Discrepancies in corrected calcium versus ionised calcium in a geriatric population: an observational study.

BACKGROUND: Calcium can be measured as ionised (Ca-ionised) or albumin-adjusted total calcium (Ca-albumin). Current clinical guidelines predominantly utilise Ca-albumin, despite Ca-ionised being the gold standard. Discrepancies can occur between these measurement modalities and can lead to clinical dilemmas. It remains unclear how large these discrepancies are in older patients. This study investigated the discrepancies between Ca-ionised and Ca-albumin in geriatric patients. METHODS: This is an observational study of all geriatric patients (n = 876) in the Jeroen Bosch Hospital (January 2018 and January 2021) in whom both Ca-ionised and Ca-albumin were measured. Misclassification of calcaemic state (i.e. low, normal or high) was calculated (percentages), the measure of agreement was described using Cohen's Kappa and for the continuous data Pearson's correlation coefficient was used. Relevant categories of age and renal function were considered for effect modification effects and studied by interaction terms in a regression model. RESULTS: In one-third of the measurements, there was a misclassification. Ca-albumin measurements failed to identify 28% of hypocalcaemia. In 3.5%, hypercalcemia based on Ca-albumin was not confirmed by Ca-ionised. The correlation coefficient between Ca-ionised and Ca-albumin was 0.743 (P = 0.01) and measure of agreement by Kappa was 0.213 (P < 0.001). In the oldest old (≥ 85 years) and patients with eGFR <30 ml/min/1.73 m2 ,the agreement by Kappa was lower, with values of 0.192 and 0.104, respectively. CONCLUSION: There is a discrepancy between Ca-albumin and Ca-ionised in one-third of the geriatric patients, leading to clinical dilemmas. In the oldest old and patients with renal dysfunction, this problem is most pronounced.

Impact of geriatric co-management on outcomes in hospitalised cardiology patients aged 85 and over.

OBJECTIVE: Cardiovascular disease and frailty are common among the population aged 85+. We hypothesised these patients might benefit from geriatric co-management, as has been shown in other frail patient populations. However, there is limited evidence supporting geriatric co-management in older, hospitalised cardiology patients. METHODS: A retrospective cohort study was performed in a large teaching hospital in the Netherlands. We compared patients aged 85 and over admitted to the cardiology ward before (control group) and after the implementation of standard geriatric co-management (intervention group). Data on readmission, mortality, length of stay, number of consultations, delirium, and falls were analysed. RESULTS: The data of 1163 patients were analysed (n = 542 control, n = 621 intervention). In the intervention group, 251 patients did not receive the intervention because of logistic reasons or the treating physician's decision. Baseline characteristics were comparable in the intervention and control groups. Patients in the intervention group had a shorter length of stay (-1 day, p = 0.01) and were more often discharged to a geriatric rehabilitation facility (odds ratio [OR] 1.97, 95% confidence interval [CI] 1.10-3.54, p = 0.02) compared with the control patients. Other outcomes were not significantly different between the groups. CONCLUSIONS: After implementation of standard geriatric co-management for hospitalised cardiology patients aged 85 and over, the length of hospital stay shortened and the number of patients discharged to a geriatric rehabilitation facility increased. The adherence to geriatric team recommendations was high. Geriatric co-management would appear to optimise care for older hospitalised patients with cardiac disease.

Effect of interprofessional and intraprofessional clinical collaboration on patient related outcomes in multimorbid older patients - a retrospective cohort study on the Intensive Collaboration Ward.

