Risk factors for chronic hepatitis B virus infection among blood donors in Bangalore,India

Objectives and Aim: We performed a study of hepatitis B virus (HBV) risk factors among blood donors in Bangalore, India. Background: HBV infection is prevalent in India and poses a potential risk of transmission by blood transfusion, but studies of risk factors for hepatitis B surface antigen (HBsAg) carriage among Indian blood donors are lacking. Methods/Materials: Using a case‐cohort design, we enrolled 71 cases with repeatedly reactive HBsAg results and a cohort of 212 contemporaneous blood donors with unknown HBsAg status. Questionnaire data were analysed using multivariable logistic regression. Results: In our multivariate analysis controlling for age, HBsAg positivity was associated with repeat donor status (OR = 0·34, 95% CI 0·17–0·71 vs first‐time donor status), residence outside Bangalore and Hosur (rural areas) (OR = 15·66, 95% CI 3·60–68·07vs Bangalore residence), having been a customer at a local barber shop (OR = 4·07, 95% CI 2·06–8·03), close contact with a person who had jaundice (OR = 13·64, 95% CI 3·71–50·24) and cigarette smoking (OR = 3·25, 95% CI 1·39–7·60). Conclusion: In addition to recognised demographic risk factors, associations with patronage of local barbers and contact with jaundiced individuals suggest behavioural risk factors that could be adopted as exclusionary criteria for blood donation in India.     

Adverse outcomes associated with inappropriate drug use in nursing homes

BACKGROUND: Little empirical evidence exists regarding the influence and outcomes of inappropriate medication use among elderly nursing home residents. OBJECTIVE: To identify the prevalence of inappropriate medication use among elderly patients in Georgia nursing homes using the Beers criteria and identify the relationship between inappropriate drug use and the likelihood of an adverse health outcome. METHODS: A cohort design was used to review 1117 patient medical records in 15 Georgia nursing homes with a high risk of polypharmacy. Prevalence of inappropriate medication use among elderly patients, as defined by the Beers criteria, was estimated. The adverse health outcomes of hospitalizations, emergency department visits, or deaths were identified from Medicaid claims data. RESULTS: A total of 519 (46.5%) patients received at least one inappropriate medication and 143 (12.8%) patients experienced at least one adverse health outcome. Logistic regression revealed that the total number of medications taken (OR 1.139, 95% CI 1.105 to 1.173) significantly increased the likelihood of receiving an inappropriate drug, while having a diagnosis of "dementia" (OR 0.748, 95% CI 0.565 to 0.991) decreased the likelihood. Inappropriate medication use increased the likelihood of experiencing at least one adverse health outcome more than twofold (OR 2.34, 95% CI 1.61 to 3.40). Propoxyphene use alone was significantly associated with the occurrence of an adverse health outcome (OR 2.39, 95% CI 1.54 to 3.71). CONCLUSIONS: Inappropriate drug use was common in our study cohort. Inappropriate use of medication in the elderly, particularly propoxyphene, is associated with a higher risk of adverse health outcomes.     

Concerns and beliefs about medicines and inappropriate medications: An internet-based survey on risk factors for self-reported adverse drug events among older adults

