External validation of six COVID-19 prognostic models for predicting mortality risk in older populations in a hospital, primary care, and nursing home setting

Objectives: To systematically evaluate the performance of COVID-19 prognostic models and scores for mortality risk in older populations across three health-care settings: hospitals, primary care, and nursing homes.Study Design and Setting: This retrospective external validation study included 14,092 older individuals of >=70 years of age with a clinical or polymerase chain reaction-confirmed COVID-19 diagnosis from March 2020 to December 2020. The six validation cohorts include three hospital-based (CliniCo, COVID-OLD, COVID-PREDICT), two primary care-based (Julius General Practitioners Network/Academisch network huisartsgeneeskunde/Network of Academic general Practitioners, PHARMO), and one nursing home cohort (YSIS) in the Netherlands. Based on a living systematic review of COVID-19 prediction models using Prediction model Risk Of Bias ASsessment Tool for quality and risk of bias assessment and considering predictor availability in validation cohorts, we selected six prognostic models predicting mortality risk in adults with COVID-19 infection (GAL-COVID-19 mortality, 4C Mortality Score, National Early Warning Score 2-extended model, Xie model, Wang clinical model, and CURB65 score). All six prognostic models were validated in the hospital cohorts and the GAL-COVID-19 mortality model was validated in all three healthcare settings. The primary outcome was in-hospital mortality for hospitals and 28-day mortality for primary care and nursing home settings. Model performance was evaluated in each validation cohort separately in terms of discrimination, calibration, and decision curves. An intercept update was performed in models indicating miscalibration followed by predictive performance re-evaluation. Main Outcome Measure: In-hospital mortality for hospitals and 28-day mortality for primary care and nursing home setting. Results: All six prognostic models performed poorly and showed miscalibration in the older population cohorts. In the hospital settings, model performance ranged from calibration-in-the-large 1.45 to 7.46, calibration slopes 0.24e0.81, and C-statistic 0.55e0.71 with 4C Mortality Score performing as the most discriminative and well-calibrated model. Performance across health-care settings was similar for the GAL-COVID-19 model, with a calibration-in-the-large in the range of 2.35 to 0.15 indicating overestimation, calibration slopes of 0.24e0.81 indicating signs of overfitting, and C-statistic of 0.55e0.71. Conclusion: Our results show that most prognostic models for predicting mortality risk performed poorly in the older population with COVID-19, in each health-care setting: hospital, primary care, and nursing home settings. Insights into factors influencing predictive model performance in the older population are needed for pandemic preparedness and reliable prognostication of health-related outcomes in this demographicGeriatrics in primary carePublic Health and primary carePrevention, Population and Disease management (PrePoD

The SUrvey for Pulsars and Extragalactic Radio Bursts – II. New FRB discoveries and their follow-up

We report the discovery of four Fast Radio Bursts (FRBs) in the ongoing SUrvey for Pulsars and Extragalactic Radio Bursts at the Parkes Radio Telescope: FRBs 150610, 151206, 151230 and 160102. Our real-time discoveries have enabled us to conduct extensive, rapid multimessenger follow-up at 12 major facilities sensitive to radio, optical, X-ray, gamma-ray photons and neutrinos on time-scales ranging from an hour to a few months post-burst. No counterparts to the FRBs were found and we provide upper limits on afterglow luminosities. None of the FRBs were seen to repeat. Formal fits to all FRBs show hints of scattering while their intrinsic widths are unresolved in time. FRB 151206 is at low Galactic latitude, FRB 151230 shows a sharp spectral cut-off, and FRB 160102 has the highest dispersion measure (DM = 2596.1 ± 0.3 pc cm−3) detected to date. Three of the FRBs have high dispersion measures (DM > 1500 pc cm−3), favouring a scenario where the DM is dominated by contributions from the intergalactic medium. The slope of the Parkes FRB source counts distribution with fluences >2 Jy ms is α=−2.2+0.6−1.2 and still consistent with a Euclidean distribution (α = −3/2). We also find that the all-sky rate is 1.7+1.5−0.9×103 FRBs/(4π sr)/day above ∼2Jyms and there is currently no strong evidence for a latitude-dependent FRB sky rate

