Respiratory Syncytial Virus Vaccination in Older Adults: Considerations for Use and Shared Clinical Decision-Making.

PURPOSE: To evaluate the impact of two newly U.S. Food and Drug Administration-approved respiratory syncytial virus (RSV) vaccines, RSVpreF3 (Arexvy™, GSK) and RSVpreF (Abrysvo™, Pfizer), on morbidity in older adults. RSV is known to cause significant health issues in this demographic. METHOD: The current article reviews Phases 1 and 2 and Phase 3 published clinical trials, the recommendations for immunization practices outlined in the Morbidity and Mortality Weekly Report, and other relevant literature on RSV infection and vaccine coadministration. A case vignette is also included to illustrate an example of the shared clinical decision-making process for vaccination. RESULTS: Findings suggest that RSVpreF3 and RSVpreF vaccines effectively reduce health complications of RSV in older adults. Successful integration of these vaccines with other immunizations is also highlighted, emphasizing the role of an interprofessional team in this process. CONCLUSION: The introduction of RSVpreF3 and RSVpreF vaccines represents a significant advancement in the management of RSV in older adults. This article underscores the importance of shared clinical decision-making in vaccine administration and the effective coordination of an interprofessional team for coadministration with other vaccines. [Journal of Gerontological Nursing, 50(3), 7-12.].

Midodrine-Induced Nightmares in the Treatment of Orthostatic Hypotension: A Case Report.

Background Midodrine was the first medication approved by the Food and Drug Administration (FDA) for the treatment of orthostatic hypotension. Pharmacologically, midodrine is a peripheral selective alpha-1-adrenergic agonist that can improve standing, sitting, and supine systolic blood pressure. Common side effects include bradycardia, supine hypertension, and paresthesia. A novel side effect of midodrine-induced nightmares has been reported in our patient. To our knowledge, this is the first reported case of midodrine-induced nightmares. Objective To investigate and report a clinically significant and unique drug adverse event of midodrine in the treatment of orthostatic hypotension. Case Presentation This report describes a case of persistent nightmares associated with midodrine use in an 83-year-old male who experienced frequent syncope episodes treated with midodrine for orthostatic hypotension (OH). After the initiation of midodrine, the patient complained of increased nightmares, which quickly led to his refusal of the medication, despite the initial improvements in his blood pressure. The timing of administration included an evening dose at 21:00. This novel adverse event of midodrine-induced nightmares will be highlighted and explored in this case report. Conclusion This case demonstrated a unique adverse event of nightmares caused by midodrine. It is hypothesized that autonomic dysfunction plays a role and further investigations should be conducted to confirm this theory. We hope that our case report highlights the importance of careful consideration when prescribing midodrine in older people with orthostatic hypotension.

Optimizing Pharmacotherapy for Direct Oral Anticoagulants in Older Adults: Strategies for Managing Drug Interactions.

Direct oral anticoagulants (DOACs) have been increasingly used by older adults. Although these medications offer several therapeutic advantages over traditional anticoagulants, such as warfarin, they have limitations. One significant concern associated with DOACs is their potential for drug-drug interactions. These interactions may compromise the safe and effective use of DOACs and can potentially lead to serious adverse events and complications, particularly major bleeding. Polypharmacy is common among older adults with chronic diseases, which can increase the risk of drug-drug interactions with DOACs. The current article discusses the impact and risks of drug-drug interactions with DOACs in the context of older adults and explores ways to improve and manage these interactions through the collaboration of an interprofessional team. [Journal of Gerontological Nursing, 49(9), 7-13.].

ASCP's 2021 Choosing Wisely® Recommendations: A Proud Accomplishment.

Choosing Wisely® (CW) is a campaign to engage physicians and patients in conversations about unnecessary tests, treatments, and procedures. The campaign began in the United States in 2012 and in Canada in 2014, and now many countries around the world are adapting the campaign and implementing it. Currently, approximately 80 societies in the United States have published CW recommendations. Each recommendation is supported by clinical guidelines (when necessary), evidence-based ratinale, including information about when these tests or procedures may be appropriate. A deprescribing task force led by Chair Beier was created by ASCP in November 2018 after several conversations between ASCP leadership (notably, President J. Hirshfield) and Beier. Task force members comprise pharmacists practicing in academia, community, and long-term care settings. The chair also invited pharmacists from international countries (Canada and Australia) where deprescribing initiatives have a strong focus and scientific literature base. One of the primary goals for Chair Beier was to add ASCP's voice to the ABIM CW Campaign. Because ASCP is a membership association that represents pharmacists, health care professionals, and students serving the unique medication needs of older patients, by adding its name to the list of supporting partners, the organization makes a compelling argument to address deprescribing initiatives, tools, scientific literature, and resources to assist in initiating deprescribing conversations and their subsequent implementation.

