Risk of Recurrent Stroke and Mortality Among Black and White Patients With Poststroke Depression.

BACKGROUND: Poststroke depression (PSD) is a treatable and common complication of stroke that is underdiagnosed and undertreated in minority populations. We compared outcomes of Black and White patients with PSD in the United States to assess whether race is independently associated with the risk of recurrent stroke and mortality. METHODS: We used deidentified Medicare data from inpatient, outpatient, and subacute nursing facilities for Black and White US patients from January 1, 2016, to December 31, 2019, to perform this retrospective cohort analysis. International Classification of Diseases, Tenth Revision codes were used to identify patients diagnosed with depression within 6 months of index stroke with no depression diagnosis 1-year preceding index stroke. We performed an unadjusted Kaplan-Meier analysis of the cumulative risk of recurrent stroke up to 3 years after index acute ischemic stroke admission and all-cause mortality following acute ischemic stroke stratified by Black and White race. We performed adjusted and reduced Cox regression to calculate hazard ratios for the main predictor of race (Black versus White), for recurrent stroke and all-cause mortality, adjusting for sociodemographic characteristics, comorbidities, characteristics of the hospitalization, and acute stroke interventions. RESULTS: Of 474 770 Medicare patients admitted with acute index stroke, 443 486 were categorized as either Black or White race and 35 604 fulfilled our criteria for PSD. Within the PSD cohort, 25 451 (71.5%) had no death or recurrent stroke within 6 months and 5592 (15.7%) had no death or readmission of any cause within 6 months. Black patients with PSD had a persistently elevated cumulative risk of recurrent stroke compared with White patients with PSD up to 3 years following acute ischemic stroke (log-rank P=0.0011). In our reduced multivariable model, Black patients had a 19.8% (hazard ratio, 1.198 [95% CI, 1.022-1.405]; P=0.0259) greater risk of recurrent stroke than White patients. The unadjusted cumulative risk of all-cause mortality was higher in this cohort of older White patients with PSD compared with Black patients; however, this difference disappeared with adjustment for age and other cofactors. CONCLUSIONS: Black patients with PSD face a persistently elevated risk of recurrent stroke compared with White patients but a similar risk of all-cause mortality. Our findings support that black race is an independent predictor of recurrent stroke in patients with PSD and highlight the need to address social determinants of health and systemic racism that impact poststroke outcomes among racial minorities.

Dose Response to Upper Extremity Stroke Rehabilitation Varies by Individual: Early Indicators of Treatment Response.

BACKGROUND: Dose response has remained a priority area in motor rehabilitation research for decades, prompting several large randomized trials and meta-analyses. These between-subjects comparisons have revealed equivocal relationships between the duration of motor practice and rehabilitation response. Prior reliance on time-consuming clinical assessments made it infeasible to capture within-subjects dose response, as tracking the dose-response trajectory of an individual requires dozens of repeated administrations. METHODS: This secondary observational cohort analysis of existing data from the gaming arms of the VIGoROUS multisite trial (Video Game Rehabilitation for Outpatient Stroke) describes the rehabilitation dose response of 80 participants with mild-moderate chronic stroke. The 3-dimensional joint position data were captured via the Kinect v2 optical sensor as participants completed a prescribed 15 hours of in-home unsupervised game-based motor practice. Kinematic dose response trajectories were fitted from hundreds to thousands of in-game repetitions for 4 separate upper extremity movements for each participant. RESULTS: Of 75 participants with sufficient data for dose-response analysis, 85% showed improved motor capacity for at least 1 movement. Dose response was bimodal; 42% required <5 hours of motor practice before reaching a plateau in movement kinematics, whereas 55% required >10 and 34% required >30 hours. We could predict with 93% accuracy whether or not an individual would ultimately respond to game-based motor practice within 5 hours of gameplay. CONCLUSIONS: Dose response varies considerably between individuals. About half of chronic stroke patients benefit from higher doses of motor practice than the current standard of care. Individualized dose-response data from motion capture rehabilitation gaming can guide clinical decision-making early on in treatment. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02631850.

Remarkable increase in the detection and molecular characterization of adenovirus F41 in children with acute gastroenteritis in Japan, 2017-2023.