BACKGROUND: The management and care of older patients with multiple health problems is demanding and complex. Interprofessional and intraprofessional collaboration has the potential to improve both the efficiency and the quality of care for these patients. However, it has proven difficult to demonstrate the efficacy of this approach in terms of objective patient-related outcomes. Recently, a care model with interprofessional and intraprofessional care was started, the Intensive Collaboration Ward (ICW). This ward combines interprofessional care and intraprofessional care for older patients with multiple health problems. The aim of this study was to evaluate the effects of ICW care in older patients with multiple health problems. METHODS: This retrospective cohort study evaluated the effects on patients outcomes. This was done by comparing patients of the new model, the ICW (ICW group), to a historical cohort of comparable patients who would have been eligible for the ICW (control group). Outcomes were medical consultations, allied health professional consultations, radiological procedures, waiting time for radiological procedures, change in primary treating specialty, length of hospital stay, readmission rate, and mortality rate. Linear and logistic regression analyses were performed, adjusted for baseline differences. RESULTS: The ICW group required significantly fewer medical consultations than the control group. Calls to specialists from the emergency room decreased significantly, but there was no change in in-person consultations on the ER. 51% of control patients had ≥ 1 in-hospital consultation compared to 21% of ICW patients (p < 0.05). Patients in the ICW group received significantly more consultations with allied health professionals and more often had a change in primary treating specialty. CONCLUSIONS: Interprofessional and intraprofessional clinical collaboration on the ICW reduced in-hospital consultations and increased allied health professionals' consultations. This approach may decrease fragmentation of care and provide more integrated, efficient and patient centered care. This may improve the overall care of older patients with multiple health problems.

Incidences of underlying causes of hypothermia in older patients in the emergency department: a systematic review.

PURPOSE: Hypothermia is a serious condition in older adults. Knowledge of a priori chances of underlying diseases may affect initial management, hence prognosis. This systematic review provided an overview of existing literature on the incidences of underlying causes of hypothermia in older patients at the emergency department. METHODS: MEDLINE, The Cochrane Library, and Embase were searched up to February 1st, 2022. Inclusion criteria were age ≥ 65 years, emergency department setting, and body temperature < 36.0 degrees Celsius. Exclusion criteria were iatrogenic hypothermia, no underlying cause reported, and patient selection based on specific diseases. Title/abstract and full-text were screened and quality was assessed using the Joanna Briggs Institute Critical Appraisal Tool. Data were presented using descriptive statistics and narrative analyses. RESULTS: Forty-one reports were included, including 6 cohort studies and 35 case reports. The 6 studies involved 2173 hypothermic patients, whose age varied from a mean of 67 to a median of 79 years and temperature from a median of 30.8 to a mean of 33.7 degrees Celsius. One study reported about primary hypothermia (incidence of 44%). Acute medical illness was often reported as underlying cause of secondary hypothermia (49-51%). Reported incidences of infection and sepsis ranged from 10 to 32%, of trauma up to 14%, and of alcohol intoxication from 5 to 26%. CONCLUSION: Limited studies have been published regarding this topic, and the overall quality of the evidence was graded as low. Causes that should not be missed include acute medical illness, trauma, alcohol intoxication, primary hypothermia, thyroid failure, and drug-induced hypothermia.

A comparison of the clinical pharmacotherapy knowledge of medical and surgical residents and consultants.

PURPOSE: Knowledge of clinical pharmacotherapy is essential for all who prescribe medication. The aims of this study were to investigate differences in the pharmacotherapy and polypharmacy knowledge of medical and surgical residents and consultants and whether this knowledge can be improved by following an online course. METHODS: Design: A before-and-after-measurement. SETTING: An online course available for Dutch residents and consultants working in hospitals. STUDY POPULATION: Dutch residents and consultants from different disciplines who voluntarily followed an online course on geriatric care. INTERVENTION: An online 6-week course on geriatric care, with 1 week dedicated to clinical pharmacotherapy and polypharmacy. Variables, such as medical vs surgical specialty, consultant vs resident, age, and sex, that could predict the level of knowledge. The effects of the online course were studied using repeated measures ANOVA. The study was approved by the National Ethics Review Board of Medical Education (NERB dossier number 996). RESULTS: A total of 394 residents and 270 consultants, 220 from surgical and 444 from medical specialties, completed the online course in 2016 and 2017. Residents had higher test scores than consultants for pharmacotherapy (73% vs 70%, p < 0.02) and polypharmacy (75% vs 72%, p < 0.02). The learning effect did not differ. Medical residents/consultants had a better knowledge of pharmacotherapy (74% vs 68%, p < 0.001) and polypharmacy (77% vs 66%, p < 0.001) than surgical residents/consultants, but the learning effect was the same. CONCLUSIONS: Residents and consultants had a similar learning curve for acquiring knowledge, but residents outperformed consultants on all measures. In addition, surgical and medical residents/consultants had similar learning curves, but medical residents/consultants had higher test scores on all measures.

