Regular Medication Use Research Articles

Gout management and outcomes during the COVID-19 pandemic: a cross-sectional internet survey.

Aim:We aimed to assess the gout management during the COVID-19 pandemic.Methods:We assessed medication use, healthcare utilization, gout-specific health-related quality of life (HRQoL) on the Gout Impact Scale (GIS), psychological distress using the patient health questionnaire-4 (PHQ-4), and resilience in people with self-reported physician-diagnosed gout during the COVID-19 pandemic in a cross-sectional Internet survey.Results:Among the 122 survey respondents with physician-diagnosed gout, 82% were prescribed urate-lowering therapy (ULT) and 66% were taking ULT daily; mean age was 54.2 years [standard deviation (SD), 13.8], 65% were male, and 79% were White. More regular use of gout medication was reported during the COVID-19 pandemic: allopurinol, 44%; colchicine, 37%; non-steroidal anti-inflammatory drugs, 36%. Gout flares were common: 63% had ⩾1 gout flare monthly; 11% went to emergency room/urgent care; and 2% were hospitalized with gout flares. Between 41% and 56% of respondents reported more difficulty with gout management and related functional status related to COVID-19; 17–37% had difficulty with healthcare access for gout. HRQOL deficits were evident for gout concern overall, 79.4 (SD, 25); unmet gout treatment need, 64.5 (SD, 27.1); and gout concern during flare, 67.3 (SD, 27.1); but less so for gout medication side effects, 48.9 (SD, 27.4). Psychological distress was moderate in 19% and severe in 15% (mild, 22%; normal, 45%). Resilience score on Connor–Davidson Resilience Scale (CD-RISC2) was 5.6 (SD, 1.8; range 0–8). Compared with no/mild psychological distress, moderate–severe psychological distress during the COVID-19 pandemic was significantly associated with more difficulty getting gout medication filled (p = 0.02), flares treated (p = 0.005), and receiving gout education (p = 0.001).Conclusion:Healthcare gaps, psychological distress, and HRQoL deficits were commonly reported by people with gout during the COVID-19 pandemic. Interventions to address these challenges for people with gout during the COVID-19 pandemic are needed.

Successful combination therapy with radiofrequency ablation and phenol injection in a young patient with refractory trigeminal neuralgia

Trigeminal neuralgia (TN) is defined as sudden, usually unilateral, severe, brief, stabbing, and recurrent pain in the distribution of one or more branches of the fifth cranial nerve. The pain is generally abrupt, severe, and can pose a significant impact on the quality of life. The etiology of TN is not always clear, and therefore, treatment can be challenging and multimodal. Pharmacotherapy is generally the first-line treatment though unsuccessful in over a third of patients requiring minimally invasive modality. We report the case of a young patient with refractory and debilitating TN with failed four sessions of radiofrequency ablation (RFA) in addition to the regular use of oral medications. Our treatment included simultaneous RFA and phenol injection with complete symptomatic resolution within fortnight after intervention. In conclusion, the treatment of TN poses a clinical challenge. Although RFA or phenol injections are recognized invasive treatment modalities, we have proven that simultaneous use of both therapies at the same time is safe and effective treatment option for refractory TN with failed previous multi-modal therapy.

The impact of sleep medications on physical activity among diabetic older adults

The purpose of this study was to examine the impact of prescription sleep medications on physical activity (PA) participation among diabetic older adults. We analyzed cross-sectional data of 1,581 respondents ≥ 50 years from the 2006–2014 waves of the Health and Retirement Study. The respondents self-reported frequency of their PA from light, moderate and vigorous activity and whether they regularly took prescription sleep medications. We found that 381 of 1,581 respondents (24%) reported regular use of prescription medications for sleep. Hierarchical linear regression models revealed that use of prescription sleep medications significantly predicted less participation in PA after controlling for demographic variables, personality traits, social support, environmental factors, social integration, sensory functions, presence of pain, prescription pain medication use, body mass index, and health conditions. The finding highlights that use of prescription sleep medications may be an important risk factor of physical inactivity in diabetic older adults.

