Antipsychotic prescribing and drug-related readmissions in multimorbid older inpatients: a post-hoc analysis of the OPERAM population.

BACKGROUND: Limited data are available on characteristics associated with antipsychotic use in multimorbid older adults. AIM: Primary: to identify patient characteristics associated with antipsychotic prescribing in a multimorbid population of older inpatients with polypharmacy. Secondary: (1) to observe if antipsychotics use during an index hospitalisation was associated with a drug related admission (DRA) within one year, and (2) to describe these cases of antipsychotic-related readmissions. METHOD: This was a secondary analysis of the OPERAM randomized controlled trial. Multivariate analysis assessed the association between characteristics and comorbidities with antipsychotic use. An expert team assessed DRA occurring during the one-year follow-up. RESULTS: Antipsychotics were prescribed to 5.5% (n = 110) patients upon admission while 7.7% (n = 154) inpatients received antipsychotics at any time (i.e. upon admission, during hospitalisation, and/or at discharge). The most frequently prescribed antipsychotics were quetiapine (n = 152), haloperidol (n = 48) and risperidone (n = 22). Antipsychotic prescribing was associated with dementia (OR = 3.7 95%CI[2.2;6.2]), psychosis (OR = 26.2 [7.4;92.8]), delirium (OR = 6.4 [3.8;10.8]), mood disorders (OR = 2.6 [1.6;4.1]),  ≥ 15 drugs a day (OR = 1.7 [1.1;2.6]), functional dependency (Activities of Daily Living score < 50/100) (OR = 3.9 [2.5;6.1]) and < 2 units of alcohol per week (OR = 2.2 [1.4;3.6]). DRA occurred in 458 patients (22.8%) within one year. Antipsychotic prescribing at any time was not associated with DRA (OR = 1.0 [0.3;3.9]) however contributed to 8 DRAs, including 3 falls. CONCLUSION: In this European multimorbid polymedicated older inpatients, antipsychotics were infrequently prescribed, most often at low dosage. Besides neuro-psychiatric symptoms, risk factors for inhospital antipsychotic prescribing were lower functional status and polymedication.

Orthostatic blood pressure drop and cardiovascular and psychotropic medication dosages in acutely ill geriatric inpatients.

OBJECTIVES: . To investigate the dose-response relationship between cardiovascular or psychotropic medication dosages and falling orthostatic blood pressure in geriatric inpatients. METHODS: . This cross-sectional study included 100 consecutive geriatric inpatients of a Belgian hospital. The end points were the maximum changes of systolic (sBP) and diastolic (dBP) blood pressure in a standing up position at one or three minutes. The dosages of six classes of vascular and five classes of psychotropic medications were expressed in terms of a proportion of defined daily doses (DDD). Bivariate and multivariate linear regression models were used. RESULTS: . The 100 geriatric patients (85 ± 5 years, 58 % women) received 7.7 ± 4 medications (mean DDD: vascular = 1.0, psychotropic = 0.74) on the day of an orthostatic test (lying sBP: 136 ± 21; dBP: 72 ± 14 mm Hg). In a standing position, sBP and dBP fell by 12 ± 17 and 11 ± 5 mmHg, respectively. At the individual level, BP change was not correlated with vascular DDD (sBP: p = 0.07, r2 = 0.04; dBP: p = 0.59; r2 = 0.004) nor with psychotropic DDD (sBP: p = 0.14, r2 = 0.02; dBP: p = 0.82; r2 = 0.0). In multivariate analysis, sBP drop was positively associated with age, diabetes, falls history, and number of medications, but not with the DDD of any of the medication classes, while dBP drop was positively associated with age, diabetes, stroke and anaemia, but again with the DDD of any of the medication classes. CONCLUSION: . No correlation was found between vascular and psychotropic medication dosages and the orthostatic blood pressure drop expressed as a continuous variable.

High body mass index is associated with increased risk of treatment failure and surgery in biologic-treated patients with ulcerative colitis.