Human adenovirus (HAdV) is one of the causative viruses of acute gastroenteritis (AGE) in children worldwide. Species F is known to be enteric adenovirus (genotypes 40 and 41) detected in stool samples. In Japan, we conducted an epidemiological study and molecular characterization of HAdV before and after the COVID-19 pandemic from 2017 to 2023. Among 821 patients, HAdV was detected in 118 AGE cases (14.4%). During a period of 6 years, the HAdV detection rates for each year were relatively low at 3.7% and 0%, in 2017-2018, and 2020-2021, respectively. However, the detection rate increased to remarkably high rates, ranging from 13.3% to 27.3% in the other 4-year periods. Of these HAdV-positive strains, 83.1% were F41 genotypes and 16.9% were other genotypes (A31, B3, C1, C2/C6, and C5). Phylogenetic analyses of the nucleotide and deduced amino acid sequences of the full-length hexon gene demonstrated that HAdV-F41 strains were comprised of three clades, and each clade was distributed across the study period from 2017 to 2023. Analysis of deduced amino acid sequences of the hexon gene of the representative HAdV-F41 strains from each clade revealed numerous amino acid substitutions across hypervariable regions (HVRs) from HVR-1 to HVR-7, two insertions in HVR-1 and HVR-7, and two deletions in HVR-1 and HVR-2 of the hexon gene compared to those of the prototype strain, particularly, those of clade 3 HAdV-F41 strains. The findings suggested that the HAdV-F41 of each clade was stable, conserved, and co-circulated for over two decades in Japan.

Nonadherence to oral cancer chemotherapy in hepatocellular carcinoma: prevalence and predictive factors in Vietnam.

PURPOSE: Standard oral cancer chemotherapy (OCT) or targeted therapy (OTT) has expanded the treatment methods for hepatocellular carcinoma (HCC). However, its principal nonadherence causes a reduction in efficacy. We aimed to evaluate the status of nonadherence and influencing factors among outpatient patients with HCC. PATIENTS AND METHODS: In 2021, a prospective observational study was conducted on 384 patients with either old or newly diagnosed HCC treated with OTT. Nonadherence to OCT was determined using the eight-item Morisky Medication Adherence Scale, with a score < 6 points. The patients were finished with a six-month follow-up investigation by questionnaires. RESULTS: 54,8% of HCC outpatients were nonadherent to OCT, with a mean Morisky score of 5.19. They dropped out of the treatment mainly because of drug side effects, such as fatigue (72.4%), hand-foot syndrome (42.7%), diarrhea (38.3%), nausea (25%), insomnia (24.7%), abdominal pain (12%), and anxiety about these adverse events (65.9%). Additionally, financial difficulties and low relative copayments were significantly correlated with the noncompliant treatment of patients (OR = 2.29, 95% CI = 1.32-3.98, P = 0.003; OR = 4.36, 95% CI = 0.95-19.93, P = 0.039, respectively). Moreover, inadequate individual information about the clinical course, the art of treatment, and medication usage instructions were suggestive barriers to adherence to treatment (OR = 1.96, 95% CI = 1.08-3.55, P = 0.024; OR = 1.86, 95% CI = 1.1-3.14, P = 0.02; OR = 2.34, 95% CI = 1.29-4.26, P = 0.004, respectively). Finally, a low level of trust in doctors was an essential factor in nonadherence (Mean of the Anderson Trust in Physician Scale scores counted 38.12 vs. 43.97, respectively for non-adherence vs. adherence, P = 0.00001). CONCLUSIONS: This study suggests a high rate of primary nonadherence to standard oral targeted therapy among HCC outpatient patients because of drug side effects, patient awareness of treatment, and lack of confidence in healthcare providers. Close supervision, proper medication instructions, appropriate dosage reductions, and comprehensive patient counseling might be necessary to control nonadherence.

Safety of non-ionic contrast media in CT examinations for out-patients: retrospective multicenter analysis of 473,482 patients.

OBJECTIVES: This study aimed to explore the incidence of and potential risk factors for adverse drug reactions (ADRs) after non-ionic iodinated contrast media (NICM) administration for CT exams in out-patient settings in China. MATERIALS AND METHODS: A total of 473,482 out-patients who underwent intravenous NICM between January 1st, 2017, and Dec 31st, 2021, were retrospectively enrolled from three institutions. The occurrence of ADRs and clinical information were recorded. Chi-square test, Poisson regression, and logistic regression analyses were used to evaluate potential ADR risk factors and correlation with demographics, season, and NICM type. RESULTS: Among the 473,482 patients (mean age 55.22 ± 14.85; 253,499 male) who received intravenous NICM, the overall ADR incidence was 0.110% (522 of 473,482), with 0.099% acute-related drug reactions (469 of 473,482) and 0.0004% serious ADRs (two of 473,482). Iopromide was associated with a higher risk of acute ADRs. Late ADRs were more frequently observed with iodixanol 320. Multi-level logistic regression of patients with acute ADRs and a control group (matched 1:1 for age, gender, NICM, prescriber department, and institution) showed that summer (adjusted OR = 1.579; p = 0.035) and autumn (adjusted OR = 1.925; p < 0.001) were risk factors of acute ADRs. However, underlying disease and scanned body area were not related to a higher ADR incidence. CONCLUSION: The use of NICM for out-patients is in general safe with a low ADR incidence. The type of contrast medium (iopromide) and the seasons (summer and autumn) were associated with a higher risk of acute ADRs. Late ADRs were more often observed with iodixanol. CLINICAL RELEVANCE STATEMENT: In comparison to in-patients, out-patients may be exposed to higher risk due to a lack of extensive risk screening, less nursing care, and higher throughput pressure. Safety data about NICM from a large population may complement guidelines and avoid ambiguity. KEY POINTS: • The incidence and risk factors for adverse events after using non-ionic iodinated contrast media are complex in out-patients. • Non-ionic iodinated contrast media are safe for out-patients and the overall incidence of adverse drug reactions was 0.110%. • There is a higher risk of acute adverse drug reactions in summer and autumn.