Assessment of regular drug use and inhaler technique skills in asthmatic children

ObjectiveThis study aimed to assess the regular use of long-term asthma-control medication and to determine inhaler techniques in asthmatic children. MethodsThe study was conducted on asthmatic children aged 6–18 years. Information on rescue and controller medications was given and the proper inhalation technique was demonstrated. One month later, patients and parents were asked to answer a questionnaire on drug use and to demonstrate their inhaler techniques. ResultsOne hundred children and/or their parents were interviewed for the study. All of the patients identified long-term asthma-control medications while quick-relief asthma medications were identified by 93% of the patients. Of the patients, 34% described the dose of their quick-relief medication correctly. All steps in the inhalation technique were correctly carried out by 60.6% of patients using a metered-dose inhaler (MDI), 80% of patients using a Turbuhaler, and 58% of patients using a capsule-based dry-powder inhaler (DPI). Of the participants, 73% reported regular use of long-term asthma-control medications. While the mean age of the patients regularly using long-term asthma medications was 9.05±2.5 years, that of patients not compliant with the regular treatment was 10.29±3.26 years (p=0.04). The most common reason for irregular drug use was forgetting to take the drug. ConclusionAdherence to long-term asthma-control medications tends to be better in younger patients. Since the most common cause of irregular drug use is forgetting to take the drug, repeated training is necessary to ensure asthma control and the successful treatment of asthmatic children.

Hypertension, antihypertensive medications use and risk of age-related macular degeneration in California Teachers Cohort.

Sustained and inadequately controlled hypertension can promote the development of age-related macular degeneration (AMD) through multiple biologic pathways. Epidemiologic studies of high blood pressure, antihypertensive therapies, and the risk of AMD thus far have been inconclusive. However, few studies evaluated risks according to the use of different classes of antihypertensive drugs or took combinations of use into account. We performed a prospective cohort study by linking the California Teachers Study (CTS) cohort (N = 88 481) to statewide hospital discharge records up to December 31, 2012. History of high blood pressure, regular use of antihypertensive medications, and comprehensive risk factor information was collected via self-administered questionnaires at baseline in 1995-1996, and information on specific classes of antihypertensive drugs was provided by a subsample of CTS participants who completed a follow-up questionnaire in 2000. We identified 1762 female teachers with AMD during 14.8 years of follow-up on average. Applying Cox proportional hazard regression, we estimated increased risks of AMD among women treated for hypertension at baseline (HR = 1.15, 95% CI: 1.03, 1.30); the magnitude of the association increased with longer duration of antihypertensive treatment. In the subsample with more specific information on type of medication use, we estimated a 45% increased risk of AMD among women receiving diuretics as monotherapy compared to women with medications more potent than diuretics (HR = 1.45, 95% CI 1.10, 1.90). In women treated with a combination of antihypertensive drugs, we observed no increased risk of AMD for any individual class of drugs.

Opioid use before and after completion of an online pain management program.

The purpose of this study was to examine the effect of a pain management course that has demonstrated efficacy in pain reduction on the use of opioid medication. Self-reported medication use was recorded at baseline assessment for all patients enrolled in a validated pain management program provided free by a university research clinic (N = 471). Participants were randomized either to receive immediate treatment or to be a wait-list control. Opioid use at baseline assessment, with the daily doses converted to morphine equivalents, was compared with the self-reported opioid medication use at posttreatment and 3-month follow-up. The relationship between opioid use and measures of psychological symptoms, pain, and disability was examined. At assessment, 85% (n = 399) reported taking some form of pain modifying or psychotropic medication, 43.1% (n = 203) reported regular opioid use and 22.9% (n = 108) reported taking additional as required (pro re nata, or PRN) opioid-containing medication. On completion, there were significant reductions in the number who reported taking regular opioids and a large reduction in the use of PRN opioids and in the reported doses of opioids. Those reductions were more strongly associated with reductions in symptoms of anxiety and depression than in measures of disability and pain. The reduction in the self-reported use of regular and PRN opioid pain-relieving medication following completion of an online pain management program with demonstrated efficacy in pain reduction appeared to be related to effective treatment of symptoms of anxiety and depression. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

