Enhancing medication management of older adults in Qatar: healthcare professionals' perspectives on challenges, barriers and enabling solutions.

Background: Polypharmacy and potentially inappropriate medications are significant challenges in older adults' medication management. The Consolidated Framework for Implementation Research (CFIR) is a comprehensive approach used to explore barriers and enablers to the healthcare system in guiding the effective implementation of evidence-based practices. Objectives: This study examines the barriers and enablers to promote safe medication management among older adults in Qatar from healthcare professionals' perspectives. This includes identifying critical factors within the healthcare system influencing medication management and suggesting practical solutions to improve it. Design: The study employs a qualitative design. Focus Groups (FGs) were conducted with healthcare professionals from the geriatric, mental health and medicine departments of Hamad Medical Corporation (HMC), the leading governmental sector in Qatar serving the older adult population. Methods: Utilising the CFIR, this study analysed feedback from healthcare professionals through FGs at HMC. A combined inductive and deductive thematic analysis was applied to transcripts from five FGs, focusing on identifying barriers and enablers to safe medication management among older adults. Two researchers transcribed the audio-recorded FG discussions verbatim, and two researchers analysed the data using a mixed inductive and deductive thematic analysis approach utilising CFIR constructs. Results: We engaged 53 healthcare professionals (31 physicians, 10 nurses and 12 clinical pharmacists) in FGs. The analysis identified current barriers and enabler themes under different CFIR constructs, including inner settings, outer settings, individual characteristics and intervention characteristics. We identified 44 themes, with 25 classifieds as barriers and 19 as enablers. The findings revealed that barriers and enablers within the inner settings were primarily related to structural characteristics, resources, policies, communication and culture. On the other hand, barriers and enablers from the outer settings included patients and caregivers, care coordination, policies and laws, and resources. Conclusion: This study identified several barriers and enablers to promote medication management for older adults using the CFIR constructs from the perspective of healthcare professionals. The multifaceted findings emphasise involving stakeholders like clinical leaders, policymakers and decision-makers to address medication safety factors. A robust action plan, continuously monitored under Qatar's national strategy, is vital. Further research is needed to implement recommended interventions.

Medication management challenges and solutions for older adults in Qatar: insights from healthcare professionals As people age, they often need multiple medications to manage their health conditions. However, taking medications that are not needed can cause harm. To improve medication management in this vulnerable population, it is essential to understand the barriers and enablers that healthcare professionals (HCPs) face. Our study used focus groups to explore these factors from the perspectives of healthcare providers in Qatar's Hamad Medical Corporation (HMC). We used the Consolidated Framework for Implementation Research (CFIR) to collect and analyse the data. Healthcare Professionals emphasised that the significant barriers to safe medication management in older adults include: • The missing medication history in electronic health records in many cases. • There is a lack of clinical decision support systems that guide and save prescribers time. • There is limited access to services such as medication therapy management and telemedicine. These services could facilitate managing complex or urgent cases. • Sometimes, communication between healthcare providers, patients, and caregivers is inadequate. It could be due to limited clinic time, HCPs' experience, or patients' health literacy. • There are unclear guidelines and policies regarding prescribing, dispensing, and stopping medications for older adults. • There is insufficient education for sub-specialists, junior HCPs, patients, and caregivers about the challenges of managing older adults' medications. • Limited patient engagement in their medication management plans could be due to low health literacy, social support, or physical or cognitive disabilities. • In addition to overcoming the previous challenges, HCPs suggested implementing a national strategy to utilise, guide, and monitor all the efforts. In conclusion, through our study, HCPs highlight the need for tailored national interventions to optimise safe medication management in older adults. The findings can inform the need for developing long-term and comprehensive strategies to help healthcare systems manage older adults' medications, leading to better health outcomes for this vulnerable population.

Enhancing Medication Safety through Implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in Ambulatory Older Adults.

