Combined interprofessional education and system intervention to improve screening older adults for dementia and falls.

The objective of this study was to increase screening for falls and dementia by improving interprofessional (IP) providers' and staffs' knowledge and attitudes toward the care of older patients and team-based care. An intervention, including education about screening and an electronic health record (EHR) flowsheet, was rolled-out across eight Federally Qualified Health Centers (FQHC). Participants were 262 IP health providers who served 6670 patients ≥ age 65 > age 65 . An EHR flowsheet with two-item screeners for falls and dementia triggered automatically for patients ≥ age 65. Documentation of screening for falls and dementia was abstracted from the EHR for the year prior to and the year after the interventions began. Baseline screening rates for falls and dementia were flat; from the start of education intervention until EHR live date, screening rates increased significantly; after EHR live date, the screening rates continued increasing significantly. A combined education-system intervention can improve screening for falls and dementia in FQHC.

Understanding social workers' hidden roles in medication safety for older adults: A qualitative study.

Older adults are vulnerable to risks associated with medications. This study explores the roles of Social Workers in facilitating medication safety for older adults. Eight social workers from federally qualified health centers participated in a case-based and interactive medication safety curriculum. They participated in an in-depth, semi-structured interview to explore their roles and strategies in assisting older adults and caregivers with medication management. Findings were transcribed and analyzed. Six themes characterizing social workers' roles in medication management were identified: a) Referral: matching patients and medication-related resources within the health-care system and community; b) Communication: connecting providers, patients, caregivers, and support system; c) Access to medicine: addressing unique needs of each patient to foster their ability to obtain their medicines; d) Social Determinants of Health: investigating the social challenges of each patient and facilitating specific medication management approaches to meet identified needs; e) Engagement: engaging patients in co-developing a treatment plan; f) Caregiver Support: preparing caregivers to assist in medication management. Social workers are trained and well positioned to provide a multi-faceted approach to improve medication management for older adults. Their unique perspectives and skills are important in addressing the complex challenges of medication management.

A retrospective review of cyproheptadine for feeding intolerance in children less than three years of age: effects and side effects.

AIM: Premature infants and those with brain injury often suffer from feeding intolerance and vomiting in the first several years of life. Cyproheptadine is a medication with antihistaminergic, antiserotonergic and anticholinergic effects, thought to increase gastric accommodation. We aimed to retrospectively review our experience using cyproheptadine for feeding intolerance and/or vomiting in children under the age of three. METHODS: This is a retrospective chart review of 39 patients less than three years of age who were prescribed cyproheptadine for feeding intolerance or vomiting and had follow-up information available. RESULTS: Starting dose ranged widely (from 0.069 to 0.825 mg/kg/day). Side effects such as sleepiness and constipation were rare. The medication had a significant positive effect, defined as resolution of vomiting, improved feeding tolerance or improved comfort with feeds, in 67% of children. An additional 28% showed possible improvement, defined as some improvement in vomiting or improvement in vomiting or feeding tolerance in conjunction with other changes in addition to cyproheptadine. CONCLUSION: In our experience, cyproheptadine appears to be safe and effective in decreasing vomiting and feeding intolerance in children less than three years of age. A trial of cyproheptadine could be considered before invasive testing in infants with feeding issues.

The Role of Community Health Workers in the Health and Well-Being of Vulnerable Older Adults during the COVID Pandemic.

The COVID-19 pandemic disrupted social support networks as well as resource access for participants. The purpose of this study was to: analyze the experiences of older adults enrolled in a geriatric-focused community health worker (CHW) support program, to gain a better understanding of how CHWs might enhance care delivery, and to further understand how COVID-19 affected the social and emotional needs and well-being of older adults during the first 18 months of the pandemic. Qualitative analysis was performed on notes entered by CHWs based on 793 telephone encounters with 358 participants between March 2020 and August 2021. Analysis was performed by two reviewers independently coding the data. Weighing the benefits of seeing family against the risks of COVID exposure was a source of emotional distress for participants. Our qualitative analysis suggests that CHWs were effective in providing emotional support and connecting participants to resources. CHWs are capable of bolstering the support networks of older adults and carrying out some of the responsibilities conventionally fulfilled by family supports. CHWs addressed participant needs that are frequently unmet by healthcare team members and provided emotional support to participants contributing to health and well-being. CHW assistance can fill gaps in support left by the healthcare system and family support structures.