Proton Pump Inhibitors and Hypomagnesemia in Older Inpatients: An Observational Study.

Purpose Proton pump inhibitors (PPIs) are prescribed frequently and can cause potentially severe hypomagnesemia. Researchers assessed the prevalence of hypomagnesemia and the association between PPI use and hypomagnesemia in hospitalized older patients. Methods Researchers conducted a single-center, observational, retrospective cohort study with patients admitted to a geriatric ward at the Jeroen Bosch Hospital in the period between June 24, 2016, and August 30, 2020. Patients were included if they were 65 years of age or older, had a serum magnesium measurement, and a complete overview of patient's current medication was present at the day of admission. The primary outcome was the occurrence of hypomagnesemia at hospital admission. Exposure to PPIs was the primary determinant investigated. Covariates were studied to identify risk factors and to adjust for potential confounding. The strength of the association between PPI and hypomagnesemia was evaluated with unconditional logistic regression, expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Results The prevalence of hypomagnesemia was 21.9% in PPI users and 15.8% in non-PPI users. Overall, the use of PPIs was associated with hypomagnesemia (ORadj = 1.38, 95% CI 1.09-1.76). A trend for this association was most pronounced in male patients (ORadj = 1.88, 95% CI 1.27-2.79), smokers (ORadj = 3.95, 95% CI 1.52-10.28), and in patients using > 7 units alcohol a week (ORadj = 4.44, 95% CI 1.40-14.12). Conclusion Older patients who are taking a PPI have a higher risk of developing hypomagnesemia than nonusers; additional factors can contribute to the risk. Physicians should be aware of PPI-induced hypomagnesemia and routinely monitor serum magnesium levels in older patients.

Performance of the APOP-screener for predicting in-hospital mortality in older COVID-19 patients: a retrospective study.

BACKGROUND: A variety of prediction models concerning COVID-19 have been proposed since onset of the pandemic, but to this date no gold standard exists. Mortality rates show a sharp increase with advancing age but with the large heterogeneity of this population in terms of comorbidities, vulnerability and disabilities, identifying risk factors is difficult. Therefore, we aimed to research the multidimensional concept of frailty, measured by the Acute Presenting Older Patient (APOP)-screener, as a risk factor for in-hospital mortality in older COVID-19 patients. METHODS: All consecutive patients of 70 years or older, with a PCR confirmed COVID-19 infection and a completed APOP-score, presenting at the Emergency Department (ED) of the Jeroen Bosch Hospital, the Netherlands, between February 27th 2020 and February 1st 2021 were retrospectively included. We gathered baseline characteristics and scored the CCI and CFS from patient records. The primary outcome was in-hospital mortality. RESULTS: A total of 292 patients met the inclusion criteria. Approximately half of the patients were considered frail by the APOP or CFS. 127 patients (43.5%) scored frail on the CFS, 158 (54.1%) scored high risk on the APOP-screener. 79 patients (27.1%) died during their hospital admission. The APOP-screener showed a significantly elevated risk of in-hospital mortality when patients scored both high risk of functional and evidence of cognitive impairment (OR 2.24, 95% 1.18-4.25). Significant elevation of in-hospital mortality was found for the high CCI-scores (≥ 5)(OR 1.78, 95% 1.02-3.11), but not for the highest CFS category (5-9, frail) (OR 1.35, 95% 0.75-2.47). The discriminatory performance of the APOP, CFS and CCI were comparable (AUC resp. 0.59 (0.52-0.66), 0.54 (0.46-0.62) and 0.58 (0.51-0.65)). CONCLUSION: Although the elevated risk for in-hospital mortality found for the most frail patients as scored by the APOP, this instrument has poor discriminatory value. Additionally, the CFS did not show significance in predicting in-hospital mortality and had a poor discriminatory value as well. Therefore, treatment decisions based on frailty or comorbidities alone should be made with caution. Approaching the heterogeneity of the older population by adding frailty as assessed by the APOP-score to existing prediction models may enhance the predictive value of these models.