101 First Steps Towards Tailoring Frailty Specific Clinical Pharmacy Referrals

Abstract Background Interdisciplinary frailty assessment teams are in development throughout Ireland. Clinical pharmacy assessment (CPA) improves patient outcomes. Review is time consuming. Prioritising patients using frailty-specific toolkits should result in the greatest benefit for patients in a resource-limited setting. Methods Consecutive acute emergency patients identified as Variable Indicative of Placement positive at triage, underwent standardised interdisciplinary assessment tool. Age, gender, reason for referral and clinical frailty score were recorded in an Excel database. From 7/1/2019 to 31/1/2019, polypharmacy, defined as 5 or more medications triggered CPA. In phase 2, 11/3/2019 to 5/4/2019, a prioritisation toolkit was used. This toolkit identified 4 groups. 1. Regular use of high-risk medication or greater than 10 medications. 2. Patients with specific pharmaceutical concerns eg. desire to reduce their medication burden; 3. Acute/Chronic Kidney Injury; 4. Medication related admission potentially related to medications or admitted with non-mechanical falls. Results In phase 1, 57 patients were referred with polypharmacy from 7/1/2019 to 31/1/2019. 49%(n=27) received CPA. The mean age(+/_SD) was 82.8(+/-6.5). The female to male ratio was 1:1. The average CFS score(+/-SD) was 5.8(+/-1.2). In phase 2, 45 patients were prioritised with the toolkit from 11/3/2019 to 5/4/2019. 55%(n=25) received CPA. The mean age was 81.1(+/-8.3). The female to male ratio was higher (2.8:1). The average CFS score was 5.9(+/-0.9). Conclusion The prioritisation toolkit slightly reduced the number of referrals for CPA. The total number of CPAs remained constant. Women accounted for a greater percentage of patients in phase 2, consistent with previously published work. Further prioritisation is needed to ensure that patients with the highest risk of medication-related safety issues are identified and reviewed. Further prioritisation will be trialled and analysed using a plan, do, study, act approach. The ultimate aim will be to create and validate a prioritisation toolkit for the frail elderly presenting through an emergency department.

Dynapenic abdominal obesity and the incidence of falls in older women: a prospective study.

Dynapenic abdominal obesity (D/AO) has been associated with negative outcomes in older people, including trait of falls. To assess the association between D/AO and the incidence of falls over 18months in older community-dwelling women. A total of 201 older women (67.97 ± 6.02years; 27.70kg/m2) underwent waist circumference measurement, and had handgrip strength assessed using a hydraulic dynamometer. Dynapenia was classified using the lower tertile of handgrip strength, while abdominal obesity was considered as a waist circumference > 88cm. D/AO was the combination of both aforementioned criteria. Volunteers were classified into four groups: normal, abdominal obesity, dynapenic, and D/AO. Participants were then tracked by phone calls for ascertainment of falls during a follow-up period of 18months. Chi-square and multivariable Cox proportional regressions were conducted. The overall incidence of falls over the follow-up was 27.5%; and for normal, dynapenic, abdominal obesity, and D/AO were 14.7%, 17.2%, 27.5%, and 40.4% (X2 = 8.341; P = 0.039), respectively. D/AO was associated with a higher risk of falls (hazard ratio: 3.595 [95% CI: 1.317-9.815], even after adjustments for age, body mass index, physical activity level, regular use of medications, peripheral sensation, chronic diseases, and history of lower-limbs pain. D/AO is more closely related to falls than either dynapenia or abdominal obesity alone, and is independently associated with an increased incidence of falls in older women. These results provide support for the concept that the combined evaluation of muscle strength and central obesity may be clinically relevant in this population.

Involvement in compensation litigation and outcome from an online pain management program.