BACKGROUND: Though pharmacokinetic studies suggest accelerated biologic drug clearance with increasing body weight, evidence of obesity's impact on clinical outcomes in biologic-treated patients with ulcerative colitis (UC) is inconsistent. AIM: To evaluate the impact of obesity on real world response to biological therapy in patients with UC. METHODS: In a single-centre retrospective cohort study between 2011-2016 of biologic-treated patients with UC, we evaluated treatment response by baseline body mass index (BMI). Primary outcome was treatment failure (composite outcome of IBD-related surgery/hospitalisation or treatment modification including dose escalation, treatment discontinuation or addition of corticosteroids); secondary outcomes were risk of IBD-related surgery/hospitalisation and endoscopic remission. We conducted multivariate Cox proportional hazard analyses to evaluate the independent impact of BMI on clinical outcomes. Stratified analysis by weight-based regimens (infliximab) or fixed-dose regimens (adalimumab, golimumab, vedolizumab, certolizumab pegol) was performed. RESULTS: We included 160 biologic-treated UC patients (50% males, 55% on infliximab) with median (IQR) age 36 y (26-52) and BMI 24.3 kg/m2 (21.4-28.7). On multivariate analysis, each 1 kg/m2 increase in BMI was associated with 4% increase in the risk of treatment failure (adjusted hazard ratio [aHR], 1.04 [95% CI, 1.00-1.08]) and 8% increase in the risk of surgery/hospitalisation (aHR, 1.08 [1.02-1.14]). The effect on treatment failure was seen in patients on weight-based dosing regimens or fixed-dose therapies. CONCLUSION: BMI is independently associated with increased risk of treatment failure in biologic-treated patients with UC, independent of dosing regimen.

Adult safeguarding; guidance for dental professionals.

The legal responsibilities of all those involved in the care of adults at risk of harm were set out in the 'Care Act 2014' which became law in England in April 2015. In the same month, the General Dental Council (GDC) announced that 'safeguarding vulnerable adults' was to become a recommended topic for continuing professional development (CPD), along with 'safeguarding children and young people.' This paper updates on relevant legislation, and outlines the role of dental professionals in adult safeguarding. It then advises on issues surrounding safeguarding concerns, using three scenarios for illustration. Rather than covering the very broad topic of abuse of adults in general, the paper focusses on 'adults at risk' to whom statutory safeguarding law applies.

Orthostatic hypotension and associated conditions in geriatric inpatients.

Screening of orthostatic hypotension (OH) was performed in 285 patients aged 75  years. Current drugs, reasons for admission, geriatric syndromes, and confounding medical conditions were collected. Patients with OH (n = 116, 41%) as compared to those without OH (n = 169) more frequently (P < 0.01) presented falls in the last 6  months (62 vs. 40%, P < 0.001), a fall as the reason for the current admission (49 vs. 26%, P < 0.001), feeling of fainting (20 vs. 6%, P = 0.002), syncope (29 vs. 4%, P < 0.001) or functional decline (71 vs. 47%, P = 0.012). No difference was observed between the two groups in terms of age (85 ± 5 vs. 84 ± 4  years), gender (59 vs. 50% female), common geriatric conditions (e.g. malnutrition 46 vs. 58%, dementia 22 vs. 26%), comorbidity or confounding conditions (dehydration 28 vs. 30%, sepsis 2 vs. 6%). No difference was detected in the use of drugs with psychotropic cardiovascular or diuretic effect, or in their associations. Orthostatic hypotension is frequent upon hospital admission and should be screened, particularly in geriatric fallers. This absence of relation between OH and drugs use suggests that non-pharmacological interventions should be first attempted in older inpatients with OH before deciding to reduce or withdraw useful drugs.

[Prescribing inappropriate medication: the new STOPP/START criteria]. / Prescription médicamenteuse inappropriée: les nouveaux critères STOPP/START.

