RESUMEN
OBJECTIVE: Drug interactions are a common cause of morbidity and mortality and may require prompt discontinuation of therapeutic regimens due to harmful side effects. Patients with acute coronary syndromes are likely to be prescribed multiple medications that are metabolized through the cytochrome P450 system, increasing the probability for drug interaction. Atorvastatin and simvastatin are both well known to interact with the oral P2Y12 agent ticagrelor. The purpose of this paper is to describe the interaction of ticagrelor with rosuvastatin leading to rhabdomyolysis, which is less clearly defined in the literature. METHOD: We report a case of a 74-year-old male who presented with bilateral lower extremity weakness and difficulty ambulating for one month after being prescribed ticagrelor for a drug eluting stent, in the setting of already being on rosuvastatin. His clinical picture and laboratory findings were consistent with a diagnosis of rhabdomyolysis. His medications were adjusted to a regimen of clopidogrel and alirocumab. One month later, he returned to his baseline status. RESULTS: The mechanism of interaction between rosuvastatin and ticagrelor appears to be multifactorial. It may be caused by CYP450-mediated metabolism from a small amount of crossover between isoenzymes. Ticagrelor may also cause acute kidney injury, increasing the concentration of rosuvastatin. Other mechanisms of interaction include genetic differences in the organic anion transporter polypeptides and transportation through p-glycoprotein. CONCLUSION: Future pharmacokinetic studies are warranted to better understand the interaction.
RESUMEN
PURPOSE OF REVIEW: The utility of aspirin and statins for primary prevention of atherosclerotic cardiovascular disease remains ambiguous in older adults. Current guidelines and recent data are vague and inconclusive. This review seeks to summarize the landscape of primary prevention of cardiovascular disease in older adults and explore the role of shared decision making. RECENT FINDINGS: Observational data suggest potential benefit of statin therapy in older adults. Aspirin is presently not recommended for primary prevention based on evidence from recent clinical trials. The implementation of shared decision making and decision aids in routine clinical practice remains challenging but may rise in coming years. Clinical trial data on the horizon may aid in solidifying guideline therapy for statin use. However, in the face of uncertainty, shared decision making between provider and patient should be utilized to determine whether pharmacotherapy may benefit older adults. Decision aids are an effective tool to guide this process.
Asunto(s)
Enfermedades Cardiovasculares , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Anciano , Aspirina/uso terapéutico , Enfermedades Cardiovasculares/prevención & control , Toma de Decisiones , Toma de Decisiones Conjunta , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Prevención Primaria , IncertidumbreRESUMEN
PURPOSE: The right ventricular outflow tract (RVOT) velocity time integral (VTI), an echocardiographic measure of stroke distance, correlates with cardiac index. We sought to determine the prognostic significance of low RVOT VTI on clinical outcomes among patients with acute pulmonary embolism (PE). MATERIALS AND METHODS: We conducted a retrospective review of echocardiograms on Pulmonary Embolism Response Team (PERT) activations at our institution. The main outcome was a composite of death, cardiac arrest, or hemodynamic deterioration. RESULTS: Of 188 patients, 30 met the combined outcome (16%) and had significantly lower RVOT VTI measurements (9.0 cm v 13.4 cm, p < 0.0001). The AUC for RVOT VTI at a cutoff of 10 cm was 0.78 (95% CI 0.67-0.90) with a sensitivity, specificity, negative predictive value, and positive predictive value of 0.72, 0.81, 0.94, and 0.42, respectively. Fifty-two patients of the cohort were classified as intermediate-high-risk PE and 21% of those met the combined outcome. RVOT VTI was lower among outcome positive patients (7.3 cm v 10.7 cm, p = 0.02). CONCLUSIONS: Low RVOT VTI is associated with poor clinical outcomes among patients with acute PE.
