Herges, Lori B.

ABSTRACT Advanced chronic diseases, or multicomplexity in older adults presents unique challenges. Transthyretin cardiac amyloidosis (ATTR‐CA) is one such scenario where heart failure is a common presentation, and management remains challenging. We describe the challenges involved in the diagnosis of ATTR‐CA in older adults, which has implications on treatment options. We discuss the application of comprehensive geriatric assessment (CGA) and shared decision making (SDM) in the context of these challenges. Based on geriatric medicine principles, an innovative framework for applying SDM in ATTR‐CA patients is proposed, including consideration of the patient priorities care approach. The proposed framework emphasizes assessing functionality, frailty, and life expectancy to help categorize risk. This framework can be applied in various advanced chronic diseases or multicomplexity. Based on risk categorization, treatment burden, and alignment with values and preferences, management pathways are suggested for each risk category. Incorporating CGA and SDM, the proposed framework supports patient‐centered care, ensuring that clinical recommendations are tailored to each older adult's unique needs and goals. In ATTR‐CA, a collaboration between cardiology and geriatric medicine provides significant value in managing older adults. The need to prevent age‐related bias in clinical decision‐making exists across all health conditions, and the proposed framework allows for a thorough evaluation of multimorbidity, frailty, disability, and patient preferences. While ATTR‐CA is used as a prototype, this integrated approach can be applied across all health conditions and is essential for delivering holistic care, improving communication, and aligning treatment plans with patient values.

Introduction Bumetanide can induce generalized musculoskeletal pain when administered as a continuous infusion, an effect that may be underrecognized. The purpose of this case series is to educate health care providers about the incidence and presentation of pain associated with bumetanide infusions, adding to the existing literature describing this adverse event. Clinical Findings Of 40 critically ill patients, 15 (38%) had increased pain scores after initiation of a continuous infusion of bumetanide, with symptoms commonly occurring 12 to 24 hours after initiation of the infusion. Reported descriptions of the pain included generalized aching, soreness, burning, allodynia, headaches, and exacerbation of underlying pain in localized areas. Increases in patient-reported pain correlated directly with initiation of the continuous infusion of bumetanide. Diagnosis Four of the 15 bumetanide-associated pain events (27%) were recognized as such by the health care team. Interventions Bumetanide was promptly discontinued in the 4 identified cases. The 11 patients (73%) whose pain was not recognized as related to bumetanide remained on a continuous infusion of bumetanide and received pain medications including opioids. Infusions were stopped when patients transitioned to dialysis (n = 8 [53%]), began receiving comfort care (n = 5 [33%]), or completed diuresis therapy (n = 2 [13%]). Outcomes For all patients, pain symptoms resolved within 24 to 48 hours after discontinuation of bumetanide infusion with no significant electrolyte abnormalities. Conclusion Bumetanide-induced pain is more common than previously described. Early recognition of this adverse event can prevent patient discomfort and escalation of treatment.

ObjectivesThe primary objective of this study was to determine whether pharmacist‐clinician collaborative (PCC) visits within 7 days after hospital discharge (early‐visit cohort) would reduce the risk of 30‐day hospital readmission compared with PCC visits eight or more days after hospital discharge (late‐visit cohort).MethodsThis retrospective study of adult primary care patients was conducted from July 26, 2013 to April 1, 2016. Patients who were included were receiving at least one medication that put them at high risk for emergent hospital admission and at least 10 total medications. A Cox proportional hazards model was used to assess 30‐day readmission risk between the two groups.ResultsThe early‐visit cohort included 393 patients; the late‐visit cohort included 109 patients. After adjusting for statistically different baseline characteristics and the LACE index score (which predicts the risk of death or unplanned readmission within 30 days after hospital discharge), 30‐day readmission risk was not significantly different between the late‐visit cohort and the early‐visit cohort (hazard ratio, 0.8; 95% confidence interval [CI], 0.34‐1.88; P = 0.61). Similarly, the difference was not significant 60 and 180 days after the PCC visit.ConclusionPatients in the early‐visit cohort had no greater risk of readmission 30 days after the visit than patients in the late‐visit cohort. Although previous research indicates that PCC visits may have significant benefits for decreasing readmission risk, delaying them may not increase the patient's risk. This finding may allow more flexibility in scheduling a pharmacist and a primary care clinician to meet with the patient.

Purpose: Cellulitis in obese patients is associated with increased rates of treatment failure compared to those with normal body mass index (BMI); however, patients have not been extensively studied in the outpatient environment or stratified based on range of obesity and associated risk factors. This study looked at antibiotic dosing and treatment failure in the obese population from the primary care perspective and accounts for BMI range, weight, comorbid diabetes, and tobacco use. Methods: This study was a retrospective chart review of 637 adult primary care patients designed to evaluate rates of treatment failure of outpatient cellulitis among patients of varying BMI. Treatment failure was defined as ( a) hospital admission for intravenous antibiotics, ( b) prolonged antibiotic course, or ( c) requiring a different antibiotic after initial course. Results: Adverse outcomes were not statistically significant between normal BMI and those with BMI ≥40 kg/m 2 . A subset of patients with a BMI ≥50 kg/m 2 was noted to have approximately twice the rate of adverse outcomes as the normal BMI group. While controlling for age, gender, race, diagnosis of diabetes mellitus, and tobacco use, a BMI of ≥50 kg/m 2 and a weight ≥120 kg was associated with adverse outcomes with an odds ratio of 2.440 (95% CI, 1.260-4.724; P = .008) and 2.246 (95% CI, 1.154-4.369; P = .017), respectively. Conclusions: Patients with cellulitis weighing >120kg or with a BMI ≥50 kg/m 2 were at greatest risk for treatment failure in the outpatient setting, even when controlling for comorbid diabetes and tobacco use. As morbid obesity continues to become more prevalent, it becomes imperative that primary care physicians have better antibiotic dosing guidelines to account for the physiologic effects of obesity to minimize the risk of increased morbidity, health care costs, and antibiotic resistance.