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BACKGROUND: Physician underprescribing and patient nonadherence are major barriers to the benefits of guideline-directed medical therapy. An important contributor to both underprescribing and patient nonadherence is concern about medication-related side effects. Yet, there are few to no data on approaches used by physicians to: (1) elicit medication-related side effects, (2) attribute these side effects to specific medications, and (3) take appropriate action. METHODS AND RESULTS: The authors conducted semistructured interviews with physicians to identify facilitators and barriers to each critical step of heart failure medication management: elicitation of side effects, attribution of side effects to a medication, and action in response to attributed side effects. Interviews were transcribed and coded using directed content analysis. For elicitation of potential side effects, limited patient communication and family discordance in reporting were key barriers, whereas guiding questions, measurement, and open channels of communication were key facilitators. For attribution of side effects, confounding from other medications, limited time for clinical encounters, and nonspecific symptoms were key barriers, whereas time-limited medication discontinuation trials and medication rechallenges were key facilitators. For taking action, challenges with weighing risks and benefits and physician fear about causing harm or interfering with other clinicians were barriers, whereas patient-physician communication and the results of a medication discontinuation trials and medication rechallenge were facilitators. CONCLUSIONS: This study generated key facilitators and barriers to 3 key aspects of heart failure medication management related to side effects that should drive future work to improve heart failure medication management.

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Diabetes is associated with numerous comorbidities, one of which is increased vulnerability to infections. This review will focus on how diabetes mellitus (DM) affects the immune system and its various components, leading to the impaired proliferation of immune cells and the induction of senescence. We will explore how the pathology of diabetes-induced immune dysfunction may have similarities to the pathways of "inflammaging", a persistent low-grade inflammation common in the elderly. Inflammaging may increase the likelihood of conditions such as rheumatoid arthritis (RA) and periodontitis at a younger age. Diabetes affects bone marrow composition and cellular senescence, and in combination with advanced age also affects lymphopoiesis by increasing myeloid differentiation and reducing lymphoid differentiation. Consequently, this leads to a reduced immune system response in both the innate and adaptive phases, resulting in higher infection rates, reduced vaccine response, and increased immune cells' senescence in diabetics. We will also explore how some diabetes drugs induce immune senescence despite their benefits on glycemic control.

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BACKGROUND: Discharging older adult patients from the hospital poses risks due to their vulnerable conditions, complex instructions and limited health literacy. Insufficient information about medication side effects adds to patient concerns. To address this, a post-discharge information summary system was developed. While it has shown positive impacts, concerns exist regarding implementation fidelity. OBJECTIVE: This study employed a theory-driven approach to understand health providers' perspectives on effective implementation. METHOD: Individual semi-structured interviews were conducted via telephone with nurses, doctors and pharmacists from local public hospitals. All interviews were audio-recorded and transcribed verbatim. Theoretical Domains Framework (TDF) was applied for direct content analysis. Belief statements were generated by thematic synthesis under each of the TDF domains. RESULTS: A total of 98 participants were interviewed. Out of the 49 belief statements covering eight TDF domains, 19 were determined to be highly relevant to the implementation of the post-discharge information summary system. These TDF domains include knowledge, skills, social/professional role and identity, beliefs about consequences, intentions, memory, attention and decision processes, environmental context and resources and social influences. CONCLUSION: Our study contributes to the understanding of determinants in implementing discharge interventions for older adult patients' self-care. Our findings can inform tailored strategies for frontline staff, including aligning programme rationale with stakeholders, promoting staff engagement through co-creation, reinforcing positive programme outcomes and creating default settings. Future research should employ rigorous quantitative designs to examine the actual impact and relationships among these determinants.

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Phentermine is an amine anorectic that acts as a sympathomimetic agent and undergoes hepatic metabolism predominantly through CYP3A4. It is commonly used as a mediation to facilitate weight loss. Side effects of phentermine can include pulmonary hypertension, valvular heart disease, palpitations, increased heart rate or blood pressure, diarrhea, and cognitive impairment. Very rarely, phentermine usage has been associated with causing ischemic colitis. The mechanism of action for ischemic colitis from phentermine is not well defined but will be discussed in this review. We present a case of a woman who used phentermine daily for weight loss and was endoscopically confirmed to have ischemic colitis after presenting with abdominal pain and bloody diarrhea.

