Characteristics of elderly patients with polypharmacy who refuse to participate in an in-hospital deprescribing intervention: a retrospective cross-sectional study.

BACKGROUND: Few studies have evaluated the characteristics of elderly patients with polypharmacy refusing deprescribing. The aim of this study was to evaluate the prevalence of potentially inappropriate medication (PIM) use in elderly patients accepting and refusing a deprescribing intervention and to investigate factors associated with deprescribing refusal. METHODS: We conducted a retrospective cross-sectional study by analyzing the electronic medical records from a single hospital. All consecutive patients aged 65 years or older who reported the use of five or more medications upon admission to the orthopedic ward from January 2015 to December 2016 and who were approached by a pharmacist for polypharmacy screening were included. Patients who had provided consent for the deprescribing intervention by the internal medicine physicians were defined as the acceptance group, and patients who did not were defined as the refusal group. The primary outcome was the use of any PIMs at admission, based on the 2015 American Geriatric Society Beers Criteria. Using multivariable logistic regression, predictive factors of refusing deprescribing were also evaluated. RESULTS: During the study period, 136 patients were eligible. Of those, 82 patients (60.3%) accepted the deprescribing intervention, and 54 patients (39.7%) declined the intervention. The mean age of all the patients was 81.1 years, and the mean number of medications at admission was 9.3. The overall proportion of patients taking any PIMs at admission was 77.2%. The proportion of patients taking any PIMs at admission was not different between the acceptance and refusal groups (78.0% and 75.9%, respectively; p = 0.84). None of the measured characteristics, including age, gender, residential status, comorbidity, alcohol use, smoking status, number of medications, or number of PIMs, were found to be associated with deprescribing refusal. CONCLUSION: The prevalence of any PIM use did not differ among elderly orthopedic patients with polypharmacy according to refusal or acceptance of the deprescribing intervention. Furthermore, none of the analyzed characteristics were found to be associated with deprescribing refusal. Given the high prevalence of PIM use, a strategy is needed for combating polypharmacy among elderly patients reluctant to undergo deprescribing.

Prevalence of the potentially inappropriate Kampo medications to be used with caution among elderly patients taking any prescribed Kampo medications at a single centre in Japan: a retrospective cross-sectional study.

BACKGROUND: Few studies have investigated the prevalence and characteristics of potentially inappropriate Kampo medication use among elderly ambulatory patients taking any prescribed Kampo medications. METHODS: A retrospective cross-sectional study was conducted using electronic medical records. All patients aged 65 years or older who continued visiting internal medicine physicians and were prescribed any Kampo medications from January 2015 to March 2015 were included. The primary outcome was the proportion of patients taking any potentially inappropriate Kampo medications that should be used with caution (hereafter referred to as UWC Kampo medications). The medication appropriateness was evaluated based on the 2015 Japan Geriatrics Society guidelines. RESULTS: Eighty eligible patients were identified. The mean age was 76.7 years, 45 patients (56.2%) were female, the mean Charlson Comorbidity Index was 1.7, the median number of non-Kampo medications used was 5.0, and the median number of Kampo medications used was 1.0. The proportion of patients taking any UWC Kampo medications was 28.8% (95% confidence interval, 18.6 to 38.9%). Medications containing Glycyrrhizae radix for chronic kidney disease or loop diuretics were the most common UWC Kampo medications. Compared with patients who did not take any UWC Kampo medications, patients who did take such medications used aconite compositions more frequently (p = 0.04) and were more likely to have uncontrolled hypertension (p = 0.02) and chronic kidney disease (p <  0.001). In a multivariable analysis, no predictive factors for the use of UWC Kampo medications were identified. CONCLUSIONS: Approximately one-fourth of the elderly patients taking any prescribed Kampo medications took at least one UWC Kampo medication, although the association between UWC Kampo medications and adverse events remains unclear. When physicians prescribe medications containing Glycyrrhizae radix to elderly patients, chronic kidney disease and the use of loop diuretics should be evaluated.

Intervention to improve the appropriate use of polypharmacy for older patients with hip fractures: an observational study.

BACKGROUND: Polypharmacy is frequently observed in hip fracture patients. Although it is associated with an increased risk of hip fracture, polypharmacy often continues after hip fracture recovery. This study aimed to evaluate the effectiveness of an intervention to improve appropriate polypharmacy for elderly patients admitted to the hospital for hip fractures. METHODS: We conducted a retrospective observational study to compare the outcomes of patients receiving the intervention (n = 32) with those of patients who received usual care (n = 132). All hip fracture patients aged 65 years or older and prescribed 5 or more medications at admission from January 2015 to December 2016 were included in the study. The intervention consisted of an assessment by internal medicine physicians of the appropriateness of polypharmacy and the de-prescription of any unnecessary medications during the patients' hospital stay. The primary composite outcome was death or the first occurrence of any new fracture. Comparisons between the intervention and usual care groups were analyzed using binary logistic regression. RESULTS: A total of 164 patients were included in the study. The mean patient age was 84.8 years, and the mean numbers of prescribed medications and potentially inappropriate medications at admission were 8.0 and 1.3, respectively. The mean follow-up period was 8.0 months. The primary composite outcome occurred in 35 (21.3%) patients. The total number of potentially inappropriate medications at discharge was significantly lower in the intervention group than in the usual care group (0.8 ± 0.8 for the intervention group vs 1.1 ± 1.0 for the usual care group; p = 0.03). However, no significant differences in the primary composite outcome were found between the intervention and usual care groups (7 in the intervention group and 28 in the usual care group, odds ratio 1.04, 95% CI 0.41-2.65; p = 1.00). CONCLUSIONS: The intervention to improve appropriate polypharmacy was associated with a reduction in potentially inappropriate medications but not an improvement in clinical outcomes. This intervention, which focused only on polypharmacy, may not effectively improve outcomes for elderly patients with hip fractures. TRIAL REGISTRATION: UMIN-CTR UMIN000025495 . Retrospectively registered 2 January 2017.