Background: Adverse drug events (ADEs), which can be especially problematic in older adults, often can be prevented by detecting potential risk factors. Sociopsychological factors such as concerns and beliefs about medicines (patients' anxieties about the harmful effects of prescribed medications) may also be risk factors related to self-reported ADEs, even when considering clinical variables such as receiving an inappropriate medication.Objectives: This study was designed to quantify the use of inappropriate medications among older adult outpatients and to determine whether an association exists between the use of inappropriate medications, concerns and beliefs about medicines, and self-reported ADEs.Methods: This cross-sectional, Internet-based survey of Medicare beneficiaries was conducted in 2007. Harris Interactive®, a New York-based marketing research firm, invited participants from their online panel who were ≥65 years of age, residents of the United States, and enrolled in the Medicare health plan to participate in the survey. The updated Beers criteria and a modified version of the Assessing Care of Vulnerable Elders quality indicators were used to determine the appropriateness of medications. Respondents' concerns about their medicines were assessed using items from a validated scale such as “Having to take medicines worries me” and “I sometimes worry about the long-term effects of my medicines.” To establish self-reported ADEs, respondents were asked, “Did you see a doctor about any side effects, unwanted reactions, or other problems from medicines you were taking in the past year?”Results: Of the 1024 panelists who responded to the survey, 874 provided all of the information required for analysis. The respondents who were included in the analyses ranged in age from 65 to 94 years; 56.6% were female, 94.4% were white, and 20.3% self-reported an ADE. The frequency of patients receiving either an inappropriate medication or a medication that failed a quality indicator was 45.8%. Stronger concerns and beliefs about medicines (odds ratio [OR] = 1.57; 95% CI, 1.02–2.39; P = 0.04) and having more symptoms (OR = 2.26; 95% CI, 1.22–4.22; P = 0.01) were significantly related to self-reporting of ADEs, whereas receiving an inappropriate medication (OR = 1.03; 95% CI, 0.65–1.64) and the number of medications received (OR = 1.28; 95% CI, 0.52–3.13) were not.Conclusions: Stronger concerns and beliefs about medicines and having more symptoms were significantly related to self-reporting of ADEs. Receiving an inappropriate medication and the number of medicines received were not significantly related.     

Urinary incontinence prevalence and risk factors in women aged 20 and over in Malatya

The purpose of this population‐based cross‐sectional study is to determine the prevalence and risk factors of urinary incontinence (UI) in women over 20 years old. The study was conducted with 800 women and the participants were stratified by age and residence. The data obtained from the study revealed that prevalence of UI was 32·4%, while the most frequently encountered type of UI was mixed urinary incontinence (72·6%). Logistic regression analysis results demonstrated the most important risk factors for UI as aging [≥50, Odds ratio (OR) 2·94, 95% confidence interval (CI) 1·68–5·13], chronic obstructive pulmonary disease (OR 2·90, 95% CI 1·15–7·34) and recurrent urinary tract infections (OR 3·30, 95% CI 1·94–5·61).     

Frailty Syndrome in Association with Depressive Symptoms and Functional Disability among Hospitalized Elderly

ABSTRACT

We sought to examine the frailty association with depression and functional disability in hospitalized older adults. In particular, we compared non-frail, pre-frail, and frail elderly hospitalized individuals. We performed a cross-sectional study with 255 hospitalized Brazilian elderly patients. We used a structured instrument to assess socio-economic data, the Fried frailty phenotype and used morbidity scales (Geriatric Depression; Katz; Lawton and Brody). The adjusted analysis revealed that frail elderly exhibit increased odds ratios (OR) for depressive symptoms (OR = 2.72, 95% CI: 1.12–6.62), disability related to basic activities (OR = 3.50, 95% CI: 1.26–9.60), and instrumental daily living (OR = 2.70, 95% CI: 1.12–6.44). Frailty in hospitalized older adults is associated with depressive symptomatology and functional disability.     

Predictors of 1-year mortality in patients with contemporary guideline-adherent therapy after acute myocardial infarction: results from the OMEGA study

Background

Predictors of long-term mortality after discharge after acute myocardial infarction (AMI) are well characterized. However, these established risk factors are based on data almost exclusively derived from older studies without consistent use of revascularization therapy and adjunctive therapy with statins, platelet inhibitors, beta-blockers and ACE inhibitors/ARBs. We therefore sought to investigate predictors of 1-year mortality in survivors of AMI treated with contemporary guideline-adherent therapy.

