The impact of pharmaceutical care interventions for medication underuse in older people: a systematic review and meta-analysis

Aims

The aim of the present study was to conduct a meta-analysis of controlled trials assessing the impact of pharmaceutical care interventions (e.g. medication reviews) on medication underuse in older patients (≥65 years).

Methods

The databases MEDLINE and EMBASE were searched for controlled studies, and data on interventions, patient characteristics and exposure, and outcome assessment were extracted. Risk of bias was assessed using the Cochrane Collaboration’s ‘risk of bias’ table. Results from reported outcomes were synthesized in multivariate random effects meta-analysis, subgroup meta-analysis and meta-regression.

Results

From 954 identified articles, nine controlled studies, mainly comprising a medication review, were included (2542 patients). These interventions were associated with significant reductions in the mean number of omitted drugs per patient (estimate from six studies with 1469 patients: – 0.44; 95% confidence interval –0.61, –0.26) and the proportion of patients with ≥1 omitted drugs (odds ratio from eight studies with 1833 patients: 0.29; 95% confidence interval 0.13, 0.63). The only significant influential factor for improving success was the utilization of explicit screening instruments when conducting a medication review (P = 0.033).

Conclusion

Pharmaceutical care interventions, including medication reviews, can significantly reduce medication underuse in older people. The use of explicit screening instruments alone or in combination with implicit reasoning is strongly recommendable for clinical practice.     

Tele-monitoring of home blood pressure in treated hypertensive patients

AIM: To compare the accuracy of clinic blood pressure (CBP) and telemedical home blood pressure (HBP) measurement in the assessment of antihypertensive effect. METHODS: 362 patients on antihypertensive medication performed HBP measurement (5 days, duplicate measurements, four times daily) and ambulatory blood pressure (ABP) monitoring in random order. Main outcome measure was the agreement of CBP and HBP with daytime ABP. RESULTS: CBP was much higher than ABP and average HBP (p < 0.001). There was a progressive decline in HBP over the course of the study, achieving the level of daytime ABP on the last 2 monitoring days. The correlation between CBP and ABP was weak (systolic: r = 0.343, diastolic r = 0.430), whereas strong correlations existed between HBP and ABP (systolic r = 0.804, diastolic r = 0.776). A progressive improvement in the strength of the correlation between average HBP of single days and ABP was obtained over the 5 monitoring days. The HBP readings taken in the afternoon showed a stronger correlation with ABP than the values measured in the morning, at noon and in the evening. Averaging more HBP readings taken on succeeding days resulted in a progressive improvement in the agreement with ABP with a further benefit when readings of day 1 were included. CONCLUSIONS: The accuracy of telemedical HBP measurement is substantially better than that of CBP. The results suggest, that HBP should be measured for 5 days, and afternoon measurements should be preferred in assessing control of hypertension.     

Nongenomic cardiovascular effects of triiodothyronine in euthyroid male volunteers

T(3) has been shown to exert cardiovascular effects. These effects have not yet been defined with regard to the mode of action (nongenomic vs. genomic) and with regard to an interaction with the adrenergic system in humans. To address these issues we conducted a randomized, double blind, 6-fold cross-over trial in 18 healthy male volunteers. After pretreatment with the beta-agonist dobutamine, the beta-blocking agent esmolol, or placebo (0.9% NaCl), 100 microg T(3) or placebo were injected. Primary target variables were systemic vascular resistance (SVR) and cardiac output (CO) within 45 min after injection of T(3) vs. placebo after placebo pretreatment. Sympatho-vagal balance was assessed by measurement of heart rate variability. T(3) caused a lower SVR and a higher CO than placebo (P < 0.001) after pretreatment with placebo. An increased low frequency (LF)/high frequency (HF) ratio (power in LF/power in HF band) after T(3) compared with placebo (P = 0.004) suggests an increase in sympathetic tone. After pretreatment with dobutamine, the effects of T(3) on SVR and CO were abolished, and the effect on LF/HF ratio was reversed. After pretreatment with esmolol, the effects on SVR and LF/HF ratio were reversed. Our data show, for the first time, nongenomic cardiovascular effects of T(3) in humans.     

The Non‐Motor Symptoms Scale in Parkinson’s disease: Validation and use

The Non‐Motor Symptoms Scale (NMSS) was developed and validated in 2007 as the first instrument for the comprehensive assessment of a range of non‐motor symptoms in Parkinson's disease (PD). Thirteen years have elapsed since its introduction and extensive international validation with good psychometric attributes has been carried out. Here, we review the validation data of the NMSS and its cross‐validity with other scales, and describe the key evidence derived from use of the NMSS in clinical studies. To date, over 100 clinical studies and trials have made use of it as an outcome measure, showing consistent and strong correlations between NMSS burden and health‐related quality of life measures. Moreover, the scale has shown to be capable of detecting longitudinal changes in non‐motor symptoms, where studies have shown differential changes over time of several of the NMSS domains. The scale has become a key outcome in several randomized clinical trials. Highlighting the prevalence and importance of non‐motor symptoms to quality of life in patients with PD, the development of NMSS has also been useful in signposting clinical and biomarker based research addressing non‐motor symptoms in PD.     

Microbiology of parapharyngeal abscesses in adults: in search of the significant pathogens

European Journal of Clinical Microbiology & Infectious Diseases - We aimed to describe the microbiology of parapharyngeal abscess (PPA) and point out the likely pathogens using the following...     

