hospitalization

A review of the possible causes, diagnosis, and management of heart failure with preserved ejection fraction. Notice that SGLT2 inhibitors reduced hospitalizations and cardiovascular deaths by <2% (absolute risk reduction) per year and have not been compared head-to-head against less expensive meds like HCTZ or ramipril. James W. Mold, MD, MPH

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Importance Heart failure with preserved ejection fraction (HFpEF), defined as HF with an EF of 50% or higher at diagnosis, affects approximately 3 million people in the US and up to 32 million people worldwide. Patients with HFpEF are hospitalized approximately 1.4 times per year and have an annual mortality rate of approximately 15%.

Observations Risk factors for HFpEF include older age, hypertension, diabetes, dyslipidemia, and obesity. Approximately 65% of patients with HFpEF present with dyspnea and physical examination, chest radiographic, echocardiographic, or invasive hemodynamic evidence of HF with overt congestion (volume overload) at rest. Approximately 35% of patients with HFpEF present with “unexplained” dyspnea on exertion, meaning they do not have clear physical, radiographic, or echocardiographic signs of HF. These patients have elevated atrial pressures with exercise as measured with invasive hemodynamic stress testing or estimated with Doppler echocardiography stress testing. In unselected patients presenting with unexplained dyspnea, the H2FPEF score incorporating clinical (age, hypertension, obesity, atrial fibrillation status) and resting Doppler echocardiographic (estimated pulmonary artery systolic pressure or left atrial pressure) variables can assist with diagnosis (H2FPEF score range, 0-9; score >5 indicates more than 95% probability of HFpEF). Specific causes of the clinical syndrome of HF with normal EF other than HFpEF should be identified and treated, such as valvular, infiltrative, or pericardial disease. First-line pharmacologic therapy consists of sodium-glucose cotransporter type 2 inhibitors, such as dapagliflozin or empagliflozin, which reduced HF hospitalization or cardiovascular death by approximately 20% compared with placebo in randomized clinical trials. Compared with usual care, exercise training and diet-induced weight loss produced clinically meaningful increases in functional capacity and quality of life in randomized clinical trials. Diuretics (typically loop diuretics, such as furosemide or torsemide) should be prescribed to patients with overt congestion to improve symptoms. Education in HF self-care (eg, adherence to medications and dietary restrictions, monitoring of symptoms and vital signs) can help avoid HF decompensation.

Conclusions and Relevance Approximately 3 million people in the US have HFpEF. First-line therapy consists of sodium-glucose cotransporter type 2 inhibitors, exercise, HF self-care, loop diuretics as needed to maintain euvolemia, and weight loss for patients with obesity and HFpEF.

Author/s:

Redfield, Margaret, Borlaug, Barry

Parkinson disease primer, part 2: management of motor and nonmotor symptoms

Aubrey Delammermore — Thu, 23 Feb 2023 06:00:00 +0000

Date Added:

February 23, 2023

Journal/Publication:

Canadian Family Physician

Publication Date:

February 1, 2023

Issue:

Volume:

Pages:

91-96

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.690291

Keywords

PMID (1):

36813521

MeSH

Levodopa

depression

Hypotension, Orthostatic

Physical Therapy Modalities

Sleep Wake Disorders

The second of a series of articles on management of Parkinson's Disease. James W. Mold, MD, MPH

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Objective To provide family physicians with an approach to the management of
motor and nonmotor symptoms of Parkinson disease (PD).
Sources of information Published guidelines on the management of PD were
reviewed. Database searches were conducted to retrieve relevant research
articles published between 2011 and 2021. Evidence levels ranged from I to III.
Main message Family physicians can play an important role in identifying and
treating motor and nonmotor symptoms of PD. Family physicians should initiate
levodopa treatment for motor symptoms if they affect function and if specialist
wait times are long, and they should be aware of basic titration approaches
and possible side effects of dopaminergic therapies. Abrupt withdrawal of
dopaminergic agents should be avoided. Nonmotor symptoms are common and
underrecognized and are a major factor in disability, quality of life, and risk of
hospitalization and poor outcomes for patients. Family physicians can manage
common autonomic symptoms such as orthostatic hypotension and constipation.
Family physicians can treat common neuropsychiatric symptoms such as
depression and sleep disorders, and they can help recognize and treat psychosis
and PD dementia. Referrals to physiotherapy, occupational therapy, speech
language therapy, and exercise groups are recommended to help preserve function.
Conclusion Patients with PD present with complex combinations of motor
and nonmotor symptoms. Family physicians should have basic knowledge of
dopaminergic treatments and their side effects. Family physicians can play
important roles in management of motor symptoms and particularly nonmotor
symptoms and can have a positive impact on patients’ quality of life. An
interdisciplinary approach involving specialty clinics and allied health experts
is an important part of management.

Author/s:

Frank, C., Chiu, R., Lee, J.