Opioïden afbouwen in de eerstelijnszorg [Tapering of opioid use in primary care]

Although opioids are frequently used as treatment for chronic non-cancer related pain, the long term benefits on pain intensity and physical functioning are rather limited. Prolonged use of opioids is accompanied by multiple risks and side effects. It is important to regularly evaluate the effectiveness and the possibility of tapering of an opioid therapy. Tapering opioid use may improve physical function. Structured counselling by a healthcare professional facilitates successful tapering. In most cases, it will be possible to taper opioids in a primary care setting. If the treating physician feels incompetent to manage the tapering process, referral to specialized psychiatric care or a pain specialist can be considered. We propose a tapering rate between 10-35% of the previous dose per week in the primary care setting. Both pharmacological and non-pharmacological interventions can be used to ease the tapering

Quantity and economic value of unused oral cancer drugs among patients who discontinue their therapy

Setting and Method: At least one-third of patients using oral cancer drugs (OCD) discontinue their therapy early due to a lack of efficacy, adverse events or high out-of-pocket costs. Therapy discontinuation may lead to medication waste if the patient has not used all dispensed medication. Insight into the waste of OCDs could provide guidance for the development of waste-minimizing strategies. The objective of this study was therefore to determine the proportion of patients who have unused OCDs after therapy discontinuation, the reasons thereof, and the quantity and economic value of these unused medications. A retrospective follow-up study was conducted using a Dutch outpatient pharmacy database. Patients (C 18 years) who did not refill an OCD prescription, which was dispensed between November 2015 and February 2016, were contacted by phone and asked about their unused medication. The economic value was calculated using Dutch medication prices. Data were descriptively analysed in STATA13. Main outcome measures: The proportion of patients with unused OCDs after therapy discontinuation, their reason for discontinuation, and the quantity of packages that remained unused, including the economic value. Results: The database included 605 patients, of whom 90 patients likely had discontinued therapy and were contacted. Of these, 42 were excluded (18 had refilled their medication, 23 could not be contacted, 1 other). Of the 48 patients who had discontinued therapy (mean age 62.6 (SD -13.0) years, 52.1% female), 22 (45.8%) patients had unused medications. Patients primarily discontinued therapy early due to adverse effects (43.5%), followed by therapy changed (17.4%) and insufficient effect (17.4%). A total of 31 packages remained unused, with a median value of 179 (IQR 24-2487), amounting to a total of 34.500. Most patients kept the unused medications at home (60.9%) or returned them to the pharmacy (26.1%). Conclusion: Almost half of patients who discontinue OCD therapies have unused medications. The majority of patients do not dispose of their unused medications. Pharmacist interventions are needed to reduce the waste of expensive cancer therapies and to educate patients about safe disposal of unused medications

Quantity and economic value of unused oral anti-cancer and biological disease-modifying anti-rheumatic drugs among outpatient pharmacy patients who discontinue therapy

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The association between patient satisfaction with information and adherence to oral anticancer agents

Introduction Adherence to anticancer agents is a critical factor in achieving adequate clinical response, and became a major challenge for patients and caregivers since the increased substitution of parenteral cytostatic by oral drugs. One of the factors that influences adherence is how well informed patients are about their therapy. This study assesses the association between patient satisfaction with information about oral anticancer agents and adherence. Materials and Methods This study was conducted among patients (>= 18 years) who began oral anticancer therapy. Patients satisfaction with information and adherence were assessed using validated questionnaires. Adherence was also assessed using refill data. Logistic regression was applied to assess the association between overall patient satisfaction with information and both self-reported adherence and adherence based on an MPR value of above 80%. Results In total, 124 patients were included in the study. The median (IQR) satisfaction with information was 15.0(4) on a scale of 0-17. Eighty-two percent of participants reported adherence, while the refill data demonstrated that 64.5% of patients had an adherence rate of 80% or higher. Overall satisfaction with information was not significantly associated with self-reported adherence (OR adj 0.98 [95% CI 0.85-1.15]) or refill-based adherence (OR adj 1.11 [95% CI 0.99-1.24]). Conclusion The findings indicate no significant relationship between patient satisfaction with information and adherence. The population was highly satisfied with information about the oral anticancer agents, which indicates a high level of satisfaction with usual care. However, the refill data reveals that 35.5% of patients were not adherent

The association between patient satisfaction with information and adherence to oral anticancer agents.

