Impact of educational intervention on prescribing inappropriate medication to elderly nursing homes residents

© 2015, Serbia Medical Society. All rights reserved. Introduction Problems with polypharmacy, adverse drug reactions and non-adherence are especially frequent among elderly nursing home residents. Objective The aim of our study was to evaluate effectiveness of a specific form of staff education on appropriateness of prescribing in a cluster of nursing homes for the elderly. Methods The study was designed as before-and-after trial of educational intervention on appropriateness of prescribing in nursing homes for the elderly. In total 20 nursing homes located in Belgrade, Serbia were included in the study with 104 elderly residents and 27 caring physicians. Appropriateness of prescribing was checked against Beers, START and STOPP criteria, before and 6 months after the intervention. Results There were 349 inappropriately prescribed drugs according to Beers criteria before the intervention and 37 drugs six months after the intervention. According to STOPP criteria there were 70 drugs inappropriately prescribed before the intervention, and 20 drugs 6 months after. When both criteria are taken together, there is a significant difference between the average number of inappropriate drugs per patient before (3.4±0.5) and after (0.6±0.7) educational intervention (t=38.902; p<0.001). Finally, before the intervention 143 appropriate drugs were omitted according to START criteria, while 6 months after the intervention there were only 67 omissions. Conclusion Simple, but well targeted educational interventions may improve polypharmacy and decrease inappropriate prescribing rate, contributing to a better care of elderly patients in nursing homes

DIFFERENTIAL DIAGNOSIS OF OPTIC NEURITIS

Abstract: Optic neuritis is inflammation of the optic nerve, which in a single or repeated attacks can severely and permanently damage visual function. Errors in diagnostic are daily and usually occur because of incomplete diagnostic procedure performed. This manuscript presents a series of 19 patients reffered with optic neuritis diagnosis. The diagnosis was confirmed in 15, while four had other changes in the optic nerve or macula. We analyzed the diagnostic specificity of the basic parameters of optic neuritis diagnosis and afferent pupillary defect showed the highest sensitivity. The spectrum of differential diagnoses is shown within this finding. Optic neuritis diagnosis should be established carefully, using usual and available diagnostic methods in ophthalmologic and neurological practice, and if necessary, refer patients to neuro-ophthalmologist, as well as to electrophysiological evaluation and other methods that help fifferentiate disease

Demographic characteristics and functional outcomes in patients with traumatic and nontraumatic spinal cord injuries

Background/Aim. Spinal cord injuries (SCI) could be associated with a significant functional impairment in the areas of mobility, self-care, bowel and bladder emptying and sexuality. The aim of this study was to compare demographic characteristics and functional outcomes of nontraumatic and traumatic spinal cord injury patients. Methods. This study was designed as retrospective case series study. A detailed medical history including sex, age, mode of trauma, and clinical and radiological examination was taken for all patients. Hospital records were used to classify the patients according to the following: mechanism of injury, neurological level of injury, functional outcomes, associated injuries, method of treatment, secondary complications and length of stay. The following clinical scores were measured in the patients: American Spinal Injury Association standards (CASTA), Functional Independence Measure (FIM), and Modified Aschworth score (MAS). Results. Out of totally 441 patients with spinal cord injury, 279 were traumatic patients (TSCI) and 162 nontraumatic patients (NTSCI); 322 men and 119 women. The mean age of the patients was 46.1 ± 19.9 years. Traumatic and nontraumatic populations showed several significant differences with regard to age, level and severity of lesion. When adjusted for these factors patients with traumatic injuries showed a significantly lower FIM score at admission and significantly better improvement in the FIM score at discharge. The two populations were discharged with similar functional outcome. Conclusions. The NTSCI patients in our study were younger, more frequently female, with less complications before rehabilitation and less frequently treated operatively than the TSCI patients. Hospital rehabilitation of the TSCI patients was longer than that of the NTSCI patients, but their functional gain from admission was also higher, so at discharge. Traumatic and nontraumatic spinal cord lesion patients achieved similar results in regard to neurological and functional status

Etiology and resistance patterns of bacteria causing ventilator-associated pneumonia in a respiratory intensive care unit