Prescribing inappropriate medication (PIM) is a common public health problem. Mainly due to associated adverse drugs events (ADE), it results in major morbidity and mortality, as well as increased healthcare utilization. For a long time, the systematic review of medications prescribed appeared as a solution for limiting PIM and the ADE associated with such prescriptions. With this aim and since 2008, the list of STOPP-START criteria has appeared as attractive in its design, as well as logical and easy to use. The initial version has just been updated and improved. After having detailed all improvements provided to the 2008 version, we present the result of its adaptation into French language by a group of French-speaking expert from Belgium, Canada, France, and Switzerland.

Validated gene expression biomarker analysis for biopsy-based clinical trials in ulcerative colitis.

BACKGROUND: Accurate and reproducible measurement of expression of pro-inflammatory cytokines in colonic biopsies from patients with ulcerative colitis (UC) is essential for proof-of-concept and mechanism-of-action studies. Few studies have rigorously established the number of biopsies required for accurate and reproducible biomarker measurements. AIM: To validate methods for measuring changes in gene expression in colonic biopsy samples. METHODS: Twelve colonic biopsies were obtained from each of six healthy controls, six patients with inactive UC and seven patients with active UC. Mayo endoscopic scores were used as a clinical reference standard. Quantitative PCR was used to assess mRNA expression of eight known inflammatory genes. The power to detect a reduction in gene expression in active vs. inactive UC was calculated using a linear mixed effect model. RESULTS: mRNA analysis of colonic biopsies is a sensitive and feasible approach for measuring inflammatory gene expression in colonic biopsies. Inflammatory biomarkers correlate with Mayo endoscopic subscores for each colonic region. For most genes, three rectal biopsies from two to four patients are required to detect changes in gene expression corresponding to active vs. inactive UC to achieve a power of 80% with an alpha of 0.05. CONCLUSION: Our data suggest that systematic measurement of inflammatory biomarkers at the mRNA level can be a valuable tool for hypothesis testing, and assessment of clinical activity and response to therapy in ulcerative colitis.

Postprandial reactive hypoglycaemia in a very old patient.

OBJECTIVE AND IMPORTANCE: Postprandial reactive hypoglycaemia (PRH) is a clinical syndrome characterized by the recurrence of symptomatic hypoglycaemia during postprandial periods. PRH remains a diagnostic challenge for clinicians, because of its atypical manifestations and low prevalence, especially in older persons. CLINICAL PRESENTATION: We report the diagnostic work-up of severe hypoglycaemic episodes in a very old patient in whom the diagnosis of PRH was made. INTERVENTION: We prescribed acarbose, an alpha-glucosidase inhibitor, to this patient to prevent the recurrence of hypoglycaemic episodes. Four years later, acarbose was always used and no further episode of hypoglycaemia had occurred. Based on the literature, we discuss the limited value of endocrine tests as well as the efficacy of the therapeutic approaches. CONCLUSION: Prescription of acarbose is useful in addition to nutritional education, the corner stone of the treatment, to avoid the recurrence of severe hypoglycaemic events due to PRH.

Reduction of potentially inappropriate medications using the STOPP criteria in frail older inpatients: a randomised controlled study.