To report on the effect of involvement in civil litigation on outcome for patients enrolled in a validated Internet-delivered pain management program, the Pain Course. Data from a randomized controlled trial (RCT) on the effect of varying levels of clinician support was used to examine the effect of involvement in civil litigation on outcome in a free online pain management course. Outcome measures were changes in scores on self-report questionnaires for depression, anxiety, and disability (PHQ-9, GAD-7, and RMDQ) from baseline to 3-month follow-up for those still involved in litigation and those who had completed litigation, compared with outcomes for those who did not report involvement in litigation. The use of regular and as-required opioid medication at assessment and follow-up were also compared. Of the 397 patients enrolled in the pain course, 290 (73.0%) were not involved in litigation, 80 (20.2%) reported involvement in litigation that had been resolved and 27 (6.8%) reported ongoing litigation. Those still involved in litigation had the highest scores on depression scales and the highest rate of opioid use. The completion rates and symptom improvement was lower among current litigants but were still positive, with effect sizes on the outcome measures of between 0.56 and 0.73, as well as a reduction in the use of opioids. Current involvement in compensation litigation was associated with lower treatment completion and less symptom improvement. Nevertheless, the positive findings have significant implications for people involved in workers' compensation and other litigation who report pain as one of their symptoms. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effect of motivational interviewing in hypertensive patients (MIdNIgHT): study protocol for a randomized controlled trial

BackgroundOnly one-third of hypertensive patients achieve and maintain blood-pressure control. This is attributed to low treatment adherence and has a negative impact on clinical outcomes. Adherence is multidimensional and involves aspects both related to patient characteristics and to the chronic nature of the disease. In this context, motivational interviewing has been proposed as an approach to foster patients’ motivations to change their behavior for the benefit of their own health, thus providing more lasting behavioral changes.Design and methodsSingle-center, parallel, randomized controlled trial with outcome-assessor blinding. This study will select adult patients (n = 120) diagnosed with hypertension who receive regular follow-up in a specialized outpatient clinic. Patients will be randomly allocated across two groups: the intervention group will have appointments focused on motivational interviewing, while the control group will have traditional appointments. Patients will be monitored face-to-face, once monthly for six months. The primary outcomes will be a reduction of at least 8 mmHg in systolic blood pressure and changes in mean blood pressure measured by 24-h ambulatory blood pressure monitoring. Secondary outcomes include improvement of adherence to a low-sodium diet, adherence to self-care behaviors, regular use of antihypertensive medications, increase or maintenance of physical activity, weight reduction, evaluation of changes in daytime sleepiness, and cessation of smoking.DiscussionThis study shows an intervention strategy that will be tested and, if effective, warrant replication in monitoring of other chronic diseases.Trial registrationClinicalTrials.gov, NCT02892929. Registered on 24 August 2016.

P073 Male gender, smoking and stenosis are risk factors for postoperative endoscopic recurrence after ileocaecal resection for Crohn's disease