© 2017, Institut za Vojnomedicinske Naucne Informacije/Documentaciju. All Rights Reserved. Background/Aim. Ventilator-associated pneumonia (VAP) incidence, causative pathogens, and resistance patterns are different among countries and intensive care units (ICUs). In Europe, resistant organisms have progressively increased in the last decade. However, there is a lack of data from Serbian ICUs. The aims of this study were to evaluate etiology and antimicrobial resistance for pathogens causing VAP in ICU patients, to examine whether there were differences among pathogens in early-onset and late-onset VAP and to identify mortality in patients with VAP after 30 and 60 days of hospitalization. Methods. A retrospective cohort study was conducted in the respiratory ICU and all adult patients diagnosed with VAP from 2009 to 2014 were included. Results. Gram negative organisms were the major pathogens (80.3%). The most commonly isolated was Acinetobacter spp (59.8%). There was a statistically significant increase in the incidence of infection with Klebsiella pneumoniae (8.9% vs 25.6%; p = 0.019). Extensively drugresistant strains (XDR) were the most common (78.7%). Lateonset VAP was developed in 81.1% of patients without differences among pathogens in comparison with early-onset VAP. Acinetobacter spp was susceptible to tigecycline and colistin with a significant increase in resistance to ampicillin/sulbactam (30.2% vs 58.6%; p = 0.01). Resistance rate of Pseudomonas aeruginosa and Klebsiella pneumoniae to carbapenems was 38% and 11%, respectively. In methicillin-resistant Staphylococcus aureus no resistance was observed against vancomycin and linezolid. There was no difference in mortality rate between patients with earlyonset and late-onset VAP after 30 and 60 days of hospitalization. Conclusion. Gram negative organisms were the primary cause of bacterial VAP of which the most common was the XDR strain of Acinetobacter spp. Patients with early- and late-onset VAP had the same pathogens. There was no difference in mortality between this two group of patients during 60 days of hospitalization

Fragile X-Associated Disorders in Serbia: Baseline Quantitative and Qualitative Survey of Knowledge, Attitudes and Practices Among Medical Professionals

We conducted a knowledge, attitude, and practice (KAP) survey of fragile X-associated disorders (FXD) in Serbia in order to obtain baseline quantitative and qualitative KAP data on fragile X mental retardation 1 gene (FMR1) pre- and full mutations (PM, FM). The survey's 16-item questionnaire included a knowledge component (12/16), such as self-assessment knowledge (SAK) and factual knowledge (FK, 2/5 questions for PM, FXTAS and FXPOI). Education-directed attitudes in the FXD field and FMR1 DNA testing practices had 4/16 items, including brief case vignettes of FXTAS and FXPOI, respectively. The study's cohort consisted of primary care physicians (referred to as “physicians” in the rest of the text) throughout Serbia (n = 284, aged 26–64 years, 176/284, 62.2% in Belgrade, Serbia) and senior medical students (n = 245, aged 23–30 years; 33.5% males) at the Belgrade School of Medicine. Strikingly, half of the survey respondents indicated “not having any” knowledge for the fragile X gene premutation and FXD. Physicians were more likely to indicate “not having any” knowledge than students (41.2% of physicians vs. 13.1% of students, P &lt; 0.05). Roughly half of the students had “minimal knowledge” (53.5 vs. 30.5% of physicians, P &lt; 0.05). Low FK was common in the cohort, as few physicians had “all correct answers” (7.5 vs. 3.7% of students, P &lt; 0.05; 16.5 vs. 9.5% of students for the 2/5 premutation-related questions). Statistical analyses identified physicians' practice setting and length of clinical experience as predictors of the lack of FK on questions related to FXD. Physicians were more likely than students to indicate “strongly agreed” to expand their knowledge of the gene premutation and FXD (90.9 vs. 66.7% of students, P &lt; 0.01). However, students more frequently indicated that they are willing to recommend DNA testing in their future practices than physicians (93.5 vs. 64.8% of physicians, P &lt; 0.001). In conclusion, there is a major gap in knowledge regarding fragile X gene PM and FXD among the study's participants in Serbia. The study's informative-educational survey serves as an initial step in the process of enhancing the KAP of medical professionals with regards to the fragile X gene premutation and FXD

Prognostic indices in diffuse large B-cell lymphoma: a population-based comparison and validation study of multiple models

