Potential adverse drug events can be signaled in Clinical Decision Support Systems (CDSSs). This study validated a Swedish CDSS (Janusmed Risk Profile) by investigating associations between calculated risk classifications of drugs with QT-prolonging potential and registered related clinical outcomes. Subjects living in Kalmar County, Sweden, between 2011 and 2020 exposed to risk drugs (risk level I: somewhat increased risk, II: moderate increased risk, III: significant increased risk) were extracted from regional electronic health records and matched to controls (risk level 0: no known increased risk) by age, sex, and index date. Ventricular arrhythmia (VA), Torsade de Pointes, cardiac arrest and death were outcomes followed for one year. Logistic regression analysis was performed adjusted for age, sex, number of drugs, days in hospital and previous diagnosis. Among the 188,453 subjects, a higher proportion of those classified by the CDSS as having a risk of QT prolongation experienced VA compared to controls (risk level I = 0.26%, II = 0.34%, III = 0.71% vs risk level 0 = 0.17%). When adjusting for other risk factors, the association decreased, but risk level III remained significant with OR 2.1 (95% CI 1.6-2.9) compared to controls. Similar results were seen for the other outcomes. Although there was an association between CDSS risk classifications and clinical outcomes, only a few subjects are affected, and other factors, such as previous diagnosis, play an important role. The need for multifactorial CDSS algorithms is thus crucial to better guide prescribers in finding high-risk patients.

Background: Vitamin D deficiency, secondary osteoporosis and low-energy fractures (LEF) as side effects of specific drugs were first described more than half a century ago. These effects are recognized in guidelines where patients prescribed risk drugs are recommended follow-up with testing and supplementation. How these drugs are managed within Swedish healthcare has not been previously investigated. 

Aim: To study epidemiological aspects of drug-related vitamin D deficiency and osteoporotic fractures.

Methods: The association between drugs for continual use and vitamin D levels in the elderly was investigated in a clinical study including more than 550 patients (paper I). Real-world data on drug prescriptions, laboratory testing and demographic variables from electronic health records were thereafter used to assess the clinical management and vitamin D levels. More than 12 000 patients prescribed risk drugs were included in this cross-sectional study (paper II). Focus group interviews were then undertaken to explore determinants of risk drug management among physicians from seven primary care centers. Thematic analysis with an inductive approach was used to create a framework addressing adherence to medical guidelines (paper III). Finally, a multifactorial risk assessment tool was developed from LEF risk factors in more than    15 000 patients prescribed antiepileptic risk drugs in a retrospective open cohort study (paper IV).

Results: A weak inverse association between the number of prescribed drugs and levels of vitamin D was found (paper I). Fewer than one in fifteen patients prescribed risk drugs were tested for vitamin D while close to a third were supplemented. Differences in management and vitamin D levels with regard to type of risk drug were found (paper II). Awareness levels, expressed beliefs and perceived responsibility were reasons behind these differences (paper III). The Kalmar Epilepsy Fracture Risk Index (KEFRI) confirmed previously suggested risk factors (paper IV). 

Conclusions: Drugs generating vitamin D deficiency, secondary osteoporosis and LEF are often overlooked in healthcare. Awareness and attitudes need to be improved and strategies to better manage patients prescribed these drugs are required in order to avoid unnecessary side effects. The KEFRI could aid clinicians in treatment decisions, potentially reducing fracture risks in specific patient groups. 

Objectives: Antiepileptic drugs (AED) are known to increase the risk of low energy fractures by causing secondary osteoporosis. In this study, we determined the value of bone mineral density (BMD) and trabecular bone score (TBS) as predictors for low energy fractures in patients prescribed AED.

Material and Methods: This case-control study included 517 low energy fractures, i.e. a combination of ICD-10 codes according to the Swedish National Board of Health and Welfare's definition of osteoporosis- related fractures and ICD-10 codes for low energy trauma, in 1 385 subjects who had all participated in a TBS convertible DXA examination between July 2011 and November 2018 in Kalmar county, southeast Sweden. The AED-users were stratified according to Cytochrome P-450 enzyme inducing ability and compared to controls. The dataset was a combination of previously collected data from the electronic health register (EHR) and new BMD and TBS data from a DXA database. Univariate and multivariate logistic regressions were applied. 

