Management of inpatient hyperglycemia: assessing knowledge and barriers to better care am…

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The effect of time to antifungal therapy on mortality in Candidemia associated septic shock.

Am J Ther. 2009 Nov-Dec;16(6):508-11

Authors: Patel GP, Simon D, Scheetz M, Crank CW, Lodise T, Patel N

The timely administration of appropriate antifungal therapy for Candida bloodstream infections (CBSI) improves clinical outcomes. However, little data exist on the effect of antifungal therapy in patients with septic shock and candidemia. We describe antifungal treatment of patients with septic shock due to CBSI and its impact on in-hospital mortality. We retrospectively reviewed medical records of hospitalized patients identified with at least one positive blood culture for Candida between January 2003 and June 2007. All septic shock patients received vasopressor therapy and had candidemia within 72 hours of refractory shock. Data collected included demographics, comorbidities, antibiotic exposure, in-hospital mortality, and intensive care-related factors. Acute Physiology and Chronic Health Evaluation II scores were calculated. Time to antifungal therapy was defined as the interval between time of collection of the first positive Candida blood culture and the time when appropriate antifungal therapy was initiated. Univariate and multivariate analyses were performed to identify variables associated with in-patient mortality. Classification and regression tree analysis was used to identify the mortality breakpoint between early and late antifungal therapy. Septic shock developed in 23% (31 of 135) patients with CBSI. In-hospital mortality was 68%. Nonalbicans Candida spp. accounted for 48% of blood isolates. Appropriate antifungal therapy was administered to 24 patients; 15 (63%) of these patients died. Classification and regression tree analysis revealed that patients who received appropriate antifungal therapy within 15 hours of collecting the first positive Candida blood culture had improved survival (P = 0.03). Early, appropriate antifungal therapy improves survival among patients with septic shock due to CBSI.

PMID: 19531934 [PubMed - indexed for MEDLINE]

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Natriuretic peptide testing for heart failure therapy guidance in the inpatient and outpatient setting.

Am J Ther. 2009 Mar-Apr;16(2):171-7

Authors: Green SM, Green JA, Januzzi JL

Acutely destabilized heart failure is one of the most common diagnoses in the modern health care system. It has high hospital readmission rates and significant short-, medium-, and long-term mortality, likely due to misdiagnosis or failure to assess adequate treatment before discharge. Cardiac biomarkers such as B-type natriuretic peptide and its amino terminal cleavage equivalent N-terminal fragment have rapidly become one of the key tools in the diagnosis and guidance of heart failure therapy. In this article, we shall review the data on the current use of the natriuretic peptides for the diagnosis, prognosis, and management of heart failure in both the outpatient and inpatient settings.

PMID: 19300043 [PubMed - indexed for MEDLINE]

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Is there a dark side to long-term proton pump inhibitor therapy?

Am J Ther. 2008 Nov-Dec;15(6):536-42

Authors: Nealis TB, Howden CW

Proton pump inhibitors (PPIs) are among the most widely used of prescription drugs. They have revolutionized the management of gastroesophageal reflux disease and other acid-related disorders. Although generally safe, concerns about possible adverse effects continue to arise. Some of these, such as gastric neoplasms, are of theoretical concern only and are related to suppression of gastric acid secretion and consequent hypergastrinemia; these have not been encountered in clinical practice despite millions of patient-years of use. Others are more idiosyncratic, unpredictable, and rare. In general, the therapeutic benefits of PPIs outweigh these potential risks. However, it is important that PPIs are only given for appropriate indications and that, whenever possible, they are used in the lowest effective dose. At present, there is no need for specific monitoring for adverse events during PPI therapy.

PMID: 19127138 [PubMed - indexed for MEDLINE]

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Effect of caffeine on myocardial perfusion imaging using single photon emission computed tomography during adenosine pharmacologic stress.

Am J Ther. 2008 Sep-Oct;15(5):431-4

Authors: Kovacs D, Pivonka R, Khosla PG, Khosla S

Approximately 6 million cardiac stress tests are performed annually in the United States, of which 2.4 million are pharmacologic stress tests using agents such as adenosine. Adenosine induces differential coronary hyperemia in normal coronary arteries versus coronary arteries with atherosclerosis, allowing single photon emission computed tomography (SPECT) imaging to identify reduced coronary flow in segments subtended by diseased coronary arteries. The potential attenuation of pharmacologic effects of adenosine in the presence of caffeine is why patients are routinely instructed to abstain from caffeine for 12 to 24 hours prior to administration of an adenosine stress test. Failure to abstain from caffeine results in cancellation or delaying of cardiac stress testing, resulting in procedural delays and its impact on patient throughput. Recent studies have evaluated such interaction and suggested a lack of clinically significant effect of caffeine on adenosine-induced hyperemia during myocardial SPECT imaging. This article reviews the clinical pharmacology of caffeine, adenosine, and dipyridamole and effect of caffeine on myocardial stress testing using adenosine and dipyridamole in clinical cardiovascular medicine. The limited published data are conflicting, but some recent publications suggest that myocardial perfusion SPECT imaging using adenosine may not be clinically significantly altered by routine consumption of caffeine, such as a cup of coffee. Although prospective randomized studies would be required to obtain a definitive answer to this question, it appears on the basis of some of the studies reviewed in this article that caffeine consumption prior to myocardial perfusion imaging may not necessitate cancellation or rescheduling of adenosine stress testing.