Integrating healthcare for follow-up of adult COVID-19 patients in an outpatient clinic: A matter of cooperation.

RATIONALE AIMS AND OBJECTIVES: A large number of patients infected with SARS-CoV-2 (COVID-19) need outpatient follow-up after hospitalization. As these patients may experience a broad range of symptoms, as do patients infected with the related SARS-CoV-1 virus, we set up a multidisciplinary outpatient clinic involving pulmonologists, internists, and geriatricians. Patients were allocated to a specialist based on symptoms reported on a self-developed questionnaire of expected symptoms of COVID-19. This study aimed to evaluate the effectiveness of this outpatient clinic. METHODS: In this retrospective study, the medical records of patients who presented to the outpatient clinic for follow-up after hospitalization for COVID-19 up to 31 August 2020, were reviewed. RESULTS: In total, 266 patients were seen at the outpatient clinic at least once. Overall, 100 patients were seen by a pulmonologist, 97 by an internist, and 65 by a geriatrician. A referral between these 3 medical specialists was needed for only 14 patients (5.3%). Fifty patients were seen by a psychologist, mostly those with a HADS score >10. Only 5 (2.2%) of the 221 patients who were not directly referred to a psychologist based on triage needed psychological support. Forty-eight patients (18%) were also seen by a physiatrist. CONCLUSION: Identifying which medical specialist (pulmonologist, internist, and/or geriatrician) should see patients attending a post-COVID outpatient clinic based on patient-reported symptoms proved an effective approach to managing the flow of post-COVID patients.

The hanging chin sign as a mortality predictor in geriatric patients at the emergency department: a retrospective cohort study.

BACKGROUND: At the emergency department, there is a need for an instrument which is quick and easy to use to identify geriatric patients with the highest risk of mortality. The so- called 'hanging chin sign', meaning that the mandibula projects over one or more ribs on the chest X-ray, could be such an instrument. This study aims to investigate if the hanging chin sign is a predictor of mortality in geriatric patients admitted through the emergency department. METHODS: We performed an observational retrospective cohort study in a Dutch teaching hospital. Patients of ≥65 years who were admitted to the geriatric ward following an emergency department visit were included. The primary outcome of this study was mortality. Secondary outcomes included the length of admission, discharge destination and the reliability compared to patient-related variables and the APOP screener. RESULTS: Three hundred ninety-six patients were included in the analysis. Mean follow up was 300 days; 207 patients (52%) died during follow up. The hanging chin sign was present in 85 patients (21%). Patients with the hanging chin sign have a significantly higher mortality risk during admission (OR 2.94 (1.61 to 5.39), p < 0.001), within 30 days (OR 2.49 (1.44 to 4.31), p = 0.001), within 90 days (OR 2.16 (1.31 to 3.56), p = 0.002) and within end of follow up (OR 2.87 (1.70 to 4.84),p < 0.001). A chest X-ray without a PA view or lateral view was also associated with mortality. This technical detail of the chest x-ray and the hanging chin sign both showed a stronger association with mortality than patient-related variables or the APOP screener. CONCLUSIONS: The hanging chin sign and other details of the chest x-ray were strong predictors of mortality in geriatric patients presenting at the emergency department and admitted to the geriatric ward. Compared to other known predictors, they seem to do even better in predicting mortality.