Asunto(s)
Deterioro Clínico , Embolia Pulmonar , Accidente Cerebrovascular , Ventrículos Cardíacos/diagnóstico por imagen , Humanos , Embolia Pulmonar/diagnóstico , Estudios RetrospectivosRESUMEN
The left ventricular outflow tract (LVOT) velocity time integral (VTI) is an easily measured echocardiographic stroke volume index analog. Low values predict adverse outcomes in left ventricular failure. We postulate the left ventricular VTI may be a signal of right ventricular dysfunction in acute pulmonary embolism, and therefore a predictor of poor outcomes. We retrospectively reviewed echocardiograms on all Pulmonary Embolism Response Team activations at our institution at the time of pulmonary embolism diagnosis. Low LVOT VTI was defined as ⩽ 15 cm. We examined two composite outcomes: (1) in-hospital death or cardiac arrest; and (2) shock or need for primary reperfusion therapies. Sixty-one of 188 patients (32%) had a LVOT VTI of ⩽ 15 cm. Low VTI was associated with in-hospital death or cardiac arrest (odds ratio (OR) 6, 95% CI 2, 17.9; p = 0.0014) and shock or need for reperfusion (OR 23.3, 95% CI 6.6, 82.1; p < 0.0001). In a multivariable model, LVOT VTI ⩽ 15 remained significant for death or cardiac arrest (OR 3.48, 95% CI 1.02, 11.9; p = 0.047) and for shock or need for reperfusion (OR 8.12, 95% CI 1.62, 40.66; p = 0.011). Among intermediate-high-risk patients, low VTI was the only variable associated with the composite outcome of death, cardiac arrest, shock, or need for reperfusion (OR 14, 95% CI 1.7, 118.4; p = 0.015). LVOT VTI is associated with adverse short-term outcomes in acute pulmonary embolism. The VTI may help risk stratify patients with intermediate-high-risk pulmonary embolism.
Asunto(s)
Ecocardiografía Doppler de Pulso , Embolia Pulmonar/diagnóstico por imagen , Volumen Sistólico , Disfunción Ventricular Izquierda/diagnóstico por imagen , Función Ventricular Izquierda , Adulto , Anciano , Femenino , Paro Cardíaco/mortalidad , Paro Cardíaco/fisiopatología , Paro Cardíaco/terapia , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Prueba de Estudio Conceptual , Embolia Pulmonar/mortalidad , Embolia Pulmonar/fisiopatología , Embolia Pulmonar/terapia , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Choque Cardiogénico/mortalidad , Choque Cardiogénico/fisiopatología , Choque Cardiogénico/terapia , Disfunción Ventricular Izquierda/mortalidad , Disfunción Ventricular Izquierda/fisiopatología , Disfunción Ventricular Izquierda/terapiaRESUMEN
In 2012, the Centers for Disease Control and Prevention issued a recommendation for hepatitis C screening of adults born between 1945-1965. Our institution incorporated birthcohort screening into its pre-admission testing program for elective orthopedic procedures on February 3, 2015. The goal of this study was to report the results and costs of pre-admission birth-cohort hepatitis C screening at our institution from February 3, 2015, to January 27, 2017. A total of 11,659 elective inpatient procedures were scheduled during this time and 97.8% of eligible patients were screened. Nine patients with active infection were identified, and four were successfully treated. Costs were calculated using time-driven activity-based costing. The total screening cost per successfully treated patient was $36,930.02. Since patients were not routinely screened at our institution before this intervention, our 97.8% screening capture rate demonstrates that pre-admission testing for elective procedures is a novel, yet effective and underutilized way, to engage "baby boomers" in screening.
Asunto(s)
Hepatitis C , Control de Infecciones , Tamizaje Masivo , Procedimientos Ortopédicos/métodos , Anciano , Análisis Costo-Beneficio , Procedimientos Quirúrgicos Electivos/métodos , Femenino , Hepatitis C/diagnóstico , Hepatitis C/epidemiología , Hepatitis C/prevención & control , Humanos , Control de Infecciones/métodos , Control de Infecciones/organización & administración , Masculino , Tamizaje Masivo/economía , Tamizaje Masivo/métodos , Persona de Mediana Edad , Periodo Preoperatorio , Estados Unidos/epidemiologíaRESUMEN
GENERAL PURPOSE: To provide information about the pathophysiology, diagnosis, and treatment options for systemic sclerosis. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Describe the pathophysiology, signs, symptoms, and diagnosis of systemic sclerosis.2. Outline the evidence-based medical and surgical management of systemic sclerosis. ABSTRACT: OBJECTIVE:: To perform a targeted review of systemic sclerosis, including epidemiology, pathophysiology, diagnosis, signs and symptoms, and medical and surgical management of upper extremity manifestations. DATA SOURCES AND STUDY SELECTION: An electronic literature review was conducted using PubMed for all publication dates through October 2017. Searches were performed using combinations of terms including "systemic sclerosis," "scleroderma," "management," "upper extremity," "hypercalcinosis," "Raynaud's phenomenon," "sympathectomy," and "digital ulcers." Only full-length articles written in English that discussed the management of upper extremity scleroderma were used. DATA EXTRACTION AND SYNTHESIS: The epidemiology, pathophysiology, diagnosis, upper extremity manifestations, and medical and surgical management of systemic sclerosis were reviewed. The case described in this article reports the utility of microsurgical interventions in the treatment of medically refractory upper extremity systemic sclerosis. CONCLUSIONS: Systemic sclerosis is a rare rheumatologic disease that greatly impacts quality of life. Medical management is the mainstay of treatment, propelling an improvement in the dismal 10-year cumulative survival rate from 54% in the 1970s to 66% in the 1990s. However, the pathophysiology of this disease is still poorly understood, and when medical management fails and the disease inevitably progresses, surgical approaches are critical.
