Irbesartan improves arterial compliance more than lisinopril

BACKGROUND Antihypertensive agents can reduce arterial stiffness. We hypothesized that an angiotensin receptor blocker (ARB) irbesartan and an angiotensin converting enzyme inhibitor (ACEI) lisinopril improved arterial compliance. METHODS A randomized, double-blind, double-dummy, controlled crossover trial. Fifteen hypertensive patients, mean age 65.5 +/- 8.9 years (mean +/- SD) were given irbesartan (150 to 300 mg/day) or lisinopril (10 to 20 mg/day) for 12 weeks and then crossed over for 12 weeks. Pulse wave velocity (PWV) in the carotid-femoral (CF), carotid-radial (CR), and femoral dorsalis-pedis (FD) were measured using a Complior((R)) PWV system. RESULTS After 12 weeks, systolic blood pressure (SBP) decreased from 162.4 +/- 12.9 to 134.5 +/- 14.8 with irbesartan and to 145.2 +/- 25 mmHg with lisinopril. Irbesartan and lisinopril reduced PWV (CF) in the elastic arterial system from 15.1 +/- 5 to 13.3 +/- 2.6 (p < 0.005) and to 14 +/- 4.7 (p < 0.05) m/s respectively (p = 0.345). Irbesartan reduced PWV (CR) and PWV (FD), whereas lisinopril did not. The difference between treatments was significant after SBP adjustment (p = 0.037 for PWV (CR) and p < 0.001 for PWV (FD)). CONCLUSIONS Irbesartan improved arterial compliance in elastic and muscular arteries, whereas lisinopril improved it only in elastic arteries

The work of older people and their informal caregivers in managing an acute health event in a hospital at home or hospital inpatient setting.

BACKGROUND: There is limited understanding of the contribution made by older people and their caregivers to acute healthcare in the home and how this compares to hospital inpatient healthcare. OBJECTIVES: To explore the work of older people and caregivers at the time of an acute health event, the interface with professionals in a hospital and hospital at home (HAH) and how their experiences relate to the principles underpinning comprehensive geriatric assessment (CGA). DESIGN: A qualitative interview study within a UK multi-site participant randomised trial of geriatrician-led admission avoidance HAH, compared with hospital inpatient care. METHODS: We conducted semi-structured interviews with 34 older people (15 had received HAH and 19 hospital care) alone or alongside caregivers (29 caregivers; 12 HAH, 17 hospital care), in three sites that recruited participants to a randomised trial, during 2017-2018. We used normalisation process theory to guide our analysis and interpretation of the data. RESULTS: Patients and caregivers described efforts to understand changes in health, interpret assessments and mitigate a lack of involvement in decisions. Practical work included managing risks, mobilising resources to meet health-related needs, and integrating the acute episode into longer-term strategies. Personal, relational and environmental factors facilitated or challenged adaptive capacity and ability to manage. CONCLUSIONS: Patients and caregivers contributed to acute healthcare in both locations, often in parallel to healthcare providers. Our findings highlight an opportunity for CGA-guided services at the interface of acute and chronic condition management to facilitate personal, social and service strategies extending beyond an acute episode of healthcare

Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool

Objectives: To develop and validate a tool to predict the risk of an older adult experiencing medication-related harm (MRH) requiring healthcare use following hospital discharge. Design, setting, participants: Multicentre, prospective cohort study recruiting older adults (65 years) discharged from five UK teaching hospitals between 2013 and 2015. Primary outcome measure: Participants were followed up for 8 weeks in the community by senior pharmacists to identify MRH (adverse drug reactions, harm from non-adherence, harm from medication error). Three data sources provided MRH and healthcare use information; hospital readmissions, primary care use, participant telephone interview. Candidate variables for prognostic modelling were selected using two systematic reviews, the views of patients with MRH, and an expert panel of clinicians. Multivariable logistic regression with backward elimination, based on the Akaike Information Criterion, was used to develop the PRIME tool. The tool was internally validated. Results: 1116 out of 1280 recruited participants completed follow-up (87%). Uncertain MRH cases (‘possible’ and ‘probable’) were excluded, leaving a tool derivation cohort of 818. 119 (15%) participants experienced ‘definite’ MRH requiring healthcare use and 699 participants did not. Modelling resulted in a prediction tool with eight variables measured at hospital discharge; age, gender, antiplatelet drug, sodium level, antidiabetic drug, past adverse drug reaction, number of medicines, living alone. The tool’s discrimination C-statistic was 0.69 (0.66 after validation) and showed good calibration. Decision curve analysis demonstrated the potential value of the tool to guide clinical decision making compared with alternative approaches. Conclusions: The PRIME tool could be used to identify older patients at high risk of MRH requiring healthcare use following hospital discharge. Prior to clinical use we recommend the tool’s evaluation in other settings