Influence of multidisciplinary team care with abundant nurse staffing on patient-reported outcomes among patients with inflammatory bowel disease in clinical remission.

BACKGROUND: Patients with inflammatory bowel disease (IBD) experience difficulties in daily life and demanding self-care needs. The goal of our support for patients is to ease their difficulties and improve their belief in their capacity to self-manage their disease (self-efficacy), by increasing their ability for self-care. The nurse's contribution is vital in empowering patients and supporting them to better manage their disease. There is evidence that higher nurse staffing levels are associated with better patient outcomes in acute care settings, but little is known about the outpatient setting. The objective of this study was to explore the impact of multidisciplinary team care with abundant nurse staffing levels on patient-reported outcome measures (PROMs) among patients with IBD, encompassing Crohn's disease (CD) and ulcerative colitis (UC), in clinical remission. METHODS: Patients with IBD in clinical remission were included because disease activity influences the patient's subjective evaluation. A total of 499 valid responses from two different sources were analyzed: 318 from a specialized IBD clinic with abundant nurse staffing and a multidisciplinary care team (UC: 83, CD: 235) and 181 from an online survey panel (UC: 109, CD: 72). The IBD Self-Efficacy Scale (IBD-SES) and the difficulty of life scale (DLS) were used as disease-specific PROMs. RESULTS: In two multiple regression models adjusted by background characteristics (age, sex, diagnosis [UC/CD], employment status, use of biologics, and disease duration) using the IBD-SES or DLS as a dependent variable, the responses from clinic patients showed a more favorable score (higher self-efficacy or lower difficulty) than the online responses. CONCLUSIONS: Multidisciplinary team care with abundant nurse staffing may improve self-efficacy and ease difficulties of life among patients with IBD in clinical remission. These results could help bring attention to nurse staffing in an outpatient setting, which has previously been overlooked, and be the first to provide evidence of its importance in encouraging enhanced staffing levels.

A newly developed algorithm for switching outpatient medications to medications listed in the hospital formulary: a prospective real-word evaluation in patients admitted electively to hospital.

PURPOSE: In many countries, outpatient and inpatient care are separated. During hospitalization, therefore, switching the outpatient medication to medication of the hospital formulary is required. METHODS: We newly designed a switching algorithm in six switching steps (S0-S5) and conducted a study at Bundeswehr Hospital Hamburg (300 beds, 80% civilians). We performed (i) a medication reconciliation to obtain information on outpatient medications and (ii) a medication review to solve drug-related-problems, e.g., drug-drug interactions. We applied (iii) the algorithm to switch medications to the hospital formulary. RESULTS: (i) We identified 475 outpatient medications (median per patient: 4; Q25/Q75 2/7) in 100 patients consecutively admitted to hospital (median age: 71; Q25/Q75: 64/80 years). Of 475 medications, the switching algorithm could not be used since product names were missing in 23.9% and strength in 1.7%. In 3.2%, switching was not required since medication was not prescribed during the hospital stay. (ii) Drug-drug interactions were identified in 31 of 79 patients with more than one medication. (iii) Of 475 medications, 18.5% were on the hospital formulary and therefore did not need to be  switched (S0), 0.2% were on a substitution-exclusion list not allowing switching (S1), 42.0% were switched to a generic medication of the hospital formulary (S2), 1.7% to a therapeutically equivalent medication (S3), 0.4% were patient-individually switched (S4), and for 8.2% a standardized/patient-individual switching was not possible (S5). CONCLUSIONS: Despite comprehensive medication reconciliation, patient- and medication-related information for switching medications to the hospital formulary was often missing. Once all the necessary information was available, standardized switching could be easily carried out according to a newly developed switching algorithm.

Age and healthy lifestyle behavior's disparities and similarities on knowledge of myocardial infarction symptoms and risk factors among public and outpatients in a resource-limited setting, cross-sectional study in greater Gaborone, Botswana.

