2010 September 18

Mitiglinide: A Novel Agent for the Treatment of Type 2 Diabetes Mellitus (October) (CE).

Sep 182010

Mitiglinide: A Novel Agent for the Treatment of Type 2 Diabetes Mellitus (October) (CE).

Ann Pharmacother. 2010 Sep 14;

Authors: Phillippe HM, Wargo KA

OBJECTIVE: To review the pharmacology, pharmacokinetics, efficacy, and safety of mitiglinide, a rapid-acting insulin secretion-stimulating agent to determine its potential role in therapy for the treatment of type 2 diabetes mellitus. DATA SOURCES: A MEDLINE search (1966-May 2010) was conducted for English-language, human studies using the terms mitiglinide, KAD 1229, S 21403, and meglitinide analogs. Abstracts presented at the American Association and European Association for the Study of Diabetes annual meetings from 2005 to 2009 were also evaluated for relevant data. STUDY SELECTION AND DATA EXTRACTION: Articles pertinent to the pharmacology, pharmacokinetics, efficacy, and safety of mitiglinide were reviewed. DATA SYNTHESIS: Mitiglinide has been shown through small clinical studies (N <400) to modestly decrease hemoglobin A1c, postprandial hyperglycemia, and oxidative stress and inflammatory markers associated with postprandial hyperglycemia. Mitiglinide exerts its hypoglycemic activity by closing adenosine triphosphate (ATP)-sensitive potassium channels in the Î²-islet cells of the pancreas. This agent has a rapid onset and short duration of action, mimicking a physiologic pattern of insulin release in nondiabetic people. Studies suggest a starting dose of 5 mg 3 times daily with meals and a maximum dose of 20 mg 3 times daily. Overall, mitiglinide is well tolerated, with the most common adverse effect being hypoglycemia. CONCLUSIONS: Mitiglinide is the third agent in the class of meglitinides that targets postprandial hyperglycemia. Because of a more intensive dosing regimen, potential cost, and lack of studies assessing the clinical impact of mitiglinide therapy on oxidative stress and inflammatory markers secondary to postprandial hyperglycemia, we cannot recommend this therapy over currently approved therapies.

PMID: 20841518 [PubMed - as supplied by publisher]

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Relation of elevated plasma Renin activity at baseline to cardiac events in patients with angiographically proven coronary artery disease.

Am J Cardiol Start a Discussion »

Sep 182010

Relation of elevated plasma Renin activity at baseline to cardiac events in patients with angiographically proven coronary artery disease.

Am J Cardiol. 2010 Sep 15;106(6):764-9

Authors: Muhlestein JB, May HT, Bair TL, Prescott MF, Horne BD, White R, Anderson JL

Plasma renin activity (PRA) is a measure of renin-angiotensin system activity and is associated with cardiovascular outcomes in patients with heart failure (HF). We conducted a prospective analysis to assess whether elevated baseline PRA is associated with cardiovascular outcomes in 1,165 patients with coronary artery disease (>/=70% stenosis on the coronary angiogram) enrolled in the Intermountain Heart Collaborative Study. The exclusion criteria included previous myocardial infarction (MI) or HF, ejection fraction </=45%, and a discharge diagnosis of MI/beta-blocker treatment. Baseline PRA measurements were evaluated as risk categories (</=0.50, 0.51 to 2.30, and >2.30 ng/ml/h) and as tertiles (</=0.40, 0.41 to 1.90, and >/=1.90 ng/ml/h). Predefined cardiovascular outcomes were assessed for a minimum follow-up of 3 years (mean 6.4 +/- 3.2, maximum 14.6) using Cox regression analysis to adjust for the baseline characteristics. The mean patient age was 64.4 years; most patients were men (73.1%) and hypertensive (63.2%). Elevated baseline PRA (high vs low category; >2.30 vs </=0.50 ng/ml/h) was associated with a significantly increased risk of 3-year cardiac morbidity/mortality (hazard ratio 1.96; p = 0.004), MI (hazard ratio 2.41; p = 0.02), HF hospitalization (hazard ratio 4.39; p = 0.03), and all-cause death (hazard ratio 1.80; p = 0.01). Elevated baseline PRA was also associated with longer-term HF hospitalization (hazard ratio 2.12; p = 0.004) and all-cause death (hazard ratio 1.56; p = 0.002). Similar results were observed for the PRA tertiles. The association of PRA with outcomes was observed after correction for hypertension, hyperlipidemia, diabetes, a family history of cardiovascular events, smoking, renal failure, and the use of statins. In conclusion, elevated baseline PRA is associated with cardiac morbidity and mortality in patients with coronary artery disease but normal left ventricular function and no previous MI or HF.

