AbstractIntroduction and objectivesLimited data describe current SBP epidemiology and specific secondary SBP prophylactic regimens, leading to variable prescribing practices. This work aims to ...compare 90-day and one-year SBP recurrence and mortality based on secondary SBP antibiotic prophylaxis regimens. Materials and methodsWe performed a retrospective cohort of patients >18 years with an SBP diagnosis from 2010 to 2015 at two academic institutions. Eligible patients had ascitic PMN counts ≥250 cells/mm 3 or a positive ascitic culture. Patients were compared based on secondary SBP prophylaxis regimens (i.e., daily, intermittent, or no prophylaxis). ResultsOf 791 patients with ascitic fluid samples, 86 patients were included. Antibiotic prophylaxis included daily ( n= 34), intermittent ( n= 36), or no prophylaxis ( n= 16). Nearly half of SBP episodes had a positive ascitic fluid culture; 50% of were gram-negative pathogens, and 50% were gram-positive pathogens. Daily and intermittent regimens had similar rates of recurrence at 90-days (19.4% vs. 14.7%, p= 0.60) and one-year (33.3% vs. 26.5%, p= 0.53). Similarly, mortality did not differ among daily and intermittent regimens at 90-days (32.4% vs. 30.6%, p= 0.87) or one-year (67.6% vs. 63.9%, p= 0.74). When comparing any prophylaxis vs. no prophylaxis, there were no differences in 90-day or one-year recurrence or mortality. ConclusionsIn patients with a history of SBP, our data indicate similar outcomes with daily, intermittent, or no secondary antibiotic prophylaxis. With available data, including ours, demonstrating a changing epidemiology for SBP pathogens, further data is required to determine if traditional approaches to secondary SBP prophylaxis remain appropriate.
To review the efficacy and safety of transitioning from dexmedetomidine to clonidine to facilitate weaning of patients from sedation with dexmedetomidine. There is a paucity of data describing ...dexmedetomidine withdrawal syndrome (DWS) as well as clonidine's place in therapy for DWS. This review will describe and analyze current literature to provide clinical recommendations.
A MEDLINE literature search was performed to identify original research articles describing DWS and/or transitioning from dexmedetomidine to clonidine for the purpose of weaning patients from sedation with dexmedetomidine. Four case reports describing DWS, 3 case reports describing the use of clonidine to treat DWS, and 3 observational studies describing the use of clonidine to facilitate dexmedetomidine weaning were identified. The incidence of and risk factors for DWS are unknown; factors including patient age and dexmedetomidine infusion rate, loading dose, and discontinuation strategy have inconsistent associations with DWS. All cases of DWS have been associated with infusion durations greater than 72 hours. While there are limited data describing clonidine use for the treatment of dexmedetomidine withdrawal, clonidine appears to be beneficial for dexmedetomidine weaning and its use for that purpose has been well described. Clonidine dosages that have been assessed for discontinuing dexmedetomidine vary from 0.1 to 0.3 mg orally or enterally every 6 to 8 hours; one study assessed use of transdermal clonidine (100 µg/24 h patch). Patients with extensive cardiac comorbidities may be more susceptible to adverse effects of clonidine, which may limit the drug's use for DWS intervention.
Despite limited supportive data, clonidine provides a promising option for sedation management in adult ICU patients, with successful transitions from dexmedetomidine reported within 24 hours after clonidine initiation.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Background:
Trials evaluating hydrocortisone (HC) for septic shock are conflicting with all finding decreased time to shock reversal but few with mortality difference. Those with improved mortality ...included fludrocortisone (FC), but it is unknown if FC affected the outcome or is coincidental as there are no comparative data.
Objective:
The objective of this study was to determine the effectiveness and safety of FC + HC versus HC alone as adjunctive therapy in septic shock.
Methods:
A single-center, retrospective cohort study was conducted of medical intensive care unit (ICU) patients with septic shock refractory to fluids and vasopressors. Patients receiving FC + HC were compared with those receiving HC. Primary outcome was time to shock reversal. Secondary outcomes included in-hospital, 28-, and 90-day mortality; ICU and hospital length of stay (LOS); and safety.