OBJECTIVES: In this cross-sectional study from Botswana, we investigated knowledge of myocardial infarction (MI) symptoms and risk factors among the general public and outpatients with MI risk factors based on age and lifestyle behaviors, in addition to assessing associations with sociodemographic and MI risk factors. METHOD: Open-ended questionnaires about 8 MI symptoms and 10 risk factors, were administered by research assistants to a representative selection of outpatients (n = 525) and the public (n = 2248). Weight and height were measured in all participants and BMI was calculated. Knowledge scores were compared between the two groups. We examined whether sociodemographic and MI risk factors had impact on the scores. Analyses were further adjusted for lifestyle behavior (smoking status, dietary status and physical activities). RESULTS: The valid response rate was 97.9% comprising 97.8% for the public (n = 2199) and 98.1% for outpatients (n = 515). Public respondents (35.2 ± 12.3 years) were younger than outpatients (38.5 ± 12.6 years). The public comprised 56.9% females while outpatients 54.6%. In general, outpatients had higher knowledge of MI symptoms than the public, with mean scores ± SD of 3.49 ± 2.84 vs 2.80 ± 2.54. Outpatients also had higher knowledge score of MI risk factors than the public, with mean scores, 5.33 ± 3.22 vs 3.82 ± 3.07. For MI symptoms, outpatients were more aware than the public for chest pains among all ages, for arm pain/ numbness, neck/ jaw pain radiating to/ from chest, and feeling sick or looking pallor on the skin among those aged 35-49 years. Among both the public and outpatients, lower knowledge of both MI symptoms and risk factors was associated with primary education, not residing/working together, history of hypertension, no history of heart disease/stroke, and obesity. There were similarities and disparities on MI knowledge among respondents with various numbers of healthy lifestyle behaviours. CONCLUSION: Results call for urgent educational campaigns on awareness and knowledge of MI and using strategies based on age and lifestyle behavior.

Cardiovascular risk associated with changes in anticholinergic load on four different scales: a registry-based cohort study of geriatric outpatients.

BACKGROUND: Recent studies have shown that anticholinergic medications are associated with cardiovascular disease. Little is known about how discontinuation of anticholinergic medication affects this association. We investigated how baseline anticholinergic load and change in anticholinergic load associates with major adverse cardiovascular events (MACE) on four different scales. METHODS: We included all geriatric outpatients aged 65 and older in Denmark between January 2011 and December 2018. Data were sourced from Danish national registries. Anticholinergic drug exposure was assessed at first contact to the outpatient clinic (baseline) and changes were assessed at 180 days after outpatient contact. Anticholinergic scales were the CRIDECO Anticholinergic Load Scale, Anticholinergic Drugs Scale, Anticholinergic Cognitive Burden and a scale by the Danish Institute of Rational Pharmacotherapy. Multivariate analyses were conducted to investigate the 1- and 5-year risk of MACE by baseline anticholinergic load and changes in anticholinergic load after 180 days. RESULTS: We included a total of 64 378 patients in the analysis of baseline anticholinergic load and 54 010 patients remained after 180 days for inclusion in the analysis of change in anticholinergic load. At baseline the mean age was 81.7 year (SD 7.5) and 68% were women. Higher level of anticholinergic load on any scale associated with greater risk of MACE in a dose response pattern. There were no association between reduction in anticholinergic load and risk of MACE. CONCLUSION: While anticholinergic load at baseline was associated with MACE, reducing anticholinergic load did not lower the risk of MACE indicating the association may not be causal.

Investigating the association between medication regimen complexity, medication adherence and treatment satisfaction among Malaysian older adult patients: a cross-sectional study.

BACKGROUND: The prevalence of medication nonadherence among Malaysian older adults is approximately 60%. However, there is a lack of studies assessing the factors associated with medication nonadherence among this population. This research aims to explore the association between medication regimen complexity (MRC), treatment satisfaction and medication adherence among Malaysian older adults. METHOD: A cross-sectional study was conducted in outpatient clinics of a teaching hospital in Pahang, Malaysia, between April 2023 and September 2023. MRC Index (MRCI), Treatment Satisfaction for Medication version II (TSQM v.II), and the Malaysian Medication Adherence Assessment Tool (MyMAAT) were used. Multivariate linear and logistic regression models were performed to test the factors affecting treatment satisfaction and medication adherence. Mediator analysis was implemented to assess the mediating role of treatment satisfaction. RESULT: The study involved 429 Malaysian older adult patients, with a prevalence of nonadherence of 51.0% (n = 219) and an MRCI mean score of 17.37 (SD = 7.07). The mean overall treatment satisfaction score was 73.91 (SD = 15.23). Multivariate logistic regression analysis expressed four significant predictors associated with nonadherence: MRC (AOR = 1.179, p = 0.002), overall treatment satisfaction (AOR = 0.847, p < 0.001), partially self-managed medication (AOR = 2.675, p = 0.011) and fully managed medication by family members/caregivers (AOR = 8.436, p = 0.004). Multivariate linear regression shows three predictors of treatment satisfaction: MRC (ß = -1.395, p < 0.001), Charlson Comorbidity Index (CCI) (ß = -0.746, p = 0.009) and self-managed medication (ß = 5.554, p = 0.006). Mediator analysis indicated that treatment satisfaction partially mediated the association between MRC and nonadherence. CONCLUSION: Nonadherence was quite prevalent among Malaysian older outpatients and was associated with regimen complexity, treatment satisfaction and patient dependence on others to manage their medications. Future studies should focus on interventions to control the factors that negatively affect patients' medication adherence.