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Hydroxychloroquine (HCQ) is an immunomodulator used in dermatology and rheumatology. Side effects may be observed on routine monitoring studies before they become clinically apparent. The goal of this retrospective chart review was to assess laboratory abnormalities in dermatologic and rheumatologic patients taking HCQ. Medical records of patients prescribed HCQ were retrospectively reviewed. Demographics, reported side effects, and parameters on baseline and follow-up complete blood count (CBC) and comprehensive metabolic panel (CMP) were recorded and graded. Laboratory abnormalities were considered severe if they were grade 3 or greater according to Common Terminology Criteria for Adverse Events v3.0 and persistent if they continued beyond subsequent laboratory testing. Of 646 eligible charts, 289 had monitoring studies for review. There were 35 severe (grade 3 or 4, 35/289; 12%) adverse events that developed, as noted on CBC or CMP. Of these 35 severe adverse events, 25 self-corrected on subsequent testing, and 10 (10/289, 3%) across 9 patients were persistent, including glomerular filtration rate, alanine transferase, alkaline phosphatase, glucose, hemoglobin and lymphopenia abnormalities. Of these 10 abnormalities, 7/10 (70%) were unlikely due to hydroxychloroquine use according to the calculated Naranjo score for each patient. Severe laboratory abnormalities while taking hydroxychloroquine are rare, even in a population with a high rate of comorbidities. Among the abnormalities observed, the majority of them (70%) were likely due to disease progression or a medication other than hydroxychloroquine. CBC and CMP monitoring for the reason of observing abnormalities while on HCQ should be at the discretion of the prescribing physician.

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Acute interstitial nephritis (AIN) is characterized by an inflammatory infiltrate of the interstitium of the kidney, typically causing a decline in kidney function. Drug-induced AIN (also called allergic AIN) is a type of AIN. Common drugs associated with AIN are antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors (PPIs). A 59-year-old male with a history of recent laparoscopic robotic sleeve gastrectomy presented to the emergency department with five weeks of progressively worsening fatigue, nausea, and lightheadedness. Postoperatively, he was prescribed omeprazole 20 mg daily for gastric ulcer prophylaxis. His other home medications were amlodipine, atorvastatin, ursodiol, and budesonide-formoterol fumarate nebulizer. His physical examination was normal. Laboratory studies revealed elevated creatinine of 4.19 mg/dL from a baseline of 0.9 mg/dL two months ago and the presence of urine eosinophils. The etiology of this elevated creatinine was unclear, prompting CT-guided left renal biopsy. The biopsy showed diffuse interstitial inflammatory infiltration with numerous lymphocytes, a large number of neutrophils, and scattered eosinophils, consistent with the allergic type of AIN. Omeprazole was discontinued and the patient received a seven-day course of prednisone. Despite treatment, permanent renal damage occurred, and the patient's new baseline creatinine was 2.3 mg/dL. AIN caused by PPIs should be considered in the differential diagnosis of acute kidney injury (AKI). AIN can be difficult to diagnose, presenting with nonspecific symptoms, such as oliguria, malaise, nausea, and vomiting. An accurate and timely diagnosis can help prevent and treat worsening renal failure.

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Erythema multiforme (EM) is a rare and typically self-limited mucocutaneous reaction known to present secondary to various triggers, with the most common being from an infectious etiology. Medications account for a small percentage of EM cases. Here, we report a case of a 55-year-old female who presented to her primary care physician with a circular rash on the palm of her right hand, which she noticed five days after being started on atorvastatin due to right branch retinal artery occlusion. The rash was identified as case of non-photoinduced EM associated with atorvastatin use presenting solely on the palmar aspect of the patient's hand and resolving four days after discontinuation of the medication. Current literature only describes photoinduced cases of EM secondary to statin use making this case unique, and it provides important insights about considering alternative lipid-lowering treatment options for patients with recurrent or persistent cases.

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Durvalumab is an immune checkpoint inhibitor (ICI) belonging to the anti-programmed death-ligand 1 (PD-L1) class, and it is used in the treatment of various end-stage malignancies. Immune checkpoint inhibitors are associated with various systemic and cutaneous adverse events. Psoriasiform drug eruptions have been clinically observed in patients who have a personal history of psoriasis being treated with ICIs. We present a unique case of de novo psoriasis in a patient being treated for poorly differentiated adenocarcinoma of the lung. The patient responded well to topical treatment and did not require discontinuation of durvalumab. Our case highlights the importance of clinician familiarity with psoriasis presentation, its association with durvalumab therapy, and treatment options for durvalumab-induced psoriasis.