Racial Differences in Retention in a Community-based Addiction Reduction Program Implemented by Peer Recovery Coaches for Women of Reproductive Age.

To identify program characteristics that influence the retention of women of reproductive age in the Community-based Addiction Reduction program (CARE), mixed-method analyses of CARE survey data and CARE Peer Recovery Coach (PRC) narrative entries of participant encounters were performed. About 251 women were enrolled in this prospective community-based implementation science intervention. We compared survey responses by race for treatment status, treatment motivation scales, and retention in the program at intake, 2-, 6-, 9-, and 12-month follow ups using Chi-square/T-tests. Qualitative analysis of PRC narrative entries was conducted following thematic analysis and crystallization immersion analytic methods. White compared with Black women in CARE were significantly more likely to be in treatment at intake (P < .001) and more motivated to engage in recovery treatment (P < .001). However, Black women were retained longer in CARE at 2- (P < .006), 6- (P < .011), and 9- (P < .004) months. PRC narrative entries were coded, and emergent themes mapped well to the 4 types of supports provided by PRC as outlined by the Substance Abuse and Mental Health Services Administration: emotional, instrumental, informational, and affiliational. Analysis of narrative entries by race revealed that Black women were given more detailed information, communications with PRC were more encouraging and proactive in identifying and meeting needs, and PRC took a more hands-on approach when assisting and linking to resources. The inclusion of PRC as integral members of SUD recovery programs may preferentially provide Black women with SUD the opportunity to build more trusting relationships with these peer coaches, thereby increasing their participation and retention.

Echinocandin use in the neonatal intensive care unit.

OBJECTIVE: To evaluate the literature regarding the use of echinocandins to treat invasive fungal infections caused by Candida spp. in patients in the neonatal intensive care unit. DATA SOURCES: Literature retrieval was accessed through MEDLINE (Jan 2000-September 2011) using the search terms echinocandin, caspofungin, micafungin, anidulafungin, and neonate with limits for age group (ie, birth to 1 month). Reference citations from identified articles were also reviewed. STUDY SELECTION AND DATA EXTRACTION: Relevant information on the pharmacokinetics, efficacy, and safety of echinocandins in neonates was selected. Prospective studies, retrospective studies, and case series in English identified from MEDLINE were evaluated. DATA SYNTHESIS: Neonates, especially preterm neonates, have many risk factors that predispose them for invasive fungal infections caused by Candida spp. To date, the only antifungals recommended for use in neonates for treatment of candidiasis are amphotericin B (deoxycholate or a lipid formulation) and fluconazole; however, the toxicities associated with amphotericin B and resistance of certain Candida spp. to fluconazole limit their use in neonates. There is a need for a broad-spectrum antifungal agent with limited toxicity for use in this patient population. The echinocandins may represent such a class of antifungals. To date, micafungin is the most studied echinocandin in the neonatal population, followed by caspofungin; however, studies evaluating their efficacy and pharmacokinetic parameters in neonates are few. CONCLUSIONS: Although studies suggest that the echinocandins may have a favorable safety profile, the lack of pharmacokinetic data and standardized study designs limit current recommendations of use of echinocandins as first-line agents in neonates in the treatment of fungal infections. However, if an echinocandin is to be used in this population, the data presented in this review suggest the use of micafungin over the other echinocandins, and higher doses of micafungin (10-15 mg/kg/day) should be used when central nervous system involvement is suspected.

Impact of 'Enhanced' Intermediate Care Integrating Acute, Primary and Community Care and the Voluntary Sector in Torbay and South Devon, UK.

Introduction: Intermediate care (IC) was redesigned to manage more complex, older patients in the community, avoid admissions and facilitate earlier hospital discharge. The service was 'enhanced' by employing GPs, pharmacists and the voluntary sector to be part of a daily interdisciplinary team meeting, working alongside social workers and community staff (the traditional model). Methods: A controlled before-and-after study, using mixed methods and a nested case study. Enhanced IC in one locality (Coastal) is compared with four other localities where IC was not enhanced until the following year (controls), using system-wide performance data (N = 4,048) together with ad hoc data collected on referral-type, staff inputs and patient experience (N = 72). Results: Coastal showed statistically significant increase in EIC referrals to 11.6% (95%CI: 10.8%-12.4%), with a growing proportion from GPs (2.9%, 95%CI: 2.5%-3.3%); more people being cared for at home (10.5%, 95%CI: 9.8%-11.2%), shorter episode lengths (9.0 days, CI 95%: 7.6-10.4 days) and lower bed-day rates in ≥70 year-olds (0.17, 95%CI: 0.179-0.161). The nested case study showed medical, pharmacist and voluntary sector input into cases, a more holistic, coordinated service focused on patient priorities and reduced acute hospital admissions (5.5%). Discussion and conclusion: Enhancing IC through greater acute, primary care and voluntary sector integration can lead to more complex, older patients being managed in the community, with modest impacts on service efficiency, system activity, and notional costs off-set by perceived benefits.