Telemedicine and Resource Utilization in Pulmonary Clinic.

BACKGROUND: Telemedicine use increased with the Covid-19 pandemic. The impact of telemedicine on resource use in pulmonary clinics is unknown. METHODS: This retrospective cohort study identified adults with pulmonary clinic visits at the University of Miami Hospital and Clinics (January 2018-December 2021). The primary exposure was telemedicine versus in-person visits. Standard statistics were used to describe the cohort and compare patients stratified by visit type. Multivariable logistic regression models evaluated the association of telemedicine with resource use (primarily, computed tomography [CT] orders placed within 7 days of visit). RESULTS: 21,744 clinic visits were included: 5,480 (25.2%) telemedicine and 16,264 (74.8%) in-person. In both, the majority were < 65-years-old, female, and identified as Hispanic white. Patients seen with telemedicine had increased odds of having CT scans ordered within 7 days (adjusted odds ratio [aOR] 1.34, [95% confidence interval 1.04-1.74]); and decreased odds of chest x-rays (aOR 0.37 [0.23-0.57]). Telemedicine increased odds of contact of any kind with our healthcare system within 30-days (aOR 1.56 [1.29-1.88]) and 90-days (aOR 1.39 [1.17-1.64]). Specifically, telemedicine visits had decreased odds of emergency department visits and hospitalizations (30 days: aOR 0.54 [0.38-0.76]; 90 days: aOR 0.68 [0.52-0.89]), but increased odds of phone calls and electronic health record inbox messages (30 days: aOR 3.44 [2.73-4.35]; 90 days: aOR 3.58 [2.95-4.35]). CONCLUSIONS: Telemedicine was associated with an increased odds of chest CT order with a concomitant decreased odds of chest x-ray order. Increased contact with the healthcare system with telemedicine may represent a larger time burden for outpatient clinicians.

Prevalence and risk of sexual violence victimization among mental health service users: a systematic review and meta-analyses.

PURPOSE: People with mental disorders are more likely to experience sexual violence than the general population, but little is known about the prevalence of sexual violence in people who use psychiatric services. This paper aims to estimate the prevalence and odds of sexual violence victimisation within mental health services by gender and mental health setting (i.e. inpatient, outpatient and mixed settings). METHODS: This study is a systematic review and meta-analysis (PROSPERO registration number: CRD4201810019). Three databases (Medline, Embase, PsychINFO) were searched and citation tracking, and reference screening of included studies was conducted. Studies were included if the prevalence and/or risk of sexual violence in psychiatric service users were reported or calculable across the past year or adult lifetime. The methodological quality of included studies was assessed. A random effects meta-analyses was conducted to estimate odds ratios and pooled prevalence estimates of sexual violence in different mental health settings. RESULTS: Twenty-six studies were included encompassing 197,194 participants. The meta-analyses revealed high pooled prevalence estimates and increased odds of sexual violence victimisation in male and female psychiatric service users compared to non-psychiatric service users. CONCLUSIONS: Mental health practitioners should be trained to respond effectively to disclosures of sexual violence, particularly from these vulnerable groups. Future sexual violence interventions should consider mental health as a treatment outcome.

An Analysis of Medication Adherence in a Large Outpatient Population During the COVID-19 Pandemic Using a Novel Value-Based Pharmacy System.

