Interventions to improve the appropriate use of polypharmacy for older people.

BACKGROUND: Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, so that many medicines may be used to achieve better clinical outcomes for patients. This is the third update of this Cochrane Review. OBJECTIVES: To assess the effects of interventions, alone or in combination, in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 13 January 2021, together with handsearching of reference lists to identify additional studies. We ran updated searches in February 2023 and have added potentially eligible studies to 'Characteristics of studies awaiting classification'. SELECTION CRITERIA: For this update, we included randomised trials only. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy (four or more medicines) in people aged 65 years and older, which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people). DATA COLLECTION AND ANALYSIS: Four review authors independently reviewed abstracts of eligible studies, and two authors extracted data and assessed the risk of bias of the included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS: We identified 38 studies, which includes an additional 10 in this update. The included studies consisted of 24 randomised trials and 14 cluster-randomised trials. Thirty-six studies examined complex, multi-faceted interventions of pharmaceutical care (i.e. the responsible provision of medicines to improve patients' outcomes), in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists, nurses and geriatricians, and most were conducted in high-income countries. Assessments using the Cochrane risk of bias tool found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low. It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool) (mean difference (MD) -5.66, 95% confidence interval (CI) -9.26 to -2.06; I2 = 97%; 8 studies, 947 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs) (standardised mean difference (SMD) -0.19, 95% CI -0.34 to -0.05; I2 = 67%; 9 studies, 2404 participants; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIM (risk ratio (RR) 0.81, 95% CI 0.68 to 0.98; I2 = 84%; 13 studies, 4534 participants; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.48, 95% CI -1.05 to 0.09; I2 = 92%; 3 studies, 691 participants; low-certainty evidence), however it must be noted that this effect estimate is based on only three studies, which had serious limitations in terms of risk of bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPO (RR 0.50, 95% CI 0.27 to 0.91; I2 = 95%; 7 studies, 2765 participants; very low-certainty evidence). Pharmaceutical care may make little or no difference to hospital admissions (data not pooled; 14 studies, 4797 participants; low-certainty evidence). Pharmaceutical care may make little or no difference to quality of life (data not pooled; 16 studies, 7458 participants; low-certainty evidence). Medication-related problems were reported in 10 studies (6740 participants) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies. This also applied to studies examining adherence to medication (nine studies, 3848 participants). AUTHORS' CONCLUSIONS: It is unclear whether interventions to improve appropriate polypharmacy resulted in clinically significant improvement. Since the last update of this review in 2018, there appears to have been an increase in the number of studies seeking to address potential prescribing omissions and more interventions being delivered by multidisciplinary teams.

An Improved and Simplified Approach to Identify the Facial Nerve During Parotid Surgery.

Precise identification and preservation of the facial nerve is mandatory to avoid dysfunction of the facial nerve during parotidectomy. In this article, the authors are introducing a new landmark to identify the facial nerve for parotidectomy that is more protective for the facial nerve. The authors use a simple approach to predict the position of facial nerve main trunk intraoperatively without geometric calculations and a lot of landmarks. An imaginary almost 2 cm line is drawn between mastoid tip inferiorly and bony-cartilaginous junction of the external auditory canal superiorly. The main trunk of the facial nerve can be visualized at the midpoint of this line. The authors have been using this landmark successfully for the last 10 years, without any functional deficit of the parotid nerve. Identifying the facial nerve at the trunk level by this landmark renders following the branches forward in the glandular parenchyma less complicated.

(3+1)D Quasiparticle Anisotropic Hydrodynamics for Ultrarelativistic Heavy-Ion Collisions.

We present the first comparisons of experimental data with phenomenological results from (3+1)D quasiparticle anisotropic hydrodynamics (aHydroQP). We compare particle spectra, average transverse momentum, and elliptic flow. The dynamical equations used for the hydrodynamic stage utilize aHydroQP, which naturally includes both shear and bulk viscous effects. The (3+1)D aHydroQP evolution obtained is self-consistently converted to hadrons using anisotropic Cooper-Frye freeze-out. Hadron production and decays are modeled using a customized version of therminator 2. In this first study, we utilized smooth Glauber-type initial conditions and a single effective freeze-out temperature T_{FO}=130 MeV with all hadronic species in full chemical equilibrium. With this rather simple setup, we find a very good description of many heavy-ion observables.

Selection of outcome measurement instruments for a core outcome set for trials aimed at improving appropriate polypharmacy in older people in primary care: a Delphi consensus study.