Characterization of beta-lactam antibiotic-induced vancomycin-resistant MRSA (BIVR) in a patient with septicemia during long-term vancomycin administration.

It was reported that some methicillin-resistant Staphylococcus aureus (MRSA) show resistance to vancomycin (VCM) and beta-lactam antibiotics; thus, they are termed beta-lactam antibiotic-induced VCM-resistant MRSA (BIVR). The VCM resistance of MRSA is induced by the administration of beta-lactam antibiotics, but this phenomenon can be difficult to detect in the clinical laboratory. We detected the BIVR strain in a 64-year-old man who had had a ventilator tube inserted directly into the windpipe during long-term VCM therapy. The patient was diagnosed with MRSA pneumonia and septicemia on July 5, 2007, and sulbactam/ampicillin (SBT/ABPC) was administered for 5 days. However, the fever recurred, and administration of VCM was resumed for 7 days from July 19. Fever developed again, and VCM was administered again for 14 days from September 30. BIVR and VCM-low-sensitive MRSA were isolated from blood on October 18 and 22, although the VCM trough concentration was 10.2 microg/ml. On October 27, we changed to a combination of fosfomycin (FOM) and arbekacin (ABK), and thereafter the fever quickly decreased and the clinical symptoms abated. We isolated five MRSA strains from the blood of the patient, three strains of VCM-sensitive MRSA, one strain of BIVR, and one strain of a VCM-low-sensitive MRSA. The DNA band patterns determined by pulsed-field gel electrophoresis were completely identical except for the VCM-low-sensitive MRSA, which was missing one band. Furthermore, the VCM-low-sensitive MRSA became sensitive to beta-lactam antibiotics. Our results indicate the possibility that long-term VCM therapy is one of the factors that allow BIVR or VCM-low-sensitive MRSA to emerge, and this allows VCM therapy for MRSA to fail.

Effect of total exemption from medical service co-payments on potentially inappropriate medication use among elderly ambulatory patients in a single center in Japan: a retrospective cross-sectional study.

OBJECTIVE: The effect of total exemption from medical service co-payments on drug prescribing practices has not been extensively evaluated. We conducted a retrospective cross-sectional study to evaluate the effect of total exemption from medical service co-payments on potentially inappropriate medication (PIM) and benzodiazepine use in elderly ambulatory patients. We defined PIM based on the Beers Criteria. RESULTS: Six hundred seventy-one consecutive patients aged 65 years or older who routinely visited internal medicine physicians were included. Their mean age was 75.7 years, and 342 (51.0%) patients were men. The proportions of patients taking any PIMs or benzodiazepines were 37.7% and 16.2%, respectively. Of all patients, 62 (9.2%) were totally exempt from medical service co-payments. The patients who were totally exempt from medical service co-payments showed a significantly increased risk of PIM (OR 2.16, 95% CI 1.28-3.66) or benzodiazepine use (OR 2.12, 95% CI 1.16-3.87) compared with patients who were not. These associations did not change after adjusting for age, gender, comorbidities and polypharmacy. These findings should be confirmed in other settings or hospitals in Japan.

Colorectal motility induction by sacral nerve electrostimulation in a canine model: implications for colonic pacing.

PURPOSE: This study investigated the role of the sacral nerves in the mechanism of defecation using adult mongrel dogs. The possibility of designing a colonic pacemaker as a new therapeutic device to treat defecation disturbances, such as fecal incontinence and severe constipation, is also discussed. METHODS: Colorectal motility during spontaneous defecation was monitored with force strain-gauge transducers implanted in the proximal, distal, and sigmoid colon, rectum, and internal anal sphincter. Under general anesthesia, the sacral nerve was stimulated electrically, and the colorectal motility response was examined. RESULTS: During spontaneous defecation, three characteristic motility patterns were observed: 1) giant migrating contractions of the colon were propagated to the rectum or anus; 2) the rectum relaxed before the giant migrating contractions were propagated; and 3) the internal anal sphincter was relaxed during the propagation of the giant migrating contraction. Sacral nerve stimulation elicited the following three unique responses: 1) contractile movements were propagated from the distal colon to the rectum; 2) a relaxation response was noted in the rectum; and 3) the internal anal sphincter exhibited a relaxation response. The duration and propagation velocity of the contractile responses and the duration of relaxation responses elicited by electrical stimulation of the sacral nerve were similar to those that occurred during spontaneous defecation, but their amplitudes were smaller. CONCLUSION: The coordinated processes of the colon and anorectum during defecation were affected by the sacral nerves. This suggests that it is possible to design a colonic pacemaker to control lower colonic and rectal movements.

Burkitt lymphoma associated with large gastric folds, pancreatic involvement, and biliary tract obstruction.

Large gastric folds in adults are seen in many benign and malignant conditions, but they are rare in children with malignant diseases such as non-Hodgkin lymphoma. The authors report a patient with non-Hodgkin lymphoma who had large gastric folds and jaundice as the initial symptoms. A 14-year-old boy was referred to the authors' hospital with upper abdominal pain and jaundice. A standard barium upper gastrointestinal series showed large gastric folds in the entire stomach. Magnetic resonance imaging showed a typical diffuse infiltrating type of pancreatic lymphoma. Because complete bilateral lower limb paralysis developed as a result of the epidural soft tissue mass, laminectomy and tumor resection were performed and a diagnosis of disseminated Burkitt lymphoma was established. After completing 6 months of chemotherapy, the patient has been disease-free without neurologic complications for 2.5 years.