[Assessment of professional practices on the use of computerized medicine cabinets by registered nurses]. / Évaluation des pratiques professionnelles sur l'utilisation des armoires informatisées de stockage des médicaments par les infirmiers diplômés d'état.

Ensuring the safety of patient medication management is a public health priority. In hospitals, the medication circuit involves risks, especially in terms of storage. As part of an institutional project, the deployment of computerized medicine cabinets in our hospital's care units was initiated in 2015. By 2022, almost all care departments were equipped. Each drug picking is carried out by the registered nurse according to the patient's name, in accordance with the administration plan. In addition, local recommendations are to collect medication for a maximum of 24hours. In this context, our objective was to assess nursing professional practices in order to identify the steps requiring action plans. To meet this objective, we i) studied the compliance of computerized drug samplings with prescriptions on a given day throughout the establishment, ii) assessed picking practices with an observational audit, and iii) proposed questionnaires, including practical cases and satisfaction questions. Over 300 prescriptions were analyzed, including 2,511 drugs requiring at least one collect on the day of the assessment. The compliance rate for picking in relation to the drugs prescribed was 44.7%. According to the audit observation, the picking compliance rate was 74.5%. Non-compliances were mainly linked to the selection of the wrong patient at the computerized medicine cabinet and/or to a picking for longer than the recommended duration. Finally, the rate of correct answers to the proposed cases was 61.9%, and nurses were generally satisfied or very satisfied with the equipment.

A model predicting fluindione dose requirement in elderly inpatients including genotypes, body weight, and amiodarone.

Indandione VKAs have been widely used for decades, especially in Eastern Europe and France. Contrary to coumarin VKAs, the relative contribution of individual factors to the indandione-VKA response is poorly known. In the present multicentre study, we sought to develop and validate a model including genetic and non-genetic factors to predict the daily fluindione dose requirement in elderly patients in whom VKA dosing is challenging. We prospectively recorded clinical and therapeutic data in 230 Caucasian inpatients mean aged 85 ± 6 years, who had reached international normalized ratio stabilisation (range 2.0-3.0) on fluindione. In the derivation cohort (n=156), we analysed 13 polymorphisms in seven genes potentially involved in the pharmacological effect or vitamin-K cycle (VKORC1, CYP4F2, EPHX1) and fluindione metabolism/transport (CYP2C9, CYP2C19, CYP3A5, ABCB1). We built a regression model incorporating non-genetic and genetic data and evaluated the model performances in a separate cohort (n=74).Body-weight, amiodarone intake, VKORC1, CYP4F2, ABCB1 genotypes were retained in the final model, accounting for 31.5% of dose variability. None influence of CYP2C9 was observed. Our final model showed good performances: in 83.3% of the validation cohort patients, the dose was accurately predicted within 5 mg, i.e.the usual step used for adjusting fluindione dosage. In conclusion, in addition to body-weight and amiodarone-intake, pharmacogenetic factors (VKORC1, CYP4F2, ABCB1) related to the pharmacodynamic effect and transport of fluindione significantly influenced the dose requirement in elderly patients while CYP2C9 did not. Studies are required to know whether fluindione could be an alternative VKA in carriers of polymorphic CYP2C9 alleles, hypersensitive to coumarins.

Effects of direct spiking of silicone oil into a model pMDI formulation.

CONTEXT: Silicone oil is used as a valve lubricant in pressurized metered dose inhalers (pMDIs). Its possible impact on drug delivery, through such effects as particle aggregation, has recently been discussed. OBJECTIVE: To examine the effects of a range of directly spiked silicone oil amounts on pMDI performance. MATERIALS AND METHODS: pMDI canisters containing a corticosteroid medicinal compound, HFA134a and accurately measured amounts of silicone oil (0, 200, 400 and 550 µg) were prepared. Samples were characterized for actuation weight, aerodynamic size (by Andersen cascade impaction, ACI), charge (by electrical low-pressure impaction, ELPI) and product appearance by visual imaging. RESULTS AND DISCUSSION: Actuation weights were unaffected by silicone oil. A small increase in aerodynamic size was observed in the presence of silicone oil as a shift from stage 5 to impactor throat. No significant change in medicinal compound recovery was seen (t-tests, p > 0.05). Fine particle fraction as a percentage of dose delivered (FPF) was unchanged, as was particle size distribution derived from charge measurements, with the addition of silicone oil (t-tests, p > 0.05). Canister opening did not indicate container interaction but that sedimentation occurred in the presence of silicone oil. Decanted suspensions containing silicone oil were more transparent. Possible interactions inside and outside the pMDI canister are described. CONCLUSION: As demonstrated previously with an alternative experimental design the study showed that silicone oil has little effect on product performance, when added to a model pMDI formulation at levels that could potentially be observed as a leachable from the metering valve.