A pharmacotherapy self-assessment improves prescribing by prompting junior doctors to study further.

AIMS: Junior doctors frequently prescribe incorrectly and this can cause serious harm to patients. Pharmacotherapy education in most medical schools falls short in preparing their students to prescribe safely in clinical practice. According to the theory of assessment-driven learning, a pharmacotherapy self-assessment for junior doctors may reduce potential harmful prescriptions in clinical practice, by revealing deficits in prescribing knowledge and skills. METHODS: In this single centre, prospective cohort study, the potential harmful prescriptions of junior doctors in clinical practice were compared before and after a pharmacotherapy self-assessment with and without additional pharmacotherapy education. RESULTS: Potential harmful prescriptions best known to cause harm to patients were studied in all the prescriptions written out by 199 junior doctors in the first 2 months of their employment in our hospital. The pharmacotherapy self-assessment reduced the total number of potential harmful prescriptions made by junior doctors relative to those made by junior doctors in the control group (1.3 vs. 3.2%, respectively; P < .001). Additional education did not reduce potential harmful prescriptions beyond the effect of the self-assessment alone (1.3 vs. 1.0%, P > .05). CONCLUSIONS: Pharmacotherapy self-assessment leads to fewer potential harmful prescriptions made by junior doctors in clinical practice, thereby improving patient safety. More research is needed to investigate whether additional pharmacotherapy education strategies reduce potential harmful prescriptions further.

Fewer patients undergo surgery when adding a comprehensive geriatric assessment in older patients with a hip fracture.

INTRODUCTION: Geriatricians have been increasingly involved in the pre-operative process in frail elderly patients with a hip fracture which can benefit re-hospitalization, post-operative functional performance, and mortality. The objective of this study was to compare the number of older patients with hip fractures who opted for non-surgical management after the addition of pre-operative comprehensive geriatric assessment (CGA) with shared decision making by a geriatrician to usual care. Secondary objectives were: reasons for non-surgical management, duration of life, and location of death. MATERIALS AND METHODS: A single-center, with a level 2 trauma center, retrospective study comparing care before and after introducing pre-operative CGA with shared decision making in September 2014. Patients ≥ 70 years with a hip fracture, admitted from January 2014 to September 2015, were included. The percentages of patients elected for non-surgical management and palliative care without or with CGA were compared. Differences in secondary objectives (age, sex, medical history, medication use, functional, and social status) were compared descriptively and qualitatively. RESULTS: With pre-operative CGA significantly more patients (or representatives) elected the non-surgical management option after hip fracture (respectively, 9.1% vs 2.7%, p = 0.008). Patient characteristics were comparable. Reported reasons not to undergo surgery include aversion to be more dependent on others, and severe dementia. CONCLUSION: The geriatrician can have an important role in decisions for non-surgical management by shared decision making in the pre-operative period in patients ≥ 70 years with a hip fracture in the emergency room.

Correction to: Fewer patients undergo surgery when adding a comprehensive geriatric assessment in older patients with a hip fracture.

The original version of this article unfortunately contained a mistake. The presentation of Figure 1 was incorrect. The correct version of Figure 1 is given in the following page.

Dementia as a predictor of morbidity and mortality in patients with delirium.

