2011 March 28

The consequences of requesting “dispense as written”.

Mar 282011

The consequences of requesting "dispense as written".

Am J Med. 2011 Apr;124(4):309-17

Authors: Shrank WH, Liberman JN, Fischer MA, Avorn J, Kilabuk E, Chang A, Kesselheim AS, Brennan TA, Choudhry NK

All US states have adopted generic substitution laws to reduce medication costs. However, physicians may override these regulations by prescribing branded drugs and requesting that they are dispensed as written. Patients also can make these requests. Little is known about the frequency and correlates of dispense as written requests or their association with medication filling.

PMID: 21435421 [PubMed - in process]

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Predictive and Associative Models to Identify Hospitalized Medical Patients at Risk for Venous Thromboembolism.

Chest Start a Discussion »

Mar 282011

Predictive and Associative Models to Identify Hospitalized Medical Patients at Risk for Venous Thromboembolism.

Chest. 2011 Mar 24;

Authors: Spyropoulos AC, Anderson FA, Fitzgerald G, Decousus H, Pini M, Chong BH, Zotz RB, Bergmann JF, Tapson V, Froehlich JB, Monreal M, Merli GJ, Pavanello R, Turpie AG, Nakamura M, Piovella F, Kakkar AK, Spencer FA,

Abstract BACKGROUND: Acutely ill hospitalized medical patients are at risk for venous thromboembolism (VTE). We assessed the incidence of VTE in the observational IMPROVE study, and derived VTE risk-assessment scores at admission and associative VTE scores during hospitalization. METHODS: Data from 15,156 medical patients were analyzed to determine the cumulative incidence of clinically observed VTE over 3 months after admission. Multiple regression analysis identified factors associated with VTE risk. RESULTS: Of the 184 patients who developed symptomatic VTE, 76 had pulmonary embolism and 67 lower-extremity DVT. Cumulative VTE incidence was 1.0%; 45% of events occurred post-discharge. Factors independently associated with VTE included: previous VTE; known thrombophilia; cancer; age >60, lower limb paralysis; immobilization ?7 days; and admission to an intensive/coronary care unit (first four were available at admission). Points were assigned to each factor identified to give a total risk score for each patient. At admission, 67% of patients had a score ?1. During hospitalization, 31% had a score ?2; for a score of 2 or 3, observed VTE risk was 1.5% vs 5.7% for a score ?4. Observed and predicted rates were similar for both models (c statistics 0.65 and 0.69, respectively. During hospitalization, a score ?2 was associated with higher overall and VTE-related mortality. CONCLUSIONS: Weighted VTE risk scores derived from four clinical risk factors at hospital admission can predict VTE risk in acutely ill hospitalized medical patients. Scores derived from seven clinical factors during hospitalization may help us further understand symptomatic VTE risk. These scores require external validation.

PMID: 21436241 [PubMed - as supplied by publisher]

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Prognosis and guideline-adherent antithrombotic treatment in patients with atrial fibrillation and atrial flutter. Implications of undertreatment and overtreatment in real life clinical practice: The Loire Valley Atrial Fibrillation Project.

Chest Start a Discussion »

Mar 282011

Prognosis and guideline-adherent antithrombotic treatment in patients with atrial fibrillation and atrial flutter. Implications of undertreatment and overtreatment in real life clinical practice: The Loire Valley Atrial Fibrillation Project.

Chest. 2011 Mar 24;

