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Introduction Use of nonbenzodiazepine sedative hypnotics or "Z-drugs"-including eszopiclone, zolpidem, or zaleplon-is discouraged for older adults; however, these medications commonly are prescribed to treat insomnia in this population. We evaluated the impact of direct-to-patient education, with or without a pharmacist consultation, on Z-drug discontinuation among Kaiser Permanente Northwest members age 64 years and older. Methods We randomized 150 patients to usual care (UC), educational information only, or educational information and pharmacist consultation. Patients age 64 years and older who received 2 to 3 Z-drug fills in 2016 were included. Logistic regression was used to calculate odds of discontinuation at 6 months among patients who received either intervention, compared with those who received UC. Results Patients who received education only and education plus pharmacist consultation were significantly more likely to discontinue Z-drug use than those who received UC (28/50 of those who received education only and 27/49 of those who received education plus consultation vs 13/50 patients who received UC). After controlling for patient demographics, comorbidity, and antianxiety and antidepressant medication use, patients who received education only had greater odds of Z-drug discontinuation than those in the UC group (adjusted odds ratio = 4.02, 95% confidence interval = 1.66-9.77). Patients who received education and a pharmacist call also had greater odds of discontinuing use of these drugs than those in the UC group (adjusted odds ratio = 4.10, 95% confidence interval = 1.65-10.19). Conclusion Patients who received direct-to-patient education with or without a pharmacist consultation were significantly more likely to discontinue Z-drug use than patients receiving UC. Providing evidence-based information about Z-drug use is an effective and low-resource method to encourage drug discontinuation.

Background : Chronic osteomyelitis remains difficult to treat and has a high rate of relapse after apparently succesful treatment. Cephalosporin has been greatly used for the antibiotic intervention for patient with osteomyelitis. The objective of this study was to explore bacterial profile and its microbial resistance pattern of each generation of cephalosporin from patients with chronic osteomyelitis at Dr. Hasan Sadikin General Hospital. Methods : A descriptive study was conducted to 39 medical records from patients with chronic osteomyelitis at Dr. Hasan Sadikin General Hospital that met both inclusion and exclusion criteria. The bacterial pattern and antimicrobial susceptibility test results were obtained from both medical record and laboratory database for five years, during the period of Januari 2009 to December 2014. Data of bacterial species, type of Gram staining, and numbers of resistance isolates to antiobiotic were taken from the collected data and analyzed in form of frequency tabulation and percentages. Results : As high as 43−52% of Staphylococcus aureus isolates were resistant to all generation of cephalosporin. Coagulase-negative Staphylococci and Streptococcus spp. showed resistance to cephalosporin as high as 29% and 67%, respectively. This study also discovered that 5 of 23 Staphylococcus aureus isolates were methicillin-resistant Staphylococcus aureus (MRSA). Klebsiella pneumoniae showed a leading number of resistance pattern for both third and fourth generation of cephalosporin (77%). Enterobacter cloacae showed highly resistance for both first and third generation of cephalosporin, between 57−86%. Conclusions : There is the high resistance of all bacteria to cephalosporin among chronic osteomyelitis patients. [ AMJ .2016;3(3):376–81] DOI: 10.15850/amj.v3n3.883

To evaluate the refractive and postoperative outcomes of a high-power foldable intraocular lens (IOL) in nanophthalmic eyes.Six ophthalmic surgical centers in Canada.Retrospective case series.Consecutive charts of nanophthalmic patients having cataract extraction and insertion of the CT Xtreme D IOL were reviewed. Demographic and clinical data were collected, including age, sex, axial length (AL), minimum keratometry (K) value and maximum K value, corneal white-to-white (WTW), anterior chamber depth, lens thickness (LT), and complications. The following preoperative and operative data were collected: uncorrected distant visual acuity (UDVA), corrected distant visual acuity (CDVA), sphere, cylinder, and spherical equivalence (SE). The primary outcome measure was change in SE. The secondary outcome measures were changes in UDVA and CDVA.A total of 21 eyes from 13 patients with a mean follow-up time of 9.6 ± 8.5 months were studied. Mean preoperative data were: age (51.4 ± 15.2 years), AL (16.63 ± 0.68 mm), minimum K value (46.20 ± 2.26 D), maximum K value (47.55 ± 2.34 D), anterior chamber depth (2.60 ± 0.49 mm), WTW (11.08 ± 1.38 mm), LT (4.70 ± 0.97 mm), and IOL power implanted (+49.9 ± 3.3 diopters [D]). SE improved from +16.11 ± 3.26 D preoperatively to +2.00 ± 2.37 D postoperatively (P.0001). UDVA improved from 1.47 ± 0.30 logMAR preoperatively to 0.74 ± 0.43 logMAR postoperatively (P = .016). CDVA did not change significantly. Five eyes (23.8%) had serious postoperative complications. Of these eyes, 2 had malignant glaucoma, 2 had vitreous hemorrhages, and 1 eye had a vitreous hemorrhage with retinal detachment resulting in visual acuity of no light perception.Implanting foldable high-power IOLs in a series of nanophthalmic eyes yielded significant improvement in UDVA and SE. Cataract surgery in these eyes carries increased risk.Iqbal Ike K. Ahmed is a consultant to Carl Zeiss Meditec AG. No other author has a financial or proprietary interest in any material or method mentioned.