INTRODUCTION: To promote optimal healthcare delivery, safeguarding older adults from the risks associated with inappropriate medication use is paramount. OBJECTIVE: This study aims to evaluate the effectiveness of implementing the Qatar Tool for Reducing Inappropriate Medication (QTRIM) in ambulatory older adults to enhance medication safety. METHOD: The QTRIM was developed by an expert consensus panel using the Beers Criteria and contained a list of potentially inappropriate medications (PIMs) based on the local formulary. Using quality improvement methodology, it was piloted and implemented in two outpatient pharmacy settings serving geriatric medicine and dermatology clinics at Rumailah Hospital, Qatar. Key performance indicators (KPIs) using implementation documentation as a process measure and the percentage reduction in PIM prescriptions as an outcome measure were assessed before and after QTRIM implementation. This study was conducted between July 2022 and September 2023. RESULTS: In the outpatient department (OPD) geriatric pharmacy, the prescription rate of PIMs was reduced from an average of 1.2 ± 0.7 PIMs per 1000 orders in 2022 to an average of 0.8 ± 0.2 PIMs per 1000 orders in 2023. In the OPD geriatric pharmacy, the results showed a 66.6% reduction in tricyclic antidepressants (TCAs) (from 30 to 10), a reduction in first-generation antihistamines by 51.7% (29 to 14), and muscle relaxants by 33.3% (36 to 24). While in dermatology, the older adult prescription rate of PIMs was reduced from an average of 8 ± 3 PIMs per 1000 orders in 2022 to a rate of 5 ± 3 PIMs per 1000 orders in 2023; the most PIM reductions were (49.4%) in antihistamines (from 89 to 45), while muscle relaxants and TCAs showed a minimal reduction. CONCLUSIONS: Implementing QTRIM with pharmacy documentation monitoring markedly reduced the PIMs dispensed from two specialized outpatient pharmacies serving older adults. It may be a promising effective strategy to enhance medication safety in outpatient pharmacy settings.

Understanding Stakeholder Views Regarding the Design of an Intervention Trial to Reduce Anticholinergic Burden: A Qualitative Study.

Background: Anticholinergic burden (ACB), is defined as the cumulative effect of anticholinergic medication which are widely prescribed to older adults despite increasing ACB being associated with adverse effects such as: falls, dementia and increased mortality. This research explores the views of health care professionals (HCPs) and patients on a planned trial to reduce ACB by stopping or switching anticholinergic medications. The objectives were to explore the views of key stakeholders (patients, the public, and HCPs) regarding the potential acceptability, design and conduct of an ACB reduction trial. Materials and Methods: We conducted qualitative interviews and focus groups with 25 HCPs involved in prescribing medication with anticholinergic properties and with 22 members of the public and patients who were prescribed with the medication. Topic guides for the interviews and focus groups explored aspects of feasibility including: 1) views of a trial of de-prescribing/medication switching; 2) how to best communicate information about such a trial; 3) views on who would be best placed and preferred to undertake such medication changes, e.g., pharmacists or General Practitioners (GPs)? 4) perceived barriers and facilitators to trial participation and the smooth conduct of such a trial; 5) HCP views on the future implementability of this approach to reducing ACB and 6) patients' willingness to be contacted for participation in a future trial. Qualitative data analysis was underpinned by Normalization Process Theory. Results: The public, patients and HCPs were supportive of an ACB reduction trial. There was consensus among the different groups that key points to consider with such a trial included: 1) ensuring patient engagement throughout to enable concerns/potential pitfalls to be addressed from the beginning; 2) ensuring clear communication to minimise potential misconceptions about the reasons for ACB reduction; and 3) provision of access to a point of contact for patients throughout the life of a trial to address concerns; The HCPs in particular suggested two more key points: 4) minimise the workload implications of any trial; and 5) pharmacists may be best placed to carry out ACB reviews, though overall responsibility for patient medication should remain with GPs. Conclusion: Patients, the public and HCPs are supportive of trials to reduce ACB. Good communication and patient engagement during design and delivery of a trial are essential as well as safety netting and minimising workload.

Outcomes of Prophylactic Mid-Urethral Sling at the Time of Robotic Sacrocolpopexy.

OBJECTIVE: To compare outcomes of patients who underwent robotic sacrocolpopexy (RSC) with and without concomitant mid-urethral sling (MUS) placement for prophylaxis or treatment of preoperative stress urinary incontinence (SUI) METHODS: We performed a retrospective review of all patients without prior incontinence procedures who underwent RSC with or without MUS placement by 3 surgeons (JA, LA, KE) at a single institution from 2012 to 2017 for treatment of pelvic organ prolapse. Patients had a MUS placed for either documented SUI or prophylaxis of SUI. We compared patient characteristics, operative details, postoperative outcomes, and complications between the groups. RESULTS: A total of 134 patients were identified. 58 (43%) had a MUS placed for documented SUI, 43 (32%) had prophylactic MUS, and 33 (25%) did not have a MUS placed. There were no differences in baseline characteristics between the 3 groups. Patients who did not have a MUS placed had less estimated blood loss (76.4 vs 63.8 vs 36.9 mL, P = .018) but no difference in operative time (P = .408), length of stay (P = .427), or postoperative urinary retention (P = .988). A total of 4 (7%) patients who had a MUS placed for SUI had persistent SUI postoperatively. There were 2 (5%) patients who had a MUS placed prophylactically and 4 (12%) patients who did not have a MUS that developed de novo SUI. CONCLUSION: In this series, we demonstrate the safety and efficacy of prophylactic MUS placement at the time of RSC. Randomized studies evaluating concomitant prophylactic sling at time of robotic sacrocolpopexy could further guide preoperative patient counseling and decision-making.