A Review of Topical Povidone-iodine to Decrease Viral Load of COViD-19.

Topical povidone-iodine (PVP-I) is currently being considered as a potential preventive measure against the spread of COVID-19. Diluted PVP-I solutions have been historically used in Asia to treat upper respiratory tract infections (URTIs) by decreasing the bacterial and viral load on oropharyngeal mucosa to decrease the transmission of diseases. Efficacy of gargling 0.23% PVP-I mouthwash in Japan demonstrated to be efficacious in lowering the prevalence of URTIs when compared with placebo. The 0.23% concentration was used in vitro on severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus, which produced undetectable results after 30 seconds of exposure. Additionally, a recent study in 2020 proved the efficacy of PVP-I 0.45%-10% in reducing COVID-19 (SARS-CoV 2) viral load in vitro. Numerous clinical trials are being conducted to determine if there is a decrease in viral load, and thus transmission, when using oral or nasal topical PVP-I in COVID-19 patients. Because of the current lack of evidence for the use of PVP-I in vivo with COVID-19, it is recommended to await the clinical trial results before initiating this practice.

A prospective study to assess the association of body mass index and contamination of urinalysis samples.

BACKGROUND: There is a commonly held belief that overweight women are more likely to offer contaminated urine samples (UAs) in the emergency department (ED) than women with normal body mass index (BMI). However, there is a paucity of research evaluating this potential concern. OBJECTIVE: We hypothesized that patients with higher BMI would be more likely to provide contaminated urine samples than women with low BMI. METHODS: This was a prospective, observational, cohort study evaluating consenting, adult, women that provided a clean catch, mid-stream sample at an inner-city ED. UAs were ordered at the discretion of the caring physician, cultures based on standardized parameters. The primary outcome parameter was the presence of UA contamination as defined by our microbiology lab. Demographic/historical data and BMI were recorded on a structured data sheet. Categorical data were analyzed by chi-square; continuous data by t-tests. Multivariable logistic regression was performed to control for confounding. RESULTS: There were 350 patients in the study group; 22% overweight, 35% obese, 17% morbidly obese, mean BMI 31. 5, and 60% provided contaminated specimens. The mean BMIs of the subjects with contaminated vs. uncontaminated UAs were significantly different (32.7 ±â€¯10.2 vs 29.7 ±â€¯8.8, p < 0.01). Within our multiple variable logistic regression model, obese and morbidly obese patients were more likely to provide contaminated UAs, while there were no significant associations for contamination with other variables except for hypertension (OR = 1.85, p = 0.02). CONCLUSION: Obesity was significantly associated with contamination of clean catch mid-stream samples in our population.

Decisional Guidance Tool for Antibiotic Prescribing in the Skilled Nursing Facility.

OBJECTIVES: To derive weighted-incidence syndromic combination antibiograms (WISCAs) in the skilled nursing facility (SNF). To compare burden of resistance between SNFs in a region and those with and without protocols designed to reduce inappropriate antibiotic use. DESIGN: Retrospective analysis of microbial data from a regional laboratory. SETTING: We analyzed 2484 isolates collected at a regional laboratory from a large mixed urban and suburban area from January 1, 2015, to December 31, 2015. PARTICIPANTS: A total of 28 regional SNFs (rSNFs) and 7 in-network SNFs (iSNFs). MEASUREMENTS: WISCAs were derived combining Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, and reports restricted to fluoroquinolones, cefazolin, amoxicillin clavulanate, and trimethoprim/sulfamethoxazole. RESULTS: Pooling the target isolates into WISCAs resulted in an average of 28 of 37 achieving a number greater than 30 with an average of 50 isolates (range = 11-113; >97% urinary). Significant differences were found in antibiotic susceptibility between grouped rSNF data and iSNF data of 75% vs 65% (2.76-11.77; P = .002). The susceptibilities were higher in iSNFs with active antibiotic reduction protocols compared with iSNFs without protocols and rSNFs (effect size = .79 vs .67 and .65, respectively) (I2 = 93.33; P < .01). Susceptibilities to cefazolin (95% vs 76%; P < .001) and fluoroquinolones (72% vs 64%; P = .048) were significantly higher in iSNFs with active urinary tract infection protocols as compared with iSNFs without antibiotic reduction protocols. CONCLUSION: These results suggest that WISCAs can be developed in most SNFs, and their results can serve as indicators of successful antibiotic stewardship programs. J Am Geriatr Soc 68:55-61, 2019.

Quality Assessment of Expired Naloxone Products from First-Responders' Supplies.