Complexities of care: Common components of models of care in geriatrics.

As people age, they are more likely to have an increasing number of medical diagnoses and medications, as well as healthcare providers who care for those conditions. Health professionals caring for older adults understand that medical issues are not the sole factors in the phenomenon of this "care complexity." Socioeconomic, cognitive, functional, and organizational factors play a significant role. Care complexity also affects family caregivers, providers, and healthcare systems and therefore society at large. The American Geriatrics Society (AGS) created a work group to review care to identify the most common components of existing healthcare models that address care complexity in older adults. This article, a product of that work group, defines care complexity in older adults, reviews healthcare models and those most common components within them and identifies potential gaps that require attention to reduce the burden of care complexity in older adults.

Opioid Treatment for Neonatal Opioid Withdrawal Syndrome: Current Challenges and Future Approaches.

Chronic intrauterine exposure to psychoactive drugs often results in neonatal opioid withdrawal syndrome (NOWS). When nonpharmacologic measures are insufficient in controlling NOWS, morphine, methadone, and buprenorphine are first-line medications commonly used to treat infants with NOWS because of in utero exposure to opioids. Research suggests that buprenorphine may be the leading drug therapy used to treat NOWS when compared with morphine and methadone. Currently, there are no consensus or standardized treatment guidelines for medications prescribed for NOWS. Opioids used to treat NOWS exhibit large interpatient variability in pharmacokinetics (PK) and pharmacodynamic (PD) response in neonates. Organ systems undergo rapid maturation after birth that may alter drug disposition and exposure for any given dose during development. Data regarding the PK and PD of opioids in neonates are sparse. Pharmacometric methods such as physiologically based pharmacokinetic and population pharmacokinetic modeling can be used to explore factors predictive of some of the variability associated with the PK/PD of opioids in newborns. This review discusses the utility of pharmacometric techniques for enhancing precision dosing in infants requiring opioid treatment for NOWS. Applying these approaches may contribute to optimizing the outcome by reducing cumulative drug exposure, mitigating adverse drug effects, and reducing the burden of NOWS in neonates.

Utilizing Pediatric Physiologically Based Pharmacokinetic Models to Examine Factors That Contribute to Methadone Pharmacokinetic Variability in Neonatal Abstinence Syndrome Patients.

Chronic intrauterine exposure to psychoactive drugs often results in neonatal abstinence syndrome (NAS). NAS is the symptomatic drug withdrawal in newborns that generally occurs after in utero chronic opioid exposure. Methadone is an opioid analgesic commonly prescribed for pharmacologic management of NAS. It exhibits high pharmacokinetic (PK) variability. The current study used physiologically based PK modeling to predict the PK profile of methadone in 20 newborns treated for NAS. The physiologically based PK simulations adequately predicted the PK profile of the clinical data for 45% of the patients. Sensitivity analyses were conducted to explore contributing factors to methadone PK variability. The data suggest that P450 enzymatic activity impacts the clearance of methadone in virtual adults and neonates, while the contribution of cardiac output may be negligible. Understanding maturational and/or pharmacogenetic changes in cytochrome P450 enzymatic activity may further explain the large PK variability of methadone in newborns with NAS and will help individualized treatment.

Electronic Health Record-Embedded Decision Support Platform for Morphine Precision Dosing in Neonates.