Authors: Gorin L, Fauchier L, Nonin E, Charbonnier B, Babuty D, Lip GY

ABSTRACT BACKGROUND: In patients with atrial fibrillation (AF), adherence to guidelines for antithrombotic treatment is poorly followed and undertreatment (or 'non-adherence' with guidelines) is associated with a worse prognosis. Our objective was to evaluate if this was also the case in a large contemporary series of unselected AF patients in 'real world' clinical practice. METHODS: All patients with AF or atrial flutter seen in our institution between 2000 and 2007 were identified in a database and followed up for mortality and stroke. Antithrombotic guideline adherence was assessed according to the 2006 ACC/AHA/ESC guidelines. RESULTS: We reviewed outcomes in 3,646 consecutive patients with AF or atrial flutter (age 71±14 years; mean CHADS(2) score 1.5±1.1). Antithrombotic treatment was in agreement with the guidelines in 53% of patients, whereas 31% were classed as 'undertreated' and 16% as 'overtreated'. Among other parameters, non permanent AF/flutter was independently associated with an increased risk of undertreatment. After a follow-up of 953±767 days (median=771, interquartile range=1,286 days), guideline adherence was associated with a lower risk of adverse events (death from all causes or stroke) compared to undertreatment (Relative risk [RR] =0.47, 95%CI 0.40-0.55, p<0.0001). Overtreatment was associated with a lower risk of adverse events compared to the guideline adherent population (RR=0.40, 95%CI 0.28-0.58, p<0.0001). Factors independently associated with increased risk of mortality or stroke were antithrombotic undertreatment, older age, heart failure, renal failure, diabetes, male sex and previous history of stroke. CONCLUSIONS: Guideline non adherence or undertreatment with antithrombotic in unselected 'real world' patients with AF or atrial flutter is independently associated with a higher risk of stroke and mortality.

PMID: 21436246 [PubMed - as supplied by publisher]

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Correlation between antibiotic consumption and resistance of Gram-negative bacteria causing healthcare-associated infections at a university hospital in Taiwan from 2000 to 2009.

J Antimicrob Chemother Start a Discussion »

Mar 282011

Correlation between antibiotic consumption and resistance of Gram-negative bacteria causing healthcare-associated infections at a university hospital in Taiwan from 2000 to 2009.

J Antimicrob Chemother. 2011 Mar 24;

Authors: Lai CC, Wang CY, Chu CC, Tan CK, Lu CL, Lee YC, Huang YT, Lee PI, Hsueh PR

Objectives This study investigated the correlation between antibiotic consumption and antimicrobial resistance in Gram-negative bacteria causing healthcare-associated infections at a university hospital in Taiwan from 2000 to 2009. Methods Disc susceptibility data of Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, Proteus spp., Pseudomonas aeruginosa, Acinetobacter spp., Stenotrophomonas maltophilia and other non-fermentative Gram-negative bacilli causing healthcare-associated infections were evaluated. Data on annual patient-days and annual consumption (defined daily doses per 1000 patient-days) of extended-spectrum cephalosporins, ?-lactam/?-lactamase inhibitor combinations, carbapenems, aminoglycosides and ?uoroquinolones were analysed. Results The trend of total consumption of extended-spectrum cephalosporins, ?-lactam/?-lactamase inhibitor combinations, carbapenems, aminoglycosides and fluoroquinolones significantly increased between 2000 and 2003 and remained stable between 2004 and 2009. The decreasing use of gentamicin and amikacin in recent years was associated with increasing susceptibility of E. coli, E. cloacae, S. marcescens and P. aeruginosa to gentamicin, as well as increasing susceptibility of P. aeruginosa to amikacin. The use of piperacillin/tazobactam was positively correlated with the prevalence of piperacillin/tazobactam-resistant E. coli and S. maltophilia. In contrast, the use of cefotaxime and piperacillin/tazobactam was negatively correlated with the prevalence of cefotaxime-resistant E. coli and piperacillin/tazobactam-resistant S. maltophilia, respectively. The consumption of fluoroquinolones was positively correlated with the rates of ciprofloxacin-resistant E. coli, piperacillin/tazobactam-resistant P. aeruginosa and ceftazidime-resistant S. maltophilia. Conclusions The relationship between antibiotic prescription and the rates of resistance for Gram-negative bacteria is complicated; every type of antimicrobial agent or even individual agent can have distinct associations with different pathogens.

PMID: 21436153 [PubMed - as supplied by publisher]

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Peri-operative management of antiplatelet therapy in patients with coronary artery disease. Joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC).

Thromb Haemost Start a Discussion »

Mar 282011

Peri-operative management of antiplatelet therapy in patients with coronary artery disease. Joint position paper by members of the working group on Perioperative Haemostasis of the Society on Thrombosis and Haemostasis Research (GTH), the working group on Perioperative Coagulation of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society for Cardiology (ESC).