Results:
There were 251 patients included (FC + HC, n = 114 vs HC, n = 137). There was no difference in time to shock reversal (65.2 vs 71 hours; P = 0.24). Cox proportional hazards model showed time to first corticosteroid dose, full-dose HC duration, and use of FC + HC were associated with shorter shock duration, while time to vasopressor therapy was not. However, in 2 multivariable models controlling for covariates, use of FC + HC was not an independent predictor of shock reversal at greater than 72 hours and in-hospital mortality. No differences were seen in hospital LOS or mortality. Hyperglycemia occurred more frequently with FC + HC (62.3% vs 45.6%; P = 0.01).
Conclusion and Relevance:
FC + HC was not associated with shock reversal at greater than 72 hours or decreased in-hospital mortality. These data may be useful for determining corticosteroid regimen in patients with septic shock refractory to fluids and vasopressors. Future prospective, randomized studies are needed to further evaluate the role of FC in this patient population.
Background: Data regarding safety of nonselective β-blockers (NSBBs) in patients with end-stage cirrhosis are conflicting, making it difficult for practitioners to justify if benefits outweigh the ...risks. Objective: Evaluate the effect of NSBB use on mortality in patients with end-stage cirrhosis. Methods: We performed a dual-center retrospective study of patients who received octreotide for a variceal bleed. Patients were stratified into 2 groups based on whether or not a NSBB was prescribed at hospital discharge. The primary outcome was 24-month mortality. Multivariable logistic regression, with 24-month mortality as the dependent variable, was performed to identify independent risk factors for the primary outcome. Results: 255 patients met inclusion criteria; 24-month mortality was 32.8%. The NSBB and no-NSBB groups had similar mortality rates at 24 months (32.0% vs 38.5%, P = 0.51). Mortality at 3 months (11.6% vs 23.3%, P = 0.08) and 12 months (22.2% vs 30.0%, P = 0.36) were similar, and there were no differences in rate of variceal bleeding (22.7% vs 13.3%, P = 0.34) or cirrhosis-related cause of death (20.4% vs 23.3%, P = 0.81). In the multivariable model, age, model for end-stage liver disease with sodium and hepatocellular carcinoma were independent risk factors for 24-month mortality. NSBB therapy had no effect on 24-month mortality (adjusted odds ratio = 1.05; 95% CI = 0.32 to 3.40). Conclusion and Relevance: In patients with end-stage cirrhosis, use of NSBBs did not affect 24-month mortality. More research is needed to determine when, and if, NSBBs should be discontinued in end-stage cirrhosis.
Background
There are more than 350 reports of hyperglycemia post-influenza vaccine according to the Vaccine Adverse Effect Reporting System. Only one case report has been published detailing unusual ...post-vaccination hyperglycemia. The mechanism as to why hyperglycemia may occur post-vaccination has not been fully elucidated.
Objective
Primary: To identify hyperglycemia within the first 24 hours of influenza vaccine. Secondary: To identify transient property of hyperglycemia within 4 days after vaccine.
Methods
Multicenter prospective cohort study. Recruitment conducted throughout San Antonio, Texas, during 2018-2020 influenza seasons. Patients were included if 18 years or older, had diabetes mellitus, and currently checking their blood glucose daily. Patients excluded if they had a recent medication change that would effect their blood glucose readings. Patients had hemoglobin A1c and blood glucose measured prior to vaccination with a single dose (0.5 mL) of the tri-valent influenza vaccine intramuscularly. Glucose readings were collected within 24 hours post-vaccination and subsequent mornings for 4 days.
Results
A total of 34 patients were included. Average patient age was 75 years with 60% white, 30% black, and 10% Hispanic. Median fasting glucose pre-vaccination was significantly lower than the median value 0 to 24 hours post-vaccination (140 vs 203 mg/dL, P < 0.0001).