BACKGROUND: Despite developing a polypharmacy core outcome set (COS) in primary care, it is not clear how these outcomes should be measured. AIM: To select outcome measurement instruments (OMIs) for a COS targeting appropriate polypharmacy in older patients in primary care. METHOD: Following the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guideline, OMIs were identified from a Cochrane review focusing on appropriate polypharmacy. The quality of OMIs was assessed using a published checklist. Subsequently, two rounds of Delphi questionnaires were conducted via the SoGoSurvey® platform, engaging stakeholders (researchers, clinicians and journal editors specialising in geriatric primary care) to achieve consensus on OMIs using a scale encompassing "agree", "disagree", or "unsure". Consensus was achieved if 70% or more participants chose "agree" and 15% or fewer chose "disagree." RESULTS: The quality of 20 OMIs identified from the Cochrane review was evaluated. Seven OMIs were selected based on meeting the COSMIN guideline's minimum requirements. Out of 188 potential participants, 57 (30.3%) consented to participate. Rounds 1 and 2 of Delphi exercises were completed by 50 respondents, achieving agreement on three OMIs: 'number of serious adverse drug reactions (ADRs)' (98%), 'number of deaths' (76%), and 'number of patients who fell' (70%) for measuring 'serious ADRs,' 'mortality,' and 'falls,' respectively. No agreement was reached for 'medication appropriateness,' 'medication side-effects,' 'quality of life,' and 'medication regimen complexity.' CONCLUSION: OMIs were selected for a limited number of outcomes in the polypharmacy COS. Future research should identify suitable OMIs for the remaining four outcomes.

A Child Plexiform Neurofibroma of the Temple Region: A Case Report.

Plexiform neurofibroma is a rare variant of neurofibromatosis type 1. Diagnosis is challenging due to the highly variable clinical presentation. Early diagnosis is essential for appropriate treatment and prevention of complications. This report describes a sporadic solitary plexiform neurofibroma in the temporal region of a seven-year-old girl. The growth of the mass began at birth and grew steadily over five years. Subsequently, the mass began to expand rapidly. The patient underwent complete surgical resection under general anesthesia. Histopathological examination revealed a plexiform neurofibroma. In conclusion, surgical excision is the gold standard for cases with symptomatic, visible, large superficial lesions.

The Diagnostic Value of Fine-Needle Aspiration Cytology in Cervical Lymphadenopathy in Correlation to Postoperative Histopathological Results in a Tertiary Care Center in Saudi Arabia.

Background Lymphadenopathy is a frequently encountered presentation in the clinical practice. Cervical lymphadenopathy implies that the cervical nodal tissue measures more than 1 cm in diameter. It requires prompt and accurate diagnosis to begin an appropriate treatment plan. Fine-needle aspiration cytology (FNAC) is considered an initial diagnostic method due to its simplicity, minimal invasiveness, quick availability of results, and low risk of complications. This study aimed to evaluate the diagnostic value of FNAC by comparing the cytological and histological diagnoses of patients with cervical lymph node enlargement at Aseer Central Hospital, Southern Region, Saudi Arabia. Methodology This observational, retrospective, record review study was conducted at the Otorhinolaryngology Head and Neck Surgery Department in Aseer Central Hospital, Abha, Saudi Arabia. Using a data collection sheet, the data of 102 patients were collected from electronic records and reviewed retrospectively. The study included patients who underwent cervical lymph node excision biopsy between 2020 and 2023 due to enlargement of the cervical lymph node. The cytological diagnoses were compared with the histopathological diagnoses of the same enlarged cervical lymph nodes. Results The most common FNAC findings were lymphomas and reactive lymph nodes (26.2% and 19.7%, respectively). The positive predictive value of FNAC was 100% and the negative predictive value was 86.7%. Overall, the diagnostic accuracy was 95.3%. Conclusions FNAC is a safe diagnostic method with minimal invasiveness and complications. This study showed that FNAC and tru-cut biopsy have good diagnostic value in examining patients with cervical lymphadenopathy regardless of their limitations and drawbacks. They have good sensitivity, specificity, positive and negative predictive values, and accuracy.

Awareness, Knowledge, and Acceptance of Dental Implants among the Geriatric Population of Jeddah, Saudi Arabia.