Background: Adherence to a medication regimen is defined as taking the medication as directed by the prescriber. Adherence is critical to achieve the desired therapeutic outcomes. Medication adherence has not been examined in large outpatient populations since the onset of the COVID-19 pandemic. A novel outpatient value-based pharmacy system (VPS) was used to collect adherence data from a large, outpatient population. The aim of this descriptive study was to analyze the reasons, medication classes, and diagnoses associated with nonadherence. Materials and Methods: Telepharmacist-documented adherence data from a large (n = 6,479) outpatient population that received remote consultation during the COVID-19 pandemic (August 1, 2020-November 28, 2022) were considered for this study. The adherence data were compiled within the VPS. Results: The overall rate of patients reporting at least one incident of nonadherence to their medication regimens was 21.5%. Medications used to treat hypertension, type 2 diabetes, and hyperlipidemia were least adhered to. Statins, beta-2 agonists, and corticosteroids were least adhered to. The most common reasons for nonadherence included knowledge gaps regarding therapy, forgetfulness, and side effects. Discussion: This represents the first descriptive analyses of adherence metrics in a large outpatient population during the COVID-19 pandemic. Polypharmacy, prevalence of diagnosis, and medication side effect profile may have contributed to the results observed. This study demonstrates the ability of a VPS to document key data to better inform the health care team. Elucidating adherence metrics in such populations may allow pharmacists and prescribers to identify subpopulations that require further education and management.

The association of childhood trauma with suicidality in adult psychiatric patients: The mediating role of NSSI and the moderating role of self-esteem.

BACKGROUND: The contribution of specific childhood trauma subtypes to suicidal thoughts and the associated mechanisms remains unclear, particularly in psychiatric patients. METHODS: Face-to-face interviews were conducted with 449 psychiatric patients aged 18-73. Childhood trauma, self-esteem, nonsuicidal self-injury (NSSI), and suicidality were assessed retrospectively. Regression and moderated mediation model were employed to examine these relationships. RESULTS: Emotional and sexual abuse were independently associated with suicidality. Female patients reported higher levels of emotional and sexual abuse, lower self-esteem, and a heightened risk of suicide. Self-esteem moderated the links between childhood trauma and NSSI, as well as between NSSI and suicidality. NSSI served as a mediator between childhood trauma and suicidality. CONCLUSIONS: Suicide prevention in mentally ill patients should involve targeted programs addressing specific childhood trauma. Additionally, psychological interventions to enhance self-esteem and assist individuals engaging in NSSI behavior are crucial.

Association of oral frailty with medical expenditure in older Japanese adults: The study of late-stage older adults in Tottori (START Tottori).

OBJECTS: This study aimed to determine the association between annual medical expenses and oral frailty in later-stage older adults (aged ≥ 75 years). No studies have investigated the association between medical costs and oral frailty, which would elucidate the association between oral frailty and the deterioration of mental and overall physical function. MATERIALS AND METHODS: In this cross-sectional study, 2190 adults (860 men and 1330 women aged 75-94 years) covered by the Medical System for the Elderly and residing in Tottori Prefecture, Japan, between April 2016 and March 2019, were included. Participants were classified into three groups: healthy, pre-orally frail or orally frail, based on dental health screening findings. The medical and dental expenses over the years, number of days of consultations and comorbidities were obtained from the Japanese Health Insurance Claims Database. RESULTS: The number of days of medical and dental consultations and annual medical expenses for outpatient care differed among the three study groups. A significant association was observed between oral frailty and high annual expenses for outpatient medical and dental care. Oral frailty was associated with higher medical expenses in participants with poor masticatory function. Higher and lower dental expenses were associated with subjective poor masticatory function and subjective impairment of swallowing function respectively. CONCLUSION: Medical and dental expenses for orally frail older adults are high, indicating that oral frailty may be related to the occurrence and severity of diseases other than oral health issues. Future studies should examine the mechanism by which oral weakness affects physical and mental functions.

Health literacy as mediator between perception of illness and self-medication behaviour among outpatients in the Kingdom of Saudi Arabia: implication to primary healthcare nursing.

INTRODUCTION: Perception of illness (PI) and self-medication (SM) have been thoroughly explored in the existing literature. However, there is a lack of understanding about the mediating effect of health literacy on PI and SM in a non-homogenous population like Saudi Arabia. As such, primary healthcare nurses who have constant interaction with the outpatients have difficulty addressing self-medication. This study aimed to investigate health literacy as mediator between PI and SM among outpatients in the Kingdom of Saudi Arabia (KSA). METHODS: This study employed a cross-sectional approach and was conducted at 10 major primary healthcare (PHC) clinics serving 30 million individuals in 13 different regions of KSA. The 424 outpatients who participated in this study were selected through convenience sampling. Data collection started in November 2022 and concluded in February 2023. RESULTS: The mean of the Brief Health Literacy Screening Tool, self-medication scale (SMS), and PI scores were 13.01 ± 3.32, 27.46 ± 7.01, and 45.56 ± 7.69, respectively. There was a significant relationship between the age and BRIEF scores (p = 0.039), and the level of education was significantly related to all variables, as were nationality and BRIEF scores (p = 0.001). Finally, occupation was significantly related to BRIEF and SMS scores (p = 0.001 and 0.003, respectively). Completing college and being non-Saudi had positively significant effects on health literacy (p < 0.01). The structural equation model (SEM) found no effect of PI on health literacy or SM behaviour (p = 0.263 and 0.84, respectively), but health literacy did have an effect on SM behaviour (p<0.001). CONCLUSION: Health literacy is an important factor in self-medication behavior and that PI is not directly related to health literacy or self-medication behavior, but that health literacy does influence self-medication behavior. Therefore, primary healthcare givers should promote public health literacy alongside the control of other conditions as one of the most effective ways to decrease the prevalence of self-medication and the risks associated with it.