Practices, issues and possibilities at the interface between geriatrics and palliative care (InGaP): An exploratory study and knotworking

Introduction With the recognition of the need for palliative care for people with non-malignant conditions, there is an increasing emphasis on interdisciplinary working between geriatric and palliative care teams. This interdisciplinary work has evolved organically; more needs to be known about current working practices. This is of policy and clinical interest as the older patient population continues to grow. Methods An exploratory qualitative interview study was undertaken of end-of-life care for older in-patients in a large London NHS Trust. 30 semi-structured qualitative interviews were conducted with staff from palliative care and geriatric medical and nursing teams, two with patients and five with carers. Questions covered: examples and perceptions of collaboration and patient/carer perceptions of clarity as to who was providing care. Interviews were transcribed and thematically analysed focusing on: examples of successful collaboration; areas of tension, duplication or confusion about responsibilities; and suggestions for future practice. Results Participants were positive about collaboration. Examples of what works well include: the referral process to the palliative care team; inter-team communication and use of face-to-face handovers; unity between the teams when communicating with patients and families. Areas for potential development include: embedding palliative care within ward multidisciplinary team meetings; continual on-ward education given rotation of staff; and improving collaboration between palliative care, physiotherapy and occupational therapy. It is unclear whether patients’ and carers’ lack of awareness of the different teams has a detrimental effect on their care or needs. Conclusions There is evidence of strong collaborative working between the teams; however, this study highlights potential areas for improvement. An exploration of these relationships in other settings is required to determine if the same themes arise with a view to inform national guidelines and policy to improve care towards the end of life

A multi-centre cohort study on healthcare use due to medication-related harm: the role of frailty and polypharmacy

Objectives To determine the association between frailty and medication-related harm requiring healthcare utilisation. Design Prospective observational cohort study. Setting Six primary and five secondary care sites across South East England, September 2013–November 2015. Participants One thousand and two hundred and eighty participants, ≥65 years old, who were due for discharge from general medicine and older persons’ wards following an acute episode of care. Exclusion criteria were limited life expectancy, transfer to another hospital and consent not gained. Main outcome measures Medication-related harm requiring healthcare utilisation (including primary, secondary or tertiary care consultations related to MRH), including adverse drug reactions, non-adherence and medication error determined via the review of data from three sources: patient/carer reports gathered through a structured telephone interview; primary care medical record review; and prospective consultant-led review of readmission to recruiting hospital. Frailty was measured using a Frailty Index, developed using a standardised approach. Marginal estimates were obtained from logistic regression models to examine how probabilities of healthcare service use due to medication-related harm were associated with increasing number of medicines and frailty. Results Healthcare utilisation due to medication-related harm was significantly associated with frailty (OR = 10.06, 95% CI 2.06–49.26, P = 0.004), independent of age, gender, and number of medicines. With increasing frailty, the need for healthcare use as a result of MRH increases from a probability of around 0.2–0.4. This is also the case for the number of medicines. Conclusions Frailty is associated with MRH, independent of polypharmacy. Reducing the burden of frailty through an integrated health and social care approach, alongside strategies to reduce inappropriate polypharmacy, may reduce MRH related healthcare utilisation

Diagnosis of patients with heart failure with preserved ejection fraction in primary care : Cohort study

