher baseline HbA1c (odds ratios [OR] 3.10 [95% confidence interval 2.22-4.33] for HbA1c ≥9% vs <7%), insulin regimen complexity (OR 3.53 [2.59-4.80] for multiple daily injections vs no insulin), and number of noninsulin medications (OR 1.17 [1.05-1.30] per 1 additional medication) were significantly associated with receipt of DSMES, whereas rurality and area-level deprivation of patient residence were not. Diabetes Self-Management Education and Support remains underutilized in this cohort of adults using telemedicine to access endocrinology care for T2D. Factors contributing to clinical complexity increased the odds of receiving DSMES. These results support a potential population health management approach using EMR data, which could target DSMES resources to those at higher risk of poor outcomes. This risk-stratified approach may be even more effective now that more people can access DSMES via telemedicine in addition to in-person care.

Changes in medication regimen complexity index following medication-related hospital admissions: A retrospective single-centre study.

Medication-related hospitalisations present an opportunity for de-prescribing and simplification of medication regimens. The Medication Regimen Complexity Index (MRCI) is a tool for measuring the complexity of medication regimens. To evaluate whether MRCI changes following medication-related hospitalisations, and to evaluate the relationship between MRCI, length of stay (LOS) in hospital, and patient characteristics. A retrospective medical record review of patients admitted to a tertiary referral hospital in Australia for medication-related problems, January 2019 to August 2020. MRCI was calculated using pre-admission medication lists and discharge medication lists. There were 125 patients who met inclusion criteria. The median (IQR) age was 64.0 years (45.0-75.0) and 46.4% were female. Median MRCI decreased by 2.0 following hospitalisation: from median (IQR) 17.0 (7.0-34.5) on admission vs 15.0 (3.0-29.0) on discharge (p<0.001). Admission MRCI predicted LOS ≥2 days (OR 1.03, 95%CI 1.00-1.05, p=0.022). Allergic reaction-related hospitalisations were associated with lower admission MRCI. There was a decrease in MRCI following medication-related hospitalisation. Targeted medication reviews for high-risk patients (e.g., those with medication-related hospitalisations) could further reduce the burden of medication complexity following discharge from hospital and possibly prevent readmissions.

RWD112 The Medication Regimen Complexity Index Score As an Indicator of Racial Health Disparities in Clinical Outcomes

Obtaining initial medication history at admission can significantly influence clinical outcomes. Medication regimen complexity index (MRCI) scores highlight the differential clinical burden among races exacted by inaccurate medication errors. In this study, we evaluated racial disparities that stem from using MRCI for the prediction of inpatient outcomes.

Children deserve simple, short, safe, and effective treatment for rifampicin-resistant tuberculosis

Children deserve simple, short, safe, and effective treatment for rifampicin-resistant tuberculosis

TMBserval: a statistical explainable learning model reveals weighted tumor mutation burden better categorizing therapeutic benefits.

A high tumor mutation burden (TMB) is known to drive the response to immune checkpoint inhibitors (ICI) and is associated with favorable prognoses. However, because it is a one-dimensional numerical representation of non-synonymous genetic alterations, TMB suffers from clinical challenges due to its equal quantification. Since not all mutations elicit the same antitumor rejection, the effect on immunity of neoantigens encoded by different types or locations of somatic mutations may vary. In addition, other typical genomic features, including complex structural variants, are not captured by the conventional TMB metric. Given the diversity of cancer subtypes and the complexity of treatment regimens, this paper proposes that tumor mutations capable of causing various degrees of immunogenicity should be calculated separately. TMB should therefore, be segmented into more exact, higher dimensional feature vectors to exhaustively measure the foreignness of tumors. We systematically reviewed patients' multifaceted efficacy based on a refined TMB metric, investigated the association between multidimensional mutations and integrative immunotherapy outcomes, and developed a convergent categorical decision-making framework, TMBserval (Statistical Explainable machine learning with Regression-based VALidation). TMBserval integrates a multiple-instance learning concept with statistics to create a statistically interpretable model that addresses the broad interdependencies between multidimensional mutation burdens and decision endpoints. TMBserval is a pan-cancer-oriented many-to-many nonlinear regression model with discrimination and calibration power. Simulations and experimental analyses using data from 137 actual patients both demonstrated that our method could discriminate between patient groups in a high-dimensional feature space, thereby rationally expanding the beneficiary population of immunotherapy.

Switch from a ritonavir to a cobicistat containing antiretroviral regimen and impact on tacrolimus levels in a kidney transplant recipient

BackgroundSolid-organ transplantation due to end-stage organ disease is increasingly performed in people living with HIV. Despite improved transplant outcomes, management of these patients remains challenging due to higher risk for allograft rejection, infection and drug–drug interactions (DDIs). Complex regimens for multi-drug resistant HIV-viruses may cause DDIs particularly if the regimen contains drugs such as ritonavir or cobicistat.Case presentationHere we report on a case of an HIV-infected renal transplant recipient on long-term immunosuppressive therapy with mycophenolate mofetil and tacrolimus dosed at 0.5 mg every 11 days due to the co-administration of a darunavir/ritonavir containing antiretroviral regimen. In the presented case the pharmacokinetic booster was switched from ritonavir to cobicistat for treatment simplification. A close monitoring of tacrolimus drug levels was performed in order to prevent possible sub- or supratherapeutic tacrolimus trough levels. A progressive decrease in tacrolimus concentrations was observed after switch requiring shortening of tacrolimus dosing interval. This observation was unexpected considering that cobicistat is devoid of inducing properties.ConclusionsThis case highlights the fact that the pharmacokinetic boosters ritonavir and cobicistat are not fully interchangeable. Therapeutic drug monitoring of tacrolimus is warranted to maintain levels within the therapeutic range.