Objective: Naloxone is an opioid receptor antagonist that reverses life-threatening effects of opioid overdose. Since the 1970s, naloxone products have been developed as injectable solutions, and more recently as nasal sprays. Naloxone products have saved many lives in emergency settings. These products are routinely carried by public safety first-responders including fire fighters (FF), law enforcement officers (LEO), and emergency medical services (EMS). Now, they are also distributed through community access programs to the public. While public safety medications are monitored, those publically distributed are not, so expired products can be possibly found on-hand in an emergency. This study analyzed the quality and stability of expired Naloxone HCl Solutions for Injection, to assess their remaining efficacies and potential risks. Methods: The samples were collected from EMS or law enforcement training supplies and expired returns, with expiration dates ranging from 1990 to 2018. Using standardized techniques, the remaining naloxone was quantified, and the main degradation products, nornaloxone (also known as noroxymorphone) and other possible species, were monitored and quantified systematically. Results: Most tested samples were found containing more than 90% of labeled naloxone, including those stored for nearly 30 years. The naloxone degradation was slow, but generally correlated with storage time length. There was no significant amount of degradation products detected across all samples. Nornaloxone was detected from some older samples, but all less than 1%. Therefore, although it is an opioid agonist, the risk caused by nornaloxone should be low. Conclusion: This quality assessment demonstrates that expired naloxone products may still meet USP standards, even after many years. Further pharmaceutical, clinical, and regulatory investigation should be conducted to confirm our findings, especially for new naloxone products with different formulations and routes of administration. Extending the shelf-life of naloxone products may have important financial and public health consequences in addressing future drug shortages and meeting the needs for this critical drug.

Students' Perspectives on Nebulized Drugs and Nebulizer Maintenance.

The geriatric population experiences a variety of respiratory concerns including chronic obstructive pulmonary disease, emphysema, asthma, pulmonary hypertension, and lower respiratory infections. Treating these illnesses often requires the use of inhaled therapies that can be delivered through multiple modalities, each of which carries its own pros and cons unique to its use in the geriatric population. Pharmacists have an opportunity to play a role in optimizing the selection of delivery devices and in providing patient and provider education on appropriate use of inhaled therapies. Through patient counseling and correct device selection, patient outcomes can be improved. This paper explores the differences among devices, provides specific information regarding drug mixing for nebulization, provides information regarding cleaning/maintenance of nebulizers, and addresses specific concerns related to geriatric care. It can serve as a reference for pharmacists and student pharmacists as they educate patients and providers.

Exclusion of Non-English Speakers in Published Emergency Medicine Research - A Comparison of 2004 and 2014.

BACKGROUND: Non-English speakers (NES) as a proportion of the United States population have steadily increased in recent years. There remains substantial risk of excluding NES from research. OBJECTIVE: To assess whether the percentage of emergency medicine (EM) studies that exclude Non-English speakers from participation has changed with time. METHODS: In a structured fashion, the lead investigator analyzed all original research articles in Academic Emergency Medicine and Annals of Emergency Medicine retrospectively for 2004 and prospectively for 2014. An independent investigator conducted a blind review of a sample of articles to assess for interobserver agreement. Demographic data were analyzed using descriptive statistics. Chi-square, t-tests, and linear regression models were utilized; alpha set at 0.05. Cohen's kappa calculated to assess interrater reliability. RESULTS: We included a total of 236 original research articles. Overall, 11% excluded NES from research (10% AEM, 12% Annals). Cohen's kappa (nonweighted) was 0.73. Comparing all articles in 2004 vs. 2014, research excluded NES 6% vs. 16% of the time respectively (P=0.02). This was not statistically significant when comparing year to year for AEM (7.3% vs. 14.5%; P=0.12) and Annals (6.7% vs. 19%; P=0.06) separately. Factors affecting NES exclusion included type of study design (P<0.001), geographic area (P=0.009) and hospital type (P=0.035). Interestingly, 42% of articles failed to mention language as an exclusion or inclusion criteria. CONCLUSION: We found that the percentage of articles excluding NES from EM research increased between 2004 and 20014. Further, many investigators do not report whether NES are excluded/included in their studies.

Support for a waiting room time tracker: a survey of patients waiting in an urban ED.

