Appropriateness of DOAC Prescribing Before and During Hospital Admission and Analysis of Determinants for Inappropriate Prescribing

Background and Objectives: Appropriate dosing of direct oral anticoagulants (DOACs) is required to avoid under- and overdosing that may precipitate strokes or thromboembolic events and bleedings, respectively. Our objective was to analyze the appropriateness of DOAC dosing according to the summaries of product characteristics (SmPC). Furthermore, determinants for inappropriate prescribing were investigated.Methodology: Retrospective cohort study of hospitalized patients aged ≥60 years with at least one DOAC intake during hospital stay. Descriptive analyses were used to summarize the characteristics of the study population. Chi-square test was used to evaluate differences between DOACs. Binary logistic regression analysis was performed to assess determinants for inappropriate prescribing.Results: For the 772 included patients, inappropriate dosing occurred in 25.0% of hospitalizations with 23.4, 21.9, and 29.7% for dabigatran, rivaroxaban, and apixaban, respectively (p = 0.084). Underdosing was most prevalent for apixaban (24.5%) compared to dabigatran (14.0%) and rivaroxaban (12.8%), p < 0.001. In 67.1% (apixaban), 26.7% (dabigatran), and 51.2% (rivaroxaban) of underdosed DOAC cases according to the SmPC, the dose would be considered appropriate according to the European Heart Rhytm Association (EHRA) guidelines. Overdosing was observed in 4.5% (apixaban), 4.7% (dabigatran), and 7.7% (rivaroxaban) of patients. For all DOACs, our analysis showed an age ≥80 years (p = 0.036), use of apixaban (p = 0.026), DOAC use before hospitalization (p = 0.001), intermediate renal function (p = 0.014), and use of narcotic analgesics (p = 0.019) to be associated with a higher rate of inappropriate prescribing. Undergoing surgery was associated with a lower odds of inappropriate prescribing (p = 0.012). For rivaroxaban, use of medication for hypothyroidism (p = 0.027) and the reduced dose (p < 0.001) were determinants for inappropriate prescribing. Treatment of venous thromboembolism was associated with less errors (p = 0.002). For apixaban, severe renal insufficiency (p < 0.001) and initiation in hospital (p = 0.016) were associated with less and the reduced dose (p < 0.001) with more inappropriate prescribing. No determinants were found in the dabigatran subgroup.Conclusions: Inappropriate DOAC prescribing is frequent with underdosing being the most common drug related problem when using the SmPC as reference. More appropriate prescriptions were found when taking the EHRA guidelines into account. Analysis of determinants of inappropriate prescribing yielded insights in the risk factors associated with inappropriate DOAC prescriptions

Management of drug-disease interactions:a best practice from the Netherlands

Background Drug-disease interactions are situations where pharmacotherapy may have a negative effect on patients' comorbidities. In these cases, it can be necessary to avoid that drug, adjust its dose or monitor therapy. In the Netherlands, pharmacists have developed a best practice how to systematically evaluate drug-disease interactions based on pharmacological considerations and implement recommendations for specific drug-disease interactions. Aim To describe the development of recommendations for drug-disease interactions and the implementation in prescribing and dispensing practice in the Netherlands. Setting Pharmacies and physicians' practices in primary care and hospitals in the Netherlands. Development A multi-disciplinary expert panel assessed if diseases had clinically relevant drug-disease interactions and evaluated drug-disease interactions by literature review and expert opinion, and subsequently developed practice recommendations. Implementation The recommendations were implemented in all clinical decision support systems in primary care and hospitals throughout the Netherlands. Evaluation Recommendations were developed for 57 diseases and conditions. Cardiovascular diseases have the most drug-disease interactions (n = 12, e.g. long QT-syndrome, heart failure), followed by conditions related to the reproductive system (n = 7, e.g. pregnancy). The number of drugs with recommendations differed between 6 for endometriosis and tympanostomy tubes, and up to 1171 in the case of porphyria or even all drugs for pregnancy. Conclusion Practice recommendations for drug-disease interactions were developed, and implemented in prescribing and dispensing practice. These recommendations support both pharmacists and physicians by signalling clinically relevant drug-disease interactions at point of care, thereby improving medication safety. This practice may be adopted and contribute to safer medication use in other countries as well

Diagnosis of prosthetic joint infection with alpha-defensin using a lateral flow device : a multicentre study