INTRODUCTION: Adherence to anticancer agents is a critical factor in achieving adequate clinical response, and became a major challenge for patients and caregivers since the increased substitution of parenteral cytostatic by oral drugs. One of the factors that influences adherence is how well informed patients are about their therapy. This study assesses the association between patient satisfaction with information about oral anticancer agents and adherence. MATERIALS AND METHODS: This study was conducted among patients (≥18 years) who began oral anticancer therapy. Patients satisfaction with information and adherence were assessed using validated questionnaires. Adherence was also assessed using refill data. Logistic regression was applied to assess the association between overall patient satisfaction with information and both self-reported adherence and adherence based on an MPR value of above 80%. RESULTS: In total, 124 patients were included in the study. The median (IQR) satisfaction with information was 15.0(4) on a scale of 0-17. Eighty-two percent of participants reported adherence, while the refill data demonstrated that 64.5% of patients had an adherence rate of 80% or higher. Overall satisfaction with information was not significantly associated with self-reported adherence (OR adj 0.98 [95% CI 0.85-1.15]) or refill-based adherence (OR adj 1.11 [95% CI 0.99-1.24]). CONCLUSION: The findings indicate no significant relationship between patient satisfaction with information and adherence. The population was highly satisfied with information about the oral anticancer agents, which indicates a high level of satisfaction with usual care. However, the refill data reveals that 35.5% of patients were not adherent

Redispensing of unused HIV post-exposure prophylaxis for medical students

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Quantity and economic value of unused oral cancer drugs among patients who discontinue their therapy

Setting and Method: At least one-third of patients using oral cancer drugs (OCD) discontinue their therapy early due to a lack of efficacy, adverse events or high out-of-pocket costs. Therapy discontinuation may lead to medication waste if the patient has not used all dispensed medication. Insight into the waste of OCDs could provide guidance for the development of waste-minimizing strategies. The objective of this study was therefore to determine the proportion of patients who have unused OCDs after therapy discontinuation, the reasons thereof, and the quantity and economic value of these unused medications. A retrospective follow-up study was conducted using a Dutch outpatient pharmacy database. Patients (C 18 years) who did not refill an OCD prescription, which was dispensed between November 2015 and February 2016, were contacted by phone and asked about their unused medication. The economic value was calculated using Dutch medication prices. Data were descriptively analysed in STATA13. Main outcome measures: The proportion of patients with unused OCDs after therapy discontinuation, their reason for discontinuation, and the quantity of packages that remained unused, including the economic value. Results: The database included 605 patients, of whom 90 patients likely had discontinued therapy and were contacted. Of these, 42 were excluded (18 had refilled their medication, 23 could not be contacted, 1 other). Of the 48 patients who had discontinued therapy (mean age 62.6 (SD -13.0) years, 52.1% female), 22 (45.8%) patients had unused medications. Patients primarily discontinued therapy early due to adverse effects (43.5%), followed by therapy changed (17.4%) and insufficient effect (17.4%). A total of 31 packages remained unused, with a median value of 179 (IQR 24-2487), amounting to a total of 34.500. Most patients kept the unused medications at home (60.9%) or returned them to the pharmacy (26.1%). Conclusion: Almost half of patients who discontinue OCD therapies have unused medications. The majority of patients do not dispose of their unused medications. Pharmacist interventions are needed to reduce the waste of expensive cancer therapies and to educate patients about safe disposal of unused medications