BACKGROUND: Hospital admissions may provide an opportunity to discontinue potentially inappropriate medications (PIMs) in older patients. Little is known about the effect of using the Screening Tool of Older People's potentially inappropriate Prescriptions (STOPP) in this context. This study aimed to test the hypothesis that specific STOPP recommendations from an inpatient geriatric consultation team (IGCT) to the hospital physician leads to reductions in PIMs for patients at discharge. METHODS: This was a randomised controlled study in 146 frail inpatients (in 2011). The intervention consisted of STOPP recommendations made by the IGCT to ward physicians to discontinue PIMs, in addition to the standard geriatric advice. RESULTS: Intervention (n = 74) and control (n = 72) groups were similar in terms of patient characteristics (median age 85 years; median number of daily drugs, seven) and PIM distribution (68 and 57 PIMs in 53 and 51 % of patients, respectively). At discharge, the reduction in PIMs was twice as high for the intervention group as for the control group (39.7 and 19.3 %, respectively; p = 0.013). The proportion of patients who still had one or more PIM at discharge did not differ between groups. In the 50 patients followed-up a year later, the majority of PIMs that had been stopped during hospitalisation had not been restarted after discharge (17/28; 61 %). The clinical relevance of PIMs identified at baseline in those patients was considered major (29 %), moderate (37 %), minor (5 %), deleterious (8 %), or not assessed (11 %). Discontinuation rate was not associated with clinical importance. CONCLUSION: Specific STOPP recommendations provided to hospital physicians doubled the reduction of PIMs at discharge in frail older inpatients. To further improve the appropriateness of prescribing in older patients, clinicians should focus on the STOPP criteria that are of major clinical importance, and general practitioners should be actively involved.

Prevalence of orthostatic hypotension and relationship with drug use amongst older patients.

INTRODUCTION: Orthostatic hypotension (OH) is said to be highly prevalent in older people. Drugs are often involved as causative factor. Nevertheless, few data are available about the prevalence of OH and its relationship with drugs in olders. OBJECTIVES: To review data about (i) the prevalence and characteristics of OH in older patients; and (ii) the relationship between OH and drugs. METHODS: Review of publications from Ovid (PubMed) from 1980 to May 2011 using the following key words: "orthostatic hypotension" combined with "elderly" or equivalent for the analysis of prevalence (first search) and "orthostatic hypotension" combined with "drugs" or equivalent to assess the relationship between OH and drugs (second search). RESULTS: Fifty-one publications (of which 14 with original data) were retrieved from the prevalence search, 31 for the second search (8 with original data: 7 retrospective studies and 1 prospective cohort study) and 12 reviews or experts opinions. Prevalence of OH varies according to the characteristics of the subjects, the settings of the studies, and the procedures of blood pressure measurement. In acute geriatrics units, two studies reported a prevalence of over 30% and one study mentioned that 68% of the patients presented with at least one episode during the day. OH was associated with several geriatric problems: gait disorders, balance disorders, falls, cerebral hypoperfusion, transient ischemic attacks, cognitive impairment, acute myocardial infarct and systolic hypertension. OH can also be asymptomatic or with atypical presentation: falls, gait disorders and confusion. Psychotropic agents (antipsychotics, sedatives, antidepressants), and cardiovascular drugs (antihypertensive agents, vasodilators, diuretics) were associated with OH. DISCUSSION: If the hypothesis of causality between drug treatment and OH is confirmed, the identification of the involved drugs could be of value for the prevention of OH and its complications. In this context, the Working Group Pharmacology Pharmacotherapy and Pharmaceutical Care of the Belgian Society of Gerontology and Geriatrics proposes to conduct a multicentre study to assess the prevalence of OH in Belgian acute geriatrics units and its relationship with drugs.

Three synchronous gastrointestinal tumours.

Mucinous cystadenomas of the appendix are rare, with significant malignant potential [Lo and Sarr in Hepatogastroenterology 50(50):432-437, 2003]. Carcinoid tumours are similarly uncommon, rarely occurring in Meckel's diverticula but are still the commonest tumour of Meckel's diverticulae [Nies et al. in Dis Colon Rectum 35(6):589-596, 1992; Modlin and Lye in Cancer 97(4):934-959, 2003; Sutter et al. in Schweiz Med Wochenschr Suppl 89:20S-24S, 1997; Weber and McFadden DW in J Clin Gastroenterol 11(6):682-686, 1989]. A 77-year-old woman presented to our clinic with a 6-week history of non-specific lower abdominal pain. A pelvic ultrasound showed an 8 × 3 × 2.5 cm mass in the right iliac fossa. Colonoscopy and CT confirmed this mass and also revealed a left colonic tumor. At laparotomy, three tumours were identified; in the appendix, a Meckel's diverticulum, and the descending colon. A subtotal colectomy and diverticulectomy were performed. Histology confirmed a T3N0 Dukes B colonic adenocarcinoma, a carcinoid of Meckel's diverticulum and a mucinous adenoma of the appendix. The patient is tumor free to date, 5 years after presentation. The presence of three synchronous tumours of different histological origin in the gastrointestinal tract has not previously been described in the literature.