Heart-type fatty acid-binding protein permits early risk stratification of pulmonary embolism.

AIMS: We investigated the value of a novel early biomarker, heart-type fatty acid-binding protein (H-FABP), in risk stratification of patients with acute pulmonary embolism (PE). METHODS AND RESULTS: We prospectively included 107 consecutive patients with confirmed PE. The endpoints were (i) PE-related death or major complications and (ii) overall 30-day mortality. Overall, 29 patients (27%) had abnormal (>6 ng/mL) H-FABP levels at presentation. Of those, 12 (41%) had a complicated course, whereas all patients with normal baseline H-FABP had a favourable 30-day outcome (OR, 71.45; P<0.0001). At multivariable analysis, H-FABP (P<0.0001), but not cardiac troponin T (P=0.13) or N-terminal pro-brain natriuretic peptide (P=0.36), predicted an adverse outcome. Evaluation of a strategy combining biomarker testing with echocardiography revealed that patients with a negative H-FABP test had an excellent prognosis regardless of echocardiographic findings. In contrast, patients with a positive H-FABP test had a complication rate of 23.1% even in the presence of a normal echocardiogram, and this rose to 57.1% if echocardiography also demonstrated right ventricular dysfunction (OR vs. a negative H-FABP test, 5.6 and 81.4, respectively). CONCLUSION: H-FABP is a promising early indicator of right ventricular injury and dysfunction in acute PE. It may help optimize risk stratification algorithms and treatment strategies.     

Rapid Response to Cyclosporin A and Favorable Renal Outcome in Nongenetic Versus Genetic Steroid–Resistant Nephrotic Syndrome

Background and objectives

Treatment of congenital nephrotic syndrome (CNS) and steroid–resistant nephrotic syndrome (SRNS) is demanding, and renal prognosis is poor. Numerous causative gene mutations have been identified in SRNS that affect the renal podocyte. In the era of high–throughput sequencing techniques, patients with nongenetic SRNS frequently escape the scientific interest. We here present the long-term data of the German CNS/SRNS Follow-Up Study, focusing on the response to cyclosporin A (CsA) in patients with nongenetic versus genetic disease.

Design, setting, participants, & measurements

Cross–sectional and longitudinal clinical data were collected from 231 patients with CNS/SRNS treated at eight university pediatric nephrology units with a median observation time of 113 months (interquartile range, 50–178). Genotyping was performed systematically in all patients.

Results

The overall mutation detection rate was high at 57% (97% in CNS and 41% in SRNS); 85% of all mutations were identified by the analysis of three single genes only (NPHS1, NPHS2, and WT1), accounting for 92% of all mutations in patients with CNS and 79% of all mutations in patients with SRNS. Remission of the disease in nongenetic SRNS was observed in 78% of patients after a median treatment period of 2.5 months; 82% of nongenetic patients responded within 6 months of therapy, and 98% of patients with nongenetic SRNS and CsA–induced complete remission (normalbuminemia and no proteinuria) maintained a normal renal function. Genetic SRNS, on the contrary, is associated with a high rate of ESRD in 66% of patients. Only 3% of patients with genetic SRNS experienced a complete remission and 16% of patients with genetic SRNS experienced a partial remission after CsA therapy.

Conclusions

The efficacy of CsA is high in nonhereditary SRNS, with an excellent prognosis of renal function in the large majority of patients. CsA should be given for a minimum period of 6 months in these patients with nongenetic SRNS. In genetic SRNS, response to CsA was low and restricted to exceptional patients.     

Effects of a Mandibular Protruding Device on the Sleep of Patients with Obstructive Sleep Apnea and Snoring Problems: A 2-Year Follow-Up

Objectives: To evaluate subjective discomfort and somnographic measures of patients with obstructive sleep apnea and snoring problems who had been treated for 2 years with a mandibular protruding device (MPD). Methods: The study population comprised 65 patients with a pretreatment diagnosis of obstructive sleep apnea (OSA) (n = 44) or habitual snoring without apnea (n = 21). After a baseline medical and somnographic examination, a functional examination of the stomatognathic system, and a questionnaire focused on sleep-related qualities, each patient received an MPD. Two follow-ups were made 6 months and 2 years after MPD treatment had been initiated, and all initial examinations were repeated. Results: At the 2-year follow-up, significant subjective improvements were registered in 90% of the patients regarding a reduction of snoring and apneas, in 76% regarding a reduction in daytime tiredness, and in 84% regarding an improvement in the quality of the night sleep (change of 50% from baseline data). At the 2-year follow-up of the OSA group, the oxygen desaturation index (ODI) had dropped significantly from a mean value of 14.7 (SD, 12.7) to 3.1 (SD, 4.2) (P < 0.001), and the mean SaO₂ nadir rose from 78.2% (SD, 8.1) to 89.0% (SD, 4.7) (P < 0.001). Only one of the snorers increased his ODI value; the others retained their initial healthy values. The OSA patients significantly reduced the amount of time they snored during their sleep. Conclusion: MPD treatment is associated with a significant reduction in subjective complaints such as disturbing snoring, apneas, daytime tiredness, and poor quality of night sleep, and with a significant reduction in ODI values in the OSA group. In addition, favorable 6-month results were unchanged after 2 years.