BACKGROUND: Colonoscopy is an important exam for diagnosis and follow-up of Crohn’s disease (CD). It has a relevant role in the management of patients after ileocaecal resection (IR), evaluating ileocolonic endoscopic recurrence (ER), performing biopsies and endoscopic dilations. This study describes the colonoscopies performed in patients previously submitted to IR for CD complications, evaluating its impact in the management and evolution of the disease. METHODS: Between January 2014 and May 2018, a total of 116 colonoscopies were performed in 62 patients with previous IR for CD. This study describes demographic data, personal and family history, use of medications, Harvey-Bradshaw index (HBI), endoscopic findings, post-colonoscopy alterations of medical treatment and need of new surgery. For endoscopic classification, Rutgeerts index for severity of post-operative CD was used, and ER was defined as scores 3i2. For statistical analysis, software SPSS 20.0 was used. It was considered statiscally significant values of p£0.05. RESULTS: Among all patients, 38.7% were male gender, which was a risk factor for ER (P < 0.05). Mean time of CD was 156 months (12–385). Prevalence of smoking was 17.7%, which also was a risk factor for ER (P < 0.05). Family history for CD was positive in 9 cases (14.5%). HBI showed low sensibility for predicting ER. Forty-five patients refered regular use of medication prescribed, while eight patients were in irregular use. Nine patients were without medication. Although there was no statistical significance (P = 0.15), the use of combotherapy was less associated with ER, when compared to other therapies. Regarding ER, 36 cases were i0; 18 cases i1, 38 cases i2; 5 cases i3; and finally, 16 cases i4. On follow-up, patients with ER more frequently had drug optimization or change of medication (P < 0.05). None of the patients classified as i0, i1, i2 e i3 needed new surgery on follow-up. Two cases classified as i4 had indication of new surgery. Ileocolonic stenosis was a risk factor for ER (P < 0.05): in a total of 23 cases, 16 were active disease with ulcerated stenosis. One balloon dilation was done in a patient with non-ulcerated ileocolonic stenosis. There were no cases of bleeding and perforation. CONCLUSION(S): Postoperative endoscopic follow-up after ileocaecal resection should be routinely performed. In our study, approximately 46% of the patients were in endoscopic remission. In contrast with previous reports, the majority of our i3 and i4 cases were managed clinically, with a low rate of new surgery (around 5%) Male sex, smoking and stenosis were risk factors for ER.

MON-250 THE MANAGEMENT OF NEPHROTOXIC MEDICATIONS IN COLONOSCOPY

The optimal management of potentially nephrotoxic drugs prior to colonoscopy is unclear. This study – part of a broader study assessing acute kidney injury (AKI) following colonoscopy – aimed to assess the current practices of medication management in patients undergoing colonoscopy, with a particular focus on whether nephrotoxic medications were withheld before the procedure. Nephrotoxic medications were defined as Renin Angiotensin Aldosterone System (RAAS) blockers [encompassing Angiotensin Receptor Blockers (ARBs), Angiotensin Converting Enzyme inhibitors (ACEI) and aldosterone antagonists], diuretics and non-steroidal anti-inflammatory drugs (NSAIDs). Adults who underwent inpatient colonoscopy at Blacktown Hospital between April 2017 and April 2018 were included in this retrospective study. Patients who were on renal replacement therapy or did not have at least one serum creatinine value in the 72 hours before and after colonoscopy were excluded. The electronic medication management (eMEDs) system provided an accurate record of medications administered, withheld or discontinued throughout the admission period. Demographic data, comorbidities, pathology results and procedural data were collected from electronic medical records. Statistical analysis was performed using SPSS v22. A total of 140 patients were included (mean age 58.5 + 1.7 years; females 53.6%). The majority of patients (n=74, 52.9%) demonstrated regular use of nephrotoxic medications, including RAAS blocking agents, diuretics or NSAIDs. Of the patients prescribed RAAS blockers (n=57, 40.7%), the likelihood of having the medication continued (n=32, 56.1%) was higher than having it withheld (n=25, 43.9%) before colonoscopy. In the patients prescribed diuretics (n=34, 24.3%), there was a similar proportion of patients continued (n=18, 52.9%) on the medication compared to withheld (n=16, 47.1%). This is also applicable to patients on NSAIDs (n=10, 4%), in which the proportions of each was equal (n=5, 50%). Multivariate analysis of the risk factors associated with AKI post-colonoscopy identified that greater reduction in systolic blood pressure (SBP) during colonoscopy was significantly associated with the incidence of AKI following colonoscopy (odds ratio per 10 mmHg reduction in SBP, 2.22; 95% CI, 1.09 to 4.52, p=0.03). Despite this, there was no statistically significant association between the withholding of RAAS blocking agents or diuretics and the incidence of AKI following colonoscopy. There is substantial variability in the prescribing patterns of RAAS blockers, diuretics and NSAID medications in colonoscopy. There is a need for data to inform standardised protocols in the management of nephrotoxic medications in the peri-procedural period, to prevent the risk of possible acute kidney impairment.

Accident patterns in trauma surgery patients with and without self-reported ADHD.