[Focus on digitalis intoxication in the elderly. Report of a case treated with digoxin-specific Fab antibody fragments]. / Mise au point sur la prise en charge des intoxications digitaliques chez le sujet age. À propos d'un cas traité par anticorps antidigitaliques.

The indications for digoxin are currently limited to rare cases of heart failure and/or atrial fibrillation. Its use should be even more rare in geriatrics its pharmacological characteristics, associated with age-related changes and comorbidities, particularly increase the risk of digoxin poisoning in the elderly. However, at least a third of aged patients suffering from heart failure and/or atrial fibrillation is treated by digitalis. Digoxin intoxication can provoke gastrointestinal troubles, neurological disturbances and, above all, cardiac conduction impairment and dysrythmias, which explain its severity and high mortality rate. Presently, first-line therapy is the administration of digoxin specific antibodies. Poor prognosis factors, frequently found in digoxin intoxications in the elderly, have been established for guiding the prescription of antibodies and their dosage. It is important for geriatricians to be able to recognize poisoning signs and the conditions in which an antidote treatment is necessary. This will permit a more effective management of the case, with the support of a poison control center and possible referral of the patient to an intensive care unit.

[Divisibility of warfarin and fluindione tablets tested in elderly patients and their family circle]. / Sécabilité comparée des comprimés de warfarine et de fluindione pour les patients âgés et leur entourage.

BACKGROUND: Vitamin K antagonist tablets are often split to fractionate the dose by elderly patients. We performed a study in order to assess the divisibility of one dosage strength of score-lined warfarin and of score-lined fluindione. METHODS: Due to a recent change in the pharmaceutical form of fluindione in order to improve the divisibility, the study was performed over 2 different periods (with the « old ¼ and with the « new ¼ pharmaceutical form). In each period, 10 patients mean aged 82 years, 10 relatives, 10 nurses, 10 medical doctors) were asked to split in half warfarin tablets (W2 1(st) period et W2 2(d) period) and fluindione tablets (F2 et F'2), and to split fluindione tablets into 4 fragments (F4 et F'4). The first end-point was the accuracy of splitting estimated by the difference between the real and the expected weight of fragmented tablets. The statistical analysis was performed using an ANOVA test with 2 variables, subject and drug. The difference between the 2 periods were analyzed using an ANOVA test with 2 variables, subject and period. RESULTS: Over the 2 periods, the differences between real and expected weight were of 4.65% for W2 1(st) phase, 9.48% for F2, 15.35% for F4, 5.56% for W2 2(d )period, 4.30% for F'2, and 6.98% for F'4. The quality of splitting was statistically poorer in the elderly patient group compared to other subjects. CONCLUSION: This study was not design to assess the clinical relevance (bleeding or thromboembolism) or the anticoagulation control of the variations in drug mass due to inappropriate splitting of tablets. However, split form of drugs should be prescribe with caution to elderly patients.

Reversal of overanticoagulation in very elderly hospitalized patients with an INR above 5.0: 24-hour INR response after vitamin K administration.

BACKGROUND: Reversal of overanticoagulation to minimize the bleeding risk is important in elderly inpatients receiving vitamin K antagonist therapy. However, no study has specifically focused on this population. The objective of this study is to evaluate whether guidelines based on American College of Chest Physicians recommendations for the management of overanticoagulation (international normalized ratio [INR] ≥5.0) can apply to elderly inpatients, and notably allow 24-hour INRs to return to the 1.8-3.2 range in this population. The influence of different factors on the vitamin K response also was evaluated. METHODS: Inpatients aged ≥75 years with INR ≥5.0 were included in this observational study. INRs were assessed on the day of the overdosage (Day 0) and on the following day (Day 1). RESULTS: Of 385 Day 0 INRs ≥5.0 (239 patients; 86±6 years), 217 were managed according to recommendations, with a mean INR decreasing from 6.8±2.4 (range: 5.0-20.0) on Day 0 to 2.7±1.3 (range: 1.1-10.1) on Day 1 (P<.0001); 55% of INRs were within the 1.8-3.2 range, 20% <1.8, and 25% >3.2. In the subset of Day 0 INRs between 5.0 and 6.0, mean INR decreased from 5.5±0.3 to 2.7±1.0 (P<.0001) on Day 1 after oral administration of 1 mg vitamin K1 (n=121) and from 5.3±0.3 to 5.0±1.6 (P=.149) without vitamin K1 administration (n=48). Among covariates entered in the multivariate analysis, including co-medications, only the vitamin K1 dose influenced Day 1 INRs, with higher doses of vitamin K1 associated with Day 1 INRs <1.8 (P<.0001). CONCLUSION: In elderly inpatients with INR ≥5.0, both vitamin K antagonist dose omission and vitamin K1 administration according to recommendations were effective in reversing overanticoagulation, allowing most INRs to return to the 1.8-3.2 range without excessive overcorrection. Therefore, American College of Chest Physicians recommendations may be applied to elderly inpatients.