Methods and results

We performed a retrospective analysis of 3,782 patients surviving acute ST-elevation and non ST-elevation myocardial infarction who were enrolled in the prospective, randomized, double-blind, controlled OMEGA trial with 104 German centers. The primary objective of the OMEGA study was to determine the effect of highly purified omega-3 fatty acid ethyl esters-90 on the rate of sudden cardiac death in patients surviving AMI and receiving current guideline-adherent treatment within the 1-year of follow-up. 80.8 % of the patients received early revascularization therapy. At discharge, 94.2 % of the patients received beta-blocker, 90.4 % ACE inhibitor/angiotensin receptor blocker, 94.3 % statin, 95.4 % aspirin and 88.4 % clopidogrel. During the 1-year follow-up 139 patients (3.7 %) died. Multivariate logistic regression analysis revealed the following independent predictors of 1-year mortality in decreasing order of importance: ejection fraction <45 % [odds ratio (OR) 2.28, 95 % confidence interval (CI) 1.53–3.41], age ≥70 years (OR 2.17, 95 % CI 1.42–3.32), no acute revascularization (OR 2.02, 95 % CI 1.33–3.08), prior stroke/transient ischemic attack (OR 1.90, 95 % CI 1.09–3.30), peripheral arterial disease (OR 1.86, 95 % CI 1.12–3.10), heart rate >85/min (OR 1.82, 95 % CI 1.23–2.71), chronic obstructive lung disease (OR 1.77, 95 % CI 1.01–3.10) and HDL cholesterol <40 mg/dl (OR 1.75, 95 % CI 1.15–2.67).

Conclusions

In patients surviving AMI and treated with contemporary guideline-adherent therapy, 1-year mortality was low. Nevertheless, traditional risk factors such as ejection fraction <45 %, older age, no acute revascularization and comorbidities were the strongest predictors of long-term mortality supporting the findings from previous studies.     

Risk factors for carbapenem-resistant Gram-negative bacteremia in intensive care unit patients

Purpose

Carbapenem-resistant (CR) Gram-negative pathogens have increased substantially. This study was performed to identify the risk factors for development of CR Gram-negative bacteremia (GNB) in intensive care unit (ICU) patients.

Methods

Prospective study; risk factors for development of CR-GNB were investigated using two groups of case patients: the first group consisted of patients who acquired carbapenem susceptible (CS) GNB and the second group included patients with CR-GNB. Both case groups were compared to a shared control group defined as patients without bacteremia, hospitalized in the ICU during the same period.

Results

Eighty-five patients with CR- and 84 patients with CS-GNB were compared to 630 control patients, without bacteremia. Presence of VAP (OR 7.59, 95 % CI 4.54–12.69, p < 0.001) and additional intravascular devices (OR 3.69, 95 % CI 2.20–6.20, p < 0.001) were independently associated with CR-GNB. Presence of VAP (OR 2.93, 95 % CI 1.74–4.93, p < 0.001), presence of additional intravascular devices (OR 2.10, 95 % CI 1.23–3.60, p = 0.007) and SOFA score on ICU admission (OR 1.11, 95 % CI 1.03–1.20, p = 0.006) were independently associated with CS-GNB. The duration of exposure to carbapenems (OR 1.079, 95 % CI 1.022–1.139, p = 0.006) and colistin (OR 1.113, 95 % CI 1.046–1.184, p = 0.001) were independent risk factors for acquisition of CR-GNB. When the source of bacteremia was other than VAP, previous administration of carbapenems was the only factor related with the development of CR-GNB (OR 1.086, 95 % CI 1.003–1.177, p = 0.042).

Conclusions

Among ICU patients, VAP development and the presence of additional intravascular devices were the major risk factors for CR-GNB. In the absence of VAP, prior use of carbapenems was the only factor independently related to carbapenem resistance.     