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Priapism is a painful and emergent side effect that has been linked to some antipsychotics and other psychiatric medications, most often trazodone. This is thought to be due to some level of alpha-1 adrenergic blockade by these medications. Aripiprazole is an atypical antipsychotic with notably weak alpha-1 adrenergic antagonism. Thus, we report on a unique case of aripiprazole-induced priapism in a patient with schizophrenia and recurrent episodes of antipsychotic-induced priapism. This study offers insight into the potential mechanism of aripiprazole-induced priapism and offers alternative medications, such as olanzapine and lumateperone, to treat the patient's ongoing psychotic disorder.

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BACKGROUND: The assessment of the side effects of the COVID-19 vaccine is crucial to inform individuals about the potential risks and benefits of vaccination and to provide appropriate medical care if necessary. The study aimed to assess the effect of the COVID-19 vaccine on smokers and diabetic individuals and to investigate the occurrence of any side effects in the subpopulation of the Al Jouf region, KSA. MATERIALS AND METHODS: The questionnaire had three main sections: the first covered basic information including gender, age, general health status, place, socio-economic position, nationality, smoking, and diabetes. Section 2 included the COVID-19 vaccination status and side effects, and the third section dealt with the dental history. Informed consent was obtained from the recruited individuals. Participants completed a Google self-administered questionnaire. RESULTS: One hundred and twenty participants responded to the survey forms. Similarly, for diabetics versus non-diabetics, there was no statistically significant difference in the type of vaccine received (chi-square value = 3.125, p-value = 0.682). For smokers versus non-smokers, the chi-square test showed a non-significant difference in side effects (chi-square = 2.56, p-value = 0.109), indicating that there was no significant difference in the side effects experienced by smokers and non-smokers. For diabetics versus non-diabetics, the chi-square test showed a non-significant difference in side effects (chi-square = 0.34, p-value = 0.560), indicating that there was no significant difference in the side effects experienced by diabetics and non-diabetics. CONCLUSION: Smokers and diabetics had higher harmful effects than non-smokers and non-diabetics. These findings need larger, robust trials to support treatment decision-making.

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Acute pancreatitis is an acute inflammatory process of the pancreas that requires hospital admission and treatment. There are many causes of pancreatitis, the most common being gallstone and alcohol-induced; other reasons include metabolic, infectious, and medication-induced. A new medication that has come to the market is empagliflozin, which is a sodium-glucose cotransporter-2 inhibitor that is common in managing type 2 diabetes mellitus and congestive heart failure. Although generally considered safe and effective, rare adverse effects have been reported. In this case, we present a 67-year-old female patient who presented with severe acute pancreatitis after two weeks of starting empagliflozin to treat her type 2 diabetes. This case report highlights the importance of considering rare adverse events associated with empagliflozin and the need for close monitoring of patients receiving this medication.

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Angioedema is a rare but known side effect of angiotensin-converting enzyme (ACE) inhibitor therapy. The most common presentations of ACE inhibitor-induced angioedema describe swellings in the oropharyngeal and periorbital regions. We describe a rare case of a 58-year-old female with a history of type 2 diabetes and hypertension taking lisinopril for the past three years and presented with recurrent episodes of abdominal pain, nausea, and vomiting around the same time she started taking the drug. Multiple computed tomography (CT) scans were performed, which showed findings consistent with edema in the proximal small bowel. Due to the recurrent nature of these episodes over the last three years, along with consistent findings of small bowel edema on imaging, lisinopril-induced angioedema was suspected. As a result, the patient was switched from lisinopril to amlodipine. During our follow-up with the patient, she reported that her symptoms had resolved following the withdrawal of lisinopril.

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Myeloma is an aggressive B-cell malignancy resulting from an uncontrolled production of plasma cells in the bone marrow. A multitude of drugs and combinations of drugs are now approved for use to treat this complex disease and nurses require knowledge and skills in recognising and managing new side effects associated with these treatments. This article presents an overview of some of the newer and recently approved drugs and the important side effects that have been associated with them. Clinical nurse specialists and advanced nurse practitioners are at the forefront of patients' treatment journeys and play a central role in supporting patients and families to manage side effects. Through this support, patients can continue the treatments for as long as possible with the aim of maintaining a good quality of life.