Thromb Haemost. 2011 Mar 24;105(5)

Authors: Korte W, Cattaneo M, Chassot PG, Eichinger S, von Heymann C, Hofmann N, Rickli H, Spannagl M, Ziegler B, Verheugt F, Huber K

An increasing number of patients suffering from cardiovascular disease, especially coronary artery disease (CAD), are treated with aspirin and/or clopidogrel for the prevention of major adverse events. Unfortunately, there are no specific, widely accepted recommendations for the perioperative management of patients receiving antiplatelet therapy. Therefore, members of the Perioperative Haemostasis Group of the Society on Thrombosis and Haemostasis Research (GTH), the Perioperative Coagulation Group of the Austrian Society for Anesthesiology, Reanimation and Intensive Care (ÖGARI) and the Working Group Thrombosis of the European Society of Cardiology (ESC) have created this consensus position paper to provide clear recommendations on the perioperative use of anti-platelet agents (specifically with semi-urgent and urgent surgery), strongly supporting a multidisciplinary approach to optimize the treatment of individual patients with coronary artery disease who need major cardiac and non-cardiac surgery. With planned surgery, drug eluting stents (DES) should not be used unless surgery can be delayed for ?12 months after DES implantation. If surgery cannot be delayed, surgical revascularisation, bare-metal stents or pure balloon angioplasty should be considered. During ongoing antiplatelet therapy, elective surgery should be delayed for the recommended duration of treatment. In patients with semi-urgent surgery, the decision to prematurely stop one or both antiplatelet agents (at least 5 days pre-operatively) has to be taken after multidisciplinary consultation, evaluating the individual thrombotic and bleeding risk. Urgently needed surgery has to take place under full antiplatelet therapy despite the increased bleeding risk. A multidisciplinary approach for optimal antithrombotic and haemostatic patient management is thus mandatory.

PMID: 21437351 [PubMed - as supplied by publisher]

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Pharmacokinetic evaluation of oral tablet form of low-molecular-weight heparin and deoxycholic acid conjugate as a novel oral anticoagulant.

Thromb Haemost Start a Discussion »

Mar 282011

Pharmacokinetic evaluation of oral tablet form of low-molecular-weight heparin and deoxycholic acid conjugate as a novel oral anticoagulant.

Thromb Haemost. 2011 Mar 24;105(6)

Authors: Park JW, Jeon OC, Kim SK, Al-Hilal TA, Lim KM, Moon HT, Kim CY, Byun Y

This study was designed to develop a solid oral dosage form of deoxycholic acid (DOCA)-conjugated low-molecular-weight heparin (LMWH) and to evaluate its oral absorption, distribution, and metabolic stability for the prospect of providing an orally bioavailable LMWH. The LMWH derivative (LHD) was synthesised and then formulated with solubilisers and other pharmaceutical excipients to form a solid tablet. Its absorption and distribution after oral administration were evaluated in mice, rats, and monkeys. The in vitro metabolic stability of LHD was examined by liver microsome assays. More than 80% of LHD was released from the tablet within 60 minutes, guaranteeing rapid tablet disintegration after oral administration. Oral bioavailability of LHD in mice, rats and monkeys were 16.1 ± 3.0, 15.6 ± 6.1, and 15.8 ± 2.5%, respectively. After the oral administration of 131I-tyramine-LHD, most of the absorbed drug remained in the blood circulation and was eliminated mainly through the kidneys. LHD was hardly metabolised by the liver microsomes and showed a stable metabolic pattern similar to that of LMWH. In a rat thrombosis model, 10 mg/kg of orally administered LHD reduced thrombus formation by 60.8%, which was comparable to the anti-thrombotic effect of the subcutaneously injected LMWH (100 IU/kg). Solid tablets of LHD exhibited high oral absorption and statistically significant therapeutic effects in preventing venous thromboembolism. Accordingly, LHD tablets are expected to satisfy the unmet medical need for an oral heparin-based anticoagulant as an alternative to injectable heparin and oral warfarin.

PMID: 21437357 [PubMed - as supplied by publisher]

Link to Article at PubMed

March 2011
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