Significance of white blood cell count and its subtypes in patients with acute coronary syndrome

Background Inflammation plays a role in the pathogenesis of coronary atherosclerosis. Materials and methods Six hundred twenty‐three patients with acute coronary syndrome (ACS) referred for coronary angiography for the first time in our hospital were enrolled in this study. White blood cell and its subtypes were measured on admission. The study population was divided into three groups based on total white blood cell count and followed up. Clinical end points were major adverse cardiac events (MACEs), including cardiogenic death, stroke, heart failure, non‐fatal myocardial infarction, rehospitalization for angina pectoris. Results The median age was 68 years (range 31–92) and 64·2% of the patients were men. The median white blood cell count was 6·48 × 10⁹ L⁻¹ (range 2·34–27·10 × 10⁹ L⁻¹). The median follow‐up duration was 21 months (range 1–116) and MACEs occurred in 167 patients. The multivariable Cox proportional hazards regression model revealed that neutrophil count [Relative risk = 1·098, 95% Confidence interval (CI): 1·010–1·193, P = 0·029) was a risk factor for MACEs. The logistic regression model revealed that lymphocyte count [Odds ratio (OR) = 1·075, 95% CI: 1·012–1·142, P = 0·018] and monocyte count (OR = 8·578, 95% CI: 2·687–27·381, P < 0·001) were predictive of stenosis ≥ 75%; Neutrophil proportion (OR = 1·060, 95% CI: 1·007–1·115, P = 0·026), monocyte count (OR = 12·370, 95% CI: 1·298–118·761, P = 0·029) were predictive of the presence of multivessel disease. Kaplan–Meier analysis of short‐term and long‐term cumulative survival showed no significant statistical differences among three groups. Conclusions Neutrophil count adds prognostic information to MACEs in ACS. Monocyte count and lymphocyte count are predictive of severity of coronary atherosclerosis.     

The association of hemoglobin A1c and high risk plaque and plaque extent assessed by coronary computed tomography angiography

The objective of this study was to investigate the relationship of Hemoglobin A1c (HbA1c) and plaque characteristics including high risk plaque and plaque extent. We retrospectively examined 1079 consecutive coronary computed tomography (CT) angiography scans and the HbA1c results. We divided the patients into four groups by the HbA1c status: non-diabetic, ≤6.0; borderline, 6.1–6.4; diabetic low, 6.5–7.1; diabetic high, >7.1. We determined segment involvement score >4 as extensive disease. High risk plaque was defined as two feature positive (FP) plaque which consists of positive remodeling (remodeling index >1.1) and low attenuation (<30 HU). Univariate and multivariate analysis including conventional cardiovascular risk factors, symptoms and medication was performed. Univariate analysis showed that diabetic patients as well as borderline patients were significantly related with 2FP plaque and extensive disease. Although the relationship of borderline patients and 2FP plaque was marginal in multivariate analysis [odds ratio (OR) 1.53, 95 % confidence interval (CI) 0.95–2.40, p = 0.07], the elevation of HbA1c was strongly associated with 2FP plaque (diabetic low, OR 2.19, 95 % CI 1.37–3.45, p < 0.005; diabetic high, OR 4.14, 95 % CI 2.57–6.67, p < 0.0005). The association of HbA1c elevation and extensive disease was quite similar between borderline and diabetic patients (borderline, OR 1.96, 95 % CI 1.29–2.95, p < 0.005; diabetic low, OR 1.94, 95 % CI 1.25–3.01, p < 0.005; diabetic high, OR 2.19, 95 % CI 1.39–3.43, p < 0.005). Patients with elevated HbA1c of >6.0 are potentially at risk for future cardiovascular events due to increased high risk plaque and extensive disease, even below the diabetic level of 6.5. Coronary CT could be used for risk stratification of these patients.     