PMID: 20816114 [PubMed - in process]

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Nonagenarian surgical admissions for the acute abdomen: who benefits?

Int J Clin Pract Start a Discussion »

Sep 182010

Nonagenarian surgical admissions for the acute abdomen: who benefits?

Int J Clin Pract. 2010 Oct;64(11):1570-1572

Authors: Toumi Z, Kesterton A, Bhowmick A, Beveridge AJ, Scott NA

Introduction:â€‚ Patients 90â€ƒyears and older form an increasing proportion of the general population. Outcomes of their acute surgical admissions are not well documented. Methods and materials:â€‚ Surgical management of 49 consecutive nonagenarian admissions (median age: 92â€ƒyears) with an acute abdomen was compared with the management and outcome of 50 younger patients (median age: 53.5) admitted with a suspected acute abdomen over the same period. Results:â€‚ Nonagenarian group consisted of mainly women (71% vs. 50%; pâ€ƒ=â€ƒ0.003). The use of laboratory investigations and imaging was similar for the patients aged over 90 and the younger patients, although proportionately fewer nonagenarians were investigated by abdominal CT scan (8% vs. 24%). Of the 49 nonagenarian patients admitted, only 4% (nâ€ƒ=â€ƒ2) were operated on. In contrast, 38% (nâ€ƒ=â€ƒ19) of patients aged 50-59 (pâ€ƒ=â€ƒ0.0001) underwent a surgical intervention. A much greater proportion of nonagenarians died in hospital than patients in the 50-59 comparator group (16% nonagenarians vs. 4% comparator patients; pâ€ƒ=â€ƒ0.04). The very large majority of survivors in both age groups were discharged back to their preadmission domicile [39 (95%) nonagenarians vs. 46 (96%) comparator 50-59â€ƒyear group]. Conclusions:â€‚ In this study, when compared with younger patients, very few nonagenarian patients (2%) with a suspected acute abdomen benefited from surgical admission. Instead, the large majority of nonagenarians either died or were discharged back to their home address without surgery.

PMID: 20846205 [PubMed - as supplied by publisher]

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Usefulness of primary angioplasty in nonagenarians with acute myocardial infarction.

Am J Cardiol Start a Discussion »

Sep 182010

Usefulness of primary angioplasty in nonagenarians with acute myocardial infarction.

Am J Cardiol. 2010 Sep 15;106(6):770-3

Authors: Danzi GB, Centola M, Pomidossi GA, Consonni D, De Matteis S, Stabile A, Sesana M, Anzuini A, Sganzerla P, Cortese B, Migliorini A, Antoniucci D

The optimal reperfusion strategy in very elderly patients with ST-segment elevation myocardial infarction is still a subject of debate. The aim of this multicenter study was to determine the medium-term outcomes of nonagenarians after primary percutaneous intervention for ST-segment elevation myocardial infarction. A systematic review of the databases of 7 Italian centers showed that these had performed 5,023 primary angioplasties over the previous 5 years, 100 of which (2%) involved patients >/=90 years old. Thirty-five subjects were in Killip class III or IV at time of presentation, 78 had multivessel coronary artery disease, and mean ejection fraction was 0.40 +/- 0.12%. In-hospital mortality was 19% and was significantly higher in patients with shock (58% vs 10%, p <0.001). Survival rate after 6 months was 68%: 16% in those with Killip class IV at admission and 81% in the remaining patients (p <0.001). Cox regression analysis identified 3 independent predictors of 6-month mortality: cardiogenic shock at presentation (hazard ratio [HR] 10.82, 95% confidence interval [CI] 4.51 to 25.93, p <0.001), Thrombolysis In Myocardial Infarction myocardial flow after percutaneous coronary intervention (HR 0.19, 95% CI 0.07 to 0.50, p = 0.001), and abciximab administration (HR 0.32, 95% CI 0.13 to 0.78, p = 0.01). In conclusion, the results of this multicenter study suggest that selected nonagenarians with acute myocardial infarction benefit from successful primary angioplasty. The treatment does not affect the poor prognosis of patients presenting with cardiogenic shock, but the administration of abciximab seems to have a positive effect on 6-month mortality.

PMID: 20816115 [PubMed - in process]

Link to Article at PubMed

Adherance to protocol during the acute management of diabetic ketoacidosis: would specialist involvement lead to better outcomes?