Introduction Nonbenzodiazepine sedative-hypnotic medications, or "Z-drugs," are commonly used to treat insomnia among older adults (≥ 65 years), despite a lack of evidence of long-term effectiveness and evidence linking long-term use with poor outcomes. Objective To understand patient and clinician barriers and facilitators to deprescribing, or discontinuation, of Z-drugs. Methods We conducted a qualitative interview study among older adults who received a deprescribing intervention and among their clinicians at Kaiser Permanente Northwest. Semistructured interviews explored perceived barriers and facilitators to successful deprescribing of Z-drugs. Interviews were audiorecorded with participant permission. Content was analyzed using QSR NVivo 10 software. Results From the perspectives of patients, the greatest challenges to deprescribing are factors related to their insomnia, including the need for effective treatment of their insomnia; health care system factors, including a desire for personalized approaches to care; and their own positive personal experiences with sedative medication use. From the clinician perspective, a lack of institutional structures and resources to support deprescribing, the attitudes and practices of previous clinicians, and patient-related factors such as dependence and a lack of alternatives to treat insomnia were the most important barriers to deprescribing. Conclusions Health care systems must provide individualized care that supports patient goals for restful sleep and quality of life while also providing evidence-based care that takes patient safety into account. To accomplish this, systems must support patients and clinicians and provide a multidisciplinary approach that addresses insomnia treatment, provides patient education about sedative medication use, and supports the discontinuation process.

Despite improvements in surgical techniques and technology, the incidence of incisional and parastomal hernias remains unacceptably high. Recently a renewed interest in hernia prevention has emerged as improvements in methods of fascial closure and the concept of prophylactic mesh augmentation (PMA) has been applied for high-risk laparotomy closures and in the creations of stomas. As with any prophylactic strategy, evaluation of the risk of the preventive treatment must be carefully weighed against the potential benefit. Outcome measures should not be limited to hernia recurrence but should also include quality of life, infectious complications, and cost. To date, several studies have reported the benefit of PMA in clinical scenarios where patients are at high risk for incisional or parastomal hernias. Further research is required, specifically well-designed comparative effectiveness studies, which assess various techniques and meshes across different patient populations to determine optimal benefit from PMA. Widespread adoption of proven techniques will require well-designed pragmatic research, strong evidence-based guidelines, coding and reimbursement efforts, and education. Risk reduction techniques hold great promise to reduce the incidence of incisional and parastomal hernia.

Esthetic sclerotherapy of the face not only concerns varicosities but also bluish varicose veins and pseudoangiomatous forms.

Background: Despite strictly defined criteria for visual field progression in the ongoing Normal-tension Glaucoma Study, the authors noted a surprisingly large number of patients reaching the endpoint. Traditional methods could not be used to check the diagnostic accuracy of their criteria, because no "gold standard" was established for distinguishing true change from physiologic long-term fluctuation. Methods: The authors developed a statistical method based on the results of duplicate tests for progression in their subjects. This method allowed the authors to assess the sensitivity, specificity, and predictive values of their diagnostic criterion. It also estimated the true incidence of progression and provided standard errors for the estimates. Results: The authors found that their original strict criteria for progression, based on duplicate testing, produced false calls of progression 57% of the time. By raising the requirement for deterioration and by repeating the entire sequence of duplicate testing once more, the authors have successfully reduced the rate of false calls to 2%. Conclusion: Accuracy in recognizing progression is improved by not accepting small changes as evidence of progression and by confirming the findings on repeat testing.