Socio-demographic differences in adherence to evidence-based drug therapy after hospital discharge from acute myocardial infarction: a population-based cohort study in Rome, Italy

What is known and Objective: Adherence to evidence‐based drug therapy after acute myocardial infarction has increased over the last decades, but is still unsatisfactory. Our objectives are to set out to analyse patterns of evidence‐based drug therapy after acute myocardial infarction (AMI), and evaluating socio‐demographic differences. Methods: A cohort of 3920 AMI patients discharged from hospital in Rome (2006–2007) was selected. Drugs claimed during the 12 months after discharge were retrieved. Drug utilization was defined as density of use (boxes claimed/individual follow‐up; chronic use = 6+ boxes/365 days) and therapeutic coverage, calculated through Defined Daily Doses (chronic use: ≥80% of individual follow‐up). Patterns of use of single drugs and their combination were described. The association between poly‐therapy and gender, age and socio‐economic position (small‐area composite index based on census data) was analysed through logistic regression, accounting for potential confounders. Results and Discussion: Most patients used single drugs: 90·5% platelet aggregation inhibitors (antiplatelets), 60·0%β‐blockers, 78·1% agents acting on the renin–angiotensin system (ACEIs/ARBs), 77·8% HMG CoA reductase inhibitors (statins). Percentages of patients with ≥80% of therapeutic coverage were 81·9% for antiplatelets, 17·8% for β‐blockers, 64·4% for ACEIs/ARBs and 76·1% for statins. The multivariate analysis showed gender and age differences in adherence to poly‐therapy (females: OR = 0·84; 95% CI 0·72–0·99; 71–80 years age‐group: OR = 0·82; 95% CI 0·68–0·99). No differences were observed with respect to socio‐economic position. What is new and Conclusion:  The availability of information systems offers the opportunity to monitor the quality of care and identify weaknesses in public health‐care systems. Our results identify specific factors contributing to non‐adherence and hence define areas for more targeted health‐care interventions. Our results suggest that efforts to improve adherence should focus on women and older patients.     

The efficacy and safety of vildagliptin in patients with type 2 diabetes: a meta-analysis of randomized clinical trials

What is known and Objective: Dipeptidyl peptidase‐4 (DPP‐4) inhibitors are a relatively new class of drugs for the management of type 2 diabetes (T2DM). Vildagliptin is an oral DPP‐4 inhibitor approved in more than 70 countries. The purpose of this meta‐analysis is to provide an update on the clinical efficacy and safety of vildagliptin in patients with T2DM. Methods: A literature search identified 30 randomized controlled trials comparing vildagliptin with comparators (placebo or other hypoglycaemic agents). Meta‐analyses were conducted for HbA1c, weight, fasting plasma glucose (FPG), hypoglycaemia and other adverse events. The outcomes of HbA1c, weight and FPG were analysed as weighted mean differences (WMD), and the number of ADRs events as relative risks (RR). Results: Compared with placebo, vildagliptin lowered HbA1c {WMD, ?0·77% [95% confidence interval (CI), ?0·96% to ?0·58%] for 100 mg/day of vildagliptin and ?0·58% [95% CI, ?0·72% to ?0·44%] for 50 mg/day of vildagliptin}. The effect was non‐inferior to thiazolidinediones, sulfonylureas and α‐glycosidase inhibitors, but inferior to metformin. Compared with placebo, treatment with 50 mg/day of vildagliptin caused neutral weight changes, while 100 mg/day of vildagliptin resulted in slight weight gain [0·95 kg (95% CI, 0·73–1·17 kg)]. In addition, compared to comparators, vildagliptin was not associated with an increase in overall risk for any adverse events [RR, 0·97 (95% CI, 0·94–0·99)]. The incidence of hypoglycaemia was low with vildagliptin, and the risk with vildagliptin was not significantly different from the comparators [0·85 (95% CI, 0·49–1·47)]. The use of vildagliptin did not display any increased risks of infection [1·03 (95% CI, 0·94–1·13) for nasopharyngitis and 1·07 (95% CI, 0·90–1·27) for upper respiratory tract infection]. What is new and Conclusion: Vildagliptin is effective in glycaemic control with a low risk of hypoglycaemia and other adverse reactions. This may have an important impact on patient adherence to this medication.     