[Drug dispensation at both community and hospital pharmacy, the highly active antiretrovirals example]. / Le double circuit de dispensation, exemple des traitements antirétroviraux : quelle pertinence ?

OBJECTIVES: Highly active antiretroviral therapies against the human immunodeficiency virus are available for patients in France in community pharmacy or in hospital pharmacy. More than 20 years after the implementation of the dual delivery system, it seems necessary to question the relevance of the dual dispensing circuit both in terms of service provided to patients and expenditure for health insurance. METHODS: The health insurance files were used to quantify the delivery of antiretrovirals therapies in the community pharmacy and in the hospital pharmacy. A survey was performed involving patients to find out their point of view on dispensing in hospital pharmacy and were the patients came from. The differential cost from the health insurance point of view between the two delivery system was calculated on the basis of the quantities delivered and the purchase prices at the hospital center in 2018. RESULTS: More than 80% of the quantities of antiretrovirals therapies are now delivered by community pharmacies. The arguments in favor of the antiretrovirals therapies dispensation by hospital pharmacy forwarded by patients are the anonymity and constant medicines availability. Health insurance is required to refund a drug at different prices depending on the delivery place, for about 37€ per box in favour of hospital dispensing. CONCLUSION: This study presents a complete inventory of the dual delivery system for antiretroviral therapies. Hospital and community therefore remain complementary to welcome outptients who will seek different delivery methods there. Little known to patients and professionals, this dual delivery system generates complexities at the stages of prescription, dispensing and reimbursement. It only concerns a minority of patients and its benefit for health insurance seems uncertain.

Covid-19: The impact of lockdown on the dispensing of hospital drugs to outpatients / COVID-19 : répercussions du confinement sur l'activité de délivrance des médicaments en rétrocession

Introduction: In response to the COVID-19 pandemic, France was under lockdown for the first time from March 17 to May 10, 2020. Purpose of the Research: The aim of this work is to study the impact of lockdown on outpatients' visits to the hospital pharmacy to collect chronic medication, in order to highlight the pharmaceutical classes concerned and to assess whether a decrease in medication adherence could be observed. Method: Retrospectively, using hospital dispensing traceability software, the dispensing of drugs during the eight weeks of lockdown was compared with that during the two eight-week periods before and after lockdown. Evolutions in the number of medicine lines dispensed and outpatient visits were analyzed over the three time periods, according to pharmaceutical classes. A specific analysis was performed between drugs only available at the hospital pharmacy and drugs available at both the community and hospital pharmacy. Results: During lockdown, 67% of patients still came regularly, but a significant decrease in the average number of lines dispensed was observed. 15% of regular patients limited their visits during this period. Patients taking drugs available at both the community and hospital pharmacy were significantly more impacted than those taking drugs that could only be dispensed at the hospital pharmacy. On the other hand, age is not a factor associated with the restriction of visits. Conclusions: Lockdown affected the visits to the hospital pharmacy of at least one in ten regular outpatients. Sending hospital drugs to community pharmacies and the help of home health care providers limited therapeutic disruptions.

Introduction: Du fait de la pandémie de COVID-19, la France a été confinée pour la première fois du 17 mars au 10 mai 2020. But de l'étude: L'objectif de ce travail est d'étudier les répercussions du confinement sur la venue des patients en rétrocession, sur les classes pharmaceutiques dispensées et sur l'observance thérapeutique. Méthodes: Les délivrances durant les huit semaines de confinement ont été comparées aux huit semaines précédentes et suivantes à partir du logiciel de traçabilité des rétrocessions. Les évolutions du nombre de lignes dispensées et de venues des patients ont été analysées sur ces trois périodes, en regard des classes pharmaceutiques. Une analyse spécifique sur les médicaments disponibles uniquement à l'hôpital et ceux disponibles également en pharmacie d'officine a été réalisée. Résultats: Durant le confinement, 67 % des patients ont continué à venir régulièrement, mais une baisse significative du nombre moyen de lignes dispensées est observée. Durant cette période, 15 % des patients réguliers ont été affectés par le confinement, n'ayant pas pu se rendre à la pharmacie. Les patients accueillis pour un médicament en double circuit ont été significativement plus affectés par le confinement que ceux accueillis pour un médicament seulement rétrocédable. L'âge n'est en revanche pas un facteur associé à la restriction des venues. Conclusions: Le confinement a influé sur les venues à la pharmacie hospitalière de près d'un patient régulier sur dix. L'envoi des médicaments rétrocédables en officine, ou l'aide des prestataires de santé à domicile, a permis de limiter les ruptures thérapeutiques.