Background: Dental implants (DI) are gaining popularity among the general population, and special consideration has been given to the geriatric population in the replacement of missing teeth subject to their medical stability. The study aimed to assess the awareness, knowledge, and acceptance regarding DI among the geriatric population of Jeddah, Saudi Arabia. Methodology: A cross-sectional survey was carried out through face-to-face interviews using a pretested and standardized questionnaire by calibrated interviewers. Participants of age >58 years who have not undergone any implant or bone graft procedures attending different prosthodontic clinics in Jeddah were recruited according to availability after obtaining consent. Responses received were converted into digital format and subjected to statistical analysis. Results: The knowledge related to DI was not satisfactory, and only 4.5% showed good knowledge. The willingness to replace the current prosthesis with DI was found in 49.6%, and it was also observed that 40% of the participants were using some tooth-supported fixed dental prosthesis. Only 41.3% and 31% were aware of bone graft and sinus lift procedures related to DI. Conclusion: Even though most participants were aware of DI, the knowledge related to it was little satisfactory. Older people should be appropriately explained about the best treatment choice for teeth replacement by connecting to their current systemic health condition with its benefits and long-term effects. Unexpectedly, the awareness related to bone graft and sinus lift procedures related to DI was found to be relatively acceptable as well as the willingness to accept bone graft if needed for DI placement was observed.

Endovascular Management of Vascular Complications in Ehlers-Danlos Syndrome Type IV.

(1) Background: The vascular type of Ehlers-Danlos syndrome (vEDS) is a rare genetic connective tissue disorder caused by pathogenic variants in the COL3A1 gene that result in arterial and organ fragility and premature death. We present five cases of vEDS that highlight the diagnosis and treatment challenges encountered by clinicians with these patients. (2) Case presentations: we present the cases of five patients with vascular complications of vEDS who were successfully managed using endovascular interventions or hybrid techniques at our institution from 2005 to 2022. (3) Conclusions: These data emphasize that a multidisciplinary approach is needed for vEDS patients and that when endovascular or hybrid treatment is performed in a timely manner by a skilled team of interventional radiologists, good results can be achieved. Our report also demonstrates that the prognosis of vEDS patients has improved over the past 20 years with a new prevention program including celiprolol therapy, physical activity adaptation and limitation, and scheduled monitoring by expert clinicians.

A new landmark for the identification of the facial nerve during parotid surgery: A cadaver study.

OBJECTIVE: Precise knowledge of facial nerve anatomy is crucial for parotid surgery. Although several surgical landmarks to identify the facial nerve have been described in literature, their position is variable, inconsistent, and difficult to follow in some cases. The purpose of this study was to prove that the facial nerve trunk (FNT) is located midway between the mastoid tip (MT) and osteocartilaginous junction of the external auditory canal (EAC). METHODS: A prospective study of 7 frozen cadaver specimens, of which 13 facial sides were dissected. The distances between the osteocartilaginous junction and the MT, between the FNT and the MT, and between the FNT and the osteocartilaginous junction were recorded, respectively. RESULTS: The distance between the osteocartilaginous junction and the MT ranged from 17 to 21 mm, with a mean of 19.5 mm (SD = ±1.19). The mean distances between the osteocartilaginous junction and the FNT and between the MT and the FNT were 9.2 mm (±1.58) and 10.3 mm (±1.79), respectively. CONCLUSION: The FNT was consistently located close to the midpoint between mastoid tip inferiorly and bony-cartilaginous junction of the EAC superiorly. LEVEL OF EVIDENCE: NA.

Outcomes of Early-stage Glottic Carcinoma Treated with Radiation Therapy: A Single Institution Experience.

OBJECTIVE:  To evaluate the outcomes of radical intent radiation therapy in early glottic carcinoma (EGC), including local control rate (LCR), disease-free survival (DFS), death specific free survival (DSFS), and overall survival (OS) rates, in Saudi patients treated at a single institution.  Materials and methods: This is an institutional review board (IRB) approved, retrospective study of 27 patients with T1-2 N0 M0, early glottic carcinoma (EGC) who were treated from 2010 to 2015 at our institution with different radiotherapy (RT) fractionation regimens. The regimens included six different fractionation schedules of radiotherapy (RT): 50 Gy (20 x 2.5 Gy) dose prescribed to 95% isodose line, 52.4 Gy (20 x 2.52 Gy), 63 Gy (28 x 2.25 Gy), 66 Gy (33 x 2 Gy), and 70 Gy (35 x 2 Gy). The cohort was stratified into two groups, ≤ 52.5 Gy (n=15) and > 52.5 Gy (n=12). The median follow-up of all patients was 31.7 months (range 7-82). RESULTS: The mean age of the cohort was 64.5 years (median 65, range: 41-83). Eleven patients (40.7%) had a history of smoking. The majority of the cohort was with T1a EGC (70.4%, n=19), and anterior commissure invasion was seen in three patients (11.1%). The mean RT doses were 55.6 Gy (range: 50-70). The five-year LCR, DFS, DSFS, and OS rates were 83.1%, 80.0%, 96.2%, and 92.6%, respectively. The LCR rates for those receiving a dose of 52.5 Gy or less were 61.3 months compared to 89.5 months for those who received more than 52.5 Gy (p=0.994). Non-smokers and patients with an unknown smoking history achieved a five-year LCR of 100%, while patients with a positive smoking history achieved a five-year LCR of 60.6% (p=0.044). CONCLUSION:  Radiation therapy for EGC in our patients showed reasonable five-year LCR with larynx preservation at 83.1%, DFS 80.0%, five-year OS rate 92.6%, and DSFS rate 96.2%. We found that smoking had a significant correlation with LCR. However, large prospective trials are warranted to evaluate the efficacy of overall treatment time, dose per fraction of above 2 Gy, and smoking effect.