Conclusion and Relevance
Hyperglycemia was noted 0 to 24 hours post-vaccination and was transient in nature with a return to baseline by post-vaccination day 2. This trial was conducted to close a potential gap in counseling regarding the flu vaccine and decrease any potential concern surrounding the vaccine in patients with diabetes that could lead to reduced vaccination rates.
Background/Objective:
Patients with intracranial hemorrhage (ICH) have a 30-day mortality rate up to 52%, and the risk of mortality is increased in patients with disease-induced coagulopathy such as ...cirrhosis. The objective of this study was to evaluate whether 4F-PCC administration mitigates hematoma expansion in ICH patients with cirrhosis not currently receiving anticoagulation therapy compared to standard of care therapies.
Methods:
This was a single-center, retrospective study comparing adult patients with ICH and history of cirrhosis who received 4F-PCC versus standard of care therapies. The primary outcome was rate of ICH expansion within 24 hours after admission.
Results:
A total of 58 patients were included with 21 who received 4FPCC vs 37 who received standard of care therapies. The 4F-PCC group had a significantly higher number of patients with Child Pugh Class C cirrhosis (85.7% vs. 48.6%, P = 0.006), higher baseline INR (1.7 vs. 1.4, P = 0.001) and more patients with a spontaneous cause of hemorrhage (61.9% vs. 29.7%, P = 0.01). Stable follow-up head CT was achieved in 68.4% of patients who received 4F-PCC versus 72.7% of patients treated with standard of care therapies (P = 0.11). Patients who received 4F-PCC had a significantly greater change in INR within 24 hours (-0.2 vs. 0, P = 0.02) and higher rate of mortality (61.9% vs. 18.9%, P = 0.001). Baseline INR > 2 and surgical evacuation for ICH were associated with decreased odds of stable follow-up head CT in the multivariate logistic regression model.
Conclusions:
A single dose of 4F-PCC did not significantly improve the rate of stable head CT at 24 hours in patients with ICH and cirrhosis. Randomized clinical trials with larger patient populations are warranted to fully determine the role of 4F-PCC in this unique population.
Study abroad (SA) experiences for health professions students may be used to heighten cultural sensitivity to future patients and incorporate interprofessional education (IPE).
Two groups of nursing ...and pharmacy students participated in an SA elective over a 2-year period, traveling to China and India.
Both groups improved significantly in knowledge, awareness, and skills following the travel experiences. Student reflections indicate that the SA experience was transformative, changing their views of travel, other cultures, personal environment, collaboration with other health professionals, and themselves.
Use of SA programs is a novel method to encourage IPE, with a focus on enhancing the acquisition of cultural competency skills.
Am J Manag Care. 2023;29(11):e353-e356. https://doi.org/10.37765/ajmc.2023.89461 _____ Takeaway Points * Data are limited on the comparative utilization of reference rituximab and its biosimilars for ...oncology and nononcology indications. * Results from this real-world analysis show increasing rituximab biosimilar adoption, with lower adoption rates for nononcology indications and academic settings. * These utilization trends provide insight into the dynamic prescribing habits of physicians. * Additional studies are warranted to uncover potential barriers to biosimilar uptake. _____ Rituximab (Rituxan) is one of a few FDA-approved drugs with available biosimilars used in the management of both oncology and nononcology indications. Increasing use of biosimilars promotes cost-effective patient care and improves patient access to treatment options.1 Physicians are gaining confidence in prescribing biosimilars and play a key role in influencing their acceptance.1 Disseminating trends in rituximab reference and biosimilar utilization by indication can provide insight into the real-world prescribing habits of physicians, quantify projected cost savings, and reveal the existence of lingering barriers to biosimilar implementation. Both of these findings are consistent with real-world data from a Canadian hospital that indicated greater on-label use of rituximab reference (59.8%) compared with off-label use (40.2%).2 Oncology made up 58.6% of the on-label use, followed by the nononcology indications granulomatosis with polyangiitis (1.0%) and rheumatoid arthritis (0.2%). Off-label use reflected more nononcology indications (oncology 22.1%, hematology 6.4%, immunology 1.7%, infectious diseases 1.0%, nephrology 6.9%, neurology 1.9%, rheumatology 0.2%).2 The diverse on- and off-label indications for rituximab biosimilar use observed within this study reflect the benefits of the abbreviated 351(k) approval pathway for biosimilar products: improving access and treatment options at a potentially lower cost.5 Trends in biosimilar utilization and diverse indications reported within this study may reflect significant cost savings to health care stakeholders.
