Deprescribing Medications Among Older People to Reduce Polypharmacy at a Comprehensive Academic Medical Center.

OBJECTIVE: To evaluate deprescribing of select high-risk medications (HRMs) in an Acute Care for the Elderly (ACE) unit with pharmacist involvement compared with usual care in older people. DESIGN: Retrospective, single-center case-control study. SETTING: Medical-surgical units at an urban academic medical center. PARTICIPANTS: Patients 65 years of age and older admitted April-June 2019, with 1 or more of the following target HRMs prior to admission were included in the study: acid suppressants, antipsychotics, or insulin. Patients admitted to the ACE unit were included in the case group; all other patients were randomly matched by HRMs in a 2:1 ratio into the control group. INTERVENTIONS: The Acute Care for the Elderly pharmacist reviewed patients' medications to identify and deprescribe select HRMs. Deprescribing was defined as discontinuation, dose or frequency reduction. RESULTS: A total of 47 patients with 56 HRMs and 89 patients with 126 HRMs were included in the case and control groups, respectively. The primary outcome of HRMs deprescribed were similar between the case and control groups (21.4% and 25.4%; P = 0.56). Among the HRMs deprescribed (discontinued, dose or frequency reduced), 83.2% were complete discontinuations in case patients and 34.4% were complete discontinuations in control patients.

Creation and Implementation of a Hospitalist-Run Propofol Sedation Program.

BACKGROUND: Pediatric hospitalists increasingly provide sedation outside the operating room. Given the large body of safety data available, propofol was identified as a beneficial addition to our hospitalist-run sedation service's medication repertoire. Currently, the training required for hospitalists to provide sedation is defined and determined locally by individual institutions. METHODS: We convened a task force to develop and implement training for hospitalists in the use of propofol for deep sedation. After implementing training, we analyzed the outcome of patients receiving propofol for deep sedation for MRI, including the adverse event rate and successful completion rate. An adverse event was defined as a significant desaturation, persistent upper airway obstruction, laryngospasm, administration of neuromuscular blockade, conversion to anesthesia, call for additional backup, or if the procedure was not able to be completed. Successful completion was defined as any patient being able to complete the imaging study or procedure with sedation performed by a hospitalist physician. RESULTS: Between September 2015 and September 2018, sedation services sedated 12 979 patients, 3929 of whom were deeply sedated with propofol. During this period, the trained hospitalists had an adverse event rate of 3.6% and a 98.9% rate of successful completion of all studies or procedures when using propofol for deep sedation. CONCLUSION: With a comprehensive training program for hospitalists in the administration of propofol, we provided effective sedation for a selective population of patients. We now have a standard approach that uses credentialed hospitalists to train new faculty for propofol administration.

Global Health and Emergency Care: Defining Clinical Research Priorities.

OBJECTIVES: Despite recent strides in the development of global emergency medicine (EM), the field continues to lag in applying a scientific approach to identifying critical knowledge gaps and advancing evidence-based solutions to clinical and public health problems seen in emergency departments (EDs) worldwide. Here, progress on the global EM research agenda created at the 2013 Academic Emergency Medicine Global Health and Emergency Care Consensus Conference is evaluated and critical areas for future development in emergency care research internationally are identified. METHODS: A retrospective review of all studies compiled in the Global Emergency Medicine Literature Review (GEMLR) database from 2013 through 2015 was conducted. Articles were categorized and analyzed using descriptive quantitative measures and structured data matrices. The Global Emergency Medicine Think Tank Clinical Research Working Group at the Society for Academic Emergency Medicine 2016 Annual Meeting then further conceptualized and defined global EM research priorities utilizing consensus-based decision making. RESULTS: Research trends in global EM research published between 2013 and 2015 show a predominance of observational studies relative to interventional or descriptive studies, with the majority of research conducted in the inpatient setting in comparison to the ED or prehospital setting. Studies on communicable diseases and injury were the most prevalent, with a relative dearth of research on chronic noncommunicable diseases. The Global Emergency Medicine Think Tank Clinical Research Working Group identified conceptual frameworks to define high-impact research priorities, including the traditional approach of using global burden of disease to define priorities and the impact of EM on individual clinical care and public health opportunities. EM research is also described through a population lens approach, including gender, pediatrics, and migrant and refugee health. CONCLUSIONS: Despite recent strides in global EM research and a proliferation of scholarly output in the field, further work is required to advocate for and inform research priorities in global EM. The priorities outlined in this paper aim to guide future research in the field, with the goal of advancing the development of EM worldwide.

Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring.

OBJECTIVES: To identify risk factors for recurrent urinary tract infection (UTI) and renal scarring in children who have had 1 or 2 febrile or symptomatic UTIs and received no antimicrobial prophylaxis. METHODS: This 2-year, multisite prospective cohort study included 305 children aged 2 to 71 months with vesicoureteral reflux (VUR) receiving placebo in the RIVUR (Randomized Intervention for Vesicoureteral Reflux) study and 195 children with no VUR observed in the CUTIE (Careful Urinary Tract Infection Evaluation) study. Primary exposure was presence of VUR; secondary exposures included bladder and bowel dysfunction (BBD), age, and race. Outcomes were recurrent febrile or symptomatic urinary tract infection (F/SUTI) and renal scarring. RESULTS: Children with VUR had higher 2-year rates of recurrent F/SUTI (Kaplan-Meier estimate 25.4% compared with 17.3% for VUR and no VUR, respectively). Other factors associated with recurrent F/SUTI included presence of BBD at baseline (adjusted hazard ratio: 2.07 [95% confidence interval (CI): 1.09-3.93]) and presence of renal scarring on the baseline (99m)Tc-labeled dimercaptosuccinic acid scan (adjusted hazard ratio: 2.88 [95% CI: 1.22-6.80]). Children with BBD and any degree of VUR had the highest risk of recurrent F/SUTI (56%). At the end of the 2-year follow-up period, 8 (5.6%) children in the no VUR group and 24 (10.2%) in the VUR group had renal scars, but the difference was not statistically significant (adjusted odds ratio: 2.05 [95% CI: 0.86-4.87]). CONCLUSIONS: VUR and BBD are risk factors for recurrent UTI, especially when they appear in combination. Strategies for preventing recurrent UTI include antimicrobial prophylaxis and treatment of BBD.

Screening for suicidal thoughts in primary care: the views of patients and general practitioners.

Background It has been argued that primary care practitioners have an important part to play in the prevention of suicide. However, levels of assessment of risk of suicide among patients treated in this setting are generally low.Methods Cross-sectional survey of general practitioners (GPs) and people being treated in primary care who had signs of depression. The study combined open and closed questions on attitudes to screening or being screened for suicidal ideation.Results One hundred and one of 132 patients took part in the survey and 103 of 300 GPs completed a questionnaire. A majority of both GPs and patients stated that people should be screened for suicidal ideation. However, an important minority of patients and GPs stated that asking or being asked such questions made them feel uncomfortable. Less than half of GPs had received formal training on the assessment of suicide risk. GPs told the researchers that barriers to screening included time pressures, culture and language, and concerns about the impact that screening could have on people's mental health. One-quarter of GPs and one-fifth of patients supported the notion that screening for suicidal ideation could induce a person to have thoughts of self-harm.Conclusions GPs and family doctors should screen for suicidal risk among depressed patients and should receive training on how to do this as part of their general training in the assessment and management of mental disorders. Research should be conducted to examine what, if any, effect screening for suicidal ideation has on mental health.