BACKGROUND: Emergency Department (ED) crowding and inpatient boarding lead to lengthy wait times for patients, which may cause them to choose to leave without being seen. A new initiative to improve communication with patients is to provide an estimated wait time with a "time tracker" display, but it is unclear whether ED patients would welcome this. OBJECTIVE: To estimate the proportion of ED patients who would favor a time tracker display. METHODS: This survey-based study was conducted from March to July 2010 at an urban academic center. After being triaged, patients were asked to answer a multiple-choice questionnaire, asking their preference toward a time tracker display. RESULTS: Of the 375 patients who were approached, 340 (91%) participated. Two hundred fourteen of them (63%) preferred an ED with a time tracker, 53 (16%) were unsure, and 73 (21%) did not prefer an ED with a time tracker. Patients with low-acuity conditions (Emergency Severity Index [ESI] 4 or 5) were 1.2 times more likely (95% confidence interval 1.0-1.4) to favor a time tracker than those with higher acuity (ESI 3). Preference was not related to race, age, insurance status, or employment. CONCLUSIONS: The majority of patients in our study preferred an ED with a time tracker display (63% for vs. 21% against). Support for a time tracker was higher among patients triaged with lower ESI levels (4 or 5). A time tracker is viewed positively by many patients and may be a beneficial addition in the ED waiting room.

How long are patients willing to wait in the emergency department before leaving without being seen?

INTRODUCTION: Our goal was to evaluate patients' threshold for waiting in an emergency department (ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness to wait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status. METHODS: We conducted this survey-based study from March to July 2010 at an urban academic medical center. After triage, patients were given a multiple-choice questionnaire, designed to ascertain how long they would wait for medical care. We collected data including age, gender, race, insurance status, and triage acuity level. We looked at the association between willingness to wait and these variables, using stratified analysis and logistic regression. RESULTS: Of the 375 patients who were approached, 340 (91%) participated. One hundred seventy-one (51%) were willing to wait up to 2 hours before leaving, 58 (17%) would wait 2 to 8 hours, and 110 (32%) would wait indefinitely. No association was found between willingness to wait and race, gender, insurance status, or perceived symptom severity. Patients willing to wait >2 hours tended to be older than 25, have higher acuity, and prefer the study site ED. CONCLUSION: Many patients have a defined, limited period that they are willing to wait for emergency care. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED without being seen. This result suggests that efforts to reduce the percentage of patients who LWBS must factor in time limits.

Zyxin controls migration in epithelial-mesenchymal transition by mediating actin-membrane linkages at cell-cell junctions.

Development is punctuated by morphogenetic rearrangements of epithelial tissues, including detachment of motile cells during epithelial-mesenchymal transition (EMT). Dramatic actin rearrangements occur as cell-cell junctions are dismantled and cells become independently motile during EMT. Characterizing dynamic actin rearrangements and identifying actin machinery driving these rearrangements is essential for understanding basic mechanisms of cell-cell junction remodeling. Using immunofluorescence and live cell imaging of scattering MDCK cells we examine dynamic actin rearrangement events during EMT and demonstrate that zyxin-VASP complexes mediate linkage of dynamic medial actin networks to adherens junction (AJ) membranes. A functional analysis of zyxin in EMT reveals its role in regulating disruption of actin membrane linkages at cell-cell junctions, altering cells' ability to fully detach and migrate independently during EMT. Expression of a constitutively active zyxin mutant results in persistent actin-membrane linkages and cell migration without loss of cell-cell adhesion. We propose zyxin functions in morphogenetic rearrangements, maintaining collective migration by transducing individual cells' movements through AJs, thus preventing the dissociation of individual migratory cells.

Development and validation of an instrument to determine patient knowledge: the oral anticoagulation knowledge test.

BACKGROUND: Studies examining the relationship between patient knowledge regarding warfarin therapy and its safe and effective use are limited by the lack of validated knowledge assessment tools. OBJECTIVE: To develop and validate an instrument to assess patient knowledge regarding oral anticoagulation therapy. METHODS: Four nationally recognized anticoagulation experts participated in the instrument development process to ensure content validity. The Oral Anticoagulation Knowledge (OAK) test was administered to subjects on warfarin and a group of age-matched subjects not on warfarin to assess construct validity. A subgroup of warfarin subjects were retested approximately 2-3 months after initial testing to assess test-retest reliability. Internal consistency reliability was assessed by calculating a Kuder-Richardson 20 value. Item analysis was used to assess performance of individual questions. RESULTS: An initial 23 item instrument was pilot tested for readability and comprehension. The OAK test was administered to 74 subjects taking warfarin and 27 age-matched subjects not on warfarin. Thirty-two subjects on warfarin repeated the OAK test an average of 75 days following initial administration. Subjects taking warfarin scored significantly higher than those not on warfarin (72% vs 52%, respectively; p < 0.001), supporting the construct validity of the instrument. Test-retest reliability was acceptable, with a Pearson's correlation coefficient of 0.81. Internal consistency reliability was confirmed by a calculated Kuder-Richardson 20 value of 0.76. CONCLUSIONS: The OAK test is a brief, valid, and reliable knowledge assessment instrument that may be a useful tool for research and clinical practice to augment patient education programs.