Attention deficit/hyperactivity disorder (ADHD) has been associated with a higher risk for accidents and injuries, leading to increased mortality. The objective of this study was to identify the types and mechanisms of accidents in a group of adult trauma victims with self-reported ADHD compared to a control group, based on Adult ADHD Self-Report Scale Version 1.1 (ASRSv1.1). A semi-open/qualitative accident questionnaire was conducted with 116 recruited patients from three trauma surgery units. The adult ADHD (aADHD) group differed significantly from the control group in self-reported psychiatric co-morbidities (p = 0.012), regular psychotropic medication use (p = 0.005), other accidents in the past year (p = 0.002), substance use before the accident (p = 0.007), and overconfidence in relation to the accident (p = 0.033). Most interestingly, we found significantly greater subjective ratings for stress (p = 0.002) and stressful/pressurising events before the accident (p = 0.026) in the adult ADHD group, as well as for self-reported stress at the time when conducting the interview (p = 0.016). The data demonstrate that special attention should be paid to interventions in stress reduction and sufficient treatment of ADHD in terms of preventing accidents and injuries in aADHD. Therefore, we suggest, in addition to pharmaceutical therapy, the integration of stress-management and coping strategies into aADHD management.

Quality of life of the family of children with asthma is not related to asthma severity

The quality of life for the family is an important outcome of childhood asthma. The aim of the study was to describe the quality of life in families who have a child with asthma. The Pediatric Quality of Life Inventory Family Impact Module was completed by the parents of 527 children with asthma. The median overall score was 75.0 (interquartile range 63.9, 87.5). The following factors were independently associated with lower quality of life: additional difficulties such as anxiety and financial hardship (3.81 [2.45, 5.93]), waking with asthma symptoms one or more nights a week (odds ratio 2.53 [1.34, 4.75]), regular use of symptoms reliever medication (2.47 [1.57, 3.87]), and female gender (1.97 [1.27, 3.05]). Lower socioeconomic status of the family and exposure to molds at home doubled the odds for lower quality of life. Physician's diagnosed asthma severity and control were associated with quality of life in univariate, but not multivariate analysis.Conclusion: Multiple factors, several of which are not related to asthma, contribute to the family burden of having a child with asthma. Clinicians should be mindful of the impact of asthma on the child and the family, and consider exploring factors not directly related to childhood asthma. What is Known: • Childhood asthma as a chronic disease impacts the quality of life of the patient, but there is also an impact on the immediate family. • There are relatively few studies exploring the quality of life of parents of a child with asthma; the results are heterogeneous and none has been carried out in an Eastern European country. What is New: • This is the first study to describe caregiver's quality of life in an Eastern European population in the context of childhood asthma. • The quality of life of the family of asthmatic child depends not only on factors related to asthma, but also non-asthma related factors such as poverty which play even more important role.

User-centered design of a customized assistive device to support feeding

This paper presents the design process of an assistive device for people with Parkinson’s disease or some level of tremor in the hands. A user-centered design approach is proposed, based on the integration of the tools House of Quality (QFD) and TRIZ in search of feasible and inventive technical solutions focused on meeting users’ requirements. 3D printing was also used as a tool to support and refine the design, through the manufacture of mock-ups and prototypes used in interaction and testing with users. The proposed design process brought relevant improvements in four main aspects: 1) facilitated the communication among members of the multidisciplinary design team (engineers, occupational therapists, end users); 2) provided a clearer identification of the design demands as well as the users’ needs, incorporating them into the process; 3) promoted a reduction in development time as a whole; 4) allowed the generation of feasible and inventive solutions, with functionality and innovation. Preliminary tests with the functional prototype have been conducted with a 60-year-old male with Parkinson’s disease on regular medication use and the single-case experimental design has been applied to evaluate the impact on the quality of the feeding task in terms of performance and satisfaction.

Prevalence of endothelial nitric oxide synthase (ENOS) gene G894T polymorphism and its association with hypertension: a population-based study with Brazilian women.

