Changes in neurocognitive assessment scores after initiating dolutegravir- versus elvitegravir-based antiretroviral therapy.

This prospective cohort study enrolled people living with HIV initiating antiretroviral therapy (ART) containing the integrase inhibitors, dolutegravir (DTG) or elvitegravir (EVG) and administered the Montreal Cognitive Assessment (MoCA) at baseline and again after approximately six months to compare changes in MoCA scores. The proportion of patients found to have cognitive impairment, as indicated by a MoCA score <26/30, on each agent were also compared and comparisons were made between changes in each domain assessed by the MoCA (visuospatial/executive, naming, attention, language, abstraction, delayed recall, and orientation). Thirty-five evaluable participants were enrolled, 18 on DTG and 17 on EVG. The median [interquartile range(IQR)] age was 44 (32 to 54) years, 63% were male, 57% were African American. The median (IQR) MoCA score at baseline was 25 (23 to 27) with no difference between groups (p=0.249). The median (IQR) change in MoCA score was 0 (-1 to 2) for DTG and 1 (0 to 3) for EVG (p = 0.183). Of those on DTG, 8 (44%) had MoCA scores <26 on follow-up compared to 11 (65%) on EVG (p = 0.229). There were no significant differences in changes in any of the individual MoCA domains.

Intravenous Vancomycin Associated With the Development of Nephrotoxicity in Patients With Class III Obesity.

BACKGROUND: A consensus statement recommends initial intravenous (IV) vancomycin dosing of 15-20 mg/kg every 8- 24 hours, with an optional 25- to 30-mg/kg loading dose. Although some studies have shown an association between weight and the development of vancomycin-associated nephrotoxicity, results have been inconsistent. OBJECTIVE: To evaluate the correlation between incidence of nephrotoxicity associated with weight-based IV vancomycin dosing strategies in nonobese and obese patients. METHODS: This retrospective cohort study evaluated hospitalized adult patients admitted who received IV vancomycin. Patients were stratified into nonobese (body mass index [BMI] <25 kg/m2), obesity class I and II (BMI 30-39.9kg/m2), and obesity class III (BMI≥40 kg/m2) groups; patients who were overweight but not obese were excluded. Incidence of nephrotoxicity and serum vancomycin trough concentrations were evaluated. RESULTS: Of a total of 62 documented cases of nephrotoxicity (15.1%), 13 (8.7%), 23 (14.3%), and 26 (26.3%) cases were observed in nonobese, obesity class I and II, and obesity class III groups, respectively ( P=0.002). Longer durations of therapy ( P<0.0001), higher initial maintenance doses in both total milligrams/day ( P=0.0137) and milligrams/kilogram ( P=0.0307), and any trough level >20 mg/L ( P<0.0001) were identified as predictors of development of nephrotoxicity. Concomitant administration of piperacillin/tazobactam, diuretics, and IV contrast were associated with development of nephrotoxicity ( P<0.005, all). Patients with class III obesity were 3-times as likely to develop nephrotoxicity when compared with nonobese patients (odds ratio [OR]=2.99; CI=1.12-7.94) and obesity class I and II patients (OR=3.14; CI=1.27-7.75). CONCLUSIONS: Obesity and other factors are associated with a higher risk of vancomycin-associated nephrotoxicity.

Comparison Between Health Insurance Claims and Electronic Health Records (EHRs) for Metastatic Non-small-cell Lung Cancer (NSCLC) Patient Characteristics and Treatment Patterns: A Retrospective Cohort Study.