AIMS: The purpose of this current multicentre study is to analyse the presence of alpha-defensin proteins in synovial fluid using the Synovasure lateral flow device and to determine its diagnostic reliability and accuracy compared with the prosthetic joint infection (PJI) criteria produced by the Musculoskeletal Infection Society (MSIS). PATIENTS AND METHODS: A cohort of 121 patients comprising 85 total knee arthroplasties and 36 total hip arthroplasties was prospectively evaluated between May 2015 and June 2016 in three different orthopaedic centres. The tests were performed on patients with a chronically painful prosthesis undergoing a joint aspiration in a diagnostic pathway or during revision surgery. RESULTS: Based on the MSIS criteria, 34 patients (28%) would have had a PJI, and 87 patients had no PJI. Testing with the lateral flow device had a sensitivity of 97.1% (95% confidence intervals (CI) 84.5 to 99.9) and a specificity of 96.6% (95% CI 90.3 to 99.2). The positive predictive value was 91.7% (95% CI 77.7% to 98.3), and the negative predictive value was 98.8% (95% CI 93.6 to 99.9). Receiver operator characteristics analysis demonstrated an area under the curve for the Synovasure test of 0.97 (95% CI 0.93 to 1.00). CONCLUSION: Our findings suggest that the Synovasure test has an excellent diagnostic performance to confirm or reject the diagnosis of a PJI. The results are promising for the care of the painful or problematic knee and hip joint arthroplasty and the test should be considered as part of the diagnostic toolbox for PJIs

Pédagogie et révolution numérique

La nécessité d’intégrer les technologies de l’information et de la communication dans l’éducation est devenue une évidence autant qu’un enjeu majeur dans le processus d’acquisition de connaissances et de compétences, partout dans le monde. Ce constat n’est cependant pas sans interrogations. Le numérique permet-il aux élèves de mieux apprendre et aux professeurs de mieux enseigner ? Conduit-il à un renouvellement des pratiques pédagogiques et à une redéfinition du métier d’enseignant ? En quoi modifie-t-il le rôle de l’école ? Pour contribuer à cette réflexion, le numéro 67 de la Revue internationale d’éducation de Sèvres propose d’interroger neuf contextes extrêmement différents, de l’Angleterre à la Corée du Sud, en passant par les États-Unis, l’Australie, l’Éthiopie, le Nigéria, l’Argentine, les Pays-Bas et la France. Les analyses présentées portent aussi bien sur des observations de classe et des projets d’établissement que sur des enquêtes ou la présentation de politiques et de plans d’action mis en œuvre au niveau national. Ces études de cas sont complétées par une étude bibliographique qui présente un état de la littérature récente sur ce sujet. Cette variété de situations analysées apporte un éclairage original sur les évolutions en cours. Tous les auteurs soulignent l’importance de la responsabilité confiéée aux enseignants et aux établissements pour intégrer le numérique dans l’éducation. Les pays les plus avancés sur ce sujet sont ceux où l’on a repensé la pédagogie, sans hésiter à remettre en question le fonctionnement du système éducatif. Across the world, the need to integrate information and communication technologies into education has become self-evident as well as a major factor in the acquisition of knowledge and skills. Yet this observation raises questions. Do digital technologies enable pupils to learn better and teachers to teach better? Do they lead to a renewal of pedagogical practices and a redefinition of teaching? How do they alter the role of school? To begin answering these questions, issue 67 of the Revue internationale d’éducation de Sèvres examines nine radically different contexts, from England to South Korea by way of the United States, Australia, Ethiopia, Nigeria, the Netherlands and France. The analyses draw on classroom observations, school initiatives and surveys and present policies and action plans implemented at national level. These case studies are accompanied by an annotated bibliography that provides a summary of recent literature on the subject. The variety of situations analysed provides an original perspective on the changes that are underway. The authors all underline the importance of the responsibility conferred to teachers and schools in integrating digital technologies into education. The most advanced countries in this area are those that have reconsidered pedagogy while examining the functioning of the education system. La necesidad de integrar las tecnologías de la información y de la comunicación en la educación se ha convertido tanto en una evidencia como en un reto mayor de adquisición de conocimientos y de competencias en el mundo entero. Dicha constatación conlleva no pocas interrogaciones. ¿Permite lo digital que los alumnos aprendan mejor y que los profesores enseñen mejor ? ¿Conduce a una renovación de las prácticas pedagógicas y a una redefinición del oficio de profesor ? ¿En qué modifica el papel de la Escuela ? Para dar algunos elementos de respuesta a estas preguntas, el número 67 de la Revue internationale d’éducation de Sèvres propone interrogar nueve contextos sumamente diferentes, desde Inglaterra hasta Corea del Sur, pasando por Estados Unidos, Argentina, Australia, Etiopía, Nigeria, Países Bajos y Francia. Estos análisis tratan tanto de las observaciones de clases y de los proyectos de establecimiento como de las encuestas o de la presentación de políticas y de los planes de acción puestos en obra a nivel nacional. Un estudio bibliográfico que establece un estado de la literatura reciente sobre este tema viene completando estos estudios de caso. La variedad de situaciones analizadas echa una luz original sobre las evoluciones actuales. Todos los autores subrayan la importancia de la responsabilidad dada a los docentes y a los establecimientos para integrar lo digital en la educación. Los países más avanzados en este tema son los que han reexaminado la pedagogía interrogando al mismo tiempo el funcionamiento del sistema educativo