IntroductionHypertension is one of the most prevalent diseases in the world, accounting for millions of deaths each year. The reduction in the concentration of nitric oxide (NO) produced by the catalysis of endothelial nitric oxide synthase (eNOS) is associated with higher blood pressure (BP) levels. This reduction might be because of genetic polymorphisms. This study investigated the prevalence of the eNOS gene G894T polymorphism in women from northeast Brazil and its association with hypertension.Material and methodsThis cross-sectional study included 810 women (aged 19–49 years). Sociodemographic, health, anthropometric, and BP data were collected. Hypertension was defined according to the following criteria: systolic BP ≥ 140 mm Hg, diastolic BP ≥ 90 mm Hg, the regular use of antihypertensive medication, or some combination thereof. Epithelial cells from the cheek mucosa were obtained for DNA extraction. Genotyping was performed via real-time PCR. The measure of association was the prevalence ratio (PR) and its 95% CI as calculated via Poisson regression.ResultsThe frequencies of the GG, GT, and TT genotypes were 57.1%, 35.7%, and 7.2%, respectively. For each of these genotypes, the prevalence of hypertension in women was 17.9%, 23.6%, and 34.4%, respectively. Relative to the GG genotype, the PRs after adjusting for cofounding factors were 1.24 (95% CI: 0.95–1.61, p = 0.11) for GT and 1.76 (95% CI: 1.16–2.67, p < 0.01) for TT.ConclusionsThe T allele of the G894T polymorphisms is associated with hypertension in women. This may have implications for prevention and treatment.

Acute kidney injury induced by thrombotic microangiopathy in two cases of Bothrops envenomation

Context: Bothrops snakes are the most frequent agents of snakebites in South and Central America. Acute kidney injury (AKI) is one of its complications and has multifactorial origin. Thrombotic microangiopathy (TMA)-induced AKI in snakebites is uncommon and is not described in Bothrops envenomation.Case details: We report two cases of patients bitten by young Bothrops jararaca who developed AKI induced by TMA. Both patients evolved with mild envenomation and received the specific antivenom within 4 h after the snakebite. None of them had hypotension or shock, bleeding or secondary infection. Patient 1 (P1) was diabetic and using oral hypoglycemic drugs, and patient 2 (P2) was hypertensive without regular use of medication. On admission, both patients had levels of fibrinogen lower than 35 mg/dL, D-dimer higher than 10,000 ng/mL. They evolved with AKI, thrombocytopenia, normal coagulation assays, anemia, lactate dehydrogenase (LDH) elevation, low haptoglobin levels, negative direct antiglobulin test, and presence of schizocytes in peripheral blood. Only P1 required renal replacement therapy, and plasmapheresis was not required. Both patients were discharged and did not require outpatient dialysis, and subsequently had normal creatinine levels.Discussion: TMA may occur in Bothrops jararaca envenomation, even in mild cases that received early specific antivenom.

Mental health need: use of administrative data and record linkage to inform mental health policy and practice