Morphine is the opioid most commonly used for neonatal pain management. In intravenous form, it is administered as continuous infusions and intermittent injections, mostly based on empirically established protocols. Inadequate pain control in neonates can cause long-term adverse consequences; however, providing appropriate individualized morphine dosing is particularly challenging due to the interplay of rapid natural physiological changes and multiple life-sustaining procedures in patients who cannot describe their symptoms. At most institutions, morphine dosing in neonates is largely carried out as an iterative process using a wide range of starting doses and then titrating to effect based on clinical response and side effects using pain scores and levels of sedation. Our background data show that neonates exhibit large variability in morphine clearance resulting in a wide range of exposures, which are poorly predicted by dose alone. Here, we describe the development and implementation of an electronic health record-integrated, model-informed decision support platform for the precision dosing of morphine in the management of neonatal pain. The platform supports pharmacokinetic model-informed dosing guidance and has functionality to incorporate real-time drug concentration information. The feedback is inserted directly into prescribers' workflows so that they can make data-informed decisions. The expected outcomes are better clinical efficacy and safety with fewer side effects in the neonatal population.

POLST Facilitation in Complex Care Management: A Feasibility Study.

BACKGROUND:: The Physician Orders for Life-Sustaining Treatment (POLST) form is an advance care planning tool designed for seriously ill patients. The discussions needed for high-quality POLST decision-making are time intensive and often do not occur in the outpatient setting. OBJECTIVE:: We conducted a single-arm feasibility study of POLST facilitation by nonphysicians using Respecting Choices Last Steps, a standardized, structured approach to facilitation of POLST conversations. SETTING/PARTICIPANTS:: Community-dwelling adults aged 65 and older enrolled in a complex care management program in a Midwestern urban hospital. MEASUREMENTS:: We assessed the feasibility and acceptability by determining the proportion of eligible patients who enrolled and completed the study, by adherence to the Respecting Choices protocol, and by responses to qualitative and quantitative survey items about the intervention. RESULTS:: We enrolled 18 (58.1%) of 31 eligible patients, with a mean age of 77.8 years (standard deviation: 6.95); 12 were African American. The POLST facilitation was delivered to all 18; 10 (55.6%) completed POLST forms. Direct observation of intervention delivery using a checklist found 85% of the required elements were performed by facilitators. We completed 6- to 8-week follow-up interviews in 16 of 18 patients (88.9%). We found 87.5% of decision makers agreed or strongly agreed that "Talking about the (POLST) form helped me think about what I really want." CONCLUSIONS:: The POLST facilitation can be successfully delivered to frail older adults in a complex care management setting, with high fidelity to protocol. Further research is needed to demonstrate the effects of this approach on decision quality and other patient-reported outcomes.

Pleomorphic lobular carcinoma of the breast: a morphologically and clinically distinct variant of lobular carcinoma.

Pleomorphic lobular carcinoma is an uncommon variant of lobular carcinoma, characterized by significant cytologic atypia that contrasts with the low pleomorphism of classical lobular carcinoma. It accounts for approximately 1% of all epithelial breast malignancies. In addition to its pleomorphism, it is characterized by aggressive behavior and shortened patient survival. Although the morphologic features of pleomorphic lobular carcinoma are well described, it often eludes accurate pathologic characterization. Some controversy surrounds the pathogenesis of pleomorphic lobular carcinoma; however, it is now considered a well-defined variant of invasive lobular carcinoma. Pleomorphic lobular carcinoma shares molecular alterations with classical lobular carcinoma, such as alterations in the gene CDH1 on chromosome band 16q22 that results in changes in E-cadherin protein function. The aggressive biology of pleomorphic lobular carcinoma relates to the acquisition of genetic alterations typical of high-grade ductal carcinoma, such as overexpression of HER2/neu and c-myc.

Octreotide for chylous effusions in congenital diaphragmatic hernia.

BACKGROUND/PURPOSE: Chylothorax is a frequent complication in congenital diaphragmatic hernia (CDH) infants and is associated with significant morbidity. The optimal treatment strategy remains unclear. We hypothesize that octreotide decreases chylous effusions in infants with CDH. METHODS: This is a retrospective study of all infants with CDH admitted to our institution from October 2006 to October 2011. RESULTS: Eleven (12%) infants developed a chylothorax. Five infants were managed conservatively with thoracostomy and total parenteral nutrition. Six infants were started on octreotide therapy. None of the infants required surgical intervention to stop the effusion. There was no significant difference in survival to discharge, length of stay, or average daily chest tube output between groups. There appeared to be a temporally associated drop in chest tube output upon initiation of octreotide in two infants; however, the overall rate of decline in chest tube drainage was unchanged. In addition, there were infants in the conservative group who demonstrated a similar drop in daily chest tube output despite the absence of octreotide. CONCLUSIONS: Our data suggest that the majority of chylous effusions in CDH infants resolve with conservative therapy alone.