Aims Heart failure with preserved ejection fraction (HFpEF) accounts for half of all heart failure (HF), but low awareness and diagnostic challenges hinder identification in primary care. Our aims were to evaluate the recruitment and diagnostic strategy in the Optimise HFpEF cohort and compare with recent recommendations for diagnosing HFpEF. Methods and results Patients were recruited from 30 primary care practices in two regions in England using an electronic screening algorithm and two secondary care sites. Baseline assessment collected clinical and patient-reported data and diagnosis by history, assessment, and trans-thoracic echocardiogram (TTE). A retrospective evaluation compared study diagnosis with H2FPEF score and HFA-PEFF diagnostic algorithm. A total of 152 patients (86% primary care, mean age 78.5, 40% female) were enrolled; 93 (61%) had HFpEF confirmed. Most participants had clinical features of HFpEF, but those with confirmed HFpEF were more likely female, obese, functionally impaired, and symptomatic. Some echocardiographic findings were diagnostic for HFpEF, but no difference in natriuretic peptide levels were observed. The H2FPEF and HFA-PEFF scores were not significantly different by group, although confirmed HFpEF cases were more likely to have scores indicating high probability of HFpEF. Conclusions Patients with HFpEF in primary care are difficult to identify, and greater awareness of the condition, with clear diagnostic pathways and specialist support, are needed. Use of diagnostic algorithms and scores can provide systematic approaches to diagnosis but may be challenging to apply in older multi-morbid patients. Where diagnostic uncertainty remains, pragmatic decisions are needed regarding the value of additional testing versus management of presumptive HFpEF

癌の化学療法に関する研究 特に制癌剤並びに制癌強化剤の担癌生体内代謝に及ぼす影響について

Background: Medication related harm (MRH) is a common cause of morbidity and hospital admission in the elderly, and has significant cost implications for both primary and secondary healthcare resources. The development of risk prediction models has become an increasingly common phenomenon in medicine and can be useful to guide objective clinical decision making, resource allocation and intervention. There are no risk prediction models that are widely used in clinical practice to identify elderly patients at high risk of MRH following hospital<br/>discharge. The aim of this study is to develop a risk prediction model (RPM) to identify elderly patients at high risk of MRH upon discharge from hospital, and to compare this with routine clinical judgment.<br/><br/>Methods/Design: This is a multi-centre, prospective observational study following a cohort of patients for 8 weeks after hospital discharge. Data collection including patient characteristics, medication use, social factors and frailty will take place prior to patient discharge and then the patient will be followed up in the community over the next 8 weeks to determine if they have experienced MRH. Research pharmacists will determine whether patients have<br/>experienced MRH by prospectively reviewing records for unplanned emergency department attendance, hospital readmission and GP consultation related to MRH. Research pharmacists will also telephone patients directly to<br/>determine self-reported MRH, which patients may not have sought further medical attention for. The data collected will inform the development of a RPM which will be externally validated in a follow-up study. <br/><br/>Discussion: There are no RPMs that are used in clinical practice to help stratify elderly patients at high risk of MRH in the community following hospital discharge, despite this being a significant public health problem. This study plans to develop a clinically useful RPM that is better than routine clinical judgment. As this is a multi-centre study<br/>involving clinical settings that serve elderly people of heterogeneous sociodemographic background, it is anticipated that this RPM will be generalizable

Diagnosis of patients with heart failure with preserved ejection fraction in primary care: cohort study

Funder: NIHR Cambridge Clinical Research FacilityAbstract: Aims: Heart failure with preserved ejection fraction (HFpEF) accounts for half of all heart failure (HF), but low awareness and diagnostic challenges hinder identification in primary care. Our aims were to evaluate the recruitment and diagnostic strategy in the Optimise HFpEF cohort and compare with recent recommendations for diagnosing HFpEF. Methods and results: Patients were recruited from 30 primary care practices in two regions in England using an electronic screening algorithm and two secondary care sites. Baseline assessment collected clinical and patient‐reported data and diagnosis by history, assessment, and trans‐thoracic echocardiogram (TTE). A retrospective evaluation compared study diagnosis with H2FPEF score and HFA‐PEFF diagnostic algorithm. A total of 152 patients (86% primary care, mean age 78.5, 40% female) were enrolled; 93 (61%) had HFpEF confirmed. Most participants had clinical features of HFpEF, but those with confirmed HFpEF were more likely female, obese, functionally impaired, and symptomatic. Some echocardiographic findings were diagnostic for HFpEF, but no difference in natriuretic peptide levels were observed. The H2FPEF and HFA‐PEFF scores were not significantly different by group, although confirmed HFpEF cases were more likely to have scores indicating high probability of HFpEF. Conclusions: Patients with HFpEF in primary care are difficult to identify, and greater awareness of the condition, with clear diagnostic pathways and specialist support, are needed. Use of diagnostic algorithms and scores can provide systematic approaches to diagnosis but may be challenging to apply in older multi‐morbid patients. Where diagnostic uncertainty remains, pragmatic decisions are needed regarding the value of additional testing versus management of presumptive HFpEF