Currently, the International Prognostic Index (IPI) is the most used and reported model for prognostication in patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL). IPI-like variations have been proposed, but only a few have been validated in different populations (e.g., revised IPI (R-IPI), National Comprehensive Cancer Network IPI (NCCN-IPI)). We aimed to validate and compare different IPI-like variations to identify the model with the highest predictive accuracy for survival in newly diagnosed DLBCL patients. We included 5126 DLBCL patients treated with immunochemotherapy with available data required by 13 different prognostic models. All models could predict survival, but NCCN-IPI consistently provided high levels of accuracy. Moreover, we found similar 5-year overall survivals in the high-risk group (33.4%) compared to the original validation study of NCCN-IPI. Additionally, only one model incorporating albumin performed similarly well but did not outperform NCCN-IPI regarding discrimination (c-index 0.693). Poor fit, discrimination, and calibration were observed in models with only three risk groups and without age as a risk factor. In this extensive retrospective registry-based study comparing 13 prognostic models, we suggest that NCCN-IPI should be reported as the reference model along with IPI in newly diagnosed DLBCL patients until more accurate validated prognostic models for DLBCL become available.</p

Endocytosis and lysosomal degradation of GluA2/3 AMPARs in response to oxygen/glucose deprivation in hippocampal but not cortical neurons

Abstract Global cerebral ischemia results in oxygen and glucose deprivation (OGD) and consequent delayed cell death of vulnerable neurons, with hippocampal CA1 neurons more vulnerable than cortical neurons. Most AMPA receptors (AMPARs) are heteromeric complexes of subunits GluA1/GluA2 or GluA2/GluA3, and the presence of GluA2 renders AMPARs Ca2+-impermeable. In hippocampal CA1 neurons, OGD causes the synaptic expression of GluA2-lacking Ca2+-permeable AMPARs, contributing to toxic Ca2+ influx. The loss of synaptic GluA2 is caused by rapid trafficking of GluA2-containing AMPARs from the cell surface, followed by a delayed reduction in GluA2 mRNA expression. We show here that OGD causes endocytosis, lysosomal targeting and consequent degradation of GluA2- and GluA3-containing AMPARs, and that PICK1 is required for both OGD-induced GluA2 endocytosis and lysosomal sorting. Our results further suggest that GluA1-containing AMPARs resist OGD-induced endocytosis. OGD does not cause GluA2 endocytosis in cortical neurons, and we show that PICK1 binding to the endocytic adaptor AP2 is enhanced by OGD in hippocampal, but not cortical neurons. We propose that endocytosis of GluA2/3, caused by a hippocampal-specific increase in PICK1-AP2 interactions, followed by PICK1-dependent lysosomal targeting, are critical events in determining changes in AMPAR subunit composition in the response to ischaemia

ECMO Support in Refractory Cardiogenic Shock: Risk Factors for Mortality

Background: Veno-arterial extracorporeal membrane oxygenation (va-ECMO) is a specialized temporary support for patients with refractory cardiogenic shock. The true value of this potentially lifesaving modality is still a subject of debate. Therefore, we aimed to investigate the overall in-hospital mortality and identify potential risk factors for mortality. Methods: We retrospectively analyzed the data of 453 patients supported with va-ECMO over a period of 14 years who were admitted to intensive care units of a tertiary university center in Austria. Results: We observed in-hospital mortality of 40% for patients with refractory cardiogenic shock. Hemorrhage, ECMO initiation on weekends, higher SAPS III score, and sepsis were identified as significant risk factors for mortality. Hemorrhage was the most common adverse event (46%), with major bleeding events dominating in deceased patients. Thromboembolic events occurred in 25% of patients, followed by sepsis (18%). Conclusions: Although the rates of complications are substantial, a well-selected proportion of patients with refractory cardiogenic shock can be rescued from probable death. The reported risk factors could be used to increase the awareness of clinicians towards the development of new therapeutic concepts that may reduce their incidence

(Un)importance of physical therapy in treatment of displaced supracondylar humerus fractures in children

Elbow joint stiffness is a common complication following supracondylar humerus fractures. In prospective study, dynamics of establishing a full range of motion in the elbow joint following the treatment of supracondylar humerus fractures were assessed, together with the effects of physical therapy on improvement in the range of motion.Two groups of patients were observed. Physical therapy was administered to the first group, comprised of 25 patients. The second group, comprised of 28 patients, underwent no physical therapy.In the first few months following treatment, the range of motion was significantly greater in the patients who had undergone physical therapy, but after 12 months, the range of motion was almost equal in the two groups.This study has shown that it takes about 12 months to establish a full range of motion after the injury, and that it is not necessary to apply physical therapy in patients with elbow fractures