Risk factors for bleeding during anticoagulation of atrial fibrillation in older and younger patients in clinical practice

Background: The prevalence of atrial fibrillation increases with age, affecting ∼5% of people aged >65 years and almost 10% of people aged >80 years.Objective: The goal of this study was to identify risk factors for bleeding during warfarin treatment of nonvalvular atrial fibrillation (NNVAF) in older patients (those aged ≥75 years) compared with younger patients (those aged <75 years) in clinical practice.Methods: All patients with NVAF newly started on warfarin at an anticoagulation clinic in a large university hospital were included in this prospective observational study. Patient details were recorded at their first visit; details of any bleeding events were recorded via telephone interview every 4 to 6 weeks for a minimum of 10 months. Patients were divided into 2 groups (ie, those ≥75 years old and those <75 years old). Logistic regression analysis was used to identify risk factors for bleeding.Results: A total of 402 patients were included in the study. Group I comprised 203 patients <75 years old (mean [SD] age, 64.33 [8.33] years) and group II comprised 199 patients ≥75 years old (mean [SD] age, 80.44 [3.99] years). Follow-up ranged from 1 to 31 months (mean [SD], 19 [8.11] months). For major bleeding, number of medications was a significant risk factor in older patients (odds ratio [OR], 3.0; 95% CI, 1.2–7.8 [P = 0.02 ]) and range of the international normalized ratio (INR) was a significant risk factor in both groups. For every unit increase in the range of INR, the odds of major bleeding increased by 0.6 (OR, 1.6; 95% CI, 1.2–2.4 [P = 0.03 ]) in younger patients and by 0.4 (OR, 1.4; 95% CI, 1.07–1.99 [P = 0.04 ])in older patients. For minor bleeding, history of hypertension was the only significant risk factor in older patients (OR, 3.3; 95% CI, 1.3–8.1 [P = 0.01 ]), while history of ischemic heart disease was the only risk factor in younger patients (OR, 1.9; 95% CI, 1.1–5.4 [P = 0.04 ]).Conclusions: Bleeding pattern was similar in both age groups regarding severity, onset, anatomic site of bleeding, and INR values during the bleeding event. Risk factors for episodes of major bleeding, which are more of a clinical concern, are potentially modifiable. They include quality of anticoagulation control in both groups and number of medications in the older age group.     

Inappropriate prescribing in older residents of Australian care homes

What is known and objective: The incidence of inappropriate prescribing is higher amongst the older age group than the younger population. Inappropriate prescribing potentially leads to drug‐related problems such as adverse drug reactions. We aimed to determine the prevalence of inappropriate prescribing in residents of Tasmanian (Australia) residential care homes using Beers and McLeod criteria. Methods: Patient demographics, medical conditions and medications were collected from medical records. The patients who fulfilled either Beers or McLeod criteria were identified and the characteristics of these patients were then compared. Results: Data for 2345 residents were collected between 2006 and 2007. There were 1027 (43·8%) patients prescribed at least one inappropriate medication. Beers criteria identified more patients (828 patients, 35·3%) as being prescribed inappropriate medication compared with McLeod criteria (438 patients, 18·7%). Patients taking psychotropic medication/s, more than six medications or diagnosed with five or more medical conditions were more likely to be prescribed an inappropriate medication (P < 0·001). The most frequently identified inappropriate medications included benzodiazepines, amitriptyline, oxybutynin and non‐steroidal anti‐inflammatory drugs. What is new and conclusion: Inappropriate prescribing, as defined by either Beers criteria or McLeod criteria, is relatively common in Australian nursing homes. The prevalence of inappropriate prescribing, and factors influencing it, are consistent with other countries. Both Beers and McLeod criteria are a general guide to prescribing, and do not substitute for professional judgment.