Asunto(s)
Enfermedad de Raynaud/terapia , Esclerodermia Localizada/diagnóstico , Esclerodermia Localizada/terapia , Úlcera Cutánea/terapia , Terapia Combinada/métodos , Fármacos Dermatológicos/uso terapéutico , Procedimientos Quirúrgicos Dermatologicos/métodos , Femenino , Humanos , Masculino , Pronóstico , Enfermedad de Raynaud/diagnóstico , Índice de Severidad de la Enfermedad , Úlcera Cutánea/fisiopatología , Extremidad SuperiorRESUMEN
The early-life intestinal microbiota plays a key role in shaping host immune system development. We found that a single early-life antibiotic course (1PAT) accelerated type 1 diabetes (T1D) development in male NOD mice. The single course had deep and persistent effects on the intestinal microbiome, leading to altered cecal, hepatic, and serum metabolites. The exposure elicited sex-specific effects on chromatin states in the ileum and liver and perturbed ileal gene expression, altering normal maturational patterns. The global signature changes included specific genes controlling both innate and adaptive immunity. Microbiome analysis revealed four taxa each that potentially protect against or accelerate T1D onset, that were linked in a network model to specific differences in ileal gene expression. This simplified animal model reveals multiple potential pathways to understand pathogenesis by which early-life gut microbiome perturbations alter a global suite of intestinal responses, contributing to the accelerated and enhanced T1D development.
Asunto(s)
Antibacterianos/efectos adversos , Diabetes Mellitus Tipo 1/inmunología , Microbioma Gastrointestinal/inmunología , Inmunidad Innata/efectos de los fármacos , Inmunidad Adaptativa/efectos de los fármacos , Animales , Antibacterianos/inmunología , Diabetes Mellitus Tipo 1/microbiología , Diabetes Mellitus Tipo 1/patología , Femenino , Microbioma Gastrointestinal/efectos de los fármacos , Íleon/inmunología , Íleon/microbiología , Inmunidad Innata/inmunología , Intestinos/microbiología , Ratones , Ratones Endogámicos NOD , Microbiota/efectos de los fármacos , Microbiota/inmunologíaRESUMEN
BACKGROUND: The Center for Medicare and Medicaid Services (CMS) is transitioning Medicare from a fee-for-service program into a value-based pay-for-performance program. In order to accomplish this goal, CMS initiated 3 programs that attempt to define quality and seek to reward high-performing hospitals and penalize poor-performing hospitals. These programs include (1) penalties for hospital-acquired conditions (HACs), (2) penalties for excess readmissions for certain conditions, and (3) performance on value-based purchasing (VBP). The objective of this study was to determine whether high-volume total joint hospitals perform better in these programs than their lower-volume counterparts. METHODS: We analyzed data from the New York Statewide Planning and Research Cooperative System database on total New York State hospital discharges from 2013 to 2015 for total knee and total hip arthroplasty. This was compared to data from Hospital Compare on HAC's, excess readmissions, and VBP. From these databases, we identified 123 hospitals in New York, which participated in all 3 Medicare pay-for-performance programs and performed total joint replacements. RESULTS: Over the 3-year period spanning 2013-2015, hospitals in New York State performed an average of 1136.59 total joint replacement surgeries and achieved a mean readmission penalty of 0.005909. The correlation coefficient between surgery volume and combined performance score was 0.277. Of these correlations, surgery volume and VBP performance, and surgery volume and combined performance showed statistical significance (P < .01). CONCLUSION: Our study demonstrates that there is a positive association between joint replacement volumes and overall hospital quality, as well as joint replacement volumes and VBP performance, specifically. These findings are consistent with previously reported associations between patient outcomes and procedure volumes. However, a relationship between joint replacement volume and HAC scores or readmission penalties could not be demonstrated.