INTRODUCTION: This review examines whether functional and cognitive decline and mortality after an episode of delirium are comparable between patients with and those without dementia. METHODS: MEDLINE and EMBASE were searched systematically for 'dementia' and 'delirium'. After screening of the results, studies were rated on relevance and validity and data were extracted. Cognitive decline was defined as decline in Mini-Mental State Examination (MMSE) score. Functional decline was defined as decline in Barthel Index (BI), score on the Instrumental Activities of Daily Living (IADL) or institutionalisation. RESULTS: From 5092 potentially relevant articles identified, eight studies were included in the review. The one-year mortality rate ranged from 11% to 45% in patients with dementia versus 22% to 44% in patients without dementia, and the overall absolute rate was 34% (95% CI 0.32-0.36). Pooled data did not show a significant difference between the groups. The MMSE scores and the Barthel Index had improved in both groups after six months, but scores on the Instrumental Activities of Daily Living (IADL) had declined. However, on all measurement points, patients with dementia scored significantly lower than patients without dementia. In addition, patients with dementia had a 33% risk of institutionalisation after an episode of delirium versus 20% in patients without dementia (95% CI 0.06-0.20). CONCLUSION: No significant differences were seen in mortality after delirium between patients with and without dementia. The overall one-year mortality was high (34%). Patients with dementia had significantly lower functional and cognitive scores and their risk of institutionalisation post-delirium was higher. Patients and their caregivers should be given this information, which may also be useful in advance care planning.

Towards a "prescribing license" for medical students: development and quality evaluation of an assessment for safe prescribing.

PURPOSE: This report describes the development and validation process of an assessment with national consensus in appropriate and safe pharmacotherapy. METHODS: A question-database on safe prescription based on literature of pharmacotherapy-related harm was developed by an expert group from Dutch medical faculties. Final-year medical students concluded a 2-year education program on appropriate and safe prescription by one of nine assessment variants of 40 multiple-choice questions each. An expert panel of professionals (n = 10) answered all database questions and rated questions on relevance. Questions were selected for revision based on lack of relevance or poor test and item characteristics. RESULTS: A total of 576 final-year medical students of the Radboud University was assessed. There was no significant difference in performance between students and content expert group (p = 0.7), probably due to learning behavior. Out of 165 questions, 59 were selected for revision. CONCLUSION: Joint national effort from a team of experts in prescription and pharmacotherapy is an appropriate way to achieve a valid and reliable last-year student drug prescription assessment.

Resilience to cognitive impairment in the oldest-old: design of the EMIF-AD 90+ study.

BACKGROUND: The oldest-old (subjects aged 90 years and older) population represents the fastest growing segment of society and shows a high dementia prevalence rate of up to 40%. Only a few studies have investigated protective factors for cognitive impairment in the oldest-old. The EMIF-AD 90+ Study aims to identify factors associated with resilience to cognitive impairment in the oldest-old. In this paper we reviewed previous studies on cognitive resilience in the oldest-old and described the design of the EMIF-AD 90+ Study. METHODS: The EMIF-AD 90+ Study aimed to enroll 80 cognitively normal subjects and 40 subjects with cognitive impairment aged 90 years or older. Cognitive impairment was operationalized as amnestic mild cognitive impairment (aMCI), or possible or probable Alzheimer's Disease (AD). The study was part of the European Medical Information Framework for AD (EMIF-AD) and was conducted at the Amsterdam University Medical Centers (UMC) and at the University of Manchester. We will test whether cognitive resilience is associated with cognitive reserve, vascular comorbidities, mood, sleep, sensory system capacity, physical performance and capacity, genetic risk factors, hallmarks of ageing, and markers of neurodegeneration. Markers of neurodegeneration included an amyloid positron emission tomography, amyloid ß and tau in cerebrospinal fluid/blood and neurophysiological measures. DISCUSSION: The EMIF-AD 90+ Study will extend our knowledge on resilience to cognitive impairment in the oldest-old by extensive phenotyping of the subjects and the measurement of a wide range of potential protective factors, hallmarks of aging and markers of neurodegeneration. TRIAL REGISTRATION: Nederlands Trial Register NTR5867 . Registered 20 May 2016.

Metoclopramide: A Safe Alternative to Domperidone? A Case Report on Severe Cardiac Adverse Effects in an Older Patient.