BACKGROUND: The clinical landscape in non-small-cell lung cancer (NSCLC) treatment has rapidly evolved in recent years. Real-world data (RWD) can provide insights into current clinical practice. OBJECTIVE: This study examined the patient characteristics and treatment patterns of patients with metastatic NSCLC using RWD sources. METHODS: This was a retrospective cohort study using health insurance claims and electronic health records (EHRs). Adult patients treated for metastatic NSCLC during the period 2017 to September 2020 were followed from the earliest treatment date until a censoring event. RESULTS: The claims cohort included 7917 patients with a mean age of 70 years and a mean follow-up period of 373 days. The EHR cohort included 7087 patients with a mean age of 67 years and a mean follow-up period of 362 days. The five most common first-line therapies (LoT1) were the same for both cohorts: carboplatin + paclitaxel, pembrolizumab, carboplatin + pemetrexed + pembrolizumab, cisplatin + pemetrexed, and nivolumab. Mean LoT1 durations were 146 and 147 days in the claims and EHR cohorts, respectively. For patients who received a second LoT (LoT2), the five most common LoT2 were also the same in both cohorts: durvalumab, nivolumab, pembrolizumab, carboplatin + pembrolizumab + pemetrexed, and carboplatin + pemetrexed. Mean LoT2 durations were 157 and 158 days in the claims and EHR cohorts, respectively. CONCLUSIONS: LoTs between the claims and EHR cohorts were comparable and showed similar treatment patterns. Traditional platinum-containing chemotherapy was most common in LoT1, whereas programmed cell death protein-1 inhibitors became the most common choices in LoT2. Our findings suggest that RWD can reliably provide up-to-date insight into current treatment modalities and indicate that new clinical evidence is rapidly adopted in patients with NSCLC.

Improving Comprehensive Medication Management (CMM) Completed Visit Rates in Newly Referred and No-Show Patient Cohorts.

BACKGROUND: Missed appointments are a common problem in health care. No-show rates and incomplete appointments for referred patients affect patient outcomes and clinician's productivity, including comprehensive medication management (CMM) visits that pharmacists provide. This study aims to compare CMM completion rates between various intervention types in communicating with the patient. METHODS: This was a prospective, multi-clinic study to examine newly implemented intervention effects on CMM completion rates. The primary outcomes were CMM completion rates among newly referred patients and CMM completion rates in any no-show patients, including both newly referred and returning patients. In the newly referred patient cohort, three intervention types (blocking time on the pharmacist's schedule to speak to the patient, sending an electronic medical record or EMR-linked message, and sending a letter) were compared to a control group with no interventions. In the no-show cohort, a pharmacist call intervention was compared to a control group consisting of sending a letter. RESULTS: Completed CMM appointment rate was six times likely with a pharmacist's in-person reminder (odds ratio [OR] 6.0; 95% confidence interval [CI] 1.58-22.77) and with an EMR-linked message (OR 6.0; 95% CI 1.76 to 20.52) when compared to sending a letter. In no-show patients, completed CMM appointment rate was 2.36 times likely with a pharmacist's call intervention versus sending a letter. CONCLUSION: Pharmacist's direct reminder to the patient when in clinic and EMR-linked message improved CMM completion rate when compared to mailing a reminder letter. Pharmacist's call to no-show patients for their CMM appointment was effective for the patients to reschedule and complete their CMM appointment compared to mailing a reminder letter.

National Prescribing Trends for High-Risk Anticholinergic Medications in Older Adults.

OBJECTIVES: To estimate prescribing tends of and correlates independently associated with high-risk anticholinergic prescriptions in adults aged 65 and older in office-based outpatient visits. DESIGN: Repeated cross-sectional analysis. SETTING: National Ambulatory Medical Care Survey (NAMCS). PARTICIPANTS: A national sample of office-based physician visits by adults aged 65 and older from 2006 to 2015 (n=96,996 unweighted). MEASUREMENTS: Prescriptions of high-risk anticholinergics, regardless of indication, were identified, and overall prescribing trends were estimated from 2006 to 2015. Stratified analyses of prescribing trends according to physician specialty and anticholinergic drug class were also performed. We used a multivariable logistic regression analysis to estimate the odds of high-risk anticholinergic prescription. RESULTS: Between 2006 and 2015, a high-risk anticholinergic prescription was listed for 5,876 (6.2%) 96,996 visits of older adults, representative of 14.6 million total visits nationally. The most common drug classes were antidepressants, antimuscarinics, and antihistamines, which accounted for more than 70% of prescribed anticholinergics. Correlates independently associated with greater odds of receiving a high-risk anticholinergic prescription were female sex, the Southern geographic region, specific physician specialties (e.g., psychiatry, urology), receipt of 6 or more concomitantly prescribed medications, and related clinical diagnoses (e.g., urinary continence) (p<.01 for all). CONCLUSION: The prevalence of high-risk anticholinergic prescriptions was stable over time but varied according to physician specialty and drug class. Quality prescribing should be promoted because safer alternatives are available.