BackgroundWith mental ill-health on the rise globally, it is crucial to investigate whether the needs of individuals with mental ill-health are fully addressed. Attempts to measure negative consequences of unmet needs have been limited by the use of cross-sectional study designs or self-report measures. We aimed to investigate the interplay between perceived mental ill-health and unmet need in relation to mental health on a population level. MethodsA record linkage methodology was implemented drawing information from the 2011 Northern Ireland Census returns and a population-wide prescribing database (n=286 717). Chronic mental ill-health was assessed through the Census self-reported mental health question (presence of an emotional, psychological, or mental health condition that has lasted or is expected to last at least 12 months) and compared with regular psychotropic medication use (monthly dosage of antidepressant, anxiolytic, antipsychotic, or antimania medication) in the 6 and 12 months after the Census. Logistic regression models adjusted for demography (age, sex, ethnicity, marital status, educational attainment, occupational social class), household (tenure, car availability), and area variables (urbanicity, deprivation). FindingsOverall, 23 803 individuals (8%) aged 25–74 years reported a chronic mental health condition, with low rates among ethnic minorities (129 [3%] of 3897 non-White individuals in receipt of medication). Of the individuals with self-reported mental ill-health, 5246 (22%) did not use psychotropic medication over the following 6 months, and 4412 (19%) did not use them by 12 months. Lower uptake was noted among men (odds ratio 0·56, 95% CI 0·52–0·60), non-white ethnic minorities (0·38, 0·26–0·54), and individuals separated, divorced, or widowed (0·75, 0·68–0·82) or unemployed (0·65, 0·53–0·81). InterpretationDiscrepancies between population mental ill-health and uptake of pharmacological treatment were more evident among men, ethnic minorities, and the economically disadvantaged. This study indicates that administrative data linkages can provide a valuable resource to define population characteristics, and inform policy and practice. However, the findings might be limited by availability of data on psychosocial and non-pharmacological interventions, use of proxy measures of mental health treatment, and the self-reported nature of the Census. Further research should explore whether this variation is due to stigma or lack of understanding or knowledge of available health-care services. FundingNone.

Medical Treatment of COPD.

Chronic obstructive pulmonary disease (COPD) is common around the world and carries a high morbidity and mortality. Symptom- and risk-oriented drug treatment is recommended, both in Germany and in other countries. It is not yet known to what extent the treatment that is actually delivered in Germany corresponds to the current recommendations in the guidelines. As recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) in 2017, 2281 patients of the national COPD cohort COSYCONET (COPD and Systemic Consequences-Comorbidities Network) were classified into Gold classes A-D on the basis of disease-specific manifestations and the frequency of exacerbations. Moreover, the regular use of medications was documented and categorized according to active substance groups. For all groups, the documented treatment that was actually given was compared to the recommended treatment. 67.6% of the patients received a combination of a long-acting anticholinergic drug (LAMA) and a long-acting beta-mimetic drug (LABA), while 65.8% received inhaled corticosteroids (ICS), 11.7% theophylline, and 12.6% oral corticosteroids (OCS). Despite recommendations to the contrary, 66% of the patients in Groups A and B (low exacerbation rates) were treated with ICS; some of these patients carried an additional diagnosis of bronchial asthma. There was evidence of undertreatment mainly in groups C and D (high exacerbation rate), because many of the patients in these groups were not treated with LAMA or LAMA/LABA as recommended. The observed deviations from the recommended treatment, some of which were substantial, might lead to suboptimal treatment outcomes as well as to avoidable side effects of medication.

Regular follow-up visits reduce the risk for asthma exacerbation requiring admission in Korean adults with asthma

BackgroundAsthma requires regular follow-up visits and sustained medication use. Although several studies have reported the importance of adherence to medication and compliance with the treatment, none to date have reported the importance of regular follow-up visits. We investigated the effects of regular clinical visits on asthma exacerbation.MethodsWe used claims data in the national medical insurance review system provided by the Health Insurance Review and Assessment Service of Korea. We included subjects aged ≥ 15 years with a diagnosis of asthma, and who were prescribed asthma-related medication, from July 2013 to June 2014. Regular visitors (frequent visitors) were defined as subjects who visited the hospital for follow-up of asthma three or more times per year.ResultsAmong 729,343 subjects, 496,560 (68.1%) were classified as regular visitors. Old age, male sex, lack of medical aid insurance, attendance of a tertiary hospital, a high Charlson comorbidity index, and a history of admission for exacerbated asthma in the previous year were significant determining factors for regular visitor status. When we adjusted for all these factors, frequent visitors showed a lower risk of asthma exacerbation requiring general ward admission (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.47–0.50; P < 0.001), emergency room admission (OR 0.83; 95% CI 0.79–0.86; P < 0.001), and intensive care unit admission (OR 0.49; 95% CI 0.44–0.54; P < 0.001) than infrequent visitors.ConclusionsRegular clinical visits are significantly associated with a reduced risk of asthma exacerbation requiring hospital admission in Korean adults with asthma.