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Antipsychotics (APs) are the cornerstone of treatment for schizophrenia (SCZ) spectrum disorders. Previous research suggests that there may be a positive association between AP-induced weight gain and/or dyslipidemia and improvement in psychiatric symptoms, often referred to as a "metabolic threshold". To determine whether a similar relationship exists for glucose parameters, we conducted a systematic search in six databases from inception to June 2022 for all longitudinal studies that directly examined the relationship between changes in glucose-related outcomes and changes in psychopathology among patients with SCZ treated with APs. We identified 10 relevant studies and one additional study that considered cognition. In most cases, we found that increased levels of fasting glucose and insulin following treatment were associated with clinical improvement. These findings contribute to existing literature that could suggest a common mechanism between AP action and metabolic side effects and support a need for additional work aimed at exploring the validity of a glucose-psychopathology relation in SCZ.

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Increasingly complex and constantly emerging cancer treatment protocols are associated with kidney toxicities. Data clearly demonstrate that when patients with cancer develop acute or chronic kidney disease, severe fluid and electrolyte abnormalities, outcomes are inferior, and the promise of curative therapeutic regimens is lessened. We present a case of a 74-year-old woman with metastatic, recurrent ER+/PR-/HER2+ invasive ductal carcinoma of the right breast, status post bilateral mastectomies, chemotherapy, radiation therapy, and hormonal therapies, who were clinically stable on Trastuzumab/Pertuzumab maintenance for about a year. She then experienced disease progression. She was started on Trastuzumab+Deruxtecan (T-Dxt). However, due to worsening diarrhea of more than 12 episodes per day, decreased oral intake, weakness and weight loss, she got admitted to the hospital. Laboratory data showed hyponatremia, hypokalemia, non-anion gap metabolic acidosis, hypomagnesemia, and hypophosphatemia. These laboratory abnormalities were initially attributed to diarrhea. Renal losses were suspected when the electrolyte abnormalities did not correct despite improving diarrhea. Urine electrolytes were hence tested. There was evidence of Fanconi syndrome with glucosuria, proteinuria, and renal potassium and phosphorus wasting. Fanconi syndrome was attributed to the Deruxtecan component of the combination chemotherapy, as she was previously on Trastuzumab with no such abnormalities. The electrolyte abnormalities resolved over the course of a few months. To our knowledge, this is the first case of Fanconi syndrome due to T-Dxt.

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Photosensitivity is a condition of heightened skin sensitivity to sunlight or other forms of ultraviolet light. The case presented here highlights a rare occurrence of diltiazem-induced photosensitivity in an 87-year-old female patient with a history of atrial fibrillation and multiple comorbidities. The patient developed a distinctive erythematous rash limited to the sun-exposed area of the left side of her face during her hospital stay for respiratory failure and pneumonia. The localized distribution of the rash, along with its resolution upon reducing sun exposure, strongly suggested a photosensitivity reaction induced by diltiazem. Prompt discontinuation of the medication and transitioning to verapamil led to the resolution of the cutaneous manifestations. This case emphasizes the importance of recognizing and managing photosensitivity reactions as potential adverse effects of medications, such as diltiazem. Further research is needed to better understand the pathophysiology and risk factors associated with photosensitivity reactions to calcium channel blockers. Through this case report, we aim to contribute to the existing knowledge in this field and emphasize the significance of vigilance in clinical practice.

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Background: While online reviews from physician rating websites are increasingly utilized by healthcare providers to better understand patient needs, it remains difficult to objectively identify areas for improvement in providing psychiatric care. Objectives: To quantitatively characterize the sentiment of online written reviews of psychiatrists to determine clinical attributes that can be strengthened to improve psychiatrists' therapeutic alliance with their patients. Materials and methods: Sentiment scores of 6,400 written reviews of 400 US-based psychiatrists on a US-based online physician rating website were obtained through a natural-language-processing-based sentiment analysis. Relationships among sentiment scores, average star ratings, and demographics were examined. Linguistic analyses determined words and bigrams that were highly associated with reviews with the most positive and negative sentiment. Findings: Sentiment scores were significantly correlated with average star ratings of the psychiatrists (R = 0.737, p < 0.001). Psychiatrists who were younger (< 56 years old) and/or practiced in the Northeast had significantly higher average star ratings than those older and/or practicing in the Southwest. Frequency analysis showed that positive reviews most frequently contained "time" (N = 1,138) and "caring" (N = 784) while negative reviews most frequently contained "medication" (N = 495) and "time" (N = 379). Logistic regression analysis revealed that reviews were more likely to be considered positive when they included "great listener" (OR = 16.89) and "comfortable" (OR = 10.72) and more likely to be negative when they included "meds" (OR = 0.55) and "side effect" (OR = 0.59). Conclusion: Psychiatrists who are younger and located in the Northeast receive more positive reviews; there may be potential for demographic bias among patient reviewers. Patients positively rate psychiatrists who make them feel heard and comfortable but negatively rate encounters centered around medications and their side effects. Our study lends quantitative evidence to support the importance of thorough and empathetic communication of psychiatrists in building a strong therapeutic alliance.