Effect of fluvoxamine on outcomes of nonhospitalized patients with COVID-19: A systematic review and meta-analysis

Aubrey Delammermore — Sun, 06 Nov 2022 05:00:00 +0000

Date Added:

November 6, 2022

Journal/Publication:

Journal of Infection and Public Health

Publisher:

Elsevier B. V.

Publication Date:

October 13, 2022

Issue:

Volume:

Pages:

1259-1264

URL:

Effect of fluvoxamine on outcomes of nonhospitalized patients with COVID-19: A systematic review and meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.jiph.2022.10.010

Keywords

Odds Ratio

Artificial respiration

control groups

hospitalization

bibliometrics

PMID (1):

36272390

MeSH

Fluvoxamine can reduce risk of hospitalization in outpatients with COVID-19. James W. Mold, MD, MPH

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Objectives: This meta-analysis investigated the use of fluvoxamine for the treatment of nonhospitalized patients with COVID-19.

Methods: PubMed, Web of Science, Ovid medline, Embase, Scopus, Cochrane Library databases, and ClinicalTrials.gov were searched for studies published before June 25, 2022. Only clinical studies that compared the efficacy and safety of fluvoxamine with other alternatives or placebos in the treatment of nonhospitalized patients with COVID-19 were included.

Results: Four studies with 1814 patients, of whom 912 received fluvoxamine, were included in this study. Compared with the control group receiving placebo or no therapy, the study group receiving fluvoxamine demonstrated a lower risk of hospitalization and emergency department (ED) visits (odds ratio [OR], 0.59; 95 % CI, 0.44-0.79; I2 = 26 %). In addition, the rate of hospitalization remained significantly lower in patients who received fluvoxamine than in the control group (OR, 0.69; 95 % CI, 0.51-0.94; I2 = 36 %). Although the study group demonstrated a lower risk of requirement of mechanical ventilation and intensive care unit admission, and mortality than the control group, these differences were nonsignificant. Finally, fluvoxamine use was associated with a similar risk of adverse events as that observed in the control group.

Conclusion: Fluvoxamine can be safely used in nonhospitalized patients with COVID-19 and can reduce the hospitalization rate or ED visits in these patients.

Keywords: COVID-19; Emergency department; Fluvoxamine; Hospitalization; SARS-CoV-2.

Author/s:

Lu, L., Chao, C., Chang, S., Lan, S., Lai, C.

Medication Overload: America’s Other Drug Problem. How the drive to prescribe is harming older adults.

Brian Desmarais — Mon, 01 Jul 2019 14:26:58 +0000

Date Added:

January 21, 2021

Publisher:

Lown Institute

Publication Date:

July 1, 2019

URL:

Medication Overload: America’s Other Drug Problem How the drive to prescribe is harming older adults

Type:

Public Health Announcements

Format:

Web Page

Keywords

MeSH

Antineoplastic Combined Chemotherapy Protocols

Daunorubicin

Etoposide

substance-related disorders

Polypharmacy is a major problem in the U.S. This report summarizes its magnitude, causes, and consequences. Other evidence suggests that when the number of meds increases beyond 4-5, any possible benefits are outweighed by the risks of adverse effects and drug-drug interactions. Medication lists should include OTCs and should be updated at every visit. Patients should be strongly encouraged to bring their medication bottles with them to every visit. James W. Mold, MD, MPH

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In the last year, older adults in the U.S. sought medical care nearly 5 million times due to serious side effects from one or more medications. More than a quarter million of these visits resulted in hospitalizations, at a cost of $3.8 billion (see Appendix A in the full report). These numbers point to a rapidly growing epidemic of medication overload among older Americans. Over the last decade, adults age 65 and older have been hospitalized for serious drug side effects, called adverse drug events (ADEs), about 2 million times. To put this in context, there were 3.2 million opioid-related hospitalizations across the entire population during the same period.1 The trend of increasing ADEs is not propelled by drug abuse, but by the rising number of medications prescribed to older adults (called “polypharmacy” in the scientific literature). More than 40 percent of older adults take five or more prescription medications a day, a threefold increase over the past two decades.2,3 The greater the number of medications—most of which are prescribed for legitimate reasons—the greater the risk for serious adverse reactions in older patients. Medication overload is causing widespread yet unseen harm to our parents and our grandparents. It is every bit as serious as the opioid crisis, yet its scope remains invisible to many patients and health care professionals. While some clinicians are trying to reduce the burden of medications on their individual patients, no professional group, public organization, or government agency to date has formally assumed responsibility for addressing this national problem. If current trends continue, we estimate that medication overload will be responsible for at least 4.6 million hospitalizations between 2020 and 2030. It will cost taxpayers, patients and families an estimated $62 billion. Over the next decade, medication overload is expected to cause the premature death of 150,000 older Americans. In this report, the Lown Institute calls for the development of a national strategy to address medication overload and help older people avoid its devastating effects on the quality and length of their lives. A subsequent National Action Plan for Addressing Medication Overload will lay out a national strategy to address the epidemic of prescribing and ensure the safety of millions of older adults who are now at risk of preventable harm and premature death.

Author/s:

Executive Summary of the Lown Institute