PMID: 18806518 [PubMed - indexed for MEDLINE]

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Antipsychotic-induced hyponatremia: case report and literature review.

Am J Ther. 2008 Sep-Oct;15(5):492-4

Authors: Kohen I, Voelker S, Manu P

We report a case of hyponatremia in a patient that occurred 3 days after initiation of treatment with aripiprazole. The patient was a 50-year-old man admitted to an inpatient psychiatric unit for exacerbation of schizophrenia. He was started on aripiprazole and developed hyponatremia that resolved when the medication was stopped. We postulate that the hyponatremia was due to an aripiprazole-induced syndrome of inappropriate secretion of antidiuretic hormone. There have been numerous case reports in the literature of hyponatremia in the literature associated with atypical antipsychotics. We caution clinicians to be aware that the potential hyponatremic-inducing effects of atypical antipsychotics can occur rapidly after initiation of the medications.

PMID: 18806526 [PubMed - indexed for MEDLINE]

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Chronic pain of osteoarthritis: considerations for selecting an extended-release opioid analgesic.

Am J Ther. 2008 May-Jun;15(3):241-55

Authors: Gibofsky A, Barkin RL

Chronic/persistent pain due to osteoarthritis is one of the most common pain conditions affecting Americans today. Inadequate pain relief or dissatisfaction with current treatments is a source of frustration and suffering for patients with chronic/persistent pain. The requirement of multiple doses of commonly used analgesics to maintain adequate pain relief is inconvenient for many patients with osteoarthritis-related chronic pain. The several extended-release opioid analgesics that have been developed may provide an opportunity for improved patient convenience; however, clinicians must consider adverse event profiles, pharmacokinetics, abuse potential, and controlled substance-scheduling status of extended-release opioid analgesics. The purpose of this review is to highlight the efficacy and safety of extended-release opioid analgesics utilized in the management plan of chronic pain due to osteoarthritis.

PMID: 18496262 [PubMed - indexed for MEDLINE]

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Rationale and design of the hemodynamic, echocardiographic and neurohormonal effects of istaroxime, a novel intravenous inotropic and lusitropic agent: a randomized controlled trial in patients hospitalized with heart failure (HORIZON-HF) trial.

Am J Ther. 2008 May-Jun;15(3):231-40

Authors: Blair JE, Macarie C, Ruzyllo W, Bacchieri A, Valentini G, Bianchetti M, Pang PS, Harinstein ME, Sabbah HN, Filippatos GS, Gheorghiade M,

BACKGROUND: Current inotropes have inodilator properties and, although are frequently used in acute heart failure syndromes, do not improve outcomes, likely from reduction in systolic blood pressure and increasing in arrhythmias, causing worsened myocardial ischemia and end-organ damage. Istaroxime is a novel agent that, in animal models, has both inotropic (inhibition of the Na/K ATPase channel) and lusitropic (stimulation of sarcoplasmic reticulum calcium ATPase activity) effects. HORIZON-HF is designed to test the hypothesis that istaroxime is effective in improving central hemodynamics and left ventricular (LV) function, without lowering systolic blood pressure, increasing heart rate, and worsening renal function or myocardial necrosis. METHODS AND RESULTS: This was a phase 2, randomized, double-blind, placebo-controlled, multicenter dose escalation exploratory study comparing 3 different doses of istaroxime to placebo in patients with LV systolic dysfunction (LV ejection fraction <or= 35%) admitted to the hospital with worsening HF. Three cohorts of 40 patients each were randomized after an initial stabilization period of <48 h 3:1 to istaroxime 0.5, 1.0, or 1.5 microg/kg/min versus placebo infused over 6 h, with increasing doses after each cohort. The primary endpoint was change in pulmonary capillary wedge pressure from baseline, whereas secondary endpoints were improvement in other hemodynamic parameters, changes in echocardiographic assessment of LV systolic and diastolic function, neurohonal activation, renal function, and myocardial integrity. Pharmacokinetics and safety were also recorded. CONCLUSIONS: The novel inotropic and lusitropic agent, istaroxime, was tested in acute heart failure syndromes using a comprehensive assessment of cardiovascular function in addition to hemodynamic measurements.

PMID: 18496261 [PubMed - indexed for MEDLINE]

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