PURPOSEThe literature describing fenofibrate-associated nephrotoxicity was reviewed.
SUMMARYFenofibrate-associated nephrotoxicity is an underrecognized adverse effect that is being reported with ...increasing frequency in the medical literature. A MEDLINE search identified articles describing fenofibrate-associated nephrotoxicity. Two retrospective chart reviews reported this adverse reaction in transplant recipients and patients with renal insufficiency. A case series of six patients noted that the adverse reaction also occurred in patients without a predisposition to renal injury. Two small prospective studies have examined fenofibrate-associated nephrotoxicity, with conflicting findings regarding the mechanism. Finally, a large retrospective review and a population-based cohort study found that patients with preexisting renal disease or taking high-dosage fenofibrate have a higher risk of developing fenofibrate-associated nephrotoxicity. Fenofibrate-associated nephrotoxicity was shown to be reversible with both discontinuation and continued use of fenofibrate, though one study found that the elevations in serum creatinine (SCr) levels were permanent in study participants. Some argue that SCr elevations described in these articles were not due to renal toxicity but may be attributed to reversible mechanisms. While several mechanisms may be biologically plausible, none of the theories have been tested in clinical trials. A possible mechanism for the increase in SCr levels may include changes in renal hemodynamics causing volume depletion and the impairment of generation of vasodilatory prostaglandins, leading to renal vasoconstriction.
CONCLUSIONFenofibrate-associated nephrotoxicity is an underrecognized adverse drug reaction. Several published reports have detailed possible etiologies; however, data detailing the true incidence of fenofibrate-associated nephrotoxicity and its associated risk factors are limited.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Introduction: Calcium channel blockers (CCB) are a leading cause of ingestion-associated fatality. Angiotensin-converting enzyme inhibitor (ACEi) overdose as part of co-ingestion is common and ...associated with refractory shock. Treatment options to manage this profound vasoplegia are limited. We describe the first case of use of newly formulated Angiotensin II for treatment of severe ACEi and CCB poisoning. Case Report: A 57-year-old man presented after suicide attempt by ingesting 20 tablets each of amlodipine 10 mg and benazepril 20 mg. His hypotension was initially managed with 35 mL/kg of crystalloid, norepinephrine, and hyperinsulinemic euglycemic therapy (HIET). His hemodynamics further deteriorated, and he developed lactic acidosis, electrolyte derangements, and renal dysfunction. Further complications of his ingestion included cardiac arrest, subsequent requirement for emergency cricothyrotomy, and renal replacement therapy. Maximal hemodynamic support with HIET therapy insulin drip 4.4 units/kg/hour, norepinephrine 2 mcg/kg/min, epinephrine 1 mcg/kg/min, vasopressin .06 units/hour, and intravenous lipid emulsion was unsuccessful. Ang II was started and titrated to maximal doses with dramatic improvement in hemodynamics. Within hours of starting Ang II, epinephrine was stopped and norepinephrine decreased by 50%. He was downgraded from the intensive care unit without any ongoing end-organ dysfunction. Discussion: Isolated CCB overdoses have high complication rates and well-established treatments. Therefore, management of CCB and ACEi co-ingestion is typically driven by CCB poisoning algorithm. There are multiple reports of CCB and ACEi co-ingestions causing treatment-refractory shock. Therapeutic options are limited by toxicities and availability of salvage therapies. Ang II is a safe and highly effective option to manage these patients.
PDF