Comparison of Adjuvant Radiation Therapy Before or After Artificial Urinary Sphincter Placement: A Multi-Institutional, Retrospective Analysis.

OBJECTIVE: To determine if the timing of radiation therapy on artificial urinary sphincter (AUS) impacts complication rates, revision rates, and number of pads per day after placement. METHODS: A retrospective review was conducted of men with prostate cancer who underwent AUS placement and radiation therapy between 1987 and 2016. RESULTS: Of 306 men, 292 (95.4%) received radiation before AUS placement (group 1) and 14 (4.6%) received radiation after AUS placement (group 2). Median follow-up was 30 months after AUS placement. Group 1 had 32 of 292 (11.0%) patients suffer from erosion, compared with 0 of 14 (0.0%) patients in group 2 (P = .191). None of the patients in group 2 had infection or mechanical failure. The number of patients who received revision in group 1 was 91 of 292 (31.2%) and in group 2 was 2 of 14 (14.3%) (P = .180). The number of pads used per day in group 1 before and after AUS placement was 5.24 ± 3.12 and 1.13 ± 1.31, respectively (P <.001). In group 2, the number of pads used per day before and after AUS placement was 6.09 ± 1.97 and 1.53 ± 0.99, respectively (P <.001). There was no significant difference in the average number of postoperative pads used per day between group 1 and group 2 (P = .907). CONCLUSION: The timing of radiation therapy does not appear to significantly affect complication rates or urinary continence, as measured in pads used after AUS placement. This multi-institutional retrospective analysis showed similar erosion and revision rates when radiation occurred after AUS placement and demonstrates preliminary safety and feasibility of the administration of radiation after AUS placement.

Technology Based Treatment for UreteroPelvic Junction Obstruction.

Surgical management of ureteropelvic junction obstruction (UPJO) has historically been performed with open pyeloplasty. With the advent of endourology, laparoscopy, and robotics, minimally-invasive techniques have been described and accepted as alternatives to open surgery. Each of these approaches has its own advantages and disadvantages, equipment needs, degree of invasiveness, and experience of the treating urologist. Advocates and critics have their own say as to their preferred technique. In this article, we review the chronological evolution of these techniques and discuss their current role in the management of UPJO.

Intralesional Injection of Interferon-α2b Improves Penile Curvature in Men with Peyronie's Disease Independent of Plaque Location.

PURPOSE: Collagenase clostridium histolyticum is the only FDA (Food and Drug Administration) approved treatment for Peyronie's disease. However, to our knowledge collagenase clostridium histolyticum has not been studied in men with ventral plaques. Given this limitation and the paucity of literature on ventral plaque outcomes, we compared the results of Peyronie's disease treatment in men with different plaque locations treated with intralesional interferon-α2b. MATERIALS AND METHODS: We retrospectively analyzed the records of men treated with intralesional interferon-α2b for Peyronie's disease at 1 institution from 2001 to 2014. The men received 2 million U interferon-α2b injected every 2 weeks for 6 to 24 treatments. All men underwent penile duplex Doppler ultrasound before and after interferon-α2b treatment. Patient characteristics, penile duplex Doppler ultrasound and objective measurements were reviewed. Patients were stratified into ventral and dorsal/lateral plaque cohorts with a positive response defined as a 20% or greater reduction in curvature. RESULTS: A total of 131 patients with a mean±SD age of 53.8±9.5 years underwent a median of 12 intralesional interferon-α2b injections (range 6 to 24). Mean pretreatment dorsal curvature was 42.5±18.6 degrees in group 1 of 111 men and mean ventral curvature was 44.5±21.5 degrees in group 2 of 21 men (p=0.66). Overall 91% of patients responded to therapy. No significant difference was noted between the 2 groups in response rate (54% vs 52%, p=0.92) or absolute change in curvature (mean 8.7±12.6 vs 9.3±17.7 degrees, p=0.84). CONCLUSIONS: Treatment with intralesional interferon-α2b provided a greater than 20% reduction in curvature in the majority of men with Peyronie's disease. This improvement was independent of plaque location.

The Effect of Duration of Penile Traction Therapy in Patients Undergoing Intralesional Injection Therapy for Peyronie's Disease.