Predicting functional adverse outcomes in hospitalized older patients: a systematic review of screening tools.

BACKGROUND: Functional decline frequently occurs following hospitalisation in older people and may be prevented or minimized by specific management. Such care processes needs appropriate early screening of older hospitalized patients. OBJECTIVE: To identify instruments able to detect on admission older hospitalized patients at risk of functional decline at and after discharge. METHODS: Functional decline is defined as loss of independence in activities of daily living (functional decline) or admission in nursing home. The systematic search used Medline 1970-2007, Web of Science 1981-2007 and references list of relevant papers. An independent epidemiologist assessed methodological quality of the retained articles. RESULTS: We found 12 studies developing predictive tools, including 7145 patients. Functional outcomes were assessed at or after discharge. Preadmission functional status, cognition, and social support were major components for prediction of functional evolution. Few instruments are fully validated and data concerning reliability are often lacking. Operational characteristics are moderate (sensitivity 29-87%, negative likelihood ratio 0.2-0.8). CONCLUSIONS: Instruments predicting functional adverse outcomes are difficult to compare due to heterogeneity of functional outcomes and hospital settings. The reason why so many tools have been developed is probably because none gives full satisfaction: their general predictive validity and performances are insufficient. Further research is needed to improve the screening of frail older patients admitted to hospital with standardized and validated tools.

Time-of-day-dependent dietary fat consumption influences multiple cardiometabolic syndrome parameters in mice.

BACKGROUND: Excess caloric intake is strongly associated with the development of increased adiposity, glucose intolerance, insulin resistance, dyslipidemia, and hyperleptinemia (that is the cardiometabolic syndrome). Research efforts have focused attention primarily on the quality (that is nutritional content) and/or quantity of ingested calories as potential causes for diet-induced pathology. Despite growing acceptance that biological rhythms profoundly influence energy homeostasis, little is known regarding how the timing of nutrient ingestion influences development of common metabolic diseases. OBJECTIVE: To test the hypothesis that the time of day at which dietary fat is consumed significantly influences multiple cardiometabolic syndrome parameters. RESULTS: We report that mice fed either low- or high-fat diets in a contiguous manner during the 12 h awake/active period adjust both food intake and energy expenditure appropriately, such that metabolic parameters are maintained within a normal physiologic range. In contrast, fluctuation in dietary composition during the active period (as occurs in human beings) markedly influences whole body metabolic homeostasis. Mice fed a high-fat meal at the beginning of the active period retain metabolic flexibility in response to dietary challenges later in the active period (as revealed by indirect calorimetry). Conversely, consumption of high-fat meal at the end of the active phase leads to increased weight gain, adiposity, glucose intolerance, hyperinsulinemia, hypertriglyceridemia, and hyperleptinemia (that is cardiometabolic syndrome) in mice. The latter perturbations in energy/metabolic homeostasis are independent of daily total or fat-derived calories. CONCLUSIONS: The time of day at which carbohydrate versus fat is consumed markedly influences multiple cardiometabolic syndrome parameters.

Lhermitte's sign, electric shock sensations and high dose ecstasy consumption: preliminary findings.