Peripheral antidopaminergic medication is frequently prescribed to treat nausea. However, domperidone is ill-famed for its severe cardiac adverse effects. Metoclopramide has been suggested as a relatively safe alternative because it has long been considered to have less significant cardiovascular adverse effects. We present an older patient who developed severe bradycardia and hypotension shortly after receiving intravenous metoclopramide. Cardiac adverse effects of metoclopramide in elderly are not frequently described in the literature, especially not in patients without a major history of cardiac disease. We recommend caution with intravenous administered metoclopramide in older patients.

Association Between Urinary Tract Infections and Antipsychotic Drug Use in Older Adults.

Antipsychotic drugs are frequently prescribed to older adults, but they may be associated with serious adverse effects. The objective was to investigate the association between use of antipsychotics in older adults and the risk of urinary tract infections (UTIs).This study was designed as a cohort study.Data were obtained from the Clinical Practice Research Datalink from January 1, 2000, to September 29, 2016.Primary care patients 65 years or older in the United Kingdom with a first prescription for an oral antipsychotic were included in the study.Incidence of UTIs was calculated for periods with and without exposure to antipsychotic drugs in one cohort. Cox proportional hazard regression analysis with Andersen-Gill extension for recurrent events was used to calculate hazard ratios (HRs) with 95% confidence interval (CI).During the study period, 191,827 individuals with a first prescription for an oral antipsychotic drug were identified. Current use of antipsychotics was associated with an increased risk of UTI compared with past use (adjusted HR, 1.31; 95% CI, 1.28-1.34). This effect was strongest in the first 14 days of use (adjusted HR, 1.83; 95% CI, 1.73-1.95) and in individuals who used more than one antipsychotic drug concomitantly (adjusted HR, 1.64; 95% CI, 1.45-1.87). The risk was slightly higher for typical antipsychotics than for atypical antipsychotics. Stratification by sex showed that risk estimates were slightly higher in men than in women.Use of antipsychotics was associated with an increased risk of UTIs in both men and women, particularly in the first weeks after the start of treatment.

The Systematic Tool to Reduce Inappropriate Prescribing (STRIP): Combining implicit and explicit prescribing tools to improve appropriate prescribing.

Inappropriate prescribing is a major health care issue, especially regarding older patients on polypharmacy. Multiple implicit and explicit prescribing tools have been developed to improve prescribing, but these have hardly ever been used in combination. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) combines implicit prescribing tools with the explicit Screening Tool to Alert physicians to the Right Treatment and Screening Tool of Older People's potentially inappropriate Prescriptions criteria and has shared decision-making with the patient as a critical step. This article describes the STRIP and its ability to identify potentially inappropriate prescribing. The STRIP improved general practitioners' and final-year medical students' medication review skills. The Web-application STRIP Assistant was developed to enable health care providers to use the STRIP in daily practice and will be incorporated in clinical decision support systems. It is currently being used in the European Optimizing thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly (OPERAM) project, a multicentre randomized controlled trial involving patients aged 75 years and older using multiple medications for multiple medical conditions. In conclusion, the STRIP helps health care providers to systematically identify potentially inappropriate prescriptions and medication-related problems and to change the patient's medication regimen in accordance with the patient's needs and wishes. This article describes the STRIP and the available evidence so far. The OPERAM study is investigating the effect of STRIP use on clinical and economic outcomes.

Missed diagnosis of pulmonary embolism with age-adjusted d-dimer cut-off value.

Pulmonary embolism (PE) is a potentially severe diagnosis with high short-term mortality. Recently, age-adjusted cut-off values (age × 10 µg/l) of D-dimer were introduced to improve the diagnostic workup in older patients. In clinical practice, PE is considered 'ruled out' in patients with a non-high clinical probability and a normal D-dimer. However, all diagnostic tests have a small false-negative rate. This small probability of misdiagnosis might be easily overlooked by clinicians when using simplified dichotomized flow charts. This case illustrates a normal D-dimer (age-adjusted) but with a PE. We recommend clinicians using the D-dimer test-either conventional or age-adjusted in a rule-out strategy to be aware of the-albeit small probability of a false-negative result.