Electric Field Navigated 1-Hz rTMS for Poststroke Motor Recovery: The E-FIT Randomized Controlled Trial.

BACKGROUND: To determine if low-frequency repetitive transcranial magnetic stimulation targeting the primary motor cortex contralateral (M1CL) to the affected corticospinal tract in patients with hemiparetic stroke augments intensive training-related clinical improvement; an extension of the NICHE trial (Navigated Inhibitory rTMS to Contralesional Hemisphere Trial) using an alternative sham coil. METHODS: The present E-FIT trial (Electric Field Navigated 1Hz rTMS for Post-stroke Motor Recovery Trial) included 5 of 12 NICHE trial outpatient US rehabilitation centers. The stimulation protocol remained identical (1 Hz repetitive transcranial magnetic stimulation, M1CL, preceding 60-minute therapy, 18 sessions/6 wks; parallel arm randomized clinical trial). The sham coil appearance mimicked the active coil but without the weak electric field in the NICHE trial sham coil. Outcomes measured 1 week, and 1, 3, and 6 months after the end of treatment included the following: upper extremity Fugl-Meyer (primary, 6 months after end of treatment), Action Research Arm Test, National Institutes of Health Stroke Scale, quality of life (EQ-5D), and safety. RESULTS: Of 60 participants randomized, 58 completed treatment and were included for analysis. Bayesian analysis of combined data from the E-FIT and the NICHE trials indicated that active treatment was not superior to sham at the primary end point (posterior mean odds ratio of 1.94 [96% credible interval of 0.61-4.80]). For the E-FIT intent-to-treat population, upper extremity Fugl-Meyer improvement ≥5 pts occurred in 60% (18/30) active group and 50% (14/28) sham group. Participants enrolled 3 to 6 months following stroke had a 67% (31%-91% CI) response rate in the active group at the 6-month end point versus 50% in the sham group (21.5%-78.5% CI). There were significant improvements from baseline to 6 months for both active and sham groups in upper extremity Fugl-Meyer, Action Research Arm Test, and EQ-5D (P<0.05). Improvement in National Institutes of Health Stroke Scale was observed only in the active group (P=0.004). Ten serious unrelated adverse events occurred (4 active group, 6 sham group, P=0.72). CONCLUSIONS: Intensive motor rehabilitation 3 to 12 months after stroke improved clinical impairment, function, and quality of life; however, 1 Hz-repetitive transcranial magnetic stimulation was not an effective treatment adjuvant in the present sample population with mixed lesion location and extent. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT03010462.

Outpatient randomized controlled trials to reduce COVID-19 hospitalization: Systematic review and meta-analysis.

This COVID-19 outpatient randomized controlled trials (RCTs) systematic review compares hospitalization outcomes amongst four treatment classes over pandemic period, geography, variants, and vaccine status. Outpatient RCTs with hospitalization endpoint were identified in Pubmed searches through May 2023, excluding RCTs <30 participants (PROSPERO-CRD42022369181). Risk of bias was extracted from COVID-19-NMA, with odds ratio utilized for pooled comparison. Searches identified 281 studies with 61 published RCTs for 33 diverse interventions analyzed. RCTs were largely unvaccinated cohorts with at least one COVID-19 hospitalization risk factor. Grouping by class, monoclonal antibodies (mAbs) (OR = 0.31 [95% CI = 0.24-0.40]) had highest hospital reduction efficacy, followed by COVID-19 convalescent plasma (CCP) (OR = 0.69 [95% CI = 0.53-0.90]), small molecule antivirals (OR = 0.78 [95% CI = 0.48-1.33]), and repurposed drugs (OR = 0.82 [95% CI: 0.72-0.93]). Earlier in disease onset interventions performed better than later. This meta-analysis allows approximate head-to-head comparisons of diverse outpatient interventions. Omicron sublineages (XBB and BQ.1.1) are resistant to mAbs Despite trial heterogeneity, this pooled comparison by intervention class indicated oral antivirals are the preferred outpatient treatment where available, but intravenous interventions from convalescent plasma to remdesivir are also effective and necessary in constrained medical resource settings or for acute and chronic COVID-19 in the immunocompromised.