The objectives of this study were to perform a preliminary investigation into the nature of electric shock-like experiences reported in association with the use of ecstasy tablets thought to contain methylenedioxymethamphetamines (MDMA). This included exploration of reports of electric shock-like experiences from the user's perspectives and identification of other variables that may be associated with their development. Furthermore we aimed to examine whether the well-recognised electric shock-like symptom, Lhermitte's sign (LS), is associated with ecstasy tablet use in some drug users. A single measure, cross-sectional survey was used incorporating mixed qualitative and quantitative methodology. A select group of ecstasy users (n = 35) recruited through a dance, music and lifestyle magazine completed a telephone interview. Lifetime prevalence of LS in the study population was 18% (n = 6). Development of LS was associated with use of more ecstasy tablets before a typical incident. This study indicates a relationship may exist between the use of ecstasy tablets and LS. The relationship may be dose dependent. The majority of the study population used other substances including alcohol when experiencing electrical shock sensations. LS may explain only a proportion of all electrical shock experiences among ecstasy users.

Type 2 diabetes in primary care in belgium: need for structured shared care.

OBJECTIVE: To picture the profile of type 2 diabetic patients in Belgium and to study the quality of care in the primary care setting, with regard, to multi-factorial approach of the disease. METHODS: Observational study of all known DM2-patients registered by 120 volunteer general practitioners. Quality of care was evaluated by the achievement of three major treatment targets: HbA1c<7%; Systolic Blood Pressure

Training and manpower issues for specialist registrars in paediatrics. How are we doing and where are we going?

All Irish paediatric higher specialist trainees' opinions about the paediatric higher specialist training (HST) scheme and related manpower issues were surveyed. Information was obtained on 1) trainees' level of satisfaction with HST, 2) their ultimate career ambitions including location of final posts, 3) attitudes to both flexible training and consultancies and 4) demographics to assess the significance of gender variations. Fifty-two eligible trainees were identified using the Royal College of Physicians of Ireland database. The survey was administered as an anonymous postal survey. The response rate was 88%. Results indicated a high level of satisfaction with HST (78%) overall although problems were noted with the half-day release programme as only 63% were facilitated. Only 30% wish to practice as subspecialists, 76% of trainees wish to work in an urban hospital and 43.5% desire a flexible consultancy suggesting an incompatibility of trainees' desires with current Irish medical manpower policy. To address these difficulties we suggest establishing more rigorous audit of training posts to ensure deficiencies are corrected and the establishment of flexible training to address gender imbalance and to promote the concept of consultant job sharing.

[From PICO to search terms on the Internet: how to find relevant information? New coxibs: do they have a better gastrointestinal safety?]. / Du PICO aux termes de recherche par Internet: comment accéder à l'information pertinente? Les nouveaux coxibs: ont-ils réellement une meilleure sécurité digestive?

In the first article of this series, we have shown how to translate a clinical problem into a well built question, by creating a PICO (Patient--Intervention--Comparison--Outcome). In this second article, we will explain how to transform the PICO in English search terms for use on the internet. We use these terms in the different databases to find the answer to the following clinical problem: "In patients aged 65 or over with hip osteoarthritis, and a history of peptic ulcer, is the risk of a new peptic ulcer less using a cox-2 inhibitor than with a classic nonsteroidal anti-inflammatory drug?"

Chronic disseminated histoplasmosis in an apparently immuno-competent Belgian patient.

A 77 year-old Belgian man was admitted for weight loss and elevated liver enzymes. He used to live in Central Africa until 1986 and denied any travel outside Belgium during the last decade. Physical examination was unremarkable except for a lip ulceration. Blood tests showed increases of liver enzymes and CEA. In the search of an abdominal cancer, CT showed a normal liver but enlarged surrenal glands, while colonoscopy disclosed multiple mucosal lesions. Colic and lip biopsies identified Histoplasma capsulatum var capsulatum. HIV serology was negative. Lymphocyte count was normal but lymphocyte function was depressed. The patient dramatically improved under oral treatment with Itraconazole 400 mg daily for six months. This case indicates that chronic disseminated Histoplasmosis can reactivate in a healthy and apparently non-immunocompromised person living in Europe.