Results: In this study BMD-spine did not predict low energy fractures; however, both BMD-hip (aOR: 0.35, 95% CI: 0.24-0.50) and TBS (aOR: 0.65, 95% CI: 0.46-0.92) were inversely related to fractures. Patients prescribed enzyme inducing AED had an increased fracture odds (aOR: 2.15, 95% CI: 1.24-3.72). There was no difference for fracture outcome between subjects with non-inducing drugs and controls (p-value 0.476). In this study 67.5% of the TBS convertible DXAs were performed within a year of the low energy fracture. Of the included patients, 82% were women.

Conclusions: While BMD-spine was not associated with low energy fractures, both BMD-hip and TBS predicted low energy fractures independently in patients prescribed AED. This is the first study demonstrating the value of TBS in patients prescribed AED. In clinical practice, BMD-hip and TBS could be combined to improve the assessment of bone health in this growing patient group. The value of the combination of the two measures should be assessed in a future prospective randomized study.

Purpose: Several medications are known to cause vitamin D deficiency. The aim of this study is to describe vitamin D testing and supplementation in patients using these “risk medications”, thereby assessing adherence to medical guidelines.Patients and methods: A database with electronic health records for the population in a Swedish County (≈240,000 inhabitants) was screened for patients prescribed the pre-defined “risk medications” during a 2-year period (2014–2015). In total, 12,194 patients were prescribed “risk medications” pertaining to one of the three included pharmaceutical groups. Vitamin D testing and concomitant vitamin D supplementation, including differences between the included pharmaceutical groups, was explored by matching personal identification numbers.Results: Corticosteroids were prescribed to 10,003 of the patients, antiepileptic drugs to 1,101, and drugs mainly reducing vitamin D uptake to 864. Two hundred twenty-six patients were prescribed >1 “risk medication”. Seven hundred eighty-seven patients (6.5%) had been tested during the 2-year period. There were no differences regarding testing frequency between groups. Concomitant supplements were prescribed to 3,911 patients (32.1%). It was more common to be prescribed supplements when treated with corticosteroids. Vitamin D supplementation was more common among tested patients in all three groups. Women were tested and supplemented to a higher extent. The mean vitamin D level was 69 nmol/L. Vitamin D deficiency was found in 24.1% of tested patients, while 41.3% had optimal levels. It was less common to be deficient and more common to have optimal levels among patients prescribed corticosteroids.Conclusion: Adherence to medical guidelines comprising testing and supplementation of patients prescribed drugs causing vitamin D deficiency needs improvement in Sweden.

Controversy pervades the definition of adequate and optimal vitamin D status. The Institutes of Medicine have recommended serum 25(OH) D levels above 50 nmol/L based upon evidence related to bone health, but some experts, including the Endocrine Society and International Osteoporosis Foundation, suggest a minimum serum 25(OH) D level of 75 nmol/L to reduce the risk of falls and fractures in older adults. In a cross-sectional study, we compared vitamin D status in people >= 75 years selected from four groups with a frailty phenotype, combined with a control group free from serious illness, and who considered themselves completely healthy. Only 13% of the 169 controls were vitamin D deficient (S-25(OH) D) < 50 nmol/L), in contrast with 49% of orthopedic patients with hip fractures (n = 133), 31% of stroke patients (n = 122), 39% of patients visiting the hospital's emergency department >= 4 times a year (n = 81), and 75% of homebound adult residents in long-term care nursing homes (n = 51). The mean vitamin D concentration of the healthy control group (74 nmol/L) was similar to a suggested optimal level based on physiological data and mortality studies, and much higher than that of many officially recommended cut-off levels for vitamin D deficiency (< 50 nmol/L). The present study provides a basis for planning and implementing public guidelines for the screening of vitamin D deficiency and vitamin D treatment for frail elderly patients.

OBJECTIVE: To summarise published HIV-specific research on readiness theories, factors influencing readiness, instruments to measure readiness and interventions to increase readiness for treatment.

METHODS: Medline and PsychInfo were searched until August 2004.

RESULTS: Two HIV-specific readiness theories were identified. Fear of side effects, emotions emerging from the diagnosis and lack of trust in the physician were some barriers to overcome in order to reach readiness. Of the three measurement instruments found, the index of readiness showed the most promise. Multi-step intervention programs to increase readiness for HIV treatment had been investigated.

CONCLUSION: Readiness instruments may be useful tools in clinical practice but the predictive validity of the instruments needs to be further established in the HIV-infected population.

PRACTICE IMPLICATIONS: Readiness instruments and practice placebo trials may serve as complements to routine care, since health care providers currently have no better than chance probability in identifying those patients who are ready to adhere.