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Background Self-medication (SM) can be defined as the improper practice of obtaining and consuming a pharmaceutical drug without the consultation or prescription of a licensed physician. This includes evaluating the intensity of signs and symptoms which could lead to treating oneself with a medicine or seeking urgent medical care. Although SM can be deemed as safe for one's health, drug accessibility accounts for an irrational choice of medicines and thus exposes oneself to the adverse effects of these medicines. Several regional studies have provided sufficient evidence about how SM has commonly been practiced and held in some settings, such as pharmacies. Aim In this study, we aimed to assess the practice and awareness of SM in the general public. Thus, we utilized a questionnaire-based survey to analyze SM awareness and practice among the general population in Jeddah and Makkah. In addition, we examined the impact of demographic variables, such as educational level, economic status, age, etc. on SM practice. Methods A cross-sectional survey was distributed via social media platforms in June 2020. The study included Jeddah and Makkah's general public, all different nationalities, and both genders, and it excluded participants below the age 18-year-old and with mental and cognitive instability. After extrapolating the sample size at a 95% confidence level with an estimated 50% response distribution, a margin of error ±5%, and accounting for a 5% non-response rate, the estimated sample size was determined to be 404. Results A total of 642 participants completed the online-based survey, but only 472 responses fit the study criteria. Most of the participants (64.6%) did not consult with a physician, i.e., practiced SM, whereas (34.5%) have visited a doctor. Furthermore, people who did not visit a doctor had the commonest belief (26.1%) that they did not need a doctor to investigate their symptoms. The awareness of SM among the general public in Makkah and Jeddah was assessed by asking whether they deem this practice harmful, harmless, or beneficial. 65.9% of the participants deemed the practice of SM as harmful, and 17.6% regarded the act as harmless. Conclusion This study revealed that 64.6% of the general public of Jeddah and Makkah practice self-medication, even though 65.9% deemed this act harmful. The contradiction between the public's opinion and the actual behavior towards self-medication implies the need for more awareness of self-medication and the importance of exploring the incentives of such behavior.

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Direct oral anticoagulants (DOACs) are well known to be associated with bleeding complications. However, little is known about their association with atraumatic splenic rupture, a potentially fatal condition. We present the case of a 73-year-old female with paroxysmal atrial fibrillation managed with rivaroxaban who developed a spontaneous atraumatic splenic rupture. This highlights the importance of recognizing this complication in patients without previous risk factors, such as abdominal trauma or infiltrative splenic disease, who are under anticoagulation with DOACs. There is a strong need for further research on this complication's underlying mechanism and management.

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Objective To increase compliance with Abnormal Involuntary Movement Score (AIMS) documentation for patients taking antipsychotics to recognize and treat tardive dyskinesia in the psychiatry outpatient clinic. Methods The Lean Six Sigma quality improvement (QI) model, utilizing DMAIC steps of define, measure, analyze, improve, control, was followed. Psychiatry attendings and residents were surveyed to assess reasons for AIMS non-documentation, and they ranked their preferred solutions to increase compliance. A random sample of patient charts for individuals on antipsychotic medications was obtained to determine AIMS documentation compliance prior to and following the implementation of improvements. Results The most highly ranked solution was implementing a one-hour AIMS training session. Three months post-intervention, a random sample of 60 patient charts showed that 87% (52/60) of patients had AIMS documented which was a significant increase compared to 3% (1/30) pre-intervention (p<0.001). Conclusion An annual, one-hour AIMS training session for residents improved rates of AIMS documentation.