Retrospective analysis of a pilot pharmacist-led hospice deprescribing program initiative.

CONTEXT: Medication deprescribing in palliative care settings has been insufficiently studied. OBJECTIVE: To determine the feasibility of a deprescribing program in hospice patients with limited life expectancy. DESIGN: Pharmacist-led, single arm, single-centered, retrospective analysis of a pilot deprescribing program in an integrated healthcare delivery organization between 9/1/2018 to 1/31/2019. OUTCOME MEASURES: The primary outcome was the proportion of patients who achieved ≥50% reduction of the recommended medications to deprescribe. RESULTS: A total of 97 patients were included in the analysis. The average age was 77.5 ± 23.7 years, with 53.6% being women and 54.6% white. The most common primary diagnosis was cancer (58.8%), with cardiovascular disease the next most common (15.5%). The mean number of baseline comorbidities was 2.0 ± 1.6. Of 698 prescriptions at the start of hospice enrollment, 79.4% of patients achieved a ≥50% reduction in medications recommended for deprescribing. This success was seen mostly in cardiovascular and other nonspecific medications. We found that every 1-unit increase in the number of patient encounters with hospice pharmacists was associated with a 3.2-fold higher odds of achieving a ≥50% reduction in medications that were recommended for deprescribing. CONCLUSION: The findings from this pilot study revealed that a collaborative, pharmacist-led, collaborative medication deprescribing program initiative was associated with a 79% success in ≥50% medication reduction. More frequent patient encounters had higher odds of success. Future studies, utilizing a control group, should focus on determining the effectiveness of the program and the impact on quality of life.

5-Fluorouracil "Chemowraps" in the Treatment of Multiple Actinic Keratoses: A Norwich Experience.

INTRODUCTION: Topical 5-fluorouracil (5-FU) has been used to treat actinic keratosis for decades. It has been an important and effective treatment which the patient can self-administer, but is limited by the surface area of skin to be treated (according to the manufacturer's guidelines) of 500 cm(2). Other topical treatments can be painful, or require hospital/health care professional input. The use of 5-FU under occlusion (chemowraps) for large areas of sun-damaged skin on the arms or legs has been described and is a potentially useful treatment option. We describe our experiences with this technique in the Norfolk and Norwich University Hospital Dermatology Department (Norwich, UK). METHODS: Five patients were recruited into this pilot study. Topical 5-FU was applied to sun-damaged limbs under occlusion, and reviewed weekly for response, and local or systemic side effects. Treatment duration was 12-14 weeks. Clinical photography was undertaken prior to, during, and after treatment to document response. RESULTS: We show that there was substantial clinical improvement in the treated skin in our patients. Experienced dermatologists reviewed all the patients, and documented the changes photographically, and by counting lesions. All patients were satisfied with their treatment regimen, and also with the end result; although two did not complete the treatment regimen due to complications not directly attributable to the treatment. CONCLUSION: Topical 5-FU under occlusion (chemowraps) may be a valid treatment option for large areas of sun-damaged skin with field cancerization changes, due to low systemic and local toxicity, and acceptability to patients.

Patients with sickle cell disease have reduced blood antioxidant protection.

In previous studies, we found that homozygous sickle cell (HbSS) patients, compared with their healthy (HbAA) counterparts, had reduced levels of the omega-3 fatty acids, eicosapentaenoic (EPA) and docosahexaenoic (DHA) acids, in red cells, platelets, and mononuclear cells. These differences were not due to lower intake of the two fatty acids. We have investigated whether reduced antioxidant status in the patients could help explain the observed phenomenon. Blood specimens previously obtained for fatty acid study from Nigerian (26 HbSS and 30 HbAA) and British (30 HbSS, 9 sickle cell-hemoglobin C/HbSC, and 15 HbAA) subjects were analyzed for antioxidant status. The Nigerian HbSS patients compared with the controls had lower plasma retinol, alpha-tocopherol, and beta-carotene concentrations (p < 0.005) and reduced activity of red cell Cu/Zn-superoxide dismutase (Cu/Zn-SOD) (p < 0.05). Similarly, the British HbSS group had reduced concentrations of plasma alpha-tocopherol (p < 0.005), and activities of red cell Cu/Zn-superoxide dismutase (p < 0.05) and Se-glutathione peroxidase (Se-GPx) (p < 0.005) than the controls. In addition, the British patients in comparison with those who had HbSC, a mild form of the disease, had lower alpha-tocopherol than that of the HbAA controls (p < 0.005). In the British sickle cell patients, there was a positive correlation between red cell ethanolamine phosphoglyceride (EPG) DHA and Cu/Zn-SOD activity (r = 0.700, p < 0.05), choline phosphoglyceride (CPG) DHA and Se-GPx activity (r = 0.605, p < 0.05), and CPG EPA and Se-GPx activity (r = 0.558, p > 0.05). Similarly, the percent DHA in red cell EPG was positively related with the activity of Se-GPx in the patients with HbSC (r = 0.674, p < 0.05). These findings suggest that the lower levels of membrane EPA and DHA in blood cells of the HbSS patients could be due to peroxidation resulting from a compromised antioxidant competence.