Evaluation of Surface Roughness of Different Direct Resin-based Composites.

AIMS AND OBJECTIVE: To evaluate surface roughness of different resin-based composites. MATERIALS AND METHODS: Three resin composites, one nanohybrid, one nanoceramic, and one bulk-fill resin-based composite, were used in this study. Cylindrical Teflon mold and 8 mm in diameter and 2 mm in thickness disc specimens were prepared. For each composite material, 15 discs were fabricated, with a total of sixty discs were obtained (n = 60). A glass slide 1-2 mm thick was placed over the strip before curing with the light-curing unit to flatten the surfaces. The specimens were then cured for 40 s through the Mylar strip and the glass slide. Five specimens per each material received no finishing treatment after being cured under Mylar strips; these specimens served as a control. Ten specimens from each composite material were finished/polished with Eve discs at coarse, medium, fine, and superfine grits for 30 s (using stopwatch) each on the specimens. After polishing, the composite surfaces were assessed quantitatively by profilometry and qualitatively by scanning electron microscopy. Data were analyzed using SPSS software. RESULTS: Tetric Evo Ceram and Tetric Evo Ceram Bulk-Fill specimens polished with Eve revealed slightly the same surface appearance as the Mylar strip. Eve discs scratched and exposed fillers of Ceram-x. Eve discs for Z250 surfaces exposed and scratched the filler particles but less than occurred with Ceram-x. CONCLUSION: Bulk-Fill and nanohybrid resin composites exhibit smoothest surfaces compared with nanoceramic and microhybrid resin composites after polishing.

Patterns of failure and survival in patients with nasopharyngeal carcinoma treated with intensity-modulated radiation therapy in Saudi Arabia.

BACKGROUND: We aimed to investigate the patterns of failure (locoregional and distant metastasis), associated factors, and treatment outcomes in nasopharyngeal carcinoma patients treated with intensity-modulated radiation therapy (IMRT) combined with chemotherapy. PATIENTS AND METHODS: From April 2006 to December 2011, 68 nasopharyngeal carcinoma patients were treated with IMRT and chemotherapy at our hospital. Median radiation doses delivered to gross tumor volume and positive neck nodes were 66-70 Gy, 63 Gy to clinical target volume, and 50.4-56 Gy to clinically negative neck. The clinical toxicities, patterns of failures, locoregional control, distant metastasis control, disease-free survival, and overall survival were observed. RESULTS: The median follow-up time was 52.2 months (range: 11-87 months). Epstein-Barr virus infection was positive in 63.2% of patients. Overall disease failure developed in 21 patients, of whom 85.8% belonged to stage III/IV disease. Among these, there were seven locoregional recurrences, three regional recurrences with distant metastases, and eleven distant metastases. The median interval from the date of diagnosis to failure was 26.5 months (range: 16-50 months). Six of ten (60%) locoregional recurrences were treated with reirradiation ± concurrent chemotherapy. The 5-year locoregional control, distant metastasis control, disease-free survival, and overall survival rates of whole cohort were 81.1%, 74.3%, 60.1%, and 73.4%, respectively. Cox regression analyses revealed that neoadjuvant chemotherapy, age, and Epstein-Barr virus were independent predictors for disease-free survival. CONCLUSION: Neoadjuvant chemotherapy followed by IMRT with or without chemotherapy improves the long-term survival of Saudi patients with nasopharyngeal carcinoma. Distant metastasis was the main pattern of treatment failure. Neoadjuvant chemotherapy, age, and Epstein-Barr virus status before IMRT were important independent prognostic factors.