Int J Clin Pract Start a Discussion »

Sep 182010

Adherance to protocol during the acute management of diabetic ketoacidosis: would specialist involvement lead to better outcomes?

Int J Clin Pract. 2010 Oct;64(11):1580-1582

Authors: Devalia B

Background:â€‚ Diabetic ketoacidosis (DKA) is a hyperglycaemic emergency associated with major morbidity and mortality. It has been shown that treating patients admitted with DKA using an integrated care pathway, or protocol, reduces time taken to initiate management thus optimising care. Early input from diabetes specialist services should also be sought. A new protocol for managing DKA was introduced in Sherwood Forest Trust in July 2008. Aims:â€‚ To assess whether the trust DKA protocol is being followed at Kingsmill and Newark District General Hospitals during acute management (first 4 h) of patients. Methods:â€‚ Retrospective case note review of all adult patients coded as DKA from July 2008 to February 2009. Results:â€‚ Seventy-eight percent of patients were correctly diagnosed according to protocol. Hundred percent of patients had IV access and correct blood tests within 1 h of admission. Eighty percent were given appropriate fluid resuscitation within the first hour. Seventy-two percent had correct insulin prescribed and 73% were on the correct sliding scale. Seventy-eight to ninety percent of patients had correct initial investigations ordered. However only 46% of patients requiring High Dependency Unit care were referred appropriately. Between hours 2 and 4 only 38% had repeat electrolytes checked and only 35-60% of patients had the correct fluid prescribed. Conclusions:â€‚ The findings indicated that there was awareness of the new DKA protocol. It was referred to and placed in clinical notes but not always followed. Management of patients with DKA within the first hour was compliant. However, subsequent fluid management and electrolyte monitoring was poor. It was found that using a protocol does help to standardise initial management of patients but further education is needed and referral criteria need clarifying. Access to 24-hour specialist services may also help to optimise management.

PMID: 20846206 [PubMed - as supplied by publisher]

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Automated drug dispensing system reduces medication errors in an intensive care setting.

Crit Care Med Start a Discussion »

Sep 182010

Automated drug dispensing system reduces medication errors in an intensive care setting.

Crit Care Med. 2010 Sep 9;

Authors: Chapuis C, Roustit M, Bal G, Schwebel C, Pansu P, David-Tchouda S, Foroni L, Calop J, Timsit JF, Allenet B, Bosson JL, Bedouch P

OBJECTIVES:: We aimed to assess the impact of an automated dispensing system on the incidence of medication errors related to picking, preparation, and administration of drugs in a medical intensive care unit. We also evaluated the clinical significance of such errors and user satisfaction. DESIGN:: Preintervention and postintervention study involving a control and an intervention medical intensive care unit. SETTING:: Two medical intensive care units in the same department of a 2,000-bed university hospital. PATIENTS:: Adult medical intensive care patients. INTERVENTIONS:: After a 2-month observation period, we implemented an automated dispensing system in one of the units (study unit) chosen randomly, with the other unit being the control. MEASUREMENTS AND MAIN RESULTS:: The overall error rate was expressed as a percentage of total opportunities for error. The severity of errors was classified according to National Coordinating Council for Medication Error Reporting and Prevention categories by an expert committee. User satisfaction was assessed through self-administered questionnaires completed by nurses. A total of 1,476 medications for 115 patients were observed. After automated dispensing system implementation, we observed a reduced percentage of total opportunities for error in the study compared to the control unit (13.5% and 18.6%, respectively; p < .05); however, no significant difference was observed before automated dispensing system implementation (20.4% and 19.3%, respectively; not significant). Before-and-after comparisons in the study unit also showed a significantly reduced percentage of total opportunities for error (20.4% and 13.5%; p < .01). An analysis of detailed opportunities for error showed a significant impact of the automated dispensing system in reducing preparation errors (p < .05). Most errors caused no harm (National Coordinating Council for Medication Error Reporting and Prevention category C). The automated dispensing system did not reduce errors causing harm. Finally, the mean for working conditions improved from 1.0 Â± 0.8 to 2.5 Â± 0.8 on the four-point Likert scale. CONCLUSIONS:: The implementation of an automated dispensing system reduced overall medication errors related to picking, preparation, and administration of drugs in the intensive care unit. Furthermore, most nurses favored the new drug dispensation organization.

PMID: 20838333 [PubMed - as supplied by publisher]

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