PURPOSE: The concomitant use of penile traction therapy with interferon α-2b has been previously described. We present an update on our clinical experience to assess the benefit and duration of daily traction. MATERIALS AND METHODS: A retrospective review of patients who underwent interferon α-2b therapy between 2001 and 2012 was performed. Charts were reviewed and data collected regarding various patient demographics, vascular parameters, objective length and curvature measurements, and use of penile traction therapy. Penile traction therapy was further stratified according to duration of daily use. RESULTS: A total of 112 patients underwent a median of 12 interferon α-2b injections (range 6 to 24). Daily use of penile traction therapy was reported by 31% of patients. There were no differences in patient demographics, initial vascular status, pretreatment stretched penile length, erect circumference and curvature between patients who followed a penile traction therapy regimen and those who did not. Overall, the use of penile traction therapy did not effect change in penile circumference (with therapy +3.2 mm [SD 6.5] vs no therapy +2.1 mm [SD 7.4], p=0.45), change in curvature (with therapy -8.1 degrees [SD 16.0] vs no therapy -9.9 degrees [SD 11.8], p=0.49) or change in stretched penile length (with therapy +2.4 mm [SD 0.9] vs no therapy +1.3 mm [SD 0.8], p=0.56). Men who used penile traction therapy 3 or more hours per day gained significantly greater stretched penile length compared to those who did not use penile traction therapy (4.4 mm [SD 0.5] vs 1.3 mm [SD 0.8], p=0.04). CONCLUSIONS: Routine penile traction therapy during intralesional injection with interferon α-2b for Peyronie's disease may result in a small but subjectively meaningful improvement in stretched penile length, without affecting curvature, if used for at least 3 hours a day.

LRRK2 secretion in exosomes is regulated by 14-3-3.

Mutations in the leucine-rich repeat kinase 2 (LRRK2) gene cause late-onset Parkinson's disease (PD). Emerging evidence suggests a role for LRRK2 in the endocytic pathway. Here, we show that LRRK2 is released in extracellular microvesicles (i.e. exosomes) from cells that natively express LRRK2. LRRK2 localizes to collecting duct epithelial cells in the kidney that actively secrete exosomes into urine. Purified urinary exosomes contain LRRK2 protein that is both dimerized and phosphorylated. We provide a quantitative proteomic profile of 1673 proteins in urinary exosomes and find that known LRRK2 interactors including 14-3-3 are some of the most abundant exosome proteins. Disruption of the 14-3-3 LRRK2 interaction with a 14-3-3 inhibitor or through acute LRRK2 kinase inhibition potently blocks LRRK2 release in exosomes, but familial mutations in LRRK2 had no effect on secretion. LRRK2 levels were overall comparable but highly variable in urinary exosomes derived from PD cases and age-matched controls, although very high LRRK2 levels were detected in some PD affected cases. We further characterized LRRK2 exosome release in neurons and macrophages in culture, and found that LRRK2-positive exosomes circulate in cerebral spinal fluid (CSF). Together, these results define a pathway for LRRK2 extracellular release, clarify one function of the LRRK2 14-3-3 interaction and provide a foundation for utilization of LRRK2 as a biomarker in clinical trials.

Bilateral synchronous sporadic renal masses: intermediate functional and oncological outcomes at a single institution.

PURPOSE: To review the intermediate term oncologic and functional outcomes after the surgical management of bilateral renal masses (BRM). MATERIALS AND METHODS: After obtaining Institutional Review Board approval, the Tulane renal surgery database (n = 890 patients) was queried for patients presenting with synchronous bilateral enhancing renal masses (n = 30 renal units). We performed a retrospective chart review evaluating oncologic and functional outcomes, specifically with respect to local recurrence and metastatic disease. We also reviewed changes in glomerular filtration rates. RESULTS: Of the 30 renal units were operated on for BRM concerning for renal cell carcinoma, 25 kidneys harbored malignancy (83.3 %). The average tumor size was 3.35 cm. Treatment of each kidney was staged; average time period to treatment of contralateral side was 3.5 months. Estimated GFR (eGFR) for these same pre-operative patients was 59 ml/min/1.73 m(2) (range 25-89). The average creatinine after treatment of one kidney was available for all patients and was 1.5 (range 0.7-2.8), with an average eGFR of 51.8 (range 29-87). The average creatinine after the second operation for these same 15 patients was 1.79 (range 0.9-3.7) with an average GFR of 41.9 (range 17-78). No patient had to undergo temporary dialysis. An average change in GFR after the second, contralateral procedure on the kidney was 17.07 mg/dl. Average oncologic follow-up was 608 days. Excluding two patients who presented with metastatic disease, the average recurrence-free survival was 92.8 %. CONCLUSION: Our data continue to underscore the need for nephron sparing surgery (NSS), especially in the setting of BRM. The average decline in GFR of 28.9 % after treatment of both kidneys and renal cell carcinoma recurrence-free rate of 92.3 % further support the efficacy of NSS in these patients.