Deprescribing as a Clinical Improvement Focus.

OBJECTIVES: Polypharmacy is a concern in the practice of geriatrics because of consequences such as adverse drug events and poorer quality of life. Deprescribing, a response to polypharmacy, refers to the systematic, programmed, and appropriate reduction in drug number and dose. Although now broadly recognized, challenges exist in practice for effective implementation. This study was conducted to determine the deprescribing success rate and relate it to drug classes and clinical settings, and to identify factors that influence the deprescribing process. DESIGN: As a performance improvement (PI) project, fellows in geriatric medicine, under supervision of faculty geriatricians, attempted deprescribing during at least 1 encounter daily at 2 long-term care (LTC) facilities and an outpatient geriatrics clinic (C) in Bronx, New York, from August 2018 to January 2019. Deprescribing was initiated following discussion and consent from patient or caregiver. Following the data collection, involved fellows and faculty physicians participated in a survey to identify factors that influenced the process. RESULTS: Out of 449 encounters, 383 encounters were included for analysis. Average patient age was 78.2 years (LTC: 77.9, C: 79.1). Average patient comorbidities was 6.5 (LTC: 6.7, C: 5.8). Deprescribing was successful in 90.1% of encounters (LTC: 96.9%, C: 67.4%). On average, 1.3 medications were deprescribed per encounter (LTC: 1.4, C: 1.0). Analgesics (32.2%), multivitamin-minerals supplements (29.7%), lipid-lowering agents (22.9%), antihistamines (46.7%), and acid blockers (26.2%) had highest success. CONCLUSIONS AND IMPLICATIONS: Deprescribing is possible in practice in both LTC and community settings at each encounter, until it is no longer applicable. Factors that contribute to successful deprescribing primarily include meaningful and earnest provider effort, ideally in collaboration with interdisciplinary team members (nurses, pharmacists, social worker, and others), besides interactions with consultants for the patient. Certain medication classes such as vitamins, minerals, analgesics, and proton pump inhibitors can be deprescribed with high success, as noted in our study, whereas antipsychotic agents, antidepressants, and ophthalmic preparations, prescribed by specialists, proved harder to deprescribe. An understanding of barriers to deprescribing (outlined in the article) and addressing them are crucial in enabling success. The study demonstrates that as a performance improvement project in collaborative effort with multiple disciplines, deprescribing is possible in health care. Factors promoting success and barriers to deprescribing are detailed. Appropriate deprescribing has the potential to help lower adverse drug events, costs of care, and possibly improve quality of life.

Individual Willingness to Share Personal Health Information with Secondary Information Users in South Korea.

People's privacy concerns about electronic health records (EHRs) have been widely discussed. Given that in principle, patients have the right to control their information in EHRs, the system will not reach its full potential without their support. Although human beings are generally inclined toward privacy, contextual differences play a role in individual decisions to disclose personal information. Likewise, patients exhibit different responses in terms of sharing their health information in diverse scenarios. Empirical work on patients' attitudes towards the secondary use of their health information is scarce. This study aims to investigate individuals' willingness to share their health information based on anonymity, information type (partial vs. whole), and the type of information user (health professionals, health researchers, health-related governmental agencies, and other governmental agencies). Furthermore, this study attempts to examine the effects of interaction between the three factors. A survey was conducted in South Korea, and the data obtained were analyzed by ANOVA. Despite the recent rapid diffusion of EHRs in South Korea, there is little discussion of patients' privacy in society. The results show that, although anonymity and the user type have a significant effect on willingness to share health information, the information type has no significant effect. The results also indicate that the willingness to share was higher for health-related governmental agencies and health professionals than for other governmental agencies. The findings reveal that, although willingness to share anonymous information does not vary significantly, the willingness differs for identified information. The study contributes to research on patients' privacy behavior by analyzing their comprehensive responses to health information-sharing investigations.

Associations of objective versus subjective social isolation with sleep disturbance, depression, and fatigue in community-dwelling older adults.

Objective: Older adults are at higher risk of experiencing social isolation, which has been linked to impaired physical and mental health. The link between social isolation and health might be due to objective deprivation of social network and/or subjective experience of loneliness. This community-based cross-sectional study examined whether the associations between social isolation and behavioral symptoms including sleep disturbance, depression, and fatigue are mostly explained by its subjective component. Methods: Randomly selected 2541 community-dwelling individuals in Los Angeles aged ≥60 years were telephone-interviewed regarding their objective and subjective social isolation (respectively social network size and loneliness), sleep disturbance, depression, and fatigue. Results: When objective and subjective social isolation were separately included in multivariate regression models, both were significantly associated with behavioral symptoms. However, once they were simultaneously included in the same multivariate models, while subjective social isolation remained strongly associated (adjusted beta 0.24 for sleep disturbance [P < 0.001], 0.44 for depression [P < 0.001], 0.17 for fatigue [P < 0.001]), objective social isolation was weakly or non-significantly associated (-0.04 for sleep disturbance [P = 0.03], -0.01 for depression [P = 0.48], -0.003 for fatigue [P = 0.89]). Additionally, those with objective social isolation were found to have worse symptoms mostly when they also experienced subjective social isolation. Conclusions: Older adults with objective social isolation may experience sleep disturbance, depression, and fatigue because they feel socially isolated, not just because they are deprived of social networks. Interventions that target social isolation might serve as potential treatments for improving behavioral health of older adults, especially by targeting its subjective component.

Considerations for physicians using ketamine for sedation of children in emergency departments.

OBJECTIVE: Ketamine use in emergency departments (EDs) for procedural sedation and analgesia is becoming increasingly common. However, few studies have examined patient factors related to adverse events associated with ketamine. This study investigated factors for consideration when using ketamine to sedate pediatric ED patients. METHODS: The study included pediatric patients receiving ketamine for laceration repair in the ED. Before sedation, information was collected about upper respiratory tract infection symptoms, allergy history, and fasting time. Patients received 2 mg/kg ketamine intravenously or 4 mg/kg ketamine intramuscularly. The primary outcomes were adverse events due to ketamine. RESULTS: We studied 116 patients aged 8 months to 7 years (2.8±1.5 years). The group with adverse events was significantly younger on average than the group without adverse events (2.5±1.5 vs. 3.1±1.5, P=0.028). Upper respiratory tract infection symptoms were not significant variables affecting ketamine sedation (48.9% vs. 43.7%, P=0.719). There was no significant association between duration of fasting and adverse events (P=0.073 and P=0.897, respectively), or between food type and adverse events (P=0.734). However, the number of attempts to sedate and ketamine dose correlated with adverse events (P<0.001 and P=0.022, respectively). In multiple logistic regression analysis, intravenous injection and ketamine dose were significant factors (odds ratio, 16.77; 95% confidence interval, 1.78 to 498.54; odds ratio, 4.37; 95% confidence interval, 1.59 to 22.9, respectively). CONCLUSION: Emergency medicine physicians should consider injection type and ketamine dose when using ketamine sedation while suturing lacerations.

Identifying the optimal hand placement site for chest compression by measuring hand width and sternal length in young adults.

OBJECTIVE: There are no specific guidelines regarding the exact hand placement location for effective chest compressions. This study was designed to identify the optimal hand placement site over the chest during cardiopulmonary resuscitation (CPR). METHODS: The sternal length (SL) of young Korean adults was measured as the distance from the suprasternal notch (SN) to the lower end of the sternum. In addition, the heel width of the hand (H) was measured 1 cm (H1) and 2 cm (H2) distal to the proximal end of the carpal bones. RESULTS: A total of 300 men and 300 women were enrolled. SL positively correlated with height (R(2)=14.2), weight (R(2)=15.3), BMI (R(2)=10.3), H1 (R(2) =3.4), and H2 (R(2) = 5.0). Mean H2 and half of the SL (SL/2) for the subgroups were M 8.4 and 10.1 cm, M' 8.3 and 9.7 cm, W 7.6 and 10.1 cm, and W' 7.4 and 9.5 cm, respectively (M, men taller than the mean; M', men shorter than the mean; W, women taller than the mean; W', women shorter than the mean). Mean H2 in men was 1.1 to 1.6 cm shorter than SL/2, whereas mean H2 in women was 2.2 to 2.9 cm shorter than SL/2. CONCLUSIONS: To find the most optimal chest compression point, from the patients' left side, CPR providers need to palpate the SN using the right little finger and placing the left heel one heel width (H2) from the SN. From the patient's right side, CPR providers should use the left little finger to palpate the SN and place the right heel one heel width (H2) from the SN.

Impact of social isolation on behavioral health in elderly: Systematic review.

AIM: To examine and compare the effects of subjective and objective social isolation on behavioral health in elderly adults. METHODS: A systematic search of PubMed was performed for original research articles from peer-reviewed journals examining one of the following topics: "Social isolation and sleep disturbance", "social isolation and depression", or "social isolation and fatigue in older adults". Studies were selected following the criteria established based on the aim of this review. Data were extracted from the articles by two independent reviewers. Due to the heterogeneity in study designs and outcome measures of the included studies, qualitative and narrative analyses were conducted. RESULTS: The set criteria were used to select a total of 16 studies for the review. Of the 16, 13 were cross-sectional studies. The characteristics of study populations were identified as follows. A total of 12 studies randomly selected subjects irrespective of pre-existing health conditions. Consequently, an unspecified number of the study subjects had chronic diseases in the studies compared. In addition, cultural and ethnic backgrounds of studies in this review were diverse, and included subjects living in North America, South America, Asia, Europe, and Oceania. Both subjective and objective types of social isolation increased behavioral symptoms, such as sleep disturbance, depressive symptoms, and fatigue in older adults. Furthermore, a few recent studies reported stronger effects of subjective social isolation than objective social isolation on sleep disturbance and depressive symptoms. CONCLUSION: Social isolation affects behavioral health in older adults. Compared to the objective social isolation, subjective social isolation contributes more significantly to sleep disturbance and depression.

Biochemical properties of full-length hepatitis C virus RNA-dependent RNA polymerase expressed in insect cells.

The hepatitis C virus (HCV) RNA-dependent RNA polymerase, NS5B protein, is the key viral enzyme responsible for replication of the HCV viral RNA genome. Although several full-length and truncated forms of the HCV NS5B proteins have been expressed previously in insect cells, contamination of host terminal transferase (TNTase) has hampered analysis of the RNA synthesis initiation mechanism using natural HCV RNA templates. We have expressed the HCV NS5B protein in insect cells using a recombinant baculovirus and purified it to near homogeneity without contaminated TNTase. The highly purified recombinant HCV NS5B was capable of copying 9.6-kb full-length HCV RNA template, and mini-HCV RNA carrying both 5'- and 3'-untranslated regions (UTRs) of the HCV genome. In the absence of a primer, and other cellular and viral factors, the NS5B could elongate over HCV RNA templates, but the synthesized products were primarily in the double stranded form, indicating that no cyclic replication occurred with NS5B alone. RNA synthesis using RNA templates representing the 3'-end region of HCV minus-strand RNA and the X-RNA at the 3'-end of HCV RNA genome was also initiated de novo. No formation of dimer-size self-primed RNA products resulting from extension of the 3'-end hydroxyl group was observed. Despite the internal de novo initiation from the X-RNA, the NS5B could not initiate RNA synthesis from the internal region of oligouridylic acid (U)(20), suggesting that HCV RNA polymerase initiates RNA